Physical Activity in Individuals with Chronic Conditions

KEY POINTS

  • • Chronic conditions are prevalent in the American population.
  • • Over 50% of adults in the United States have at least one chronic condition.
  • • Increased physical activity has been shown to yield multiple benefits to individuals with a wide variety of chronic conditions.
  • • These benefits include improvements in physical function and health related quality of life as well as reduction of risk of co-morbid conditions.

INTRODUCTION

Chronic conditions are very common in the US population (1). Over half of Americans (51.7%) have at least one chronic condition and about one third (31.5%) have multiple chronic conditions (2). The prevalence of chronic conditions increases with age. About 80% of adults over the age of 65 or older have multiple chronic conditions (3). A listing of the most common chronic conditions in the United States in adults and children is found in Figure 9.1.

Physical Activity can play an important role for individuals who have chronic conditions. It can assist in the therapy of a chronic condition such as in formal rehabilitation programs. Physical activity can also lower the risk of developing chronic conditions and play an important role in reducing likelihood of comorbid conditions in individuals with chronic conditions (1, 4). Moreover, physical activity can play an important role in preventing chronic conditions from getting w'orse over time.

The purpose of the current chapter is to provide a summary of the most common chronic conditions in adults in the United States and outline the multiple important roles that increased physical activity can play in ameliorating or treating them. Some of these chronic conditions such as cancer, hypertension, diabetes, and multiple sclerosis are also discussed in more detail in other chapters in this book.

PHYSICAL ACTIVITY IN CANCER SURVIVORS

According to the U.S. National Cancer Institute, a person is considered to be a cancer survivor from the time of diagnosis until the end of life. Currently there are approximately 15 million people in the United States who are considered cancer survivors (5). Improvements in treatments and detection of cancer have contributed to increased survival. Most of the studies have been done in physical activity and in

Most prevalent chronic conditions in adults and children, 2010

FIGURE 9.1 Most prevalent chronic conditions in adults and children, 2010.

(Physical Activity Guidelines Advisory Committee. 2018 Physical Activity Guidelines Advisory Committee. 2018 Physical Activity Guidelines Advisory Committee Scientific Report. Individuals with Chronic Conditions. Washington, DC: U.S. Department of Health and Human Services; 2018.) (From Gerteis J, Izrael D, Deitz D, et al. Multiple chronic conditions chartbook. AHRQ Publications No, Q14-0038. Rockville, MD: Agency for Healthcare Research and Quality; April 2014.)

cancer survival have been done on individual cancers since there is a great diversity of types of cancers and their underlying mechanisms.

Perhaps the most evidence regarding physical activity in cancer survivors is available in the area of breast cancer where greater amounts of physical activity after diagnosis are associated with lower risk of breast cancer specific mortality and allcause mortality. This benefit has been demonstrated both in pre and postmenopausal breast cancer survivors. The role of physical activity in cancer survivors is particularly important since more than three million US women are living with the diagnosis of breast cancer (6).

In the area of colorectal cancer there is moderate evidence that increased levels of physical activity after diagnosis are associated with lower risk of colorectal cancer specific mortality and all-cause mortality. More than 1,300,000 individuals are colorectal cancer survivors (7, 8). Colorectal cancer accounts for about 52,600 deaths per year in the United States.

In prostate cancer survivors there is also some evidence of an inverse relationship between the highest and lowest levels of physical activity after diagnosis and all-cause mortality. More than 3,000,000 U.S. men are living with the diagnosis of invasive prostate cancer (9). As with many other cancers, prognosis is influenced by the stage at diagnosis and availability and access to appropriate therapies. The leading cause of death in older individuals with prostate cancer is cardiovascular disease (CVD).

The role of physical activity in overall cancer treatment and prognosis for many different cancers is important for a variety of reasons. It is estimated that 42% of men and 38% of women will develop cancer during their lifetimes (10). As therapies have continued to improve, the number of years that affected individuals will live continues to increase. Many cancer survivors can expect to live for decades after the diagnosis (11). With this body of information, the literature that supports an inverse relationship between greater levels of physical activity and decreased allcause mortality and cancer specific mortality plays a very important role.

The Physical Activity Guidelines for Americans 2018 Scientific Advisory Report supported the recommendations for breast, colorectal, and prostate cancer survivors to increase physical activity (1). There are less data available in other cancers but this is an area of ongoing research. For all of these reasons, increased physical activity should be encouraged in survivors of breast, prostate, or colorectal cancer.

OSTEOARTHRITIS

Various arthritic conditions are prevalent in the US population. Arthritis affects over fifty four million Americans (12). Osteoarthritis (OA) is the most common joint disorder in the United States, affecting an estimated 30.8 million adults.

It is highly likely that the real burden of OA has been underestimated (13). OA of the knee and hip is the leading cause of mobility impairment in older adults in the United States. While OA is more common in older adults, it also can affect a wide spectrum of age groups. For example, tw'o million Americans under the age of 45 have knee arthritis (14). As the population continues to age it is expected that the prevalence of OA will continue to grow. Some estimates have indicated there may be 74 million individuals with OA by the year 2040. This represents almost 26% of the total population of adults over the age of 18 (15).

