Programme effect on Mental Health 2018 and 2019

Measurement of Mental health

Mental health was assessed with the CES-D depression questionnaire. 

The 20 items in the CES-D scale reflect on the components of depression in nine different groups as defined by the American Psychiatric Association Diagnostic and Statistical Manual–5. These components include:

·         Sadness (Dysphoria)

·         Loss of Interest (Anhedonia)

·         Appetite

·         Sleep

·         Thinking/Concentration

·         Guilt/Worthlessness

·         Tiredness/Fatigue

·         Movement/Agitation

·         Suicidal Ideation

 A CES-D cut-off score of 16 or greater reflects individuals at risk for clinical depression. More specifically: 0-16 = No to mild depressive symptomatology; 16-23 = Moderate depressive symptomatology and 24-60 = Severe depressive symptomatology.  

Number of Patients with Mental Health Symptomology at baseline

We’ve tested 323 referred patients since we started in January 2018. 

A total of 33.2% of these patients presented with moderate (15.6%) and severe (17.6%) depressive symptomology at baseline. 

Relationship of Mental health Symptomology with measures of Health and Fitness

Depressive symptomology contributed significantly to the variances of measures of health and fitness in both males and females, at baseline.  

In Males, depressive symptomology contributed statistically significantly (p<0.05) to the variances of resting heart rate (4.8%), systolic blood pressure exercise response (4%), percentage body fat (6.3%), VO2peak, (5.8%) and overall cardiovascular risk (4.4%).  

The depression score contributed statistically significantly (p<0.05) to the variances of BMI (13.7%), waist circumference (10.2%), percentage body fat (7.3%), fat weight (12.3%) and VO2peak (9.6%), in females.   

A total of 134 of the 323 starters have so far completed 10-weeks training at OraKinetics. The programme effect on the mental health of these patients is presented in Table 4.1.  

As can be seen in Table 4.1 the 10-weeks training had a statistically significant (p<0.01) and large effect size impact (ES>0.8) on all three of the symptomology groups (mild depression - ES=1.1; moderate depression – ES=2.1 and severe depression – ES=1.9).   

The effect of the programme on the patients with severe depression (CES-D≥24) was impressive with the mean baseline value of 30.2 decreasing to 17.1 (p<0.001: ES=1.9) at the final assessment. It calculates as a 44% change. From a clinical perspective, these patient’s classification, therefore, shifted from severe depression to mild depressive symptomatology.  

Table 4.1: Programme effect on Mental Health (January 2018 to March 2019); (n=134)

ES=effect size (>0.3 – small effect; >0.5 moderate effect; >0.8 large effect); * = p < 0.01

In the 64 patients with mild and severe depressive symptomology the programme improved resting hemodynamic variables (e.g., resting systolic blood pressure, resting diastolic blood pressure, Mean Arterial pressure and resting heart rate) by respectively 4.4%, 4.8%, 4.7%, and 5.3%. The mean VO2peak of this group with depressive symptomology improved by 24%.   

Cardiovascular fitness was linearly related to the CES-D scores at baseline which indicates a clear positive relationship between cardiovascular fitness and mental health. 

However, the post-training data reveals that baseline cardiovascular fitness did not limit our programme effect on depression. The amount of improvement made over 10-weeks in cardiovascular fitness did not impact on the depression results. Those whose cardiovascular fitness improved by less than 20% evidenced similar (46% vs. 44%) reductions in depression symptomology than those whose VO2peak values improved by more than 40%. 

Summary 

The data indicates that disease-imposed restrictions on trainability (e.g., inability to improve cardiovascular fitness due to the level of disease development) did not negate the impact of our programme on mental health. It is a pleasing result which demonstrates programme effect on mental health independent from the severity of the problem.

HEALTH PROMOTION IN THE WORKPLACE: A SENSIBLE PRACTICE

The current medical system is often described as a bottom-of-the-cliff system due to a strong focus on the treatment of disease as opposed to prevention of disease. Lifestyle or non-communicable diseases (NCDs) currently account for over 63% of the annual death toll in most countries. Globally, the leading NCDs include cardiovascular diseases, cancers, diabetes mellitus, mental disorders, and chronic kidney diseases, while the major pathophysiologic risk factors for many of these diseases include overweight/obesity, hypertension, and hyperglycemia, all of which are treatable to a large extent by individualized clinical exercise interventions.

The economic impact of NCD’ is considerable. Between 2010 and 2030, the direct and indirect costs of NCDs worldwide are estimated to exceed US$30 trillion and push millions of people below the poverty line, accompanied by unprecedented levels of economic and social strain on healthcare systems and national economies.

Few genuine solutions to the global NCD burden have been proposed. However, it has been acknowledged that major suffering could be averted and billions to trillions of dollars could be saved if a large proportion of the public were to adopt health-supporting behaviors. There are very little funds available within the healthcare systems for disease prevention programmes. Health-promotion at or through the workplace, therefore, makes considerable sense. It is a practical and economically viable solution for the out of control escalating health care costs of modern society.

