Review articleExercise: Should it matter to internal medicine?☆
Introduction
A 71 year old man died unexpectedly. An extensive myocardial infarction occurred while he was gardening in the first day of his vacation, and led him to sudden death shortly thereafter.
His daughter, a 45 year old woman who has always considered herself healthy, refers to her Internist for advice: “I'm worried. I know that genetics is important in the development of myocardial infarction… my grandmother suffered for an ischemic heart disease too, and she died due to congestive heart failure after two myocardial infarctions. She and her son, my father, were treated for high blood cholesterol level… One week before he died he performed a blood test: his total cholesterol was 277 mg/dl, HDL 46 mg/dl, and LDL 192 mg/dl, triglycerides were 196 mg/dl and fasting glucose 97 mg/dl. His blood pressure was 150/90 mmHg, is it right? He was only 71 years old! His body weight was about 95 Kg, but he was tall, more or less 1.88 m! Is there something that I may do in order to avoid the same fate?”
The Internist asks about her, medical history and life styles, performs a physical assessment, prescribes blood and urine test analysis, and other instrumental tests in order to assess any subclinical organ damage (electrocardiogram, echocardiogram, determination of Intima Media Thickness) [1] that might contribute to total cardiovascular risk. Blood tests show: total cholesterol 228 mg/dl, HDL 83 mg/dl, LDL 127 mg/dl, triglycerides 60 mg/dl, fasting glucose 91 mg/dl. Her blood pressure is 135/85 mm/Hg, BMI is 29 Kg/m2 and waist circumference is 88 cm. Her eating habits are regular and she is sedentary.
If we calculate cardiovascular risk factor using traditional algorithms [2], [3], [4], as SCORE, we find that the father would have had a 10-year risk of fatal CVD of 10% (no surprise!) and the daughter a risk lower than 1%! Considering also that the performed instrumental tests did not suggest any subclinical organ damage, is the Internist allowed to reassure his/her patient leaving her to her destiny (whatever it will be) or could he/she do anything else?
To delve into every single cardiovascular component per se, allows to find room to improve her lifestyle and consequently her health (see Table 1). BMI, waist circumference, cholesterol, blood pressure values and physical activity levels need to be ameliorated. Lifestyle changes, in particular to optimize body weight and to become physically active, represent the answer to the woman's question and should be prescribed. The goal of this approach [5], [6] is not obviously to determine nor the absolute, nor the relative risk to develop cardiovascular diseases, but it is to concretize at individual level a clinical preventive strategy. Generally Internists are used and have all the requested tools (awareness, knowledge and skills) to help their patients lose body weight and reduce cholesterol blood level primarily prescribing ad hoc diet; is not always the same if they have to counsel and even more prescribe physical exercise as therapy. A fundamental goal of exercise prescription is to bring about a change in personal health behavior including habitual physical activity [7] and hence direct patients to initiate, maintain, or increase their level of physical activity [8]. Scientific literature clearly shows that counseling and prescribing regular exercise, in everyday clinical practice, may be effective in helping patients to incorporate regular exercises in their daily routines [8], [9], [10], [11], obtaining clinical benefits. The essential is to know how to do it effectively, to have received effective education and training in just how to do it so that it can work [8]. The main foes may be: to underestimate the required skills, thinking that simple “good sense” could be enough for a correct prescription; to consider exercise prescription outside medical role; and to believe that people cannot change physical activity habits [9], [12], [13], [14], [15].
Section snippets
Benefit of physical exercise in internal medicine
The concept of a beneficial relationship between exercise and health is as old as the writings of Hyppocrates (5th century BC) [16]. Eons of interest and scientific investigations eventually followed through, and the role of regular exercise in determining health grew of importance so much as to be proposed as therapy [17] at the end of Nineties and being considered itself a real therapy ten years later when the scientific community launched the slogan “exercise is medicine” [18], [19] The
Approaching patients to exercise
While the sport medicine physician generally works with subjects used to the concept, benefits and practical issues of exercise, and willing to perform; the internist has to approach subjects who actually do not (Fig. 2). Hence, in order to prescribe exercise successfully, it is important not only to assess the patients' health status, in order to be sure to prescribe a safe and efficacious exercise [20], [48], but also to motivate him/her to become physically active [8], [79]. To maintain
Exercise prescription
Considering the huge amount of evidence supporting that exercise is beneficial to health, international scientific communities [8], [18], [19] indicate that it is both the role and the responsibility of a clinician to prescribe exercise to patients who would benefit from it, after a tailored medical evaluation and, if the case [20], [47], order pre-exercising testing to determine the possible presence of health risks when attempting regular exercise. Exercise prescription should be developed
Conclusions
We can conclude saying that the evidence favoring the introduction of exercise into clinical practice is irrefutable. Consequently we may agree with the statement that it should be considered now an imperative of clinical prevention that all patients understand the risks of a sedentary life and that exercise is important in treating and preventing chronic diseases [18]. We believe that a synergistic approach to exercise and sport (Fig. 2) might suggest a key role for the internal medicine
Learning points
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Regular physical exercise is now considered a preventive and therapeutic strategy for a wide array of chronic diseases. The evidence favoring the introduction of exercise into clinical practice is irrefutable.
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It is both the role and the responsibility of a clinician to prescribe exercise to patients who would benefit from it, after a tailored medical evaluation. If deemed necessary, clinician should order appropriate pre-exercise tests to determine the possible presence of health risks when
Conflict of interest
None.
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Source of support: ASI contract DCMC, PRIN 2007.