Role of Physical activities in prevention of non-communicable diseases


Role of Physical activities in prevention
of non-communicable diseases

Lt. Gen. Mahmud Ahmad Akhtar
Former Surgeon General Army/DGMS (IS)
Prof. Emeritus (Medicine and Therapeutics)

“I have saved the lives of 150 people by heart transplant. If I had focused on preventive medicine earlier, I might have saved 150 million.”

Prof. Christian Barnard,
Pioneer Heart
Transplant Surgeon.

Similar sentiments were echoed by the famous American Cardiologist Prof. Lowe who made many innovations in cardiology. In this write-up, the role, types, intensity and duration of physical activities/ exercises in the prevention of non-communicable diseases (NCDs) are discussed. Insufficient physical activity including more sitting has emerged as one of the leading risk factors for the rise of non-communicable diseases in many countries around the globe. Pakistan has got one of the highest in the world. The diseases are increasing like a wild fire. According to International Health Organization, people who are insufficiently active have 20-30 % increased risk of death as compared to people who are sufficiently active.

In Pakistan, adults and adolescents population is becoming increasingly inactive. The results of sports competition at national and international forums are fair indicators of the trend. The drop in physical activity is partially due to increase in sedentary behavior at home, at academic institutions, on the job and use of passive mode of transport. Population explosion, increased poverty, fear of violence (terrorism), crime in outdoor areas, high density of traffic, use of cars/ buses, transport instead of bicycling/ walking, low air quality (pollution) lack of parks/ playgrounds (even in teaching institutions), sidewalks and sports, recreation facilities and rapid urbanization have contributed to it. Urbanization leads to lack of activities, exposure to air, water pollution, access to processed / junk food rich in sugar and saturated fat, to nicotine and alcohol. The policies of planning and architecture of town and cities producing concrete jungles, eliminating green areas, discourage walking and cycling.

Policies of adoption of passive transportation system by providing massive spaces to passive transportation and practically nothing for active transportation discourages activities. It is an anti-democratic policy of ignoring rights of a large majority of population on foot/ bicycle. While the most developed richest countries of the world like Nordic/ Germany, Holland are very actively encouraging active transportation, Pakistan’s rulers have been doing quite the opposite, pursuing elitist policies -also hurting economically, taking huge loans for luxurious modes of transportation. Recent studies have shown that lifestyle therapies like physical activities, diet etc can even cancel the adverse genetic background that is good lifestyle triumphs the bad genetics. Those men and women with the highest aerobic fitness, have lesser statistical likelihood of developing heart disease no matter how worrisome their genetic profiles are. Even persons with the stout grip strength have reduced cardiac diseases risk, although not to same extent. Exercise can even strengthen an aging heart that is in 50s.

Lt. Gen. (R) Mahmud Ahmad Akhtar

Perils of prolonged
sitting – Sitting Syndrome

The studies have shown that the recommended exercise of thirty minutes of moderate intensity alone in not enough to achieve and maintain good health. In the modern day, desk work style sitting for prolonged periods is a norm. A typical office worker can easily log more than 10 to 11 hours a day in a chair. These long stretches of sitting have been found associated with increased risk of poor cholesterol profiles, diabetes mellitus, heart attacks, strokes, peripheral vascular disease, renal failures, dementia, osteoporosis, fatty liver etc. It has also been found that sitting more than one hour inactivates enzymes that dispose of fats, causing fat deposits, obesity, metabolic disorders. A recent study carried out at the university of Texas South-Western center on 1700 volunteers of men and women of diverse ethnicities revealed that those who sat for longer hours had increase of serum tropins, albeit not like in heart attacks. According to the authors, it constituted subclinical injury. They suggested both exercise and being less sedentary are important for the health of the heart. Thus, there is damage to the heart through atherosclerosis of coronary arteries plus subclinical necrosis of myocardium.

Recent research published in (June 2018) at Maastricht university in the Netherlands showed that after four days of sitting non-stop, the women and men showed greater insulin-resistance and undesirable changes to their endothelial cells, increasing risk of cardiac disease but in other subjects after a few days of moderate cycling there was enhanced endothelial cell health. Their insulin sensitivity and cholesterol profiles were unchanged. On the other hand both insulin and cholesterol levels that is metabolic activity were better after standing or strolling, far at least five hours a day. But endothelial cell health had not changed. The light activity seemed not to have affected that marker of heart health.

Dr. Barnard Dy-viver at Maastricht, the lead university researcher concluded that exercise and standing up have distinct effects on the body, therefore, in addition to exercise, prolonged sitting should be avoided. Prolonged sitting cancels out benefits of small exercise. In the West, at many places, standing working desks have replaced sitting desks. It is a wise policy to have a break every hour, stand up and have a walk - indulge in less sitting a significant risk factor. Standing and strolling have health friendly values.

