The Harvard Medical School Family Health Guide

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Exercise and Fitness

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Killer snow

Every winter, about 1,200 Americans die from a heart attack or some other cardiac event during or after a big snowstorm, and shoveling is often the precipitating event.

Why is shoveling so hazardous?

Shoveling uses your shoulders and arms, and upper body exercise tends to put strain on the heart because those muscles aren’t well conditioned.
Working in an upright position adds to the arduousness because blood pools in the legs and feet, so to maintain blood pressure, your heart must work harder.
Much of snow shoveling is isometric exercise: your muscles are working, but there's little actual movement until you finally heave a shovelful up on the bank. During isometric exercise of any type, your heart rate goes up, and your blood vessels constrict, presumably to send more blood to the straining muscles. As a result, your blood pressure goes up.
Without knowing it, shovelers sometimes perform a version of the Valsalva maneuver, bearing down as they would during a bowel movement while holding their breath. Waiting to exhale while straining like that can lead to abrupt changes in your heartbeat and blood pressure.
First thing in the morning, the time when many people dig out from a storm, stress hormone levels tend to be higher, platelets in the blood “stickier,” and heart attacks more likely.
Shoveling involves exposure to the cold, another cardiac stressor.
People who are out of shape often shovel, making the sudden intense exercise even harder on the heart.
Most people don’t warm up before they shovel or cool down afterward.

If you have a heart condition, you shouldn’t shovel under any circumstances. People older than 50 should also try to avoid it. Contact your local council on aging to see if they provide a list of teens in your neighborhood who you can hire to do the job for you. Or buy a snow blower. If you must shovel, take it easy. Rest often. Dress warmly and stay well hydrated. Wherever possible, push the snow rather than lift it. Clear only the snow that blocks your path into the house, the rest will melt on its own. And of course, listen to your body. Head home if you experience potential signs of heart trouble, including chest pain, palpitations, undue shortness of breath, fatigue, lightheadedness, or nausea. Also stop if your fingers or toes get numb or hurt — you could have frostbite.

January 2003 Update

Physical activity benefits all ages

The frail health often associated with aging is in large part due to physical inactivity, according to a report released by the U.S. Department of Health and Human Services (HHS). It also advises that it’s never too late to benefit from becoming physically active.

The report cites that even moderate levels of activity — such as washing a car or raking leaves — can produce considerable benefits that can be even more noticeable in older adults. Regular exercise improves cholesterol levels, reduces blood pressure, cuts body fat, and lowers blood sugar. Physical activity also improves bone and muscle strength. All in all, people who exercise live longer — and they also live better.

Current guidelines recommend at least 30 minutes of moderate physical activity a day. However, few older Americans reach this level. Lack of physical activity and poor diets are the major causes of obesity, an epidemic that is affecting people of all ages.

In the '70s and '80s, doctors were telling Americans to run; now, they are asking people to walk. Walking can be a moderately intense aerobic activity. But even at a more relaxed pace, walking has huge benefits. The distance actually seems more important than the pace — and it doesn't take heroic distances to get real benefit. In 1993, the Harvard Alumni study found that men who walked just 1.3 miles a day had a 22% lower death rate than those who walked less than 0.3 mile a day.

Strong muscles also improve your health. So set aside 15 minutes two or three times a week for resistance or strength training as well as 10–15 minutes at least three times a week for stretching exercises.

The HHS report provides strategies that individuals, doctors, and even communities can follow to promote physical activity. Individuals are encouraged to take part in activities that they enjoy and to make them a daily part of life. Doctors should help patients start and continue these regimens and overcome any difficulties they encounter. Communities can establish programs tailored to seniors’ physical activity needs and improve walking or bike trails.

