Exercise Prescription from Eight to Eighty

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Exercise Prescription from Eight to Eighty
Activity

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

2
Overview

• Obesity chronic disease epidemic
• Motivational counseling technique
• Basics of the exercise Rx
• Exercise Rx for youth and adults
• The exercise Rx for seniors
• Provide you facts and tools to use in clinic

Objective
3
Overview

• Obesity chronic disease epidemic
• Motivational counseling technique
• Basics of the exercise Rx
• Exercise Rx for youth and adults
• The exercise Rx for 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
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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(No Transcript)
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Overview Shifting the Paradigm
Exercise
Activity

• Exercise Training

Activity Play, Fun, Functional Fitness
Stephens, USUHS, 2001
10
Overview

• Obesity and chronic disease epidemic
• Motivational counseling technique
• Basics of the exercise Rx
• Exercise Rx for youth and adults
• The exercise Rx for seniors

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Exercise prescription doesnt work without
addressing the behavior!
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Motivational CounselingTool 1 Scaling
Questions
How important is it for you to change__?
How confident are you that you can change__?
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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Overview

• Obesity and chronic disease epidemic
• Motivational counseling technique
• Basics of the exercise Rx
• Exercise Rx for youth and adults
• The exercise Rx for seniors

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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) PrescriptionOrthopedic
Risk

• Kids/Teens Dont you ignore
• Adults Dont let patients ignore
• Older Adults
  Be positive!

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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?
Low Risk Mod Risk High Risk
Moderate Exercise NOT NECESSARY NOT NECESSARY RECOMMENDED
Vigorous Exercise NOT NECESSARY RECOMMENDED RECOMMENDED

• 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) 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

• Obesity epidemic the Big problem
• Motivational counseling technique
• Basics of the exercise Rx
• Exercise Rx for youth and adults
• The exercise Rx for 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 (Activity) Prescription for KidsWhy
Exercise Works in Kids

• Begin with 1 set of 10-15 reps progression to 3
  sets
• 6-8 exercises, mix of upper and lower body
• Both single and multi-joint exercises
  non-consecutive sessions
• Resistance increase by 5-10 as strength improves

• Emphasize proper technique and adult supervision

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Overview

• Obesity epidemic the Big problem
• Motivational counseling technique
• Basics of the exercise Rx
• Exercise Rx for youth and adults
• The exercise Rx for seniors

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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)

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Exercise (Activity) Prescription for AdultsNew
Hopkins Projections

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

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Exercise (Activity) Prescription for AdultsThe
Adult Weight Cycle
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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

• Obesity epidemic the Big problem
• Motivational counseling technique
• Basics of the exercise Rx
• Exercise Rx for youth and adults
• The exercise Rx for seniors

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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
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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

53
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 and adults
• Flexible Paradigm (FP)
• Children Train up
• Adults Fitness
• Seniors Functional Fitness
• Components
• Aerobic Strength

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Finish Line!

• The exercise Rx for seniors
• Aerobic strength
• Balance and flexibility
• Tools to Use

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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
BEAT NAVY!
Washington D.C. Stretch Limo
Preston, Idaho Stretch Limo