The role of diet for prevention and management of hypertension.

PURPOSE OF REVIEW: Regular consumption of a diet high in sodium, energy dense foods, fat content, refined carbohydrates, added sugar and low in fruits and vegetables contributes to an increased risk of developing hypertension (HTN) and cardiovascular disease. This review aims to provide a synopsis of evidence-based dietary approaches that have been effective in lowering blood pressure (BP) in pre-HTN and individuals with HTN. RECENT FINDINGS: Recent dietary recommendations have emphasized overall dietary patterns and its relation between food and BP. The Dietary Approaches to Stop Hypertension (DASH) diet and modifications to the DASH diet, coupled with reductions in sodium intake, show dose-dependent decreases in BP. Implementation of digital lifestyle interventions based on the DASH diet have been effective and show potential for clinical application. SUMMARY: Adopting a diet rich in plant-based foods, whole grains, low-fat dairy products, and sodium intake within normal limits can be effective in the prevention and management of HTN. These diets have been found to be more effective in older adults and hypertensive persons, particularly in studies that provided meals or frequent dietary counseling.

Trajectories of the relationships of physical activity with body composition changes in older men: the MrOS study.

BACKGROUND: Excess adiposity gains and significant lean mass loss may be risk factors for chronic disease in old age. Long-term patterns of change in physical activity (PA) and their influence on body composition decline during aging has not been characterized. We evaluated the interrelationships of PA and body composition at the outset and over longitudinal follow-up to changes in older men. METHODS: Self-reported PA by the Physical Activity Scale for the Elderly (PASE), clinic body weight, and whole-body lean mass (LM) and fat mass, by dual-energy x-ray absorptiometry (DXA), were assessed in 5964 community-dwelling men aged ≥65 years at baseline (2000-2002) and at two subsequent clinic visits up until March 2009 (an average 4.6 and 6.9 years later). Group-based trajectory modeling (GBTM) identified patterns of change in PA and body composition variables. Relationships of PA and body composition changes were then assessed. RESULTS: GBTM identified three discrete trajectory patterns, all with declining PA, associated primarily with initial PA levelshigh-activity (7.2% of men), moderate-activity (50.0%), and low-activity (42.8%). In separate models, GBTM identified eight discrete total weight change groups, five fat mass change groups, and six LM change groups. Joint trajectory modeling by PA and body composition group illustrated significant declines in total weight and LM, whereas fat mass levels were relatively unchanged among high-activity and low-activity-declining groups, and significantly increased in the moderate-activity-declining group. CONCLUSION: Although patterns of change in PA and body composition were identified, groups were primarily differentiated by initial PA or body composition rather than by distinct trajectories of change in these variables.

Exercise, hormones and skeletal adaptations during childhood and adolescence.

Although primarily considered a disorder of the elderly, emerging evidence suggests the antecedents of osteoporosis are established during childhood and adolescence. A complex interplay of genetic, environmental, hormonal and behavioral factors determines skeletal development, and a greater effort is needed to identify the most critical factors that establish peak bone strength. Indeed, knowledge of modifiable factors that determine skeletal development may permit optimization of skeletal health during growth and could potentially offset reductions in bone strength with aging. The peripubertal years represent a unique period when the skeleton is particularly responsive to loading exercises, and there is now overwhelming evidence that exercise can optimize skeletal development. While this is not controversial, the most effective exercise prescription and how much investment in this prescription is needed to significantly impact bone health continues to be debated. Despite considerable progress, these issues are not easy to address, and important questions remain unresolved. This review focuses on the key determinants of skeletal development, whether exercise during childhood and adolescence should be advocated as a safe and effective strategy for optimizing peak bone strength, and whether investment in exercise early in life protects against the development of osteoporosis and fractures later in life.

Cardiorespiratory fitness and physical activity in the lens of social justice - Reporting on the disparities that exist.

Cardiorespiratory fitness (CRF), heavily influenced by physical activity (PA), represents a strong and independent risk factor for a wide range of health conditions, most notably, cardiovascular disease. Substantial disparities in CRF have been identified between white and non-white populations. These disparities may partly account for group differences in susceptibility to poor health outcomes, including non-communicable disease. Race and ethnic differences in CRF may partly be explained by social injustices rooted in persistent structural and systemic racism. These forces contribute to environments that are unsupportive for opportunities to achieve optimal CRF levels. This review aims to examine, through the lens of social justice, the inequities in key social ecological factors, including socioeconomic status, the built environment, and structural racism, that underly the systemic differences in CRF and PA in vulnerable communities. Further, this review highlights current public health initiatives, as well as opportunities in future research, to address inequities and enhance CRF through the promotion of regular PA.