The complete report is available at www.ahrq.gov/ppip/activity.htm

August 2002 Update

New guidelines for stroke prevention

With more than 700,000 Americans having strokes each year, doctors and patients need to focus on stroke prevention. In light of this, the American Heart Association (AHA) has issued a statement that details how to identify and modify risk factors. Here are the AHA's tips, along with other general guidelines for lowering stroke risk:

Blood pressure. You should get your blood pressure checked at least every two years because many people with high blood pressure don't even know they have it (130–139 mm Hg systolic pressure over 85–89 diastolic pressure is considered high-normal, while anything above 140 over 90 is considered high). If you have high blood pressure, the following lifestyle changes can help lower it:

Eat more fruits and vegetables. Potassium-rich foods like bananas and oranges may be especially good.
Pass on salt. Salt makes the body hold onto water, and the heart has to work harder to pump the extra fluid.
Lose weight. The heavier you are, the harder your heart has to work to pump blood to all parts of your body.
Exercise. Even if you don't need to lose weight, exercise can reduce high blood pressure and may even prevent it.
Limit your alcohol. Having more than two alcoholic drinks a day significantly increases your risk of high blood pressure.
Quit smoking. Smoking increases your risk of heart attack, as well as many other diseases. And if you live with a smoker, make sure he or she quenches his cravings outside. Exposure to secondhand smoke can double your risk of stroke.
Learn to relax. Various kinds of behavioral therapy, like biofeedback, yoga, and tai chi may lower blood pressure.

These lifestyle changes can also help with other causes of stroke, like
atherosclerosis (hardening of the arteries) and high cholesterol. If the changes don't lower your blood pressure, your doctor may prescribe a medication such as a diuretic or beta blocker.

Other conditions. The AHA recommends that patients with diabetes and children with sickle cell disease closely monitor their blood pressure with screenings every six months.

Non-modifiable risk factors. Black, Hispanic, Chinese, and Japanese people are at increased risk for stroke compared to whites. Men and postmenopausal women are also at higher risks than others. If one of your parents had a stroke, you are at greater risk as well, either because of genetics or shared lifestyle traits.

While you can't do anything about non-modifiable risk factors it's helpful to know if you fall into a high-risk group so you can carefully monitor controllable factors.

July 2002 Update

Asthma Education Leads to Improvement in Children

Managing your child's asthma should include meeting with an asthma educator a few times, according to a follow-up study. Presented at the meeting of the American Academy of Allergy, Asthma, and Immunology, the study reports that after attending an interactive training program three times patients felt less worried about their asthma and had fewer asthma-induced awakenings during the night. Both patients and their caregivers, who also took part in the program, made better decisions about asthma care.

The 30 subjects, asthmatic children ages 6–12, underwent ACE IT! (Asthma Care Education: Intensive Training), an interactive, small-group education program. The sessions included a motivational talk by a teenage athlete with asthma and a pharmacist's discussion of medications. A nurse and asthma specialist also taught the participants about the clinical nature of asthma, environmental controls, relaxation techniques, and asthma action plans.

Researchers evaluated the children at the beginning and end of the training, after six months, and again a year later. After the courses, the number of patients reporting two or more nocturnal awakenings per month dropped from 9 to 5, and the number of symptom-free days also improved, from an average of 20 days per month to over 25 days per month.
The patients were more willing to use the tools available to them, such as medications and peak flow meters, devises that asthmatics breath into to help detect airway changes. They also worked harder to avoid things that triggered their asthma, such as pets or dust.

The researchers plan to continue tracking these 30 children to study the long-term effects on quality of life, morbidity, and cost of treatment. A previous study published in the Journal of Allergy and Clinical Immunology in 2000, found that the training program was much more effective than simply handing out educational materials.

May 2002 Update

New Cancer Prevention Guidelines

While some risk factors for developing cancer, such as family history, can not be changed, there are ways for people to reduce their chances. The American Cancer Society (ACS) recently released new dietary and physical activity guidelines for cancer prevention.

One of the most basic tenets of a healthy diet is eating plenty of fruits and vegetables. The ACS recommends eating no less than 5 servings of a variety of fruits and vegetables every day. Many people have heard of antioxidants but aren't sure exactly what they are or what they do. Antioxidant nutrients (such as vitamin C, vitamin E, and carotenoids) protect the body against the tissue damage that occurs as a result of normal metabolism. Because such damage is associated with increased cancer risk, the antioxidant nutrients are thought to protect against cancer. Studies suggest that people who eat more vegetables and fruits, which are rich sources of these antioxidants, have a lower risk for some types of cancer, but studies of antioxidant supplements have not yet shown a reduction in cancer risk.