The workplace is considered the ideal place for health promotion for the reasons highlighted below:

a.       The population is captive

New Zealand had 528,170 enterprises in 2017. The number of paid employees in these enterprises was 2.2 million in 2017 which is 95% of the working population (2.3 million between the ages of 25 to 64 years). This large group is essentially captive due to the nature of the workday.

Webster defines captive as ‘obliged or forced to listen, whether wanting or not.’ Health promotion information delivered at the workplace are generally hard to avoid and therefore have considerable potential to influence a large percentage of the population directly (48.8% of the 4.5 million New Zealanders).

It is virtually impossible for a person who works seven to eight hours per day at the same location not to take notice of strategically well-delivered health information. It will be hard not to be influenced if you are constantly motivated and supported at the workplace to make healthier lifestyle choices.

Blair et al. (1986) report a 104% increase in leisure time and work-related physical activity energy expenditure two years after the implementation of a worksite lifestyle intervention programme. In New Zealand, 48 percent of adults are inactive, with women, at 50 percent, more inclined to take it easy than men, at 45 percent. Sedentary employees incur $250 more in annual health care costs than moderately active (1-2 times/wk) and very active (3 + times/wk) employees (Wang et al., 2004). 

A 1% reduction in excess weight, elevated blood pressure, glucose, and cholesterol, has been shown to save $83 to $103 annually in medical costs per person (Henke et al., 2010). 

Shipley and Orleans (1988) report a 22.6% smoking cessation at Johnson and Johnson. During 2000–2004, cigarette smoking was estimated to be responsible for $193 billion ($96 billion in direct medical cost and $96.8 billion in lost productivity) in annual health-related economic losses in the United States (Centers of disease control, 2008).

Vickery and Kalmer (1983) documented a 35% decrease in medical visits for non-serious health issues after implementation of a self-care education programme.         

b.      There is potential for effective incentives

A large portion of the population at the worksite are stable enough to utilize a wide variety of incentives. Programme participation and adherence to healthy behaviors can be the objectives of incentives. The use of monetary incentives (e.g., paid gym membership), material goods, time-off (e.g., to attend structured supervised exercise sessions), lottery prizes, or recognition are all feasible and appropriate for use at the worksite. Incentives can add a significantly larger impact to a health promotion programme’s impact on the lifestyle of employees and their families.   

c.       The potential to influence behavior is high

The repeated exposure abilities associated with the worksite along with the large number of people exposed to communication, incentives and social reinforcement, make the potential to influence behavior the greatest of any social setting. Interdepartmental competitions (e.g., group with greatest amount of weight lost or highest attendance of workshops) as well as company sports club constructions and competitions (e.g., company squash or tennis league, and cycle and running clubs) could provide social support unique to the workplace. 

While the potential for behavior change is high, it still requires a focused effort for the promotion programme to fully realize its potential. 

d.      There is a real potential to influence family members

Employees will undoubtedly share lifestyle information with family members meaning that worksite health promotion will gain access to large parts of the society through spouses/partners that work. Exercise incentives, in particular, can easily be constructed to involve family members directly.  

e.       For many, job relationship stretches over a long time period

For a distinct percentage of the workforce, there is a stable work relationship that allows long-term exposure to wellness programming. Approximately 35-45% of the workforce seems to remain with a given employer for 10 to 15 years. Most people have at least three distinct careers each lasting more than seven years. As more companies and public agencies implement wellness programmes, there is also much greater continuity in wellness programming for individuals who change jobs.  

f.        Employers can give credibility to the health promotion initiative

Because most employees view their employer with some sense of credibility, the employer's promotion of concepts can give added credence to it.

g.       Employees perceive wellness programmes as a benefit

Wellness programmes are often seen as a tangible benefit. Survey data reveal that the provision of wellness programmes to impact positively on employees view of the company. 

h.      Economics of scale is possible in programming

Due to large numbers of individuals employed at many worksites, it is possible to gain benefits from economies of scale in programming activities. Lower prices can be negotiated for groups at gyms and with psychologists and dieticians.    

i.        Potentially all parties can benefit

If a wellness programme is successful, all parties can potentially benefit.

Benefits for employees

Benefits for employers

·         Increased lifestyle knowledge

·         Increased opportunity to take control of health

·         Improved health and quality of life

·         Lower cost gym membership

·         More support to make and maintain lifestyle changes

·         Reduced medical cost on the long-term

·         Reduced pain and suffering from poor health and lifestyle choices

·         Affordable professional health to make dietary and exercise-related lifestyle changes

·         Increased worker morale

·         Higher productivity

·         Informed and health conscious workforce

·         Positive public relations

·         Recruitment tool

·         Reduced sick leave absenteeism

·         Reduced disability claims

·         Decreased health care utilization

·         Reduced premature retirement

·         Decreased overall health benefit costs

·         Fewer on-the-job accidents

·         Lower casualty insurance costs

Most experts agree that exercise should be the cornerstone of health promotion initiatives. A wealth of empirical evidence accumulated over the past several decades has shown that exercise can be used to prevent, manage, and treat many leading NCDs and risk factors. Physical exercise impact on NCD’s in a direct (through inducing physiological changes, e.g., lowering glucose and insulin levels) and indirect (triggering the adaptation of other healthy behaviors, e.g., healthier diet, smoking cessation and reduced alcohol consumption) way. There is indeed irrefutable evidence of the effectiveness of exercise in the primary and secondary prevention of many leading NCDs and a reduction in related mortality.