The impact of the COVID-19 pandemic on cardiovascular health behaviors and risk factors: A new troubling normal that may be here to stay.

In March 2020, the Coronavirus disease 2019 (COVID-19) outbreak was officially declared a global pandemic, leading to closure of public facilities, enforced social distancing and stay-at-home mandates to limit exposures and reduce transmission rates. While the severity of this "lockdown" period varied by country, the disruptions of the pandemic on multiple facets of life (e.g., daily activities, education, the workplace) as well as the social, economic, and healthcare systems impacts were unprecedented. These disruptions and impacts are having a profound negative effect on multiple facets of behavioral health and psychosocial wellbeing that are inextricably linked to cardiometabolic health and associated with adverse outcomes of COVID-19. For example, adoption of various cardiometabolic risk behavior behaviors observed during the pandemic contributed to irretractable trends in weight gain and poor mental health, raising concerns on the possible long-term consequences of the pandemic on cardiometabolic disease risk, and vulnerabilities to future viral pandemics. The purpose of this review is to summarize the direct and indirect effects of the pandemic on cardiometabolic health risk behaviors, particularly related to poor diet quality, physical inactivity and sedentary behaviors, smoking, sleep patterns and mental health. Additional insights into how the pandemic has amplified cardiovascular risk behaviors, particularly in our most vulnerable populations, and the potential implications for the future if these modifiable risk behaviors do not become better controlled, are described.

The path forward: Highlighting social justice pearls in public health campaigns and initiatives to deliver equitable healthy living medicine.

The prevalence of unhealthy living behaviors is largely driven by environments that support them and has become a key concern at global, national, and individual (patient) levels. Healthy Living Medicine offers a compelling path forward to move people towards healthy living behaviors and better health outcomes when complemented by socially just and equitable public campaigns and initiatives. Some of the concepts that are critical for these campaigns and initiatives that will be discussed in this manuscript include the social determinants of health, the communication loop, health literacy, and implicit bias and discrimination. Considering what is practical and achievable, examples of actionable, socially-just strategies will be described to inform and encourage health professionals and other stakeholders to prioritize healthy living and reverse the poor health trajectory among our most vulnerable populations.

Physical function trends and their association with mortality in postmenopausal women.

OBJECTIVE: Research is limited regarding the predictive utility of the RAND-36 questionnaire and physical performance tests in relation to all-cause, cardiovascular disease (CVD), and total-cancer mortality in older women. METHODS: Data on the RAND-36 questionnaire, gait speed, and chair stand performance were assessed in 5,534 women aged ≥65 years at baseline. A subset (n = 298) had physical function assessments additionally at follow-up (years 1, 3, or 6). Multivariable Cox proportional hazards regression models estimated associations (HR) for a 1-standard deviation (SD) difference in baseline RAND-36 scores and performance tests (alone and combined) with mortality outcomes in the overall cohort and in models stratified by enrollment age (<70 and ≥ 70 y). The relative prognostic value of each physical function exposure was assessed using the Uno concordance statistic. RESULTS: A total of 1,186 deaths from any cause, 402 deaths from CVD, and 382 deaths from total-cancer were identified during a mean follow-up of 12.6 years. Overall, each 1-SD unit higher baseline RAND-36 score was associated with significantly lower all-cause mortality (HR =0.90) and discriminatory capacity (Uno = 0.65) that was comparable to each performance exposure (HRs 0.88-0.91; Uno = 0.65). These findings were consistent in women aged <70 and ≥ 70 years. The associations of RAND-36 and performance measures with CVD mortality and total-cancer mortality were not significant in multivariable models nor in age-stratified models. CONCLUSIONS: The RAND-36 questionnaire is a reasonable substitute for tracking physical functioning and estimating its association with all-cause mortality in older adults when clinical performance testing is not feasible.

Longitudinal physical performance and blood pressure changes in older women: Findings form the women's health initiative.

