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John Saxton
Professor of Clinical Exercise Physiology
University of East Anglia
The World Health Organisation
predicts that chronic conditions
will be the leading cause of
disability by 2020 and that, if not
successfully managed, will
become the most expensive
problem for health care systems
CHD
Osteoporosis
Kidney
disease
Stroke
Common
chronic
conditions
Asthma
COPD
Depression
Cancers
Arthritis
Diabetes
•
In England, 15.4 million people are currently living with a
chronic condition
•
It is estimated that up to three-quarters of those over 75 y
are suffering from a chronic condition, and this figure
continues to rise
•
By 2030, the estimate is that the incidence of chronic
disease in the over 65s will more than double
•
The treatment of chronic conditions accounts for 70% of
total health and social care costs
The ageing population
By 2034, it is projected that:
• nearly a quarter (23%) of the UK population will be
aged ≥65 y (from 16% in 2008)
• 5% of the UK population will be ≥85 y
Life expectancy (LE) versus Healthy Life Expectancy (HLE)
Women
90
Age (years)
70
66.7
68.8
HLE
60
50
40
30
80
70
64.3
Age (years)
80
90
LE
81.6
80.4
76.8
Men
62.5
40
30
10
10
0
0
2006-8
HLE
50
20
2001
64.4
67
60
20
1981
70.9
LE
77.4
75.7
1981
2001
2006-8
Office for National Statistics 2011
The evolution of man and
lifestyle behaviours
from Homo erectus to Homo sapiens…
The world of today is not the environment we evolved in…
Our lifestyles have been transformed from that of
wandering hunter-gatherers to sedentary consumers of
more than we need to survive
from Homo erectus to Homo sapiens…
‘Homo sedentarius’
‘Homo obesus’
Self-reported sedentary time
Health Survey for England 2008, Volume 1: Physical activity and fitness
Mean number of hours per working
day in occupational activities, by sex
Prevalence of overweight and obesity
Health Survey for England 2009, Volume 1: Health and Lifestyles
How important is the link
between physical inactivity
and chronic disease?
As early as the ninth century
B.C., the ancient Indian
system of medicine (Ayurveda)
recommended exercise and
massage for the treatment of
rheumatism
Greek philosopher
Hippocrates (‘the father of
medicine’) acknowledged
the virtues of exercise for
physical and mental health
in the 4th century B.C.
World Health Organisation statistics
• Physical inactivity is estimated to be the
principal cause of ~30% of the ischaemic heart
disease burden, ~27% of the diabetes burden
and ~21-25% of the breast and colon cancer
burdens (WHO 2009).
• Worldwide, approximately 3.2 million deaths (6%
of all deaths) each year are attributable to
insufficient physical activity (WHO 2010).
WHO 2009
Evidence for the health
benefits of exercise
Jerry N Morris 1910 - 2009
Bus drivers in their 40’s were nearly five times more likely to develop ischaemic
heart disease than age-matched conductors (Morris et al. 1966; Lancet 2; 553559).
40% reduced risk of fatal heart attack and a 50% reduction in non-fatal coronary
events among British male civil servants who participated in vigorous exercise
requiring peaks of energy expenditure (Morris et al. 1980; Lancet 2: 1207-1210).
Ralph S Paffenbarger Jr 1922 - 2007
28% reduced risk of all-cause mortality among USA college alumni reporting a
weekly exercise energy expenditure of 2000 kcal.week-1 (Paffenbarger et al.
1986; NEJM 314; 605-613).
Steven N Blair 1939 7.9% decrease in all cause mortality for every 1 min improvement in
treadmill walking time (roughly equivalent to 1 MET increase in aerobic
exercise capacity) among men attending medical check-ups at the Cooper
Clinic in Dallas USA (Blair et al. 1995; JAMA 273; 1093-1098).
AICR/WCRF
Expert Report
2007
How much exercise is needed
for health and fitness?
WHO Global Recommendations on
Physical Activity for Health (2010)
•
150 minutes of moderate-intensity aerobic physical activity or 75
minutes of vigorous intensity aerobic physical activity throughout
the week, or an equivalent combination of the two.
•
For additional health benefits, aim to increase this to 300 minutes
of moderate aerobic physical activity or 150 minutes of vigorousintensity aerobic physical activity per week or an equivalent
combination of the two.
•
Aerobic activity should be performed in bouts of at least 10
minutes duration.