Regular physical activity can yield significant benefits for people with OA. The current guidance from the PAGA 2018 Scientific Report recommends 150 minutes per week of moderate intensity aerobic exercise and two days a week of muscle strengthening exercise for individuals with OA. These levels of activities can generate substantial benefits for the overall population with pre-existing osteoarthritis. Benefits of physical activity in individuals with OA include decreased pain and improved physical function as well as improved health related quality of life, slower rates of disease progression and decreased likelihood of comorbid conditions (1,4).

PHYSICAL ACTIVITY AND HYPERTENSION

Hypertension is the most common and preventable risk factor for cardiovascular disease (CVD) (16). Data from the 2017 American College of Cardiology (ACC)/AHA Guidelines for the Prevention, Detection, and Evaluation and Management of High

Blood Pressure estimates that 46% of adults in the United States have high blood pressure utilizing the criteria of SBP/DBP >130 over > 80 mm Hg (17).

According to the Framingham Heart Study, over 90% of adults who are free of hypertension at age 55 or 65 years will develop hypertension during their lifetime. It is estimated that for every 10 mm Hg increase in diastolic blood pressure or 20 mm Hg increase in systolic blood pressure above 120 over 75 mm Hg results in a doubling of the risk of heart disease (16). Hypertension is a significant risk factor for cardiovascular disease (CVD). High blood pressure is second only to cigarette smoking as a preventable cause of death for any reason (17). Regular physical activity conveys multiple health related benefits for individuals with hypertension.

There are multiple health related benefits for increased physical activity in individuals who have high blood pressure. These benefits include lowering blood pressure. As shown in Figure 9.2.

Regular aerobic physical activity can result in lowering of systolic blood pressure of approximately 8 mm Hg and lowering of diastolic blood pressure of approximately 6 mm Hg (18). Both of these represent significant reductions. Control of high blood pressure also lowers the risk of CVD and reduces the likelihood of progression of high blood pressure itself. In addition, regular physical activity can improve health related quality of life and increase physical function in individuals with high blood pressure (18). For all of these reasons, regular physical activity at the level of general recommendations from the PAGA 2018 Scientific Report is highly desirable in individuals with hypertension.

Blood pressure response to 16 weeks of aerobic physical activity, by resting blood pressure level

FIGURE 9.2 Blood pressure response to 16 weeks of aerobic physical activity, by resting blood pressure level.

Physical Activity Guidelines Advisory Committee. 2018 Physical Activity Guidelines Advisory Committee. 2018 Physical Activity Guidelines Advisory Committee Scientific Report. Washington, DC: U.S. Department of Health and Human Services; 2018 (1). (Adapted from Cornelissen VA, Smart NA. Exercise training for blood pressure: a systematic review and meta-analysis. J Am Heart Assoc. 2013;2(l):e004473. doi:10.1161/

JAH A.l 12.004473.)

PHYSICAL ACTIVITY AND TYPE 2 DIABETES (T2DM)

T2DM is prevalent in the population with over 9% of the population currently diagnosed with this condition (19). Physical Activity can play multiple positive health related roles in individuals with T2DM. For example, the leading cause of death in people with T2DM is CVD. Physical activity is associated with a 30-40% reduction in the risk of CVD mortality in individuals with T2DM (20).

There is a dose/response relationship with increasing levels of physical activity, lowering both the risk of CVD and CVD mortality in individuals with T2MD. In addition, regular physical activity can improve physical function and health related quality of life in individuals with T2DM (21).

Importantly, there is substantial evidence of an association between aerobic activity, muscle strengthening activity, and the combination of these two modalities with disease progression in people with T2DM including Hb-AlC, blood pressure, body mass index, and lipids.

There is a dose response relationship between physical activity and cardiovascular disease mortality in individuals with T2DM (22). This is illustrated in Figure 9.3.

As shown in Figure 9.3 there is an approximately 40% decrease in CVD mortality from individuals with T2DM who meet the PAGAC 2018 guidelines of 150 to 300 minutes of moderate to vigorous physical activity per week (23). Even

Dose-response relationship between physical activity and cardiovascular disease mortality in individuals with type 2 diabetes

FIGURE 9.3 Dose-response relationship between physical activity and cardiovascular disease mortality in individuals with type 2 diabetes.

Physical Activity Guidelines Advisory Committee. 2018 Physical Activity Guidelines Advisory Committee. 2018 Physical Activity Guidelines Advisory Committee Scientific Report. Washington, DC: U.S. Department of Health and Human Services; 2018. (Adapted from Sadarangani K, Hamer M, Mindell J, et al. Physical activity and risk of all-cause and cardiovascular disease mortality in diabetic adults from Great Britain: Pooled analysis of 10 population-based cohorts. Diabetes Care. 2014;37:1016-1023.)

individuals who have some regular physical activity, but do not meet guidelines in individuals with T2DM, have their cardiovascular mortality reduced by 30%. For all of these reasons, there is strong evidence that increased levels of physical activity play multiple important health related roles in individuals with T2DM.

Finally, regular physical activity in addition to modest weight loss (5-7%), has been shown to lower the risk in individuals with prediabetes progressing to diabetes. In the Diabetes Prevention Program the combination of 150 minutes of daily moderate to vigorous physical activity plus 5-7% of weight loss resulted in to 58% decrease in the likelihood of T2DM (24). These reductions in risk are particularly significant given that 36-38% of individuals in the United States have prediabetes (25). More information related to the role of physical activity in diabetes and prediabetes may be found in Chapter 5.

 
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