BACKGROUND: This study evaluated the association between changes in physical performance and blood pressure (BP) (e.g., systolic [SBP], diastolic [DBP], pulse pressure) in older women. METHODS: 5627 women (mean age 69.8 ± 3.7 y) with grip strength, chair stand, gait speed performance and clinic-measured BP at baseline and at least one follow-up (years 1, 3 or 6) were included. Generalized estimating equation analysis of multivariable models with standardized point estimates described the longitudinal association between physical performance and BP changes in the overall cohort, and in models stratified by baseline cardiovascular disease (CVD), time-varying antihypertensive medication use (none, ≥1) and enrollment age (65-69 y; 70-79 y). RESULTS: Overall, each z-score unit increment in grip strength was associated with 0.59 mmHg (95% CI 0.10, 1.08) higher SBP, and 0.39 mmHg (95% CI 0.11, 0.67) higher DBP. In stratified models, a standardized increment in grip strength was associated with higher SBP in women without CVD (0.81; 95% CI 0.23-1.39), among antihypertensive medication users (0.93; 95% CI 0.44, 1.41) and non-users (0.37; 95% CI 0.03, 0.71), and in those aged 65-69 y (0.64; 95% CI 0.04, 1.24). Similarly, a standardized increment in any of the three performance measures was associated with modestly higher DBP in antihypertensive medication users, and those aged 70-79 y. Associations between any performance measure and pulse pressure change were not significant. CONCLUSION: These results suggest a positive, and statistically significant relationship between physical performance and BP that appears to be influenced by CVD history, antihypertensive medication use, and age.

Exergaming and Virtual Reality for Health: Implications for Cardiac Rehabilitation.

Cardiac Rehabilitation (CR) programs, focused on improving the health trajectory of patients with cardiovascular disease, strive to increase physical activity (PA) and cardiorespiratory fitness. However, historically low compliance with recommended PA has prompted exploration of alternatives to traditional courses of exercise therapy. One alternative, exergaming, or the requirement of physical exercise inherent to a video game's activities, has shown to have a promising impact in improving patient self-efficacy for exercise training using digital hardware (eg, the Wii or the Xbox Kinect). Furthermore, novel technologies in virtual reality can provide an engaging, immersive environment for exergaming techniques, maximizing goal-oriented training and building self-efficacy for patients during CR. Many groundbreaking institutions are already calculating energy expenditure of commercially successful virtual reality games and finding promise in the cardiometabolic responses to a number of virtual reality games. Research is still limited in establishing the efficacy of these games, but virtual reality and exergaming are quickly proving to be appropriate and equivalent alternatives to traditional exercise programs. Though studies have examined the impact of prescriptive exergaming on PA, they have yet to examine the potential for genuine integration of game-based motivational techniques and immersive environments into clinical interaction. The purpose of this review is to describe the current body of evidence and the impact and future potential of virtual reality and exergaming. Further, we will introduce the concept of a "Clinical Arcade" as a new approach to integration of these techniques in CR care.

Prioritizing movement to address the frailty phenotype in heart failure.

Frailty is a highly prevalent multisystem syndrome in older adults with heart failure (HF) and is associated with poor clinical prognosis and increased complexity of care. While frailty is neither disease nor age specific, it is a clinical manifestation of aging-related processes that reflects a reduced physiological ability to tolerate and recover from stress associated with aging, disease, or therapy. Within this context, physical frailty, which is distinctly oriented to physical functional domains (e.g., muscle weakness, slowness, and low activity), has been recognized as a critical vital sign in older persons with HF. Identification and routine assessment of physical frailty, using objective physical performance measures, may guide the course of patient-centered treatment plans that maximize the likelihood of improving clinical outcomes in older HF patients. Exercise-based rehabilitation is a primary therapy to improve cardiovascular health in patients with HF; however, the limited evidence supporting the effectiveness of exercise tailored to older and frail HF patients underscores the current gaps in management of their care. Interdisciplinary exercise interventions designed with consideration of physical frailty as a therapeutic target may be an important strategy to counteract functional deficits characteristic of frailty and HF, and to improve patient-centered outcomes in this population. The purpose of this current review is to provide a better understanding of physical frailty and its relation to management of care in older patients with HF. Implications of movement-based interventions, including exercise and physical rehabilitation, to prevent or reverse physical frailty and improve clinical outcomes will further be discussed.