Reference list

Blair, S.N., Piserchia, P.V., Wilbur, C.S & Crowder, J.H. 1986. A public health intervention model for worksite health promotion. Impact on exercise and physical fitness in a health promotion plan after 24 months. Journal of the American Medical Association, 255(7): 921-926.  

Centers for Disease Control and Prevention. 2008. Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses— United States, 2000–2004.  Morbidity and Mortality Weekly Report 2008; 57(45):1226–8 [accessed 2011 Mar 11].  

Henke, R.M., Carls, G.S., Short, M.E., Pei, X., Wang, S., Moley, S., et al.  2010. The Relationship between Health Risks and Health and Productivity Costs Among Employees at Pepsi Bottling Group.  J Occup Environ Med, 52(5): 519–527.

Shipley, R & Orleans, T. 1988. Effect of the Johnson and Johnson LIVE FOR LIFE program on employee smoking. Preventive Medicine, 17: 25-34.  

Vickery, D & Kalmer, H. 1983. Effect of a self-care education program on medical visits. Journal of the American Medical Association, 250(21): 2952-2956. 

Wang, F., McDonald, T., Champagne, L., Edington, D.W. 2004. Relationship of Body Mass Index and Physical Activity to Health Care Costs Among Employees. J. Occup Environ Med, 46(5): 428-436.   

LETTER TO MINISTER OF HEALTH - June 2018

Request to revisit the Clinical Physiologists Registration Board’s application to be included in the Health Practitioners Competency Assurance Act

Dr. Lukas Dreyer Ph.D., OraKinetics Clinic Ltd (lukas@orakinetics.co.nz)

Associate Professor James Stinear Ph.D., University of Auckland (j.stinear@auckland.ac.nz)

June 2018

Main Points:

A.      Clinical Exercise Physiology New Zealand Inc. is a society, members of which are regulated by that society’s rules, and also regulated by the NZ Clinical Physiologists Registration Board. 

B.      The Clinical Exercise Physiologists’ profession in NZ is a relatively new allied health profession that treats patients with suffering a wide range of medical conditions formerly treated almost exclusively with medications and rest. Scientific and clinical evidence supporting the safe and effective effects of clinical exercise is large and continues to grow.

C.       Clinical Exercise Physiologists form a growing and substantial part of the healthcare workforce in Australia, South Africa, the US, Canada, and the UK. This growth is due to cost effectiveness and safety. Compared with some medications, well-planned and executed exercise specific to a clinical population is virtually free of adverse side effects.

D.      The previous government steadfastly declined to add any “new” health professions to the HPCA Act. This puts patients at risk because they are often referred to gyms where no clinical exercise expertise is available. Therefore, patients and the several allied health professions that form the NZ Clinical Physiologists Registration Board plus Clinical Exercise Physiologists are not afforded protection given to patients and other health professionals in NZ.

1.       Introduction

This request relates to two professional organizations: the Clinical Exercise Physiology New Zealand Inc. (CEPNZ) and the Clinical Physiologists Registration Board (CPRB). These societies were separate entities until CEPNZ was accepted as a member organization of the CPRB in 2017.

2.       The health profession of Clinical Exercise Physiology (CEP)

CEP is a relatively new health profession in New Zealand. The profession was established in the mid-nineteen-eighties in the USA, Canada, and South Africa. It has also become well established in Australia, where the name of the professional’s equivalent to clinical exercise physiologists in NZ is ‘Accredited Exercise Physiologist’ (AEP).  In 2006, Medicare (Australian Government: Department of Human Services) began funding AEP services in Australia. Patients with chronic medical conditions may claim a Medicare benefit (rebate) for a maximum of five visits to an allied healthcare professional per calendar year, including AEP services. ‘‘Chronic medical condition,’’ is defined as ‘‘a condition that has been, or is likely to be, present for at least six months, or is terminal”. Exercise physiology services for patients with diabetes include one assessment and up to eight group exercise sessions per calendar year.

The effect of the above on the clinical exercise physiology profession in Australia was profound. The number of exercise physiology services provided nationwide under the Chronic Disease Management Plan increased by 614% from 2006 to 2012. The largest rise occurred between 2006 and 2007 (+118 %), and since 2007, the number of services has increased by 19–37 % annually. The number of Type 2 diabetics referred to CEPs has increased by 211% between 2008 and 2012 in Australia. These data indicate the public’s and the medical profession’s growing acceptance of the effectiveness of professionally guided exercise as a treatment for chronic diseases caused by or exacerbated by physical inactivity.