•
Muscle strengthening exercises (involving major muscle groups)
on 2 or more days per week.
Limit the amount of time spent in sedentary activities
Objective physical activity levels
Health Survey for England 2008, Volume 1: Physical activity and fitness
Waiting to take the escalator
“Whenever I feel like
exercise, I lie down until
the feeling passes”
How can we get people to
exercise at the right levels and
in the right way to optimise the
health benefits?
Exercise in the management
of long-term conditions
The role of exercise in
ameliorating the impact of
chronic disease, improving
quality of life and survival
Muscular
Perceived
fatigue
Motor
Anxiety
Depression
Stress
Morphological
(Body
composition)
Perceived
ability to cope
Sense of control
Healthrelated
Quality of life
&
Disease-free
survival
Cardiorespiratory
Metabolic
Self-esteem
Social
integration
Cognitive
function
Immunological
Enjoyment
of life
Molecular
Physiological
Perceived
Physical
attractiveness
Mood states
Psychosocial
Key research questions:
• Can exercise training counteract the adverse
physiological and psychological consequences of
disease and its treatments?
• Function; quality of life; disease-free survival
• In those with long-term conditions, what is the role
of exercise in disease modification? How does
exercise interact with drug treatments? Can exercise
counteract the side-effects of drug treatments?
• Why do some patients respond/adapt differently to
exercise training?
• What are the contra-indications to exercise in
different clinical groups?
Where exercise has proven
benefits to a clinical group –
how can it be optimised?
INTENSITY
FREQUENCY
F-I-T-T
PRINCIPLE
TIME
TYPE
Vignettes – the application of exercise science
to the management of long-term conditions
• Optimising exercise rehabilitation in
terms of engagement and health
benefits in peripheral arterial disease
• Impact of exercise on quality of life and
disease-free survival after cancer
• Exercise and symptoms of clinical
fatigue in multiple sclerosis
Peripheral arterial disease
(intermittent claudication)
Affected arteries
of the lower limb
External iliac artery
Aortic and iliac
arteries 30%
Femoral artery
Femoral and
popliteal arteries
80-90%
Popliteal artery
Tibial and
peroneal arteries
40-50%
Posterior tibial artery
Anterior tibial artery
Dorsalis pedis
(palpation point)
TREATMENT STRATEGIES FOR IC
•
EXERCISE THERAPY
•
PHARMACOLOGICAL TREATMENTS
•
CV RISK FACTOR MODIFICATION
•
SURGICAL INTERVENTIONS
“Stop smoking and keep walking”
Problem!
A significant proportion of patients do not
engage in walking exercise!!
Alternative exercise rehabilitation
strategies - rationale
Arm cranking exercise
Leg cranking exercise
• A large proportion (~ 35%) of patients exceed
their leg-cycling aerobic exercise tolerance
during arm-cranking exercise
• Less exercise pain during arm-cranking, despite
similar perceived exertion and higher blood
lactate at maximal exercise tolerance
Zwierska et al. (2006); EJVES
Arm-cranking exercise trials
Calf muscle haemoglobin saturation during walking (NIRS)
Pre
Post
NIRS time to minimum StO2 was increased after arm-cranking exercise training
Evidence of a reduction in systemic
inflammation after arm-crank training
Geometric mean difference (mg.l-1)
Circulating hs-CRP
0.00
-0.25
-0.50
-0.75
-1.00
-1.25
-1.50
-1.75
-2.00
-2.25
-2.50
Armcranking

Legcranking
Chi square analysis showed
that the proportion of
patients in the arm-cranking
group with a favourable hsCRP profile (defined as <
1.72 mg.l-1) was higher than
in the control group at the
24-week time-point (50% vs
23%, respectively; P < 0.05).