DXA Versus Clinical Measures of Adiposity as Predictors of Cardiometabolic Diseases and All-Cause Mortality in Postmenopausal Women.

OBJECTIVE: To investigate whether dual-energy x-ray absorptiometry (DXA) estimates of adiposity improve risk prediction for cardiometabolic diseases over traditional surrogates, body mass index (BMI), waist circumference (WC), and waist-to-hip ratio (WHR) in older women. PATIENTS AND METHODS: We analyzed up to 9744 postmenopausal women aged 50 to 79 years participating in the Women's Health Initiative who underwent a DXA scan and were free of cardiovascular disease and diabetes at baseline (October 1993 to December 1998) and followed through September 2015. Baseline BMI, WC, WHR, and DXA-derived percent total-body and trunk fat (%TrF) were incorporated into multivariable Cox proportional hazards models to estimate the risk of incident diabetes, atherosclerosis-related cardiovascular diseases (ASCVDs), heart failure, and death. Concordance probability estimates assessed the relative discriminatory value between pairs of adiposity measures. RESULTS: A total of 1327 diabetes cases, 1266 atherosclerotic cardiovascular disease (ASCVD) cases, 292 heart failure cases, and 1811 deaths from any cause accrued during a median follow-up of up to 17.2 years. The largest hazard ratio observed per 1 standard deviation increase of an adiposity measure was for %TrF and diabetes (1.77; 95% CI, 1.66-1.88) followed by %TrF and broadly defined ASCVD (1.22; 95% CI, 1.15-1.30). These hazard ratios remained significant for both diabetes (1.47; 95% CI, 1.37-1.57) and ASCVD (1.22; 95% CI, 1.14-1.31) even after adjusting for the best traditional surrogate measure of adiposity, WC. Percentage of trunk fat was also the only adiposity measure to demonstrate statistically significant improved concordance probability estimates over BMI, WC, and WHR for diabetes and ASCVD (all P<0.05). CONCLUSION: DXA-derived estimates of abdominal adiposity in postmenopausal women may allow for substantially improved risk prediction of diabetes over standard clinical risk models. Larger DXA studies with complete lipid biomarker profiles and clinical trials are needed before firm conclusions can be made.

Predictive Value of DXA Appendicular Lean Mass for Incident Fractures, Falls, and Mortality, Independent of Prior Falls, FRAX, and BMD: Findings from the Women's Health Initiative (WHI).

In the Women's Health Initiative (WHI), we investigated associations between baseline dual-energy X-ray absorptiometry (DXA) appendicular lean mass (ALM) and risk of incident fractures, falls, and mortality (separately for each outcome) among older postmenopausal women, accounting for bone mineral density (BMD), prior falls, and Fracture Risk Assessment Tool (FRAX® ) probability. The WHI is a prospective study of postmenopausal women undertaken at 40 US sites. We used an extension of Poisson regression to investigate the relationship between baseline ALM (corrected for height2 ) and incident fracture outcomes, presented here for major osteoporotic fracture (MOF: hip, clinical vertebral, forearm, or proximal humerus), falls, and death. Associations were adjusted for age, time since baseline and randomization group, or additionally for femoral neck (FN) BMD, prior falls, or FRAX probability (MOF without BMD) and are reported as gradient of risk (GR: hazard ratio for first incident fracture per SD increment) in ALM/height2 (GR). Data were available for 11,187 women (mean [SD] age 63.3 [7.4] years). In the base models (adjusted for age, follow-up time, and randomization group), greater ALM/height2 was associated with lower risk of incident MOF (GR = 0.88; 95% confidence interval [CI] 0.83-0.94). The association was independent of prior falls but was attenuated by FRAX probability. Adjustment for FN BMD T-score led to attenuation and inversion of the risk relationship (GR = 1.06; 95% CI 0.98-1.14). There were no associations between ALM/height2 and incident falls. However, there was a 7% to 15% increase in risk of death during follow-up for each SD greater ALM/height2 , depending on specific adjustment. In WHI, and consistent with our findings in older men (Osteoporotic Fractures in Men [MrOS] study cohorts), the predictive value of DXA-ALM for future clinical fracture is attenuated (and potentially inverted) after adjustment for femoral neck BMD T-score. However, intriguing positive, but modest, associations between ALM/height2 and mortality remain robust. © 2021 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Physical Activity Trajectories and Associated Changes in Physical Performance in Older Men: The MrOS Study.

