A VIEW FROM THE OFFI CE
MORE SUPPORT FOR A HEALTHY LIFESTYLE
(DID WE NEED ANY?)
LIFESTYLE RISK FACTORS PREDICT DISABILITY AND DEATH IN HEALTHY AGING ADULTS [THE 15TH MAJOR LIFESTYLE STUDY]: For the development of my "Formula for Health" I had collected 13 major observational studies and 1 RCT to support the synthesis of lifestyle essentials into just 5 lifestyle factors. These were cited in my Editorial in American Family Physician in 2010. Now it is time to add a new observational study to the list.(1)
"[The] [p]ositive health effects of maintenance of normal weight, routine exercise, and nonsmoking are known for the short and intermediate term." These investigators studied the effects of these risk factors into advanced age. They collected data from 2,327 college alumnae aged 60 years of more who were followed annually (1986-2005) by questionnaires addressing health risk factors, history, and Health Assessment Questionnaire disability. Mortality data were ascertained from the National Death Index. Low-, medium-, and high-risk groups were created on the basis of the number (0, 1, > 2) of health risk factors (overweight, smoking, inactivity) at baseline. The medium- and high-risk groups had higher disability than the low-risk group throughout the study (P , 0.001). Low-risk subjects had onset of moderate disability delayed 8.3 years compared with high-risk subjects. Mortality rates were higher in the high-risk group (384 vs 247 per 10,000 person-years). The authors conclude: "Seniors with fewer behavioral risk factors during middle age have lower disability and improved survival. These data document that the associations of lifestyle risk factors on health continue into the ninth decade."
COMMENT: We already knew this, at least for elderly Europeans (aged 70-95 years) from the HALE Study which looked at 4 factors (not smoking, Mediterranean diet, exercise, and some consumption of alcohol. The benefits observed in the HALE study were truly dramatic-- 61-64% reductions in coronary and peripheral vascular mortality, 36% reductions in cancer (of all causes), and a 60% reduction in all-cause mortality. [It's OK to gasp.]
So how much more data will it take before something like the "Formula for Health" becomes the cornerstone of all primary care--from cradle to grave? (Of course, it is NOT a data problem. Those who could be persuaded by data WERE persuaded a long time ago. For the rest, the data are irrelevant. It will probably take until ALL of the MONEY runs out to pay for procedures, tests, and medications before we give primary prevention a chance.
REVIEWING THE "FORMULA FOR HEALTH": DOES ADVICE TO EXERCISE WORK? Of course, it does, but it's hard to prove. For this reason the USPSTF has dismissed physician counseling for exercise to the trash bin of "insufficient evidence," which I have always considered unfair. "The USPSTF found insufficient evidence to determine whether counseling patients in primary care settings to promote physical activity leads to sustained increases in physical activity among adult patients. Controlled trials of physical activity counseling in adult primary care patients were of variable quality and had mixed results. There were no completed trials with children or adolescents that compared counseling with usual care practices." [Not updated since 2002] While we have to make concessions to the fact that the studies are few, small, often uncontrolled, and generally use suspicious "self-reported" amounts of exercise as outcomes, the remarkable thing is that a few minutes of physician or practice time, whether face-to-face or by phone or by class, makes a difference; the trend among studies is phenomenal. And, all of the lifestyle studies with their more global perspective identify exercise as a key component of a healthy lifestyle that is associated with the dramatic improvements in outcomes as mentioned above.
The British are far more pragmatic and ultimately more fair, and with good reason. The BMJ has just published a systematic review of physical activity promotion based in primary care and found that it significantly increases physical activity levels at 12 months.(2) A prior meta-analysis of cohort studies found that self reported achievement of the official UK exercise goal (150 minutes of moderate intensity activity each week) was associated with a 19% reduction in the rate of all cause mortality, compared with sedentary behavior.(3) In the UK only 39% of men and 29% of women achieve this goal (2008). A Cochrane review of interventions to promote physical activity in community dwelling adults showed a moderate effect on self reported physical activity and cardiorespiratory fitness at a minimum of 6 months of follow-up. In addition, similar brief interventions have previously been shown to reduce smoking and alcohol use. One of the major problems with previous studies on exercise are that reviews included non-randomized trials and trials with short follow-up duration. Since the USPSTF recommendation (2002), however, there have been several large trials of physical activity promotion based in primary care with outcomes data after at least 12 months. It is time to take a fresh look. [Shame on you, USPSTF!]
These investigators found a total of 15 relevant randomized controlled trials with 8745 subjects. Most interventions took place in primary care, included health professionals in delivery, and involved advice or counseling given fact to face or by phone (or both) on multiple occasions. In the 13 trials presenting self-reported physical activity, there were small to medium positive intervention effects as 12 months (OR, 1.42). The number-needed-to treat for one additional sedentary adult to meet internationally recommended levels of activity as only 12 (7-33). These are very positive results.
Here are some other noteworthy aspects of the data to consider:
- The authors could find no unpublished studies on brief interventions to promote exercise. Funnel plots of their pooled data did not suggest any publication bias.
- A planned subgroup analysis showed significantly larger intervention effects on self reported activity in studies where control participants received no intervention than where they received a lesser comparator intervention. This analysis suggests that the observed positive effect on exercise levels may be underestimated as it appears that the comparator interventions themselves had positive effects. "The additional percentage of participants who reported meeting international activity recommendations at 12 months, compared with baseline, was 11-47% in participants allocated to receive an intervention, and 8-47% in those allocated to receive a comparator intervention. The corresponding range for those allocated to receive no intervention was from -2% to +19%. These findings suggest that briefer interventions, as used in the comparator groups, might achieve effects that are similar to those of more intensive interventions."
