Exercise: A Way to Living

1
ExerciseA Way to Living

• Anthony Beutler, M.D.
• Brian K. Unwin, M.D.
• Jeff Goodie, Ph.D.
• Department of Family Medicine
• Uniformed Services University
• Bethesda, MD

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Overview

• Inactivity obesity related-disease epidemic
• Understanding Exercise Terminology
• How to Write an Exercise Prescription
• Considerations for adults, youth and seniors
• Provide you facts and tools to use in FP SM
  clinics

Objective
3
Overview

• Inactivity obesity related-disease epidemic
• Understanding Exercise Terminology
• How to Write an Exercise Prescription
• Considerations for adults, youth and seniors

4
Obesity EpidemicNHANES Adult Obesity
80 70 60 50 40 30 20 10
66 Overwt
31 Obese
1962 1972 1978
1992 2002
Hedley et al, JAMA 291(23) 2004
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Obesity Epidemic Modifiable Risk FactorsActual
Causes of Death
Top 3 Behavoiral
Mokdad, JAMA, 2004
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Obesity Epidemic Why Providers Dont Discuss
Behavior Change

• For Example - Smoking Cessation
• Too time-consuming (42)
• Not effective (38)
• No confidence in ability (22)
• Unpleasant personal experience (18)
• Low confidence in knowledge (16)

Vogt, Addiction, 2005
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Overview Physicians, their Patients Exercise

• 47 of primary care physicians include an
  exercise history as part of their initial
  examination
• Only 13 of patients report physicians giving
  advice about exercise
• Physically active physicians are more likely to
  discuss exercise with their patients

(Self Report)
Eakin, Am J Prev Med, 2005 Abramson, Clin J Sport
Med, 2000 Walsh, Am J Prev Med, 1999
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BMIs of US FM Docs 19 24 43 25 30 40
gt31 17 (Females more likely to have normal
BMI than males) Prelim AIM Physician BMI project
AAFP 2005
Bias?
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Overview Shifting the Paradigm
Exercise
Activity

• Exercise Training

Activity Play, Fun, Functional Fitness
Stephens, USUHS, 2001
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Overview Why Exercise?
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Overview Why Exercise?

• Be Active
• To Lose Weight
• Penance for Bad Food Choices
• Because I Have To
• Treat Disease X

I exercise because I want to and I like to enjoy
life
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Overview

• Inactivity obesity related-disease epidemic
• Understanding Exercise Terminology
• How to Write an Exercise Prescription
• Considerations for adults, youth and seniors

13
Definitions of Exercise Intensity

• Physical Activity Body movement by contraction
  of skeletal muscle which substantially increases
  energy expenditure
• Exercise Physical activity that can provide
  health benefits and improve fitness

• Low
• Moderate
• High

Heart Rate, VO2max, METs, RPE
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Definitions

• Max Heart Rate (MHR)
• 220- age MHR (/- 15 bpm)
• Heart Rate Reserve (HRR)
• HRR MHR - Resting HR(RHR)
• Target Heart Rate (THR)
• THR HRR X TI RHR
• TI - Training Intensity, usually 40-60 for
  moderate exercise

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What is VO2max?
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Definition of VO2max

• Functional aerobic capacity Maximal ability of
  the body to take in, transport and use oxygen
• Fick Equation

VO2max (HRmax x SVmax) x (CaO2max -CvO2max)
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FICK EQUATION
VO2max (HRmax X SVmax) X (CaO2max - CvO2max)
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METS
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Metabolic Equivalents

• One MET is equivalent to the amount of oxygen
  used while resting in the sitting position (3.5
  ml O2/kg/min)
• Wide individual range of variation
• Higher the skill level, wider the variation
• Based on 70 kg person
• Widely used in cardiac rehabilitation

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Energy Expenditure Activities

• Running (5 mph) 8-12
• Sex 5
• Shuffleboard 2
• Soccer 10
• Swimming 6
• Tennis 8
• Volleyball 5
• Walking 2-6