Choosing whole grains over processed (refined) grains and sugars will also help, so stick to whole grain rice, bread, pasta, and cereals. Also, limit your red meat intake. When you do eat it, choose the way you cook it carefully. While adequate cooking is necessary to kill harmful microorganisms in meat, some research suggests that frying, broiling, or grilling it at very high temperatures creates chemicals that might increase cancer risk. Braising, steaming, and poaching meats cuts down on the production of these chemicals.

Drinking too much alcohol is an established cause of cancers of the mouth, throat, liver, and breast. Therefore, the ACS recommends limiting alcoholic consumption to 2 drinks per day for men and 1 drink per day for women.

The ACS also reminds people to remember that "low fat" or "fat free" snacks like cakes and cookies are often high in calories. High sugar intake can lead to obesity and elevated insulin levels, conditions that increase cancer risk.

Physical activity is also an important component in the prevention of cancer. Adults should engage in moderate-to-vigorous activity (walking, leisurely bicycling, running, swimming) for 30 minutes or more at least 5 days a week.

Simple additions to your daily routine such as taking the stairs instead of the elevator, taking 10-minute exercise breaks at work, and walking to visit co-workers instead of emailing them are simple ways to increase your activity level.

An unhealthy diet and lack of exercise can lead to weight gain and obesity, conditions that are associated with developing cancers of the breast, colon, endometrium, esophagus, gallbladder, pancreas, and kidney.

In addition to the general guidelines set forth by the ACS, there are also answers to frequently asked questions about the rumored or theoretical relationships between cancer and such substances as aspartame, beta-carotene, calcium, coffee, fish oils, fluorides, folic acid, saccharin, and tea.

The ACS suggests that public, private, and community organizations create environments that support the adoption and maintenance of these healthful eating and physical activity behaviors. People should have access to healthful foods in schools, at work sites, and when on daily outings in their town or city.

For a copy of the complete set of guidelines, call the American Cancer Society at 1-800-ACS-2345.
April 2002 Update

Bicycle Helmets Save Lives

Although bicycling is one of the most popular sports, injuries associated with bicycling are the leading cause of emergency room visits for children and adolescents. Unfortunately, many of these injuries include head trauma.

Previous studies have shown helmets can sharply reduce the serious head injuries that can occur with cycling. But the majority of children (and their parents) still don't use helmets regularly. Why? Reasons suggested include discomfort, lack of style, peer pressure, and not recognizing the importance of helmets on short rides.

The American Academy of Pediatrics recently published a statement emphasizing the importance of correct bicycle helmet use. In these recommendations, all bicyclists (children and parents alike) should wear proper helmets every time they ride. A helmet made after March 1999 should be used. These newer helmets meet US Consumer Product Safety Commissions standards.

Children should be properly fitted because helmets come in several sizes. Keep in mind that:

In its correct position, the helmet should sit low on the forehead and be parallel to the ground.
Velcro pads should be placed in, or removed from, the inside of the helmet as needed to make the helmet fit snugly.
The chinstrap should be adjusted so that no more than two fingers can be placed between the strap and the chin.
The helmet should not shift or come off when the child shakes his head.
All helmets should be replaced every five years.

February 2002 Update

Salt Restriction More Potent Than Exercise

Physicians often give patients with hypertension a daunting list of lifestyle changes to help lower their blood pressure: lose weight, exercise more, eat less salt, drink less alcohol, eat more foods rich in calcium, potassium, and magnesium. Of course, these changes do work — people who follow them can reduce their need for medications or even do without blood pressure-lowering drugs. But which of these lifestyle changes gives you the biggest bang for your buck?

University of Colorado researchers recently compared the impact of exercise or moderate salt restriction in 35 healthy older women with high-normal blood pressure or mild hypertension (systolic blood pressure 130–159 mm Hg), none of whom were using drugs to lower their blood pressure. Half the women exercised for three months — starting at 30 minutes a day three or four times a week and working up to 45 minutes a day every day, if possible. The other half tried to reduce their daily salt intake to less than 2.4 grams of sodium (the amount in a level teaspoon of table salt) without otherwise changing their diets. All were asked to try to avoid gaining or losing weight.

The clear winner, reported in the American Journal of Cardiology, was sodium restriction. Among the women who ate less salt, average systolic blood pressures fell 16 mm Hg, compared with a still-respectable 5 mm Hg in the exercise group. By the study's end of the study, systolic blood pressure was lower in 88% of the women who ate less salt and in 55% of the exercisers.