BACKGROUND: Physical activity (PA) is important to maintaining functional independence. It is not clear how patterns of change in late-life PA are associated with contemporaneous changes in physical performance measures. METHODS: Self-reported PA, gait speed, grip strength, timed chair stand, and leg power were assessed in 3,865 men aged ≥ 65 years at baseline (2000-2002) and Year 7 (2007-2009). Group-based trajectory modeling, using up to four PA measures over this period, identified PA trajectories. Multivariate linear regression models (adjusted least square mean [95% confidence interval {CI}]) described associations between-PA trajectories and concurrent changes in performance. RESULTS: Three discrete PA patterns were identified, all with declining PA. Linear declines in each performance measure (baseline to Year 7) were observed across all three PA groups, but there was some variability in the rate of decline. Multivariate models assessing the graded response by PA trajectory showed a trend where the high-activity group had the smallest declines in performance while the low-activity group had the largest (p-for trend < .03). Changes in the high-activity group were the following: gait speed (-0.10 m/s [-0.12, -0.08]), grip strength (-3.79 kg [-4.35, -3.23]), and chair stands (-0.38 [-0.50, -0.25]), whereas changes in the low-activity group were the following: gait speed (-0.16 [-0.17, -0.14]), grip strength (-4.83 kg [-5.10, -4.55]), and chair stands (-0.53 [-0.59, -0.46]). Between-group differences in leg power trajectories across PA patterns were not significant. CONCLUSIONS: Declines in functional performance were higher among those with lower PA trajectories, providing further evidence for the interrelationship between changes in PA and performance during old age.

Cardiometabolic responses to cardiac rehabilitation in people with and without diabetes.

BACKGROUND: Type 2 diabetes and cardiometabolic comorbidities manifesting as the metabolic syndrome (MetS) are highly prevalent in coronary heart disease (CHD) patients attending cardiac rehabilitation (CR). The study aimed to determine the prevalence of cardiometabolic derangements and MetS, and compare post-CR clinical responses in a large cohort of CHD patients with and without diabetes. METHODS: Analyses were conducted on 3953 CHD patients [age: 61.1 ±â€¯10.5 years; 741 (18.7%) with diabetes] that completed a representative 12-week CR program. A propensity model was used to match patients with diabetes (n = 731) to those without diabetes (n = 731) on baseline and clinical characteristics. RESULTS: Diabetic patients experienced smaller improvements in metabolic parameters after completing CR, including abdominal obesity, and lipid profiles (all P ≤ .002), compared to non-diabetic patients. For both groups, there were similar improvement rates in peak metabolic equivalents ([METs]; P < .001); however, peak METs remained lower at 12-weeks in patients with diabetes than without diabetes. At baseline, the combined prevalence of insulin resistance (IR) and diabetes was 57.3%, whereas IR was present in 48.2% of non-diabetic patients, of which rates were reduced to 48.2% and 32.8% after CR, respectively. Accordingly, MetS prevalence decreased from 25.5% to 22.3% in diabetic versus 20.0% to 13.4% in non-diabetic patients (all P ≤ .004). CONCLUSIONS: Completing CR appears to provide comprehensive risk reduction in cardio-metabolic parameters associated with diabetes and MetS; however, CHD patients with diabetes may require additional and more aggressive attention towards all MetS criteria over the course of CR in order to prevent future cardiovascular events.

The Importance of School-based Healthy Living Initiatives: Introducing the Health and Wellness Academy Concept.

Over the last 15 years, the number of school and community based health-intervention programs in the United States has grown. Many of these programs aim to prevent non-communicable chronic disease diagnoses (e.g., obesity, cardiovascular disease and type-2 diabetes). The Department of Physical Therapy in the College of Applied Health Sciences (CAHS) at the University of Illinois at Chicago (UIC) created a school-based wellness program (SBWP) that focuses on nutrition and physical activity, providing tailored experiences that motivate adolescents to make healthier lifestyle choices. The SBWP began as a camp for children in the surrounding neighborhoods and implemented healthy living practices utilizing students from Departments in the CAHS. From this camp, the Health and Wellness Academy (HWA) evolved. This paper provides a review of school-based initiatives and introduces the UIC HWA, an innovative and reproducible approach that can bring positive environmental change by improving health outcomes for children and their families.