Despite the public’s growing acceptance of CEP-services in Australia, it has been estimated that less than 1% of the overweight and obese population and only about 0.8% of the diabetic population is being referred for clinical exercise physiology treatment in Australia. The reasons for this are varied and mostly relate to a traditional reliance on medications and a lack of awareness and appreciation for the effectiveness of specific exercise regimens prescribed and delivered for specific diagnoses by clinical exercise physiologists. It should be noted that sports trainers, personal trainers, and gyms rarely if ever have staff with clinical training capable of providing safe and effective exercise plans for chronically ill patients.

In October 2015 Deloitte Access Economics Pty Ltd published a comprehensive financial analysis on the value of accredited exercise physiologists in Australia. Exercise & Sports Science Australia (ESSA) essentially commissioned Deloitte Access Economics to estimate the benefits of employing accredited exercise physiologists. They chose three groups of chronic conditions commonly managed by exercise physiologists in Australia:

·         Type 2 diabetes (including pre-diabetes);

·         Mental illness (including physical comorbidities); and

·         Cardiovascular and other chronic diseases managed in community settings.

Deloitte Access Economics utilized data from the 2011-12 Australian Health Survey (AHS) (Australian Bureau of Statistics, 2013) which is a large, comprehensive health survey conducted in Australia. The survey was designed to collect a range of information regarding health issues such as current health status, risk factors for conditions, actions taken to help treat or manage conditions, and various lifestyle decisions. The AHS asked participants to identify service utilization in the previous two weeks for the following topics:

·         number of GP consultations;

·         number of specialist consultations;

·         number of admissions to hospital as an inpatient;

·         number of visits to outpatient clinics;

·         number of visits to an emergency/casualty department; and

·         number of visits to day-clinics.

Based on the AHS survey data Deloitte Access Economics estimated that:

·         The total annual wellbeing gains attributable to accredited exercise physiologist’s interventions in Australia are $6,115 and $7,967 per person with pre-diabetes and type 2 diabetes respectively, noting that no productivity estimates were able to be made for type 2 diabetes.

·         The total annual wellbeing gains due to accredited exercise physiologists in Australia for people with cardiovascular disease are $1903 per person per year.

Clinical exercise physiologists have the potential to profoundly impact on the health and well-being of New Zealanders when one considers that non-communicable diseases (NCDs) currently account for over 63% of the annual death toll. Over 80% of these deaths occur in low- to middle-income countries. Globally, the leading NCDs include cardiovascular diseases, cancers, diabetes mellitus, mental disorders, and chronic kidney diseases, while the major pathophysiologic risk factors for many of these diseases include overweight/obesity, hypertension, and hyperglycemia, all of which are treatable to a large extent by individualized clinical exercise interventions. The economic impact is therefore very high.

Between 2010 and 2030, the direct and indirect costs of NCDs worldwide are estimated to exceed US$30 trillion and push millions of people below the poverty line, accompanied by unprecedented levels of economic and social strain on healthcare systems and national economies.

Few genuine solutions to the global NCD burden have been proposed. However, it has been acknowledged that major suffering could be averted and billions to trillions of dollars could be saved if a large proportion of the public were to adopt health-supporting behaviors. A wealth of empirical evidence accumulated over the past several decades has shown that exercise can be used to prevent, manage, and treat many leading NCDs and risk factors. There is indeed irrefutable evidence of the effectiveness of exercise in the primary and secondary prevention of many leading NCDs and a reduction in related mortality.

An example of how a CEP service can thrive in NZ follows. U-Kinetics (62 Grey Street; Palmerston North) began offering a CEP service in 2012. U-kinetics is utilized in this document as a prime New Zealand example of how the CEP profession can positively and cost-effectively impact the health of many New Zealanders. The U-kinetics service has demonstrated CEP’s ease of acceptance in NZ society. The MidCentral DHB funds the U-Kinetics services in Palmerston North. It provides supervised exercise rehabilitation programmes mainly for patients with chronic diabetic, cardiac, and obstructive pulmonary (COPD) diseases. From the 273 diabetic and 353 cardiac patients who completed 12-weeks of training at U-kinetics since 2012, we have estimated that U-Kinetics saved the health care system (for diabetic and cardiac patients) a total of $2.85 million over the last five years.

Importantly, it should be stated, that the figure of $2.85 million is a very conservative estimation of the overall financial impact of CEP treatment on the local health care bill. Not added to that calculation is the 273 respiratory patients who also completed 12-weeks training at U-kinetics.

The impact of the U-Kinetics programme on referred patients has been well documented and reported to the DHB.  Since 2012 a total of 899 patients completed their first 12-week programme (many continued with a second referral). Statistically, the physical activity profiles (doing physical activity at home daily such as walking or house chores) of the entire cohort improved significantly by 34% (p < 0.001: Effect Size (ES) = 0.31) and functional capacities (mean VO2max) improved by 28% (p < 0.001; ES = 0.70).

