Health prevention – from the viewpoint of medicine Christoph Gutenbrunner
Christoph Gutenbrunner, MD, PhD, Professor Department for Rehabilitation Medicine Institute for Balneology and Medical Climatology Hanover Medical School D-30625 Hannover gutenbrunner.christoph@mh-hannover.de
Overview
Health prevention: what is it? Chronic health conditions: how do they begin? Recovery and Adaptation: how does it work? Health prevention: what are the strategies?
Health resort: why to go there? Effects: do we have any scientific evidence? Conclusions: what are the preconditions? Health prevention – from the viewpoint of medicine Christoph Gutenbrunner 16th Annual ESPA Congress Belek, May 25th, 2011
Health prevention: what is it?
Health prevention – from the viewpoint of medicine Christoph Gutenbrunner 16th Annual ESPA Congress Belek, May 25th, 2011
Health strategies: ICHA-HC (OECD 2001; 2010)
Health prevention – from the viewpoint of medicine Christoph Gutenbrunner 16th Annual ESPA Congress Belek, May 25th, 2011
Health prevention: ICHA-HC (OECD 2001) Prevention and public health services: ◦ Maternal and child health ◦ Family planning and counselling ◦ School health services ◦ Prevention of communicable diseases (e.g. vaccination) ◦ Prevention of non-communicable diseases - public health services of health education, disease prevention (incl. Interventions against smoking, alcohol abuse) - services provided by self-help groups; general health education and health information (incl. campaigns in favour of healthier life-styles, safe sex, etc.)
◦ Occupational health care ◦ All other miscellaneous public health services Health prevention – from the viewpoint of medicine Christoph Gutenbrunner 16th Annual ESPA Congress Belek, May 25th, 2011
Health prevention: what is it? Health prevention in health resorts may aim at ◦ diagnosis and assessement of risk factors (e.g. physical inactivity, obesity and metabolic syndrome, distress, smoking etc.) ◦ reducing risk factors (e.g. weight reduction, blood pressure normalisation, stop smoking etc.) ◦ health education (reducing risk behavior, supporting healthy life style) ◦ normalise autonomuos dysfunction and enhance physical capacity (both cardiovasular and muscular performance) ◦ improve mood, energy and drive Health prevention – from the viewpoint of medicine Christoph Gutenbrunner 16th Annual ESPA Congress Belek, May 25th, 2011
Chronic health conditions: how do they begin?
Health prevention – from the viewpoint of medicine Christoph Gutenbrunner 16th Annual ESPA Congress Belek, May 25th, 2011
Metabolic syndrome in obesity 220 500
Plasma glucose
Plasma insulin 200
450 180 400 160 350
blood sugar regulation in the i.v.-glucosetolerance test th
(5 min)
140 300 120 250 100 200 150
16th Annual ESPA Congress Belek, May 25th, 2011
60
100
40
50
20
0
0
Health prevention – from the viewpoint of medicine Christoph Gutenbrunner
80
Normal body weight Overweight n=16, each Data from Melani et al. (1967)
Chronic health conditions: how do they begin?
Risk factors for chronic health conditions (examples) ◦ physical inactivity ◦ unhealthy food ◦ distress ◦ smoking
Early signs for chronic health conditions (examples) ◦ insuline resistance ◦ blood pressure dysregulation ◦ muscle weakness ◦ reduced airway clearance Conclusion: most chronic health condition initially start from dysregulation of autonomous functions Health prevention – from the viewpoint of medicine Christoph Gutenbrunner 16th Annual ESPA Congress Belek, May 25th, 2011
Recovery and Adaptation: how does it work?
Health prevention – from the viewpoint of medicine Christoph Gutenbrunner 16th Annual ESPA Congress Belek, May 25th, 2011
Recovery and Adaptation: how does it work?