In our rural society, many farmers spend hours in smoking Huqas while sitting producing double deleterious effects. This should be eradicated – cause of extreme risk of metabolic disorders like obesity, diabetes mellitus, heart attacks, strokes and renal failure, fatty liver and its sequelae. There is also economic losses due to loss of labour working hours and also enormous expenditure on treatment of resultant diseases. Pakistan’s agriculture output per acre is far less even than Indian Punjab due to these factors. Inactivity has become a wide spread disorder in Pakistan.

Mental Functions

Exercise also improves mental functions, well-being and prevent Alzheimer’s disease. It has been found that starting school activities with morning exercises improves the academic performance. Studies have also shown that a stroll after lunch improves work performance. The workers felt more enthusiastic and relaxed. Many work places also have weight lifting exercises. Weight lifting lifts mood. Exercise helps in prevention of stress, anxiety and depression.

Intensity of exercise

Question arises what exactly is a brisk walk? Current exercise guidelines almost always state that we should always walk at a brisk pace rather than stroll leisurely. But the recommendation do not define what brisk walking means. And when they do, can deploy daunting terminology or technicalities. For instance three metabolic equivalent of tasks are METS meaning that it uses about three times as much energy as standing still or brisk walking occurs at pace that increases our heart rate about seventy percent of our heart rate measurement that few fully understand. Even the simplest term used by the “USA Centers for Disease Control and Prevention” and other agencies in their guidelines defines brisk walking and other moderate intensity activities as occurring at a pace which people can talk and not sing is difficult to comprehend. That definition seemed impracticable to Dr. Contine saying “who wants to sing when they walk”.

In order to solve the puzzle, Dr. Tudor-locke analyzed 38 studies that included hundreds of men and women ranging in age from 18 to elderly and many different BMIs studied their walking pace and cadence which is the number of steps they take per minute as well as heart rate increase and respiration.

The conclusion was that brisk walking involves a pace of 2.7 miles per hour or put more simply one hundred steps per min (100 STEPS PER MINUTE) – easy to measure for 10 seconds and multiply with six. For elderly people studies are continuing – they may need more steps. Thirty minutes exercise means three thousand (3000) steps. One can ramp up pace and make walking vigorous which mean about 130 steps per minute – jogging generally means 140 steps per minute. Exercise schedules can be ramped up like young people can include short bursts of running in between brisk walking.

Recommendation is “FOCUS ON LESS SITTING and more on STANDING and Exercise”. Take stairs – park automobile outside the parking lot, have walking or standing meeting. Physical activities in all forms: standing, stretching, muscle strengthening, aerobic (walking, cycling, swimming, house chores, gardening etc.) are beneficial in different ways.

Duration of exercise

From the new study published in March 2018, in the journal of “American Heart Association”, the scientists chose data of about 4850 men and women past the age of 40 who had worn activity trackers. Using the accelerometers readouts, the scientists determined how many minutes per day in total each person had spent in moderate or vigorous physical activity. They defined moderate activity as an essence. Brisk walking and vigorous activity which was rare as work outs similar to jogging. The researchers also looked at how long each session of activity had continued. If a single session, went more than five minutes, it was considered a bout of exercise. Less than five minutes was considered to be sporadic physical activity such as walking down the halfway or up to a brief flight of stairs. Finally, they considered the death records to determine whether and when the participants died through 2011. The scientists found that moving strongly improved longevity. The men and the women who were least physically active, exercised moderately for fewer than twenty minutes a day were at the highest risk of pre-mature death. Those who moved more, especially if they managed about an hour in total physical activity, even during the course of the day, cut their mortality risk in half, the researchers found. It did not matter how they accumulated those minutes. If people walked five minutes or longer, meaning in exercise bouts. However, they gained the same benefit if they walked sporadically in short but repeated spurts as long as they moved often. This is an important finding. THE MESSAGE IS THAT ALL PHYSICAL ACTIVITY COUNTS, the more the better and anything is better than nothing says Dr. William Kraus, a professor of Duke University who conducted the study. With the researches in national cancer institution. Dr. Kaus says that if you cannot go for a long walk, a few short walks is likely to be just as good for you. There are many old people with disabilities who cannot walk, they can do exercise on stationery bicycles or do the upper body exercises. Scientists and experts are considering changes in the guidelines later this year to the formal exercise guidelines which are encouraging.

Physical Fitness

Being in shape is important to a long life according to a new study of the links between physical fitness and mortality. The study also explored whether there was any ceiling to the benefits of fitness – whether in essence you can exercise too much. The answer it found…is a “REASSURING NO” (Provided the person is healthy to do exercise – not suffering from a disease not incompatible with intense exercise).

The new study which was published Oct 2018, in JAMA net-work open, a group of researches including clinicians at the Cleveland Clinic looked in an objective ways measured the relationship between endurance and longevity and whether they can overdo exercise and potentially shorten their life-spans. They had record of thousands of men and women who had completed treadmill tests at the clinic. The researches turned to database, had records of 122007 middle-aged or older men and women. They grouped people by fitness from those who were in the bottom quarter of fitness to those who were below average, above-average or highly fit, essentially in the top 25 % of fitness. They also marked off a small group in the top 2% or so of endurance and categorized them as having “elite” fitness.