The number of patients with a functional capacity of higher than 8 Metabolic equivalents (MET) (1 MET = 3.5 ml.kg.min-1; 8 MET x 3.5 = VO2 of 28 ml.kg.min-1) increased from 8.7% at baseline to 30.6% after their first 12-weeks. This is a clinically important finding considering that a 6.1-year follow-up study of 527 men with cardiovascular disease found that the highest all-cause mortality occurred in the individuals with a functional capacity of lower than 4.4 MET. In contrast, no deaths occurred among patients who averaged 9.2 METs or more (VanHees et al., 1994).  

Within the entire U-Kinetics cohort, 39.1% presented with a functional capacity of lower than 4.3 METs at baseline, compared to 10.5% after 12-weeks of exercise training. A total of 28.6% of the extremely low fit patients, therefore, transitioned out of the high mortality and potential hospitalization functional capacity zone of lower than 4.4 MET, over the 12-weeks.

Of great importunacy was the effect of the U-Kinetics programme on the 10.5% of individuals who were still in the high mortality/hospitalization zone (presenting with functional capacities of lower than 4.3 METs at their final assessment). The mean functional capacity of this 10.5%, ─ who were the most fragile individuals within the cohort ─ improved by a surprising 14% (p < 0.001; ES = 0.78). These were either the very old (over 70 years) or the individuals with extreme low ejection fractions due to damage to the left ventricle and advanced lung disease (e.g., late Stage 2 or Stage 3 COPD). Paradoxically, it is these individuals who generally experience some discomfort during exercise and who tend to avoid physical exertion. Consequently, it is critical that clinically trained exercise physiologists are utilized to improve the functional capacity of such extremely fragile populations. These patients are highly unlikely to engage in formal exercise, thereby essentially depriving them of the health gains they otherwise could achieve.

It has been observed in the literature that community interventions are on average 50% less effective than clinical trials. To maximize outcomes for a given individual, exercise needs to be prescribed and delivered with regard to the functional and disease-related limitations, as well as any domestic, social, and occupational constraints of each individual patient. It is therefore important to integrate professionals that have specialist training and expertise in the many factors involved in exercise prescription and delivery within the healthcare system. A recent article published by Benatar et al. (2016) in the New Zealand Medical Journal, 129 (1435) entitled ‘Cardiac Rehabilitation in New Zealand – moving forward’ identified the lack of qualified exercise rehabilitation specialists as one of the major problems in New Zealand when it comes to management of cardiac patients.  The authors state that apart from the Heart Guide Aotearoa (HGA) there is a paucity of options for cardiac patients. Furthermore, less than 50% of so-called ‘cardiac rehabilitation programmes’ available in New Zealand DO NOT assess exercise capacity at all, or formally risk-stratify patients prior to starting an exercise rehabilitation program. This is unacceptable. It is analogous to a physician providing treatment without a diagnosis. Trainers and therapists who do not assess exercise capacity and do not routinely monitor patients with electrocardiography are therefore forced to provide low levels of exercise that have mostly been shown to be ineffective.

The scope of practice for Clinical Exercise Physiologists extends well beyond better-known exercise rehabilitation programmes for respiratory, cardiac, and diabetic patients. For example, clinical exercise physiologists are trained to provide patients who would typically be eligible for compensation under the Accident Compensation Act with exercise-related services (functional testing and recovery management). This ability is particularly valuable when individuals who have an accident also suffer from a wide range of medical conditions, e.g., neuromuscular and skeletal conditions such as arthritis, osteoporosis, chronic pain syndromes, spinal cord injuries, stroke, and cancer. Exercise testing and treatment of individuals with musculoskeletal conditions such as back pain, shoulder, neck, knee, ankle and hip injuries (pre- and post-surgery) also fall within the scope of practice of clinical exercise physiologists.  This wide range of medical conditions makes it essential that the exercise therapist is both trained, and practices, in a way that allows safe and effective interventions to be delivered.

3.       CEPNZ Inc.

The CEPNZ society (of which the authors of this document are foundation members) was created in 2012. We developed our Standards and Scope of Practice document (which includes our registration process) and officially launched the society in 2017. In 2016 and 2017 (twice), three groups of candidates wrote the CEPNZ registration exam simultaneously in Palmerston North, Auckland, and Christchurch.  The examination is demanding, with 20 failed attempts to pass the exam. At the time of writing 50 CEPs have been admitted to the Register. The profession currently operates as a self-governing profession. The Board presently consists of a wide range of practicing and academic clinical exercise physiologists.  

4.       Negotiations with the Accident Compensation Corporation and being added to the Health Practitioners Assurance Act

In 2017 the CEPNZ opened negotiations with ACC to obtain vendor-ship status for registered CEPs. CEPs are trained to deliver numerous parts of ACC contractual services in the areas of pain management, patient well-being, impairment assessments, training for independence, vocational rehabilitation, home and community support, etc. The feedback from ACC was that the profession needs to register under the HPCA Act as a health provider. In all communication with ACC, this has been the standard response even though various individuals in ACC leadership groups have admitted that this requirement should not be an obstacle.