• Bowling 3
• Cycling (lt10 mph) 4
• Dancing 5
• Desk Work 6
• Golf (walking) 2
• Fishing (sitting) 1.5
• (standing) 4
• Lawn Mowing 3-8

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Relative Perceived Exertion

• God gives us our relatives--thank God we can
  choose our friends.
• - Michel de Montaigne

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Relative Perceived Exertion Scale (Borg)
Add zero to RPE HR
Add zero to C-RS MHR
RPE Scales. Original (6-20) on left, and Revised
Scale (1-10) on rightcorrelates with HR and VO2
Borg GA Medical Science in Sports and Exercise
143377-389, 1982
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Putting It All Together
Exercise Intensity
HRmax lt30 30-49 50-69 70-89 ? 90
VO2max lt25 25-44 45-59 60-84 ? 85
RPE lt10 10-11 12-13 14-16 ? 17
METS lt2.5 2.5-4.4 4.5-5.9 6.0-8.4 ? 8.5
Low
Moderate
High
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Overview

• Inactivity obesity related-disease epidemic
• Understanding Exercise Terminology
• How to Write an Exercise Prescription
• Considerations for adults, youth and seniors

25
Exercise prescription doesnt work without
addressing behavioral aspects!
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Motivational CounselingTool 1 Scaling
Questions
Rollnick S. Health Behavior Change a guide for
practitioners. Edinburgh Churchill Livingstone
2000
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Motivational Counseling SMART Goal Setting

• Specific
• Where, when, how
• Measurable
• How much? How many?
• Attainable
• Realistic
• Track

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Motivational Counseling TOOL 2 Importance and
Confidence

• FOLLOW-UP!!
• Use stepped-care approach
• Consider resources
• Physical Therapy
• Behavior change specialists
• Psychologists, Social Work, Psychiatry
• Community resources
• Support groups

Scaled Confidence Question
Patient Action Plan!
Other behavioral interventions!
SMART Goal Setting
MacGregor K et al. J Am Board Fam Med 2006 19,
215-223
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The Exercise (Activity) Prescription1 - Assess
Baseline Fitness

• Ways to Establish Patients Baseline Fitness

• SCE (Sub-maximal Cycle Ergometry)
• GXT/ETT
• AIM
• LOOK-501

Tool 3 - Americans In Motion
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The Exercise (Activity) Prescription1 - Assess
Baseline Status

• Establish Patients Baseline Fitness

• SCE
• GXT

• AIM
• LOOK-501

• Establish Goals, Realities Outcomes

• What does the patient want?
• What does the patient need?
• What does the patient already do?

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The Exercise (Activity) Prescription1 - Assess
Baseline Status

• Establish Patients Baseline Fitness

• SCE
• GXT

• AIM
• LOOK-501

• Establish Goals, Realities Outcomes

• What does the patient want?
• What does the patient need?
• What does the patient already do?

• Evaluate and Control Risk Factors

• Orthopedic risk
• Cardiovascular risk

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The Exercise (Activity) Prescription2 - Assess
Cardiovascular Risk
Does My Patient Need A Treadmill Test?
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The Exercise (Activity) Prescription2 - Assess
Cardiovascular Risk
ACSM Guidelines

• Moderate Risk
• Older individuals
• ? 2 risk factors
• High Risk
• Signs/Symptoms of cardiac dz
• Known cardiac, pulmonary or metabolic (DM)
  disease

• Low Risk
• Men lt 45, Women lt55
• No cardiac symptoms
• ?1 risk factor

• Cardiac Risk Factors
• Cigarette smoking
• Fam Hx. of early CAD
• LDL gt130 or HDL lt35
• Hypertension
• Impaired fasting gluc
• (gt110mg/dL)
• Obesity (BMI gt30)
• Sedentary lifestyle

Positive Factor High serum HDL (gt60)
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The Exercise (Activity) Prescription2 Does My
Patient Need an ETT?