Saxton et al. (2008); EJVES
Impact on exercise pain tolerance
Leg training group
Variable
Arm training group
Control group
Baseline
24 weeks
Baseline
24 weeks
Baseline
24 weeks
Heart rate at CD (beats.min-1)
91 ± 3
91 ± 2
93 ± 2
95 ± 2
87 ± 3
87 ± 3
Heart rate at MWD (beats.min-1)
107 ± 3
120 ± 4**†
110 ± 4
116 ± 4**†
98 ± 3
97 ± 3
1.90 ± 0.11
2.26 ± 0.14*
1.95 ± 0.14
2.40 ± 0.17**†
1.66 ± 0.09
1.69 ± 0.11
CR-10 at CD
1.0 (0.3 – 3.0)
0.5 (0.3 – 2.0)
1.0 (0.3 – 3.0)
1.0 (0.3 – 3.0)
1.8 (0.5 – 3.0)
1.0 (0.3 – 5.0)
CR-10 at MWD
6.0 (3.0 – 11.0)
7.0 (2.0 – 11.0)
5.0 (2.5 – 11.0)
7.0 (2.5 – 11.0)†
5.5 (2.5 – 11.0)
5.0 (1.0 – 10.0)
13.0 (9 – 20)
15.0 (7 – 19)††
13.5 (7 – 20)
16.0 (6 – 20)**††
15.0 (7 – 19)
14.0 (6 – 20)
Blood lactate at MWD (mM)
RPE at MWD
Zwierska I et al. (2005). J Vasc Surg 42:1122-30.
Mechanisms?
• Central cardiovascular adaptations?
• Blood rheology (changes in viscosity)?
• Exercise pain threshold/tolerance?
• Improved blood flow/distribution linked to
improved ability of lower limb arteries to
dilate during exercise
Nordic pole walking (NPW) study
• To investigate whether
the use of Nordic poles
leads to an improvement
in common parameters
of walking performance
in patients with
intermittent claudication
• To compare the
cardiopulmonary
responses and level of
leg-pain evoked by NPW
with those evoked by
normal walking exercise
in this patient group
Experimental set-up and Methods
Methods
• N = 20 patients with
intermittent claudication
recruited from SVI
• Patients were familiarised
with the NPW technique,
allowed ample practice
time, performed “dummy
run”
• Two treadmill walks: 3.2
km.h-1 @ 4% gradient in
random order
Wide belt H-P-Cosmos Saturn Treadmill
During NPW:
• The level of claudication pain at MWD was less despite
higher oxygen consumption
• For 9/20 patients (45%), the NPW test was terminated for
reasons other than claudication pain (e.g. breathlessness/
breathing hard, mouth dry, very tired, exhausted), versus
only 1 in the normal walking condition
• These results suggest that NPW could be a useful
ergogenic aid for improving the cardiopulmonary stimulus
to exercise rehabilitation in claudicants
Cancer survivorship
• There are over 200 different types of cancer
Acute Lymphoblastic Leukemia, Adult
Acute Lymphoblastic Leukemia, Childhood
Acute Myeloid Leukemia, Adult
Acute Myeloid Leukemia, Childhood
Adrenocortical Carcinoma
Adrenocortical Carcinoma, Childhood
AIDS-Related Cancers
AIDS-Related Lymphoma
Anal Cancer
Astrocytoma, Childhood Cerebellar
Astrocytoma, Childhood Cerebral
Bile Duct Cancer, Extrahepatic
Bladder Cancer
Bladder Cancer, Childhood
Bone Cancer, Osteosarcoma/Malignant Fibrous
Histiocytoma
Brain Stem Glioma, Childhood
Brain Tumor, Adult
Brain Tumor, Brain Stem Glioma, Childhood
Brain Tumor, Cerebellar Astrocytoma, Childhood
Brain Tumor, Cerebral Astrocytoma/Malignant
Glioma, Childhood
Brain Tumor, Ependymoma, Childhood
Brain Tumor, Medulloblastoma, Childhood
Brain Tumor, Supratentorial Primitive
Neuroectodermal Tumors, Childhood
Brain Tumor, Visual Pathway and Hypothalamic
Glioma, Childhood
Brain Tumor, Childhood (Other)
Breast Cancer
Breast Cancer and Pregnancy
Breast Cancer, Childhood
Breast Cancer, Male
Bronchial Adenomas/Carcinoids, Childhood
Carcinoid Tumor, Childhood
Carcinoid Tumor,Gastrointestinal
Carcinoma, Adrenocortical
Carcinoma, Islet Cell
Carcinoma of Unknown Primary
Central Nervous System Lymphoma, Primary