So if you're trying to lower your blood pressure, should you just forget about exercise and work harder at eating less salt? No. Exercise has other benefits besides lowering blood pressure — it can help control weight, improve the cholesterol profile, stave off diabetes, and keep bones strong. The real message from this study is that everyone should exercise, but that people who are trying to control blood pressure should lower their sodium intake, too.
December 2001 Update

Diet and Exercise Dramatically Delay Type 2 Diabetes

Americans at high risk for type 2 diabetes can sharply lower their chances of getting the disease with diet and exercise, according to the results of a major clinical trial. The same study also found the oral diabetes drug metformin (Glucophage) reduces diabetes risk, though less dramatically.

The findings came from the Diabetes Prevention Program (DPP), a major clinical trial comparing diet and exercise to metformin in 3,234 people with impaired glucose tolerance, a condition that often precedes diabetes. Smaller studies in China and Finland had previously shown diet and exercise can delay type 2 diabetes in at-risk people. But the DPP, conducted at 27 centers nationwide, is the first major trial to show diet and exercise can effectively delay diabetes in a diverse American population of overweight people with impaired glucose tolerance (IGT). IGT is a condition in which blood glucose levels are higher than normal but not yet diabetic.

Of the 3,234 participants enrolled in the DPP, 45 percent are from groups that suffer disproportionately from type 2 diabetes: African Americans, Hispanic Americans, Asian Americans and Pacific Islanders, and American Indians. The trial also recruited others known to be at higher risk for type 2 diabetes, including people age 60 and older, women with a history of gestational diabetes, and people with a first-degree relative with type 2 diabetes.

Participants ranged from age 25 to 85, with an average age of 51. All had impaired glucose tolerance as measured by an oral glucose tolerance test, and all were overweight, with an average body mass index (BMI) of 34. They were randomly assigned to one of the following groups: intensive lifestyle changes with the aim of reducing weight by 7 percent through a low-fat diet and exercising for 150 minutes a week; treatment with the drug metformin (850 mg twice a day), approved in 1995 to treat type 2 diabetes; and a standard group taking placebo pills in place of metformin.The latter two groups also received information on diet and exercise.

During an average follow up of about 3 years, about 29 percent of the group receiving standard treatment developed diabetes. In contrast, 14 percent of the diet and exercise, and 22 percent of the metformin arms developed diabetes. Volunteers in the diet and exercise arm achieved the study goal, on average a 7 percent — or 15-pound — weight loss, in the first year and generally sustained a 5 percent total loss for the study's duration. Participants in the lifestyle intervention arm received training in diet, exercise (most chose walking), and behavior modification skills.

In all, participants in the random intensive lifestyle intervention reduced their risk of type 2 diabetes by 58 percent, and those who received metformin reduced their risk of getting type 2 diabetes by 31 percent.
September 2001 Update

Walk, Don't Run for Weight Loss

People often disrupt their sedentary lifestyles with bouts of high-intensity exercise, like running or aerobics, to avoid gaining weight or developing heart disease. But a new study shows spending some of your day engaged in moderate activity, like biking, walking, or even taking the stairs at work, may be more a successful method for boosting daily calorie expenditure and losing weight.

The study, published in Nature, involved 30 healthy, non-obese women and men. For two weeks, the participants’ energy expenditure was measured, while their activity levels were tracked using portable motion sensors and activity diaries. The investigator found the amount of moderate activity, not vigorous exercise, was a significant predictor of total energy expenditure. He hypothesized that moderate activity usually occupies a larger portion of the day compared to more vigorous exercise. For instance, studies on obese subjects have found adding intense exercise to diet didn’t enhance weight loss because the extra energy expenditure didn’t offset the reduced time spent on other physical activities.

This small, but informative study provides strong evidence that exchanging some of time you sit in front of a TV for moderate activity increases total daily energy expenditure and metabolic rate. Short bursts of vigorous activity in an otherwise inactive and unhealthy lifestyle is not enough. So take the stairs, not the elevator, and go for a walk at lunch. But don’t be discouraged from going for a run. Aerobic activities, like jogging, swimming and brisk walking, help make your heart stronger and more efficient, which can lower your heart disease risk still further.
June 2001 Update

National Cholesterol Education Program Releases New Guidelines for Treating and Preventing High Cholesterol

On May 15, 2001, the National Cholesterol Education Program (NCEP) — coordinated by the National Heart, Lung, and Blood Institute (NHLBI) — released the first major revision of its recommendations for detecting and lowering high cholesterol in adults since 1993.