• Always Screen
• Patents with known CAD
• Patients with symptoms of CAD
• Anyone with known medical disease
• Moderate risk patient for vigorous exercise

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The Exercise (Activity) Prescription3 Write
the Prescription

• Which Guideline to Use?
• American College of Sports Medicine (ACSM)
  American Heart Association
• CDC
• Surgeon General Guidelines
• National Cholesterol Education Program
• American Geriatrics Society
• American Diabetes Association

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The Exercise (Activity) Prescription

• Mode
• Duration
• Frequency
• Intensity
• Timely Follow Up
• Therapy (Preventive and/or Therapeutic)

The MD FITT Prescription
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The Exercise (Activity) Prescription3 Write
the Prescription

• 2007 ACSM Guidelines For Adults 18-65

Vigorous Intensity (jogging) 20 minutes 3 times
per week
Moderate Intensity (brisk walk) 30 minutes 5
times per week
Or
MODE
And
DURATION
FREQUENCY
Strength Building Exercise (weight/resistance
training) 8-10 exercises 2 times per week
Haskell, Med Sci Sports Exerc, 2007
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The Exercise (Activity) Prescription3 Write
the Prescription
2007 ACSM Guidelines For Adults 18-65
Intensity
Vigorous (gt6 METs) Jogging Heavy
loads Competitive Swimming Tennis Volleyball S
kiing Bicycling Etc
Light (lt 3 METs) Walking in home Light
household Leisure
Moderate (3-6 METs) Brisk walking Heavy
household Recreational Basketball
Bicycling Dancing Swimming Volleyball
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The Exercise (Activity) Prescription

• Mode
• Duration
• Frequency
• Intensity
• Timely Follow Up
• Therapy (Preventive and/or Therapeutic)

The MD FITT Prescription
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Exercise (Activity) Prescription in Adults
Orthopedic Injury vs. VO2max GainIn Vigorous
Exercise
Gettman, Med Sci Sports Exerc, 1977
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The Exercise (Activity) PrescriptionTool 4 The
AIM Fitness Prescription
Mode
Duration Frequency Intensity
Paradigm Kids Activity Adults Fitness Older
Adults Functional Fitness
Timely Followup
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Overview

• Inactivity obesity related-disease epidemic
• Understanding Exercise Terminology
• How to Write an Exercise Prescription
• Considerations for adults, youth and seniors

43
Exercise Prescription in AdultsNational Health
Interview Survey 2006
X

• One in three adults reports regular leisure time
  physical activity
• Women have higher rates of inactivity than men
• Race/Ethnicity differences
• Hispanics (22.6)
• White (33.7)
• Black (25.3)
• Less active with aging (17 _at_ 75 and older)

www.cdc.gov/nchs/data/nhis/earlyrelease/earlyrelea
se200706.pdf
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Exercise (Activity) Prescription for AdultsNew
Hopkins Projections

• By 2015
• 75 of adults overwt or obese
• 41 will be frankly obese

Epidemiologic Reviews. 2007. 29(1) 6-28
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Exercise (Activity) Prescription for AdultsThe
Adult Weight Cycle
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Overview Why Exercise?

• Be Active
• To Lose Weight
• Penance for Bad Food Choices
• Because I Have To
• Treat Disease X

I exercise because I want to and I like to enjoy
life
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Good News for Your Patients
Exercise (Activity) Prescription for
AdultsAdults, Exercise Mortality Good News
for Your Patients
Relative Risk of Total Mortality
Normal Weight (BMI 18 24)
Overweight (BMI 25-30)
Obese (BMI 31- 36)
From Lee, Am J Clin Nutr, Mar 1999
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Overview

• Inactivity obesity related-disease epidemic
• Understanding Exercise Terminology
• How to Write an Exercise Prescription
• Considerations for adults, youth and seniors

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Exercise (Activity) Prescription for
KidsBenefits of Exercise in Children

• Behavioral
• Scholastic performance
• Teen-pregnancy rate
• Smoking
• Sense of self-efficacy
• Health
• Obesity DM, HTN, CAD
• Osteoporosis

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Exercise (Activity) Prescription for KidsTrends
in Youth Exercise
How are we doing over the past 15 years?