Cerebellar Astrocytoma, Childhood
Cerebral Astrocytoma/Malignant Glioma, Childhood
Cervical Cancer
Childhood Cancers
Chronic Lymphocytic Leukemia
Chronic Myelogenous Leukemia
Chronic Myeloproliferative Disorders
Clear Cell Sarcoma of Tendon Sheaths
Colon Cancer
Colorectal Cancer, Childhood
Cutaneous T-Cell Lymphoma
Endometrial Cancer
Ependymoma, Childhood
Epithelial Cancer, Ovarian
Esophageal Cancer
Esophageal Cancer, Childhood
Ewing's Family of Tumors
Extracranial Germ Cell Tumor, Childhood
Extragonadal Germ Cell Tumor
Extrahepatic Bile Duct Cancer
Eye Cancer, Intraocular Melanoma
Eye Cancer, Retinoblastoma
Gallbladder Cancer
Gastric (Stomach) Cancer
Gastric (Stomach) Cancer, Childhood
Gastrointestinal Carcinoid Tumor
Germ Cell Tumor, Extracranial, Childhood
Germ Cell Tumor, Extragonadal
Germ Cell Tumor, Ovarian
Gestational Trophoblastic Tumor
Glioma, Childhood Brain Stem
Glioma, Childhood Visual Pathway and
Hypothalamic
Hairy Cell Leukemia
Head and Neck Cancer
Hepatocellular (Liver) Cancer, Adult (Primary)
Hepatocellular (Liver) Cancer, Childhood (Primary)
Hodgkin's Lymphoma, Adult
Hodgkin's Lymphoma, Childhood
Hodgkin's Lymphoma During Pregnancy
Hypopharyngeal Cancer
Hypothalamic and Visual Pathway Glioma,
Childhood
Intraocular Melanoma
Islet Cell Carcinoma (Endocrine Pancreas)
Kaposi's Sarcoma
Kidney Cancer
Laryngeal Cancer
Laryngeal Cancer, Childhood
Leukemia, Acute Lymphoblastic, Adult
Leukemia, Acute Lymphoblastic, Childhood
Leukemia, Acute Myeloid, Adult
Leukemia, Acute Myeloid, Childhood
Leukemia, Chronic Lymphocytic
Leukemia, Chronic Myelogenous
Leukemia, Hairy Cell
Lip and Oral Cavity Cancer
Liver Cancer, Adult (Primary)
Liver Cancer, Childhood (Primary)
Lung Cancer, Non-Small Cell
Lung Cancer, Small Cell
Lymphoblastic Leukemia, Adult Acute
Lymphoblastic Leukemia, Childhood Acute
Lymphocytic Leukemia, Chronic
Lymphoma, AIDS-Related
Lymphoma, Central Nervous System (Primary)
Lymphoma, Cutaneous T-Cell
Lymphoma, Hodgkin's, Adult
Lymphoma, Hodgkin's, Childhood
Lymphoma, Hodgkin's During Pregnancy
Lymphoma, Non-Hodgkin's, Adult
Lymphoma, Non-Hodgkin's, Childhood
Non-Hodgkin's During Pregnancy
Lymphoma, Primary Central Nervous System
Macroglobulinemia, Waldenstr�m's
Male Breast Cancer
Malignant Mesothelioma, Adult
Malignant Mesothelioma, Childhood
Medulloblastoma, Childhood
Melanoma
Melanoma, Intraocular
Merkel Cell Carcinoma
Mesothelioma, Malignant
Metastatic Squamous Neck Cancer with Occult
Primary
Multiple Endocrine Neoplasia Syndrome, Childhood
Multiple Myeloma/Plasma Cell Neoplasm
Mycosis Fungoides
Myelodysplastic Syndromes
Myelodysplastic/Myeloproliferative Diseases
Myelogenous Leukemia, Chronic
Myeloid Leukemia, Adult Acute
Myeloid Leukemia, Childhood Acute
Myeloma, Multiple
Myeloproliferative Disorders, Chronic
Nasal Cavity and Paranasal Sinus Cancer
Nasopharyngeal Cancer
Nasopharyngeal Cancer, Childhood
Neuroblastoma
Non-Hodgkin's Lymphoma, Adult
Non-Hodgkin's Lymphoma, Childhood
Non-Hodgkin's Lymphoma During Pregnancy
Non-Small Cell Lung Cancer
Oral Cancer, Childhood
Oral Cavity and Lip Cancer
Oropharyngeal Cancer
Osteosarcoma/Malignant Fibrous Histiocytoma of
Bone
Ovarian Cancer, Childhood
Ovarian Epithelial Cancer
Ovarian Germ Cell Tumor
Ovarian Low Malignant Potential Tumor
Pancreatic Cancer
Pancreatic Cancer, Childhood
Pancreatic Cancer, Islet Cell
Paranasal Sinus and Nasal Cavity Cancer
Parathyroid Cancer
Penile Cancer
Pheochromocytoma