Interestingly, ACC has employed various CEP graduates as case managers over the last five years. Some of our graduates also secured employment as cardiac and respiratory technicians at DHBs in Palmerston North, Wellington, Auckland, and Hamilton. At least one physiotherapy franchise has employed CEPs as therapists to deliver ACC funded physiotherapy services under the ‘supervision’ of the physiotherapists. It is clear that clinical exercise physiologists can and do provide a much-needed service to ACC because they are often employed as supervisors or managers of ACC patient rehabilitation. Paradoxically they are not eligible to be contracted by ACC to conduct the rehabilitation work on their own; rather they need to be “supervised” by therapists who themselves are mostly un-trained or not capable of providing the detailed level of exercise-related service for which the CEP is trained to deliver

5.       CEPNZ’s relationship with the CPRB

When the CEPNZ society started to investigate the process for inclusion under the HPCA Act, we become aware that the Clinical Physiology Registration Board (CPRB) established in 2005 has an application to the Ministry of Health pending for being included as a regulated allied healthcare profession.

CEPNZ Inc. consequently resolved to amalgamate with the CPRB. This took place in 2017. Two CEPNZ Board members sit on the CPR Board. Both Boards share similar principles, and by sharing subsequent submissions to the ACC and the Government asking for CPRB (including CEP) registrants to be included under the Act, a more efficient process of inclusion, and thereafter, administration is likely. The original application did not include CEPs. To the best or our knowledge, the original application (submitted prior to CEPNZ joining the CPRB) is pending with the Ministry.

It is important to note that the individual professional societies represented on the CPRB take care of any disciplinary activities necessary for their professions.

6. Conclusion

We respectfully ask for the CPRB application to be revisited, with the addition of CEPs, and that all CPRB member professions (including CEPs) be appended to the HPCA Act, thus providing insurance cover via ACC for patients and CPRB/CEP health professionals, and also removing the barrier for member professions to claim on the patient’s behalf when the patient qualifies for compensation from ACC.

Reference list

Australian Bureau of Statistics 2013, Microdata: Australian Health Survey, National Health Survey, 2011-12, Cat. no. 4324.0.55.001, ABS, Canberra.

Benatar, J., Doolan-Noble, F & McLachlan, A. 2016. Cardiac rehabilitation in New Zealand – moving forward. The New Zealand Medical Journal, 129(1435): 6897.

VanHees, L., Fagard, R., Thijs, L., Staessen, J., & Amery A. (1994). Prognostic significance of peak exercise capacity in patients with coronary artery disease. Journal of the American College of Cardiology, 23(2): 358363.

EXERCISE EFFECT ON DEPRESSION

Mental Health Results - January to June 2018

A total of 80 patients on the U-Kinetics waiting list completed a 10-week exercise rehabilitation programme at OraKinetics between January and June 2018; 21 were referred by the MDHB medical specialists (9 Cardiac, 1 Diabetes, and 11 Respiratory) and 59 by GP’s (29 Cardiac, 21 Diabetes, and 9 Respiratory).

Programme effect on mental health was assessed with the CES-D depression questionnaire.

As indicated in Table 1, the patients evidenced statistically significant (p<0.01) improvements in mental health after 10-weeks. Statistical significance was assessed with p-values and Cohen’s effect sizes. P-values refer to the probability that the difference is not attributable to a chance occurrence. A p-value of p<0.05 indicate a chance of less than 5 out of 100 and p<0.01 a chance of less than 1 out of 100 and so forth.  Cohen’s effect sizes is a power statistic and illustrate the meaningfulness of the treatment effect. The effect size is the difference between the means (pre- versus post-test) divided by the largest standard deviation. Effect size values of >0.5 indicate moderate effect and >0.8 large effect. From a clinical perspective; the programme had a large effect (ES=0.8) on the overall mental health score.

The programme impact on the mental health measure is a noteworthy result considering that the baseline mean score of 17.5 indicates borderline moderate depressive symptomatology. It is unrealistic to expect an impact on something that is normal or close to the recommended levels. From a clinical perspective, it is, therefore, useful to always consider whether the baseline values were elevated, at baseline, as part of interpreting treatment effect.

The 20 items in the CES-D scale reflect on the components of depression in nine different groups as defined by the American Psychiatric Association Diagnostic and Statistical Manual–5. These components include:

• Sadness (Dysphoria)
• Loss of Interest (Anhedonia)
• Appetite
• Sleep
• Thinking/Concentration
• Guilt/Worthlessness
• Tiredness/Fatigue
• Movement/Agitation
• Suicidal Ideation

A CES-D cut-off score of 16 or greater reflects individuals at risk for clinical depression. More specifically: 0-16 - No to mild depressive symptomatology; 16-23 - Moderate depressive symptomatology and 24-60 - Severe depressive symptomatology.

In total 47% of the group presented with mild depression at baseline; 25% with moderate and 29% with severe depression. As indicated in Table 1 the 10-weeks training had a statistically significant (p<0.01) and large effect size impact (ES>0.8) on all three of the symptomology groups (mild depression - ES=1.0; moderate depression – ES=2.8 and severe depression – ES=2.2). 