One of the fundamental features of the new guidelines is the accurate assessment of heart disease risk using a new "global risk assessment tool" that combines multiple risk factors into a measure of a person's absolute risk of developing coronary heart disease within the next 10 years. According to the guidelines, patients who have a risk of 20% or higher should receive aggressive therapy to control cholesterol levels. In addition to aggressive treatment of high LDL cholesterol, as laid out in the 1993 report, the revised guidelines also recommend a more assertive treatment approach for diabetes, low HDL levels, and high triglyceride levels.

Specific changes include:

Treating high cholesterol more aggressively for those with diabetes, even if they do not have heart disease.
A full lipid profile (which measures total cholesterol, LDL, HDL, and triglycerides) as the first test for high cholesterol (rather than simply testing total cholesterol and HDL and performing a full lipid profile only if total cholesterol is high).
A new level at which low HDL becomes a major risk factor for heart disease. The 1993 guidelines defined a low HDL as less than 35 mg/dL; now it is less than 40 mg/dL.
More aggressive treatment of high triglyceride levels.
Advising against the hormone replacement therapy (HRT) as an alternative to cholesterol-lowering drugs for post-menopausal women.

Another key change in the guidelines is intensified lifestyle recommendations regarding nutrition, exercise, and weight control to treat high cholesterol. The updated diet advises that less than 7% of daily calories come from saturated fat and limits dietary cholesterol to less than 200 mg per day. It also allows up to 35% of daily calories from total fat, provided most come from unsaturated or monounsaturated fat, which doesn't raise cholesterol levels. Additionally, the guidelines strongly underscore the need for weight control and physical activity, both of which improve various heart disease risk factors.

The revised recommendations also emphasize careful attention to the metabolic syndrome, a particular cluster of cardiovascular risk factors that is becoming increasingly common in the United States. Characteristics of metabolic syndrome include too much abdominal fat, high blood pressure, high blood sugar, elevated triglycerides, and low HDL.

For more information, see the "Live Healthier, Live Longer" Web site by going to the NHLBI home page at www.nhlbi.nih.gov and clicking on ATP III Cholesterol Guidelines under Highlights.

2001 Cholesterol Guidelines

Total Cholesterol Level	Total Cholesterol Category
Less than 200 mg/dL	Desirable
200-239 mg/dL	Borderline High
240 mg/dL and above	High
LDL Cholesterol Level	LDL Cholesterol Category
Less than 100 mg/dL	Optimal
100-129 mg/dL	Near optimal/above optimal
130-159 mg/dL	Borderline high
160-189 mg/dL	High
190 mg/dL and above	Very high
Trigylceride Level	Triglyceride Category
Less than 150 mg/dL	Normal
150-199 mg/dL	Borderline high
200-499	High
Greater than or equal to 500	Very high
HDL Cholesterol Level	HDL Cholesterol Category
Less than 40 mg/dL	Low (representing increased risk)
60 mg/dL and above	High (heart protective)

Three Categories of Risk that Modify
LDL Cholesterol Goals

Risk Category	LDL Goal (mg/dL)
Coronary Heart Disease (CHD) and CHD equivalents	Less than 100
Multiple (2+) risk factors	Less than 130
0-1 risk factor	Less than 160

Risk factors (exclusive of LDL cholesterol): cigarette smoking; blood pressure greater than or equal to 140/90 mm Hg or on antihypertensive medication; HDL cholesterol less than 40 mg/dL; a family history of coronary heart disease before age 55 in a father or brother or age 65 in a mother or sister; age above 45 for men and 55 for women

May 2001 Update

More Evidence That Pumping Iron Is Good for Seniors Too

Two recent studies published in the Journal of the American Geriatrics Society add more data to the mounting evidence that exercise is important at any age and that resistance (or weight) training has considerable benefits for older adults.