• TV watching
• Biking
• Smoking
• Obesity

Up 100
Down 45
Still Up from 1991
Wanna Guess?

• 45 of new DM cases in 10-19 yo are DM type 2

MMWR 51(19) 409-12 Alberti, Diabetes Care, 2004
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NHANESPrevalence of Overweight Youth Ages 2-19
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Exercise (Activity) Prescription for KidsTrain
Up A Child

• 25 of obese preschoolers become obese
• 80 of obese 14 year-olds remain obese
• 70 of obese children who lose weight will
  maintain that loss as adults
• BMI at 18 years stronger predictor of DM2 than at
  ANY other age

Train up a child in the way he should go and
when he is old, he will not depart from it. -
Proverbs 226
Allen, J Pediatr, 2007 Flegal, Physiol Behav,
2005
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Exercise (Activity) Prescription for
KidsExercise Works for Children
Factors that Alter Body Fat, Body Mass, and
Fat-Free Mass in Pediatric Obesity LeMura LM,
Mazeikas MT

• Meta-analysis of 30 RCT
• Ages 5 - 17
• Pre post intervention body composition
• Exercise highly effective treatment for
  pediatric obesitylow intensity, long duration
  exercise
• Aerobic exercise combined with resistance
  training

Med Sci Sports Exerc, 2002
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Exercise (Activity) Prescription for KidsWhy
Exercise Works in Kids
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Exercise (Activity) Prescription for
KidsGuidelines for Pediatric Exercise

• 60 minutes of activity each day (minimum)
• Moderate-to-vigorous activity
• Can accumulate in small bouts, wide variety of
  sports activities

• - American Academy of Pediatrics
• - American College of Sports Medicine

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Exercise Training in ChildrenStrength Training
in Children

• Myths Facts
• Recommendations for Strength Training in Children
• Final Cautions

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• Not my fault being the biggest and the strongest.
  I dont even exercise.

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Exercise Training in ChildrenStrength Training
Myth 1

• Myth
• Children cant build muscular strength until
  after puberty
• Vrijens Med Sport 1978

• Fact
• 22-74 strength gains in boys girls after 8
  weeks of training
• Faigenbaum, Ramsay, Lillegard and others

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Exercise Training in ChildrenStrength Training
Myth 2

• Myth
• Weightlifting will stunt a childs growth
• Kato, Jap Un Sport Sci, 1964

• Fact
• No decrease in stature, improved bone density
  with proper nutrition weightlifting
• Arendt, Clarke, Morris

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Exercise Training in ChildrenStrength Training
Myth 3

• Myth
• Weightlifting provides only anaerobic exercise

• Fact
• Heart rate sustained at 130 - 150 bpm for 30
  minutes in 12-15 yo weightlifters
• Faigenbaum, Clin Sport Med, 2000

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Exercise Training in ChildrenStrength Training
Myth 4

• Myth
• Growth plate injuries are common in prepubescent
  and adolescent weightlifters
• - NEISS reports

• Facts
• Rare case reports only
• No reported growth plate injuries in over 100
  studies of weightlifting in chidren
• Micheli, Clin Sport Med, 2000

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Exercise Training in ChildrenStrength Training
Myth 5

• Myth
• I dont want my baby hanging out with a bunch of
  half-naked, iron-pumping hooligans

• Facts
• Improved self-efficacy and self-esteem in 12-16
  yo girls who participated in 12 weeks of strength
  training
• Holloway, J Appl Psych, 1998

• Facts
• You can pick your friends and your kid can pick
  his nose, but you cant pick your kids friends
• - Chris Farley, noted philosopher

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Exercise Training in ChildrenRecommendations
for Strength Training

• Begin with 1 set of 10-15 reps
• 6-8 exercises, mix of upper and lower body
• Both single and multi-joint exercises

• Emphasize proper technique

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Exercise Training in ChildrenRecommendations
for Strength Training

• Progression based on individual needs and goals
• 1 to 3 sets
• 8-15 reps per set
• 2-3 nonconsecutive training sessions per week
• Increase resistance 5-10 as strength improves