Let Us Talk About Moving: Reframing the Exercise and Physical Activity Discussion.

Noncommunicable and chronic disease are interchangeable terms. According to the World Health Organization, "they are of long duration and generally slow progression. The 4 main types of chronic diseases are cardiovascular diseases (ie, heart attacks and stroke), cancers, chronic respiratory diseases (such as chronic obstructive pulmonary disease and asthma), and diabetes." We have known about the benefits of physical activity (PA) for thousands of years. Perhaps our approach, from public health messaging to the individual clinical encounter, as to how PA and exercise are discussed and prescribed can be improved upon, with the ultimate goal of increasing the likelihood that an individual moves more; ultimately moving more should be the goal. In fact, there is an incongruence between the evidence for the benefits of physical movement and how we message and integrate PA and exercise guidance into health care, if it is discussed at all. Specifically, evidence clearly indicates any migration away from the sedentary phenotype toward a movement phenotype is highly beneficial. As we necessarily move to a proactive, preventive healthcare model, we must reconceptualize how we evaluate and treat conditions that pose the greatest threat, namely chronic disease; there is a robust body of evidence supporting the premise of movement as medicine. The purpose of this perspective paper is to propose an alternate model for promoting, assessing, discussing, and prescribing physical movement.

An Update on the Role of Cardiorespiratory Fitness, Structured Exercise and Lifestyle Physical Activity in Preventing Cardiovascular Disease and Health Risk.

The cardiovascular disease (CVD) pandemic has placed considerable strain on healthcare systems, quality of life, and physical function, while remaining the leading cause of death globally. Decades of scientific investigations have fortified the protective effects of cardiorespiratory fitness (CRF), exercise training, and physical activity (PA) against the development of CVD. This review will summarize recent efforts that have made significant strides in; 1) the application of novel analytic techniques to increase the predictive utility of CRF; 2) understanding the protective effects of long-term compliance to PA recommendations through large cohort studies with multiple points of assessment; 3) and understanding the potential harms associated with extreme volumes of PA.

Assessing the Value of Moving More-The Integral Role of Qualified Health Professionals.

Being physically active or, in a broader sense, simply moving more throughout each day is one of the most important components of an individual's health plan. In conjunction with regular exercise training, taking more steps in a day and sitting less are also important components of one's movement portfolio. Given this priority, health care professionals must develop enhanced skills for prescribing and guiding individualized movement programs for all their patients. An important component of a health care professional's ability to prescribe movement as medicine is competency in assessing an individual's risk for untoward events if physical exertion was increased. The ability to appropriately assess one's risk before advising an individual to move more is integral to clinical decision-making related to subsequent testing if needed, exercise prescription, and level of supervision with exercise training. At present, there is a lack of clarity pertaining to how a health care professional should go about assessing an individual's readiness to move more on a daily basis in a safe manner. Therefore, this perspectives article clarifies key issues related to prescribing movement as medicine and presents a new process for clinical assessment before prescribing an individualized movement program.

Enhancing Participation in Cardiac Rehabilitation: A Question of Proximity and Integration of Outpatient Services.

Numerous investigations have established the strong clinical utility of cardiac rehabilitation, while clinical guidelines continually call for a high level of referral and participation. Historically, medical facilities have faced challenges referring eligible patients to cardiac rehabilitation, enrolling only a small portion of those receiving referral. Consequently, less than ~10% of qualifying patients receive any amount of cardiac rehabilitation. This sobering figure has prompted many efforts to identify barriers to referral as well as enrollment and accordingly propose strategies to bolster participation rates. Although reports have highlighted improvements through focused approaches, enrollment rates still lag behind the goal of reaching 70% by 2022, proposed by the Million Hearts Cardiac Rehabilitation Collaborative. An area of inquiry that has received little to no attention in this effort has been the influence of proximity between physician-driven outpatient clinics and cardiac rehabilitation facilities. In this report we outline the development and design of a clinical faculty practice aimed to maintainclose geographical proximity between our physicianclinic and the cardiac rehabilitation area. We also propose that our impressive enrollment rates of 57% within our facility and 73% when including patients that started alternative exercise programs were likely due to establishing a close proximity between the respective practices.