Short-term recovery (minutes) ◦ recovery of local metabolic processes Sleep-wakefulness (day) ◦ recovery of autonomous functions Functional adaptation (weeks) ◦ improvement of autonomous regulation Trophical adaptation (months) ◦ growth of (specific) tissues Neuroplasticity (months to years) ◦ enhancement of neuronal functions Health prevention – from the viewpoint of medicine Christoph Gutenbrunner 16th Annual ESPA Congress Belek, May 25th, 2011
Functional adaptation Functional adaptive processes evoked by balneological stimuli may lead to adaptive normalization of functions controlled by the autonomous regulation system ◦ e.g. cardio-respiratory, metabolic, digestive or immune functions Adaptive normalization is formally characterized by ◦ convergence of functional parameters ◦ aiming at normal values ◦ coincidence of normal values with functional optima
Health prevention – from the viewpoint of medicine Christoph Gutenbrunner 16th Annual ESPA Congress Belek, May 25th, 2011
Adaptive normalisation (blood pressure) Hypertension (n=8)
Systolic blood pressure [mmHg]
Normal blood pressure (n=80)
Gutenbrunner & Ruppel: Phys Med Rehab Kuror 1992; 2: 58-64
Health prevention – from the viewpoint of medicine Christoph Gutenbrunner 16th Annual ESPA Congress Belek, May 25th, 2011
Low blood pressure (n=16)
Days of treatment
Gutenbrunner & Ruppel: Phys Med Rehab Kuror 1992; 2: 58-64
Health prevention – from the viewpoint of medicine Christoph Gutenbrunner 16th Annual ESPA Congress Belek, May 25th, 2011
Initial values (classes of 10 mmHg) days 1-3
Increase Decrease
Target value
Normal range
Change of blood pressure (linear regression) days 4-28
Adaptive normalisation (blood pressure) Normalisation of the systolic blood pressure
Reactive periods (vigilance functions) Reaction time
Cited from: Gutenbrunner & Hildebrandt: Handbuch der Balneologie und medizinischen Klimatologie, Springer 1998
Frequency [Hz]
Reaction time [ms]
Patients
Health prevention – from the viewpoint of medicine Christoph Gutenbrunner 16th Annual ESPA Congress Belek, May 25th, 2011
Controls optical acoustical
Shimmer test
Days of treatment
Long-term effects (physical working capacity) Group 1 (n = 17)
W130 [% of initial value]
Group 2 (n= 45)
Cited from: Gutenbrunner C, Hildebrandt G: Handbuch der Balneologie und medizinischen Klimatologie, Springer 1998 Health prevention – from the viewpoint of medicine Christoph Gutenbrunner 16th Annual ESPA Congress Belek, May 25th, 2011
Weeks
Months after end of treatment
Study on body weight changes
Aim of the study: formal evaluation of the body weight changes undergoing complex spa treatment Patients: 646 patients undergoing spa treatment in Bad Wildungen, most of the because of musculoskeletal problems (low back pain, cervical pain, osteoarthritis of knee and or hip) Inclusion: consecutive patients (with wide range of body weight) Evaluation: ◦ Daily blood pressure measurements ◦ Body weight at the begin and at the end of treatment Health prevention – from the viewpoint of medicine Christoph Gutenbrunner 16th Annual ESPA Congress Belek, May 25th, 2011
Change of body weight [kg]
Changes of body weight
Deviation from normal weight [%] (begin of treatment) Health prevention – from the viewpoint of medicine Christoph Gutenbrunner 16th Annual ESPA Congress Belek, May 25th, 2011
Gutenbrunner C, Ruppel K: Akt Ernähr Med 1992; 17: 8 (1992).
Body weight changes and calorie intake Change of body weight [kg]
Diet: 2300 kcal/day
1000 kcal/day
800 kcal/day
Deviation from normal weight [%] (begin of treatment) Health prevention – from the viewpoint of medicine Christoph Gutenbrunner 16th Annual ESPA Congress Belek, May 25th, 2011
Gutenbrunner C, Ruppel K: Akt Ernähr Med 1992; 17: 8 (1992).
Recovery and Adaptation: how does it work?
Short-term recovery (one night of good sleep; relaxation at weekend) lead to improvement of body functions, well being and performance but does not normalize autonomous regulation Long-term recovery or functional adaptation (three to six weeks of adaptation) improve regulation capacity ◦ physical and psychological stress can be compensated ◦ performance is increase for many months ◦ risk factors may be reduced Long-term training (mostly more than six weeks of adaptation) increases capacity of specific functional tissues (muscle strength, bone density and others) Health prevention – from the viewpoint of medicine Christoph Gutenbrunner 16th Annual ESPA Congress Belek, May 25th, 2011
Health prevention: what are the strategies?
Health prevention – from the viewpoint of medicine Christoph Gutenbrunner 16th Annual ESPA Congress Belek, May 25th, 2011
Health prevention: what are the strategies?
Analizing risk factors and diagnosing early signs of chronic diseases (check-up) Improving autonomous regulation by functional adaptation and increase performance
Training to compensate insufficient functions Teach health generating factors and pathophysiological knowledge Enable persons to handle with stress Modify behavior aiming at reducing risk behavior and support healthy living Health prevention – from the viewpoint of medicine Christoph Gutenbrunner 16th Annual ESPA Congress Belek, May 25th, 2011
Health resort: why to go there?