It is well known that strength training can improve muscle strength and balance — of particular importance in preventing falls and fractures in seniors. Research on just how much training is required to derive these benefits has been conducted primarily in younger people. The first study looked at how often older people must exercise. Forty-six people (both men and women) between the ages of 65 and 79 years were assigned to a resistance exercise program to be performed one, two, or three days per week. Study results showed that seniors exercising one or two times per week had about the same improvements in muscle strength and coordination as did those who exercised three times per week.

Researchers at the University of Maryland Exercise Science Laboratory conducted the second study, which was designed to look at the effects of strength training on resting blood pressure in older adults (the average age in this study was roughly 69). Eleven men and 10 women who had not been exercising regularly were assigned to a six-month training program using weight lifting machines. Not only did the study volunteers show significant increases in upper- and lower-body strength, but both groups also demonstrated significantly lowered diastolic blood pressure (the bottom number in a blood pressure reading). Interestingly, only the men in the group experienced significantly lowered systolic blood pressures (the top number in a blood pressure reading). Perhaps the best news was that the reduction in blood pressure brought these patients’ readings into the normal range. Investigators also noted that the improvement in blood pressure was not related to weight loss associated with increased exercise.

The bottom line, however, is not news at all. Exercise is important, good for individuals of every age group, and the health benefits are many. Even doing a little is a whole lot better than doing no exercise at all.

Journal of the American Geriatrics Society, Vol. 47, No. 10, pp. 1208–14.
Journal of the American Geriatrics Society, Vol. 47, No. 10 pp. 1215–21.

Walking for Women: A Great Step Toward Fitness

Ask any doctor for his or her advice for healthy living and you'll find exercise a part of the prescription. However, it is one that patients must "fill" themselves and that can be tough. The most recent guidelines from the Centers for Disease Control and Prevention, the American College of Sports Medicine, and the Surgeon General's report recommend that individuals get at least 30 minutes of moderate-intensity activity on most (ideally all) days of the week. Yet 60% of Americans don't regularly engage in physical exercise at all.

Harvard Medical School researchers recently compared the effects of brisk walking with more vigorous forms of exercise, specifically in women. For this report, study investigators followed 72,488 women participating in the Nurses' Health Study for 11 years. At the start of the study in 1986, these women were all between the ages of 40 and 65 and had no known heart disease or cancer. They completed regular, detailed questionnaires about their physical activity.

Researchers found that vigorous exercise and brisk walking reduces the risk of heart attack for women by roughly the same amount. The bottom line is that brisk walking for three or more hours per week can reduce a woman's risk of cardiovascular disease by 30%-40%. Women who walk for a longer time or combine walking with other vigorous physical activity can expect to reduce their risk of heart disease even more. So women don't have to sign up for aerobics or train for a marathon to substantially reduce their heart disease risk. A good start is putting one foot in front of the other at a good pace. For more information on exercise and fitness, see page 51 of the Family Health Guide.

New Pneumococcal Vaccine for Children Less Than Two Years Old

A new vaccine called Prevnar is the first vaccine to protect children less than two years old against the bacteria Streptococcus pneumoniae, which is the leading cause of pneumonia, bacterial meningitis, bacteremia, sinusitis, and acute otitis media, or middle-ear infections, in young children. In addition to protecting children from pneumococcal infection, vaccination with Prevnar also decreases transmission of pneumococci from one child to another, an effect known as "herd immunity." Furthermore, since middle-ear infections are the leading reason that children need to take antibiotics, vaccination with Prevnar could reduce the need for antibiotics in this age group. This, in turn, should slow or reverse the trend of antimicrobial resistance. A different pneumococcal vaccine, known generically as PPV23, has been available to adults for years, but it has not been effective in children less than two years old.

The Centers for Disease Control and Prevention's (CDC's) Advisory Committee on Immunization Practices (ACIP) recommends that all children less than two years old should be vaccinated with Prevnar. Children aged two to five years old should receive a two-shot series of Prevnar followed by one dose of PPV23 if they are high-risk, a category that includes children with HIV, immunocompromising conditions, chronic illness, or sickle cell disease. Prevnar may also be considered for children between two to five years with priority given to those who are between the ages of 24 and 35 months, of African-American, American Indian, or Alaska Native descent, or who attend group day care centers.

Since Prevnar has not been studied sufficiently in children older than five years who are at high risk for serious pneumococcal disease, ACIP continues to recommend that children five and older receive PPV23.


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