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Exercise Training in ChildrenFinal Cautions in
Weightlifting

• Qualified Adult Supervision
• No Pain, No Gain... No Way!
• Focus on Proper Technique
• Beware the dreaded Add-On

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Overview

• Inactivity obesity related-disease epidemic
• Understanding Exercise Terminology
• How to Write an Exercise Prescription
• Considerations for adults, youth and seniors

67
Exercise (Activity) Prescription for Older
AdultsDis-fitness Cycle
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Exercise (Activity) Prescription for Older Adults
Fitness and Functional Status
Normal
Healthy Adults
Function
Near Frail
THRESHOLD
Poor
Frail Adults
Strength
Low
High
Established Populations for Epidemiologic Studies
of the Elderly (EPESE) . J Gerontology,
199449(3)M109-15
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Exercise (Activity) Prescription for Older Adults
Exercise and Aerobic Capacity
Active
Active Aging
Reduced Activity Weight Gain
VO2 Max
Sedentary
Exercise Intervention
80
20
Age
70
Exercise (Activity) Prescription for Older Adults
Strength Use It Lose Less of it

• Losses

• Gains

• Sedentary people lose large amounts of muscle
  mass (20-40)
• 6 per decade loss of Lean Body Mass (LBM)

• Lean body mass increases 1-3 kg
• Resistance training improves strength by a range
  of 40-150
• Muscle fiber area 10-30

Aerobic Activity IS NOT sufficient to stop this
loss!

• BOTTOM LINES
• MUSCLE STRENGTHENING EXERCISES REQUIRED
• MUST INCLUDE BALANCEFLEXIBILITY IN OLDER ADULTS
• FEWER FALLS, FRACTURES, DISUSE, FRAILTY AND
  SARCOPENIA

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Exercise (Activity) Prescription for Older
AdultsWhats Different for Older Adults?
2007 ACSM Guidelines For Older Adults
Intensity Rating 5-6/10 Intensity is relative
to level of fitness
Balance Exercise (not specified) 3 times per week
Moderate Intensity (brisk walk) 30 minutes 5
times per week
Vigorous Intensity (jogging) 20 minutes 3 times
per week
Flexibility Activities (static stretch) 10
minutes 10-30 seconds/stretch 3-4 repetitions All
days of the week
Strength Building Exercise (weight/resistance
training) 8-10 exercises 2 times per week
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Exercise (Activity) Prescription for Older
AdultsA little more about balance
Dynamic
Static
Intensitysensory or time
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The MD FITT Prescription (for the older adult)

• Mode
• AerobicStrength BalanceFlexibility
• Duration
• Frequency
• Intensity
• Touch gt No Touch gt Eyes Closed for balance
• 5-6/10 self-perceived exertion
• Timely Follow Up
• Therapy (Preventive and/or Therapeutic)

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Exercise (Activity) Prescription for Older Adults
Tool 5
http//www.nia.nih.gov/NR/rdonlyres/8E3B798C-237E-
469B-A508-94CA4E537D4C/0/NIA_Exercise_Guide407.pdf
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Finish Line!

• Obesity and chronic disease epidemic
• Ours and Theirs Problem
• Motivational counseling technique
• Scaled Questions
• Importance and Confidence

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Finish Line!

• Basics of the exercise Rx
• Paradigms (Activity and Fitness)
• Assess baseline fitness
• Assess risks
• MD FITT
• Mode, Duration, Frequency, Intensity, Timely
  follow up and Therapy (Preventive and
  Therapeutic)

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Finish Line!

• Exercise Rx for
• Youth
• Adults
• Seniors
• Components
• Aerobic Strength Flexibility

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Questions?
Exercise Prescription From Eight to Eighty
Activity
Brian Unwin, MD Colonel, USA, MC Department of
Family Medicine Uniformed Services University
Anthony Beutler, MD Major, USAF, MC Department of
Family Medicine Uniformed Services University
Washington D.C. Stretch Limo
Preston, Idaho Stretch Limo