- Only one study reported an objective measure of physical activity level as an outcome, and in this study it was not significantly different. The authors call for more studies with an objective measure of outcome.
- Only one study found a significant intervention effect on adverse events, reporting a relative 11% increase in falls and a 6% increase in injuries among intervention participants.
- Since follow-up was limited to only 12 months in most trials, the effect of the exercise intervention of diabetes, cardiovascular events, or mortality could not be assessed.
COMMENT: The USPSTF has been way too timid. They are missing the forest for the trees. Promoting exercise should be consider one of the absolute core activities of primary care practice. It's not. The USPSTF could be helping. It is not.
WALKING TO SAVE YOUR MIND: The Japanese have conducted a trial to evaluate the efficacy of a municipality-led walking program under the Japanese public Long-Term Care Insurance Act to prevent mental decline.(4) These data are from the program in the city of Takasaki. One hundred fifty community members aged 72.0 =/- 4 were randomly divided into intervention and control groups. A walking program was conducted once a week for 90 minutes for 3 months. The program encouraged participants to walk on a regular basis and to increase their steps per day gradually. The intervention was conducted in small groups of approximately six in order to obtain possible benefits in both exercise and social interaction. Cognitive function was measured using 9 tests in 5 domains: memory, executive function, word fluency, visuospatial abilities, and sustained attention. Quality of life, depressive state, functional capacity, range of activities, and social network were also assessed as well as motor function. There were significant differences between the intervention and control group in word fluency related to frontal lobe function (P=0.01), quality of life (P=0.002), functional capacity including social interaction (P < 0.001), and motor function (Timed Up and Go Test; P=0.002). COMMENT: As opposed to the "do nothing" attitude of the USPSTF, this is the kind of program we should be starting in our practices. Get every staff member (including a stint for yourself!) to lead a group at different hours during the day. I had a resident a few years ago (my esteemed Chief Resident at Santa Rosa, Dr. Serena Brewer, Touro graduate) who designed a project to do just this in a residency clinic setting. It would even reimburse well (if a provider spent some face-to-face time with each patient). You know what doomed it in this setting? The supporting hospital's fears of potential legal liability in the case that a patient might slip and fall. Sigh. We have to do better than this.
HOW OFTEN SHOULD I EXERCISE, DOC? The answer from Joseph Alpert, MD [Editor-in-Chief of American Journal of Medicine] is "Only on the days you eat."(8) His full answer is: "Our DNA heritage with its highly complex biochemical and physicological processes is appropriate to a very active lifestyle, not a modern 21st centruy couch potato, fast-food existence. Consdequently, we should make every effort to include elements that resemble the Paleolithic lifestyle [of our ancestors] in our modern daily existence. My lifestyle includes daily exercise, lots of fruits and vegetables in the diet, and avoidance of heavily engineered snack food. Of course, I also do not smoke tobacco nor do I consume large quantities of alcohol. I recommend these liefstyle elements to all my patients. When friends or family ask, 'How often should I exercise?' my answer is always 'Only on the days you eat.' That seems to get the message across." COMMENT: It's a shame that he didn't mention relaxation or stress reduction. But perhaps that is not an option for the Editor in Chief of American Journal of Medicine.
ANOTHER ASIAN STUDY: AS LITTLE AS 15 MINUTES OF EXERCISE EACH DAY MAY PROLONG LIFE: A prospective cohort study from Taiwan examined the association between physical activity and mortality.(5) In this study, people who did as little as 90 minutes of exercise each week (who would ordinarily be considered physically inactive) were analyzed as a separate group. Around 12.5% (28,311 of 226,493 subjects) of those who exercised at all did so for about 15 minutes of 6 days a week. The study followed up for an average of 8 years more than 400,000 people who underwent regular health check-ups. Compared with people who exercised very little, those who did not exercise at all had a 17% higher risk of dying from any causes, and an 11% higher risk of dying from cancer. Each extra 15 minutes of daily exercise was linked with a 4% reduction in the risk of dying from any cause, and a 1% lower risk of cancer related death. The results held in both sexes, regardless of age, smoking and drinking habits, and overall risk of cardiovascular disease. The authors conclude that, at age 30, men who exercised for 15 minutes each day on average could expect to live 2.6 years longer than their peers who did not exercise at all; women could expect 3.1 years of extra life. Among 30 year olds who met the recommendations for physical activity--30 minutes exercise on 5 days a week--men could expect to live 4.2 years longer and women 3.7 years longer, compared with their physically inactive peers.
1. Chakravarty EF et al. Lifestyle risk factors predict disability and death in healthy aging adults. Am J Med 2012; 125: 190-197.
2. Orrow G. et al. Effectiveness of physical activity promotion based in primary care: systematic review and meta-analysis of randomised controlled trials. BMJ 2012; 344:e1389 doi: 10.1136/bmj.e1389 (March 26, 2012).
3. Woodcock J et al. Non-vigorous physical activity and all-cause mortality: systematic review and meta-analysis of cohort studies. Int J Epidemiol 2011; 40: 121-38.
4. Maki Y et al. Effects of an intervention using a community-based walking program for prevention of mental decline: a randomized controlled trial. J Am Geriatr Soc 2012 Mar; 60(3): 505-10. doi: 10.1111/j.15
5. Wen CP et al. Minimum amount of physical activity for reduced mortality and extended life expectancy: a prospective cohort study. Lancet 2011; 378: 1244-53.