The effect of the programme on the patients with severe depression (CES-D≥24) was impressive with the mean baseline value of 29.9 decreasing to 15.8 (p<0.001: ES=2.2) at the final assessment. It calculates as a 47% change. From a clinical perspective, these patient’s classification, therefore, shifted from severe depression to mild or no depressive symptomatology.

It is a pleasing result which demonstrates programme effect on mental health independent from the severity of the problem. Interestingly, cardiovascular fitness was linearly related to the CES-D scores at baseline (see Figure 2). It indicates a clear positive relationship between cardiovascular fitness and mental health. All three cardiovascular fitness groups presented with no depressive symptomology (CES-D score <16) at the re-assessment. Typically, those more severe disease pathophysiology (e.g., stages II and III COPD or ejection fraction impairment due to left ventricle damage after miocardioal infarction) presents with lower levels of fitness at baseline. Therefore, the more severe the disease, the more it imposes on trainability (e.g., session duration, training load, sets, and reps) and hence on the ability to make improvements in strength and cardiovascular fitness over 10-weeks. However, the data in Figure 2 reveals that baseline cardiovascular fitness did not limit our programme effect on depression.

Also, the amount of improvement made over 10-weeks in cardiovascular fitness did not impact on the depression results. Those whose cardiovascular fitness improved by less than 20% evidenced similar (46% vs. 44%) reductions in depression symptomology than those whose VO2max values improved by more than 40%.

The data, therefore, seems to indicate that disease imposed restrictions on trainability (e.g., inability to improve cardiovascular fitness due to the level of disease development) did not negate the impact of our programme on mental health.

SIT LESS, MOVE MORE!

Being sedentary is not just a lack of exercise, it is a potential independent risk factor for heart disease and stroke, according to a science advisory from the American Heart Association.

Regardless of how much physical activity someone gets, prolonged sedentary time could negatively impact the health of your heart and blood vessels.

Recent studies have documented the deleterious effect of overall sedentary time on central adiposity (larger waist circumference), fasting triglyceride levels and markers of insulin resistance. With prolonged periods of sitting, fewer skeletal muscle contractions may impact the glucose control kinematics leading to metabolic syndrome.

In one study it required two years of high-intensity exercise to reverse the effects of heart aging due to sedentary lifestyle on ejection fraction and cardiac stiffness.

This study greatly improves our understanding of cardiac compliance and plasticity with aging as well as the power of exercise-induced cardiac remodeling. We certainly know that "exercise works" even beyond the simple parameters of weight, BP, glucose levels, insulin resistance, lipids, etc., but this study starts to elucidate some of the deeper mechanistic variables.

Note that this program was more than get off the couch and walk the dog.

The two takeaway messages from this is that:

1. Sitting time poses a cardiovascular risk even if you exercise. Consider that three hours of exercise per week is only 5.3% of 57 waking hours per week (eight hours for seven days per week).
2. To improve and maintain heart health exercise needs to pitch at an intensity that challenges the cardiovascular system.

Our new tool that measures arterial stiffness

Measurements are interpreted against this graph. We can measure the impact of our programme on arterial stiffness over time.

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Six weeks training produced lowest HbA1c levels in eight years for diabetic patient

One of our diabetic patients (female; 65 years of age) were able to lower her HbA1c levels to the lowest it has been in eight years within 6-weeks after starting with us.

The term HbA1c refers to glycated haemoglobin. It develops when haemoglobin, a protein within red blood cells that carries oxygen throughout your body, joins with glucose in the blood, becoming 'glycated'. To put it in simple terms HbA1c is sugar-coated haemoglobin; think of a toffee apple (the apple being the haemoglobin and the syrup-coating being glucose).

Glycated haemoglobin (HbA1c) provide an overall picture of what your average blood glucose levels have been over a period of weeks/months.

It is important because the higher the HbA1c, the greater your risk of developing diabetes-related complications. 

When the body processes sugar, glucose in the bloodstream naturally attaches to haemoglobin. The amount of glucose that combines with this protein is directly proportional to the total amount of sugar that is in your system at that time.

Red blood cells in the human body survive for 8-12 weeks before renewal. Measuring glycated haemoglobin (or HbA1c) can consequently, be used to determine average blood glucose levels over the last 12-weeks thereby, providing a useful gauge for clinicians of the patient's ability/successfulness to manage/control his/her blood glucose.

Two large-scale studies - the UK Prospective Diabetes Study (UKPDS) and the Diabetes Control and Complications Trial (DCCT) - demonstrated that improving HbA1c by 1% (or 11 mmol/mol) for people with type 1 diabetes (T1DM) or type 2 diabetes (T2DM) cuts the risk of microvascular complications by 25%.

Microvascular complications include:

·       Retinopathy

·       Neuropathy

·       Diabetic nephropathy (kidney disease)

Research has also shown that people with type 2 diabetes who reduce their HbA1c level by 1% are: 

·       19% less likely to suffer cataracts

·       16% less likely to suffer heart failure

·       43% less likely to suffer amputation or death due to peripheral vascular disease

How do you lower your HbA1c levels?