Health prevention – from the viewpoint of medicine Christoph Gutenbrunner 16th Annual ESPA Congress Belek, May 25th, 2011
Health resort: why to go there?
Specific health promoting factors ◦ climate ◦ landscape, training facilities Expertise to solve the problem and to treat the health condition and means to do so , e.g. ◦ doctors, psychologists, therapists, dieticians ◦ baleotherapy, physiotherapy, training Environment supporting well-being, e.g. ◦ scenery and architecture ◦ cultural events, places for spirituality
Health prevention – from the viewpoint of medicine Christoph Gutenbrunner 16th Annual ESPA Congress Belek, May 25th, 2011
Balneotherapy: modalities Substances, e.g.: ◦ Mineral waters (Na, Ca, Mg, Cl, SO4, H2S, CO2, trace elements) ◦ gases (CO2, H2S, Rn) ◦ peloids (mud, peat, fango and others) Modes of application, e.g.: ◦ bathing ◦ drinking ◦ inhalation Dosage, e.g.: ◦ single use ◦ series ◦ combination Health prevention – from the viewpoint of medicine Christoph Gutenbrunner 16th Annual ESPA Congress Belek, May 25th, 2011
Gutenbrunner C et al.: J Biometeorol 2010; 54: 459-507
Effective factors of health resort treatments Health resort medicine: performance of comprehensive medical concepts for prevention, therapy and rehabilitation including ◦ medical examination ◦ balneotherapy ◦ hydrotherapy ◦ physiotherapy ◦ diet ◦ psychotherapy ◦ education ◦ change of environment ◦ climate ◦ cultural factors Gutenbrunner C et al.: J Biometeorol 2010; ◦ and others 54: 459-507 Health prevention – from the viewpoint of medicine Christoph Gutenbrunner 16th Annual ESPA Congress Belek, May 25th, 2011
Effects: do we have any scientific evidence?
Health prevention – from the viewpoint of medicine Christoph Gutenbrunner 16th Annual ESPA Congress Belek, May 25th, 2011
Lower Saxony Cardiovascular Prevention Study Aim of study: Are inpatient rehabilitative measures effective in patients with an elevated cardio-vascular risk factor profile? Design of study: Prospective controlled study Inclusion criteria: At least two cardiovascular risk factors or LDL<135 mg% Intervention: Three weeks inpatient rehabilitative measures in a specialized rehab centre including physical medicine, balneotherapy, diet and health education Controls: Care of their family doctors Health prevention – from the viewpoint of medicine Christoph Gutenbrunner 16th Annual ESPA Congress Belek, May 25th, 2011
Lower Saxony Cardiovascular Prevention Study Parameters: Metabolic risk factors, blood pressure, behavioral risk factors (diet, stress behavior), psychometric variables Time points: Two weeks before (T1), two weeks after (T2) and one year after the treatment or control period (T3) (all measurements were carried out at day-to-dayconditions) Number of cases: ◦ Includes cases: n = 199 (49 women, 150 men) ◦ Drop outs: n = 23 ◦ evaluable cases: - study group: n = 82 - control group: n = 94 Health prevention – from the viewpoint of medicine Christoph Gutenbrunner 16th Annual ESPA Congress Belek, May 25th, 2011
Lower Saxony Cardiovascular Prevention Study Parameter
p-value ( T1-T2)
p-value ( T1-T3)
Overall effect
p = 0,000*)
p = 0,020*)
BMI [kg/m2]
p = 0,000**)
p = 0,021**)
Apolipoprotein B [mg/dl]
p = 0,015**)
p = 0,008**)
Fasting insulin [mg/dl]
p = 0,035**)
p = 0,034**)
Fibrinogen [mg/dl]
p = 0,950**)
p = 0,215**)
Mean arterial blood pressure [mmHg]
p = 0,002**)
p = 0,101**)
Gutenbrunner et al.: Phys Med Rehab Kuror 2001; 12: 272-283 Health prevention – from the viewpoint of medicine Christoph Gutenbrunner 16th Annual ESPA Congress Belek, May 25th, 2011
Lower Saxony Cardiovascular Prevention Study [mg/dl] 10
Change of Apolipoprotein B
difference
5 0 -5 -10
p<0,05
-15 0,6
Effect size
effect size
0,5 0,4 0,3 control group (n=82) study group (n=71)