Pineal and Supratentorial Primitive
Neuroectodermal Tumors, Childhood
Pituitary Tumor
Plasma Cell Neoplasm/Multiple Myeloma
Pleuropulmonary Blastoma
Pregnancy and Breast Cancer
Pregnancy and Hodgkin's Lymphoma
Pregnancy and Non-Hodgkin's Lymphoma
Primary Central Nervous System Lymphoma
Primary Liver Cancer, Adult
Primary Liver Cancer, Childhood
Prostate Cancer
Rectal Cancer
Renal Cell (Kidney) Cancer
Renal Cell Cancer, Childhood
Renal Pelvis and Ureter, Transitional Cell Cancer
Retinoblastoma
Rhabdomyosarcoma, Childhood
Salivary Gland Cancer
Salivary Gland Cancer, Childhood
Sarcoma, Ewing's Family of Tumors
Sarcoma, Kaposi's
Sarcoma (Osteosarcoma)/Malignant Fibrous
Histiocytoma of Bone
Sarcoma, Rhabdomyosarcoma, Childhood
Sarcoma, Soft Tissue, Adult
Sarcoma, Soft Tissue, Childhood
Sezary Syndrome
Skin Cancer
Skin Cancer, Childhood
Skin Cancer (Melanoma)
Skin Carcinoma, Merkel Cell
Small Cell Lung Cancer
Small Intestine Cancer
Soft Tissue Sarcoma, Adult
Soft Tissue Sarcoma, Childhood
Squamous Neck Cancer with Occult Primary,
Metastatic
Stomach (Gastric) Cancer
Stomach (Gastric) Cancer, Childhood
Supratentorial Primitive Neuroectodermal Tumors,
Childhood
T-Cell Lymphoma, Cutaneous
Testicular Cancer
Thymoma, Childhood
Thymoma and Thymic Carcinoma Thyroid Cancer
Thyroid Cancer, Childhood
Transitional Cell Cancer of the Renal Pelvis and
Ureter
Trophoblastic Tumor, Gestational
Unknown Primary Site, Carcinoma of, Adult
Unknown Primary Site, Cancer of, Childhood
Unusual Cancers of Childhood
Ureter and Renal Pelvis, Transitional Cell Cancer
Urethral Cancer
Uterine Cancer, Endometrial
Uterine Sarcoma
Vaginal Cancer
Visual Pathway and Hypothalamic Glioma,
Childhood
Vulvar Cancer
Waldenstrom's Macroglobulinemia
Wilms' Tumor
Cancer survivorship
Treatment
cycle
Lifestyle behaviours influencing
QoL / disease-free survival
Disease
recurrence /
Second primary
tumour
Cancer
diagnosis
Recovery / rehabilitation
Stages of the cancer Pre-diagnosis
experience
Treatment /
surveillance
End of life
Lifestyle
behaviours
influencing
risk
Lifestyle behaviours
influencing treatment
outcome / QoL
Time-line
Lifestyle behaviours
influencing QoL
% Risk reduction
0
Holmes et al. (2005)
(Overall mortality)
9-14.9 MET-h/week moderate intensity PA
Breast cancer studies
Holmes et al. (2005)
(Breast cancer mortality)
9-14.9 MET-h/week moderate intensity PA
Pierce et al. (2007)
(Overall mortality)
25 MET-h/week total recreational PA
Holick et al. (2008)
(Overall mortality)
4-10.2 MET-h/week moderate intensity PA
Holick et al. (2008)
(Breast cancer mortality)
4-10.2 MET-h/week moderate intensity PA
Irwin et al. (2008)
(Overall mortality)
Colorectal
cancer
studies
150 min per week moderate intensity PA
Meyerhardt et al. (2006a)
(Disease recurrence or death)
18-26.9 MET-h/week total recreational PA
Meyerhardt et al. (2006b)
(Colorectal cancer mortality)
18 MET-h/week total recreational PA
10
20
30
40
50
60
70
80
90
% Risk reduction
Prostate cancer studies
0
Kenfield et al. (2011)
(Overall mortality)
≥ 90 min/week normal/brisk pace walking
Kenfield et al. (2011)
(Prostate cancer mortality)
≥ 3 h/week vigorous activity
Richman et al. (2011)
(Prostate cancer progression)
≥ 3 h/week brisk walking
10
20
30
40
50
60
70
80
90
Weight gain is a problem
for breast cancer patients
The majority of women gain weight and %
body fat between 1-3 years post-diagnosis
(Irwin et al. 2005; JCO 23, 774-782)
Mechanisms of weight gain?