The answer is by shifting your focus from controlling your glucose with insulin to controlling your insulin levels with diet and exercise. Don’t think glucose control think insulin control.

It is is a crucially important concept for diabetics and people who want to lose weight to understand.

The body release insulin to lower glucose. T1DM’s don’t produce enough insulin while T2DM’s are resistant against insulin. What most people don’t seem to realise is that it is the insulin that drives the insulin resistance. The practical significance of this (for both T1DM and T2DM) is that the more insulin you use, the more resistant you become against insulin.   

Type 1 diabetics that don’t control their glucose intake will require more and more insulin over time because the more insulin they inject, the more they become resistant against it. It is a vicious cycle; the more insulin you inject, the more insulin you are going to need over time.

Every time you eat your glucose spike. High glycaemic, sugary or starchy foods will create higher spikes requiring more insulin. The slower the body to lower the spike due to insulin resistance or not enough insulin the longer glucose will stay elevated. The longer your blood glucose stays elevated, the more haemoglobin becomes sugar-coated and the higher your HbA1c.

Again, the key concept to understand is that your focus should not be on controlling your glucose with insulin. Rather focus on reducing your insulin needs by managing the type and amount of food you put in your mouth.

Another way to control or lower your insulin needs is to exercise. There are three primary things to consider if you want to maximise exercise effect on diabetes and HbA1c, namely:

1.      Exercise intensity

The intensity at which you pitch your exercise has been shown to be important to maximise training effect on glucose control. High-intensity interval training (HIIT) or sprint interval training is a strategy that is intended to improve performance with short training sessions. A HIIT session involves a warm-up period, several short, maximum-intensity efforts separated by moderate recovery intervals, and a cool-down period. All studies that have assessed insulin response to HIIT recorded significant improvements of between a 23 and a 58% increase in insulin sensitivity. Insulin sensitivity has typically been assessed by measuring fasting insulin and by glucose tolerance tests.

In healthy, nondiabetic individuals, the improvement in fasting insulin and insulin resistance after HIIT ranges from 23 to 33%, whereas in individuals with T2DM, two studies have reported greater insulin sensitivity improvements of 46% and 58%.

It is potentially dangerous for unfit individuals to start-off with HITT training. It is best to seek professional advice and help with your exercise programme if you have not done any high-intensity or physically challenging exercises for longer than 5-years.

There are ways to optimise exercise intensity to maximise the effect on glucose even in those who are very unfit, but it is best to do it in a controlled/supervised environment.  

2.      Type of exercise

The type of exercise you use and the way you structure your exercise session has also been shown to be important if you want to maximise programme effect on glucose control.

3.      Timing of exercise

A 20 to 30-minute brisk walk after a meal will lower you’re your glucose levels significantly and speed up the time it takes your body to normalise your glucose levels.  

Some Client feedback on our programme

Below is some client feedback and re-assessment data demonstrating the effect of our programme. The first table shows the effect of the programme on some perceived variables of health and well-being as sampled with a scientific validated qeustionnaire.

The last three tables are clients personal feedback. They were asked to give us feedback on how they experienced the programme. 

A p-value is an indication of statistical significance. Significance is normally set at p<0.05 or lower which means the change is smaller than 5 out of 100 that you will not get the same result if your repeat the experiment. RSBP stands for resting systolic blood pressure. Watt3 is the wattage the clients were able to manage during the 3rd stage of the 12-minute cycle ergometer test. VO2peak and MET reflect cardiovascular capacity or fitness. Role-physical reflects clients perceived ability to mange his or her physical role (at home and work) on a daily basis. Role-emotional reflect ability to manage percieved emotional role at home or at work on a daily basis. CES-D is a validated depression score. HADS stands for Hospital Anxiety and Depression Scale; it is a short assessment tool normally used in hospital settings to determine patients level of anxiety and depression.

Our main task is to improve individuals health but this type of feedback is really what matters to us. We want clients to feel supported and safe no matter how severe their health conditions. 

Ketone diet linked to better mangement of COPD

The ketone diet has been shown, in a recent scientific study, to supress NLRP3 inflammasone which is a major driver of COPD and other chronic diseases. 

https://www.ncbi.nlm.nih.gov/m/pubmed/25686106/

It suggest that diet might be important when it comes to the management of COPD. A ketone diet is essentially a diet low in acellular (man-made) carbohydrates and sugar.  Ketone bodies are produced when the body starts breaking down fat for energy. You need to reduce your glucose and insulin levels before the body will start metabolising fat.

Fasting, high-intensity exercise and avoiding sugar or carbohydrates in your diet has been shown to raise ketone bodies. The link below will take you to a great article on the ketogenic diet.

https://www.inverse.com/article/40558-keto-diet-body-reset-science

U-Kinetics back as OraKinetics

Article on Stuff and in the Manawatu Standard about recent development with U-Kinetics services in Palmerston North.