0,2 0,1 0,0 T1-T2
T1-T3
Health prevention â&#x20AC;&#x201C; from the viewpoint of medicine Christoph Gutenbrunner 16th Annual ESPA Congress Belek, May 25th, 2011
T1-T2
T1-T3
Gutenbrunner et al.: Phys Med Rehab Kuror 2001; 12: 272-283
Lower Saxony Cardiovascular Prevention Study [kg/m²] 1,0
Change of BMI
difference of BMI
0,5 0,0 -0,5 -1,0 -1,5
p<0,001
-2,0
0,6
Effect size
effect size
0,5 0,4 0,3 control group (n=50) study group (n=49)
0,2 0,1 0,0 T1-T2
T1-T3
Health prevention – from the viewpoint of medicine Christoph Gutenbrunner 16th Annual ESPA Congress Belek, May 25th, 2011
T1-T2
T1-T3
Gutenbrunner et al.: Phys Med Rehab Kuror 2001; 12: 272-283
Renal stone formation metaphylaxis study Design of the Study: ◦ Controlled study, cross-over-design Patients: ◦ Patients with multi-episodic CaOx-urolithiasis (n=34) Setting: ◦ Everyday activities, nutrition protocol Intervention: ◦ 1.5 l/d bicarbonated water (2,673 mg HCO3/l) ◦ 1.5 l/d low-mineralized water (98 mg HCO3/l) Main Outcome Parameters: ◦ urinary pH, magnesium- and citrate excretion ◦ CaOx supersaturation Health prevention – from the viewpoint of medicine Christoph Gutenbrunner 16th Annual ESPA Congress Belek, May 25th, 2011
Renal stone formation metaphylaxis study Baseline Controls Baseline Bicarbonate Water
Patients with Recurrent Urolithiasis n = 34 [l]
Urinary Volume
4,0
Urinary pH
7,0
3,5
4,5
Supersaturation CaOx
4,0
*** 3,0
***
***
3,5 6,5 3,0
***
2,5
* 6,0
2,5
2,0 2,0 1,5
KaragĂźlle et al., World J Urol 2007; 25: 315-323
5,5
1,0
Health prevention â&#x20AC;&#x201C; from the viewpoint of medicine Christoph Gutenbrunner 16th Annual ESPA Congress Belek, May 25th, 2011
1,5
1,0
***
Germa Spa Visit Study
Health prevention â&#x20AC;&#x201C; from the viewpoint of medicine Christoph Gutenbrunner 16th Annual ESPA Congress Belek, May 25th, 2011
Effects: do we have any scientific evidence?
It has been shown that serial application of belnotherapy and exercise can induce functional adaptation leading to improved autonomous regulation (with long-term effects) Clinical preventions studies show that systematic and medically driven health resort interventions lead to a reduction of cardiovascular risk factors and increase physical performance (long-tem effects) Clinical studies with patients show beneficial effects of balneotherapy and health resort medicine on pain in muskuloskeletal disorders (e.g. low-back-pain, osteoarthritis), mental d isorder (anxiety, depression) and others (skin disorders, cardiovascular disorder, airway disease) Health prevention – from the viewpoint of medicine Christoph Gutenbrunner 16th Annual ESPA Congress Belek, May 25th, 2011
Conclusions: what are the preconditions?
Health prevention â&#x20AC;&#x201C; from the viewpoint of medicine Christoph Gutenbrunner 16th Annual ESPA Congress Belek, May 25th, 2011
Conclusions: what are the preconditions?
For health prevention health resorts must provide: ◦ Medical check-up done by a doctor ◦ individual prevention plan ◦ balneotherapy according to individual need (prescription!) ◦ supervised exercise treatment ◦ dietary programs ◦ health education programs Clients must ◦ actively participate in the program ◦ stay long enough (3 to 6 weeks) From the medical perspective outcome research is a must! Health prevention – from the viewpoint of medicine Christoph Gutenbrunner 16th Annual ESPA Congress Belek, May 25th, 2011
Christoph Gutenbrunner, MD, PhD, Professor Health prevention â&#x20AC;&#x201C; from the viewpoint of medicine Department for Physical Medicine and Rehabilitation Institute for Gutenbrunner Balneology and Medical Climatology Christoph Hanover Medical School 16th Annual ESPA Congress D-30625 Hannover th Belek, May 25 , 2011 gutenbrunner.christoph@mh-hannover.de