• Chemotherapy / endocrine therapy
• Reduction in lean body mass and resting
energy expenditure
• Reduction in physical activity due to fatigue
• Increased food ingestion – linked to coping
mechanisms / treatment-related appetite
• Being overweight or obese is negatively
associated with postmenopausal breast cancer
risk and survival
• Obesity is associated with later stage at
diagnosis
• Regardless of weight at diagnosis, evidence
that every 5 kg increase in body weight confers
a 14% increased risk of all cause mortality
(Reviewed in Hede et al. 2008; JNCI 100, 298-299)
• 24% improvement in relapse-free survival
evoked by diet-induced weight loss within a year
of diagnosis vs controls who gained weight
(Chlebowski et al. 2006; JNCI 98, 1767-1776)
Randomised controlled trial:
The effects of a combined Diet and
Exercise intervention on Biomarkers
associated with disease Recurrence
After breast cancer treatment:
The Sheffield DEBRA trial.
Patients
• 90 post-menopausal women with a BMI > 25
kg/m2 who completed their breast cancer
treatment 3-18 months previously randomised to
lifestyle intervention or usual care control group
Intervention – 6 months
• 3 supervised exercise sessions per week
comprising 30 min of moderate intensity aerobic
exercise (treadmill walking, stepping, cycling)
• Individualised healthy eating plan with the aim of
inducing a steady weight loss of up to 0.5 kg each
week
Changes in aerobic fitness
10.0
**
9.0
8.0
ml·kg-1·min-1
7.0
6.0
5.0
4.0
N=47
3.0
2.0
N=43
1.0
0.0
Intervention
group
Control
group
0.50
0.00
-0.50
-1.00
-1.50
-2.00
**
-2.50
Mean difference (kg/m2)
Mean difference (kg)
Body mass
BMI
0.20
0.00
-0.20
-0.40
-0.60
-0.80
-1.00
-1.20
WHR
Outliers removed
0.000
0.0
Mean difference
Mean difference (cm)
Waist circumference
-1.0
-2.0
-3.0
-4.0
-5.0
-6.0
*
**
**
Outliers included
-0.005
-0.010
-0.015
-0.020
-0.025
-0.030
-0.035
-0.040
-0.045
-0.050
**
**
Depression and quality of life
Beck Depression Inventory
15.0
12.5
10.0
**
7.5
5.0
2.5
0.0
Pre
Post
Pre
Post
Control
Group
FACT-B
**
120.0
115.0
110.0
105.0
100.0
95.0
Pre
Post
Intervention
Group
Pre
Post
Weight loss ≥1kg versus <1kg
2.00
1.50
1.00
0.50
0.00
N=48
-0.50
-1.00
-1.50
-2.00
-2.50
-3.00
-3.50
-4.00
N=42
Fatigue in clinical populations
Disease processes that limit exercise tolerance
and become apparent during physical exertion
Cardiovascular disease
Cardiac disorders
Pulmonary disease
Anaemia/blood disorders
Musculoskeletal disorders
Metabolic disorders
Hormonal disorders
Infectious diseases
Autonomic disorders
Sleep disorders
Disease
process
Pain
Poor
sleep
“Low energy
fatigue”
Stress
Drug
treatments
Low selfefficacy
Depression
• Multi-dimensional and
complex
• Not caused by exertion
and does not improve
with rest
• Subjective symptom
Anergia
•
•
•
•
•
•
•
•
•
... lack of interest, energy or spirit
... lack of physical or mental energy
... disinclined to exert effort
... loss of interest
... mental lethargy
... sluggish and indifferent
... drowsy and dull
... apathetic
... excessive tiredness/urge to sleep
Extreme and persistent tiredness, weakness or exhaustion –
mental, physical or both
… to sum up
“Those who think they
have not time for
bodily exercise will
sooner or later have to
find time for illness”
Edward Stanley, Earl of Derby 1826-1893, British
Statesman. The Conduct of Life, address at
Liverpool College, 20 December 1873.
The End