Then the researchers checked death-record for the decade after people had completed their stress tests. They noted strong correlations between fitness and mortality. It was found that the greater someone’s fitness, the less likely he/she was to have died prematurely and vice versa, the numbers showed. The correlation held true at every level of fitness, people with the lowest fitness were likely to die early than those with high fitness lived longer than those whose fitness was above average.

Even at the loftiest reaches of endurance, the advantage held. The 2% of the people with elite fitness lived longer than those with high fitness and were 80% were less likely to die prematurely than the men and women with the lowest endurance. “We did not see any indication that you can be too fit” said Dr. Wael Jaber, the study senior author and cardiologist at the Cleveland Clinic Levner College of Medicine. More surprisingly when the researchers compared the longevity benefits of endurance to those of other health factors, fitness held up well. The data also showed high risk of smoking.

Situation in Pakistan

In Pakistan, the incidence of abdominal obesity is very high. The abdominal girth should be less than 35 and a half inch in males and less than 31 and a half in females. Even the security service personnel are seen frequently with central obesity. A recent study published in the Pakistan Armed Forces Medical Journal, carried out in the armed forces hospital showed high incidence of / prevalence of metabolic syndromes in the Pak Armed Forces, more than the Saudi, Jordan and Indian armed forces. The most unfortunate thing is that nothing is being done to combat it.

The elected political leaders and parties and selected officials all over the world give special importance to health and fitness of the nation. In this regard, the Greeks started Olympic Games competitions. Our selected and elected rulers should be the role models like the leaders of the UK, the Royal family, other Europeans leaders, Russian president Putin, Chinese president Xi and others. The Chinese leaders have launched a nation-wide exercise and physical fitness programme. Pakistan’s problems are far more acute.

Health- destructive diets rich in saturated fats, sugar, salts, red meat, processed food, junk food, sodas (weapons of mass destruction) are consumed while health promoting diets containing vegetables, fruits, whole grains, pulses and mono-polyunsaturated fats are not consumed. Exercise games, sports other types of physical activities are on the steep decline. Tobacco smoking is on tremendous increase, also in the academic campuses even female students are indulging to it.

It is the need of the hour that all out national campaign should be carried out through academia, media and religious leaders, citing also religious teachings to create awareness and adopt preventive measures. Our priorities are lop sided. Emphasis on prevention, health promotion, earlier detection and treatment of diseases is not accorded, but done on underpasses, overpasses, metros, beautifying the cities of Lahore, Islamabad, Karachi etc. and neglecting over 90% of the Pakistan’s gullible population living in slums and shanti towns of cities, rural areas of Baluchistan, Sindh, South Punjab, KPK, FATA, Northern areas etc.- i.e. the REAL PAKISTAN Rs. 60 billion were spent on a 27km strip of track in Lahore for the orange line. The expenditure on orange line was Rs. 450 billion while on health for the whole province was comparatively very meagre. Even potable water which is essential for life and fundamental human rights. There are twenty five million children out of school-40 percent of children are suffering from stunting jeopardizing not only their future but also country’s- a large young population instead of becoming boom is going for bust. It is elitist undemocratic policy - Elitist rule by the elites, for the elites. The founder of Pakistan envisaged Pakistan to be a social welfare democratic state.

For the curative side, there should be network of cardiac / stroke units all over the country. The success of treatment depends up to the earlier the patient reaches the unit i.e. within two hours. Our elite rulers are developing expensive, luxurious non-cost effective medical institutes. In the private sector, a few bedded clinics are doing stenting, cardiac by-pass operations. There is no reason that 250 bedded district hospitals to not undertake these treatments. The progressive countries first built units all over the country and institutes later that too for research purposes which is not done in Pakistan. Lifesaving facilities and medicines should be available to citizens all over the country. WHO’s Essential Medicine System devised by the WHO’s Drug Expert Committee is not implemented in Pakistan with the result a large number of life-saving medicines are not available in Pakistan- the only middle flow income country in Pakistan causing highest mortalities, morbidities in the world- with the exception of a few sub Saharan countries. It is high time that lifesaving Essential Medicines are made available to the people all over the country and at all times- the poor people should get them free of cost. Non availability of many antibacterial drugs is not only increasing mortality but also worsening the problem of anti-bacterial resistance- it needs urgent solution.

We must set our priorities right, pay maximum attention to prevention and control of diseases, promotion of health, early diagnosis and treatment. There should be a network of proper medical facilities spread all over the country rather making luxurious self-serving diseases palaces. The Punjab Govt. spent Rs seventy thousand per person on uplift of Lahore while it spent Rs. Four hundred per person on a town in Southern Punjab, the PM house in Islamabad spread over 108 acres is 10 times larger than USA’s White House. In this context, the messages of Prof. Dr. Christian Bernard, Prof Lowe and other medical dignitaries and examples of the progressive countries, the way they evolved their Health system should be kept in view.