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Exercise: A Way to Living

Exercise: A 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. Overview. Inactivity & obesity related-disease epidemic Understanding Exercise Terminology

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Exercise: A Way to Living

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  1. Exercise:A 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

  2. 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

  5. Obesity Epidemic Modifiable Risk Factors“Actual Causes of Death” Top 3 Behavoiral Mokdad, JAMA, 2004

  6. Obesity Epidemic Why Providers Don’t 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

  7. 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

  8. BMI’s of US FM Docs: 19 – 24: 43% 25 – 30: 40% >31: 17% (Females more likely to have normal BMI than males) Prelim AIM Physician BMI project – AAFP 2005 Bias?

  9. Overview Shifting the Paradigm: Exercise Activity Exercise = Training Activity = Play, Fun, Functional Fitness Stephens, USUHS, 2001

  10. Overview Why Exercise?

  11. 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”

  12. 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

  14. 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

  15. What is VO2max?

  16. 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)

  17. Diffusion Ventilation Perfusion FICK EQUATION (220 - Age) Sinus Node Dysfunction Drugs (e.g., B - blockers) PaO2 Hgb [ ] SaO2 • Skeletal Muscles • Aerobic Enzymes • Fiber Type • Muscle Disease • Capillary Density Genetic Factors (Heart Size) Conditioning Factors Contractility/Afterload/Preload Disease Factors Wall Motion/Ventricular Fxn Valve Stenosis or Regurgitation VO2max = (HRmax X SVmax) X (CaO2max - CvO2max)

  18. METS The MET

  19. 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

  20. Energy Expenditure Activities Activity METS Activity METS Bowling 3 Cycling (<10 mph) 4 Dancing 5 Desk Work 6 Golf (walking) 2 Fishing (sitting) 1.5 (standing) 4 Lawn Mowing 3-8 Running (5 mph) 8-12 Sex 5 Shuffleboard 2 Soccer 10 Swimming 6 Tennis 8 Volleyball 5 Walking 2-6

  21. Relative Perceived Exertion • “God gives us our relatives--thank God we can choose our friends.” - Michel de Montaigne

  22. Relative Perceived Exertion Scale (Borg) Category RPE Scale Category-Ratio Scale 6 0 Nothing at all 7 Very, very light 0.3 8 0.5 Extremely weak 9 Very light 0.7 10 1 Very weak 11 Fairly Light 1.5 12 60% VO2 Max 2 Weak 13 Somewhat hard 2.5 14 3 Moderate 15 Hard 4 16 85% V02 Max 5 Strong 17 Very Hard 6 18 7 Very strong 19 Very, very hard 8 20 9 10 Extremely strong * Add zero to RPE = HR * Add zero to C-RS = % MHR RPE Scales. Original (6-20) on left, and Revised Scale (1-10) on right—correlates with HR and VO2 Borg GA: Medical Science in Sports and Exercise 143:377-389, 1982

  23. Putting It All Together Exercise Intensity HRmax <30% 30-49% 50-69% 70-89%  90% VO2max <25% 25-44% 45-59% 60-84%  85% METS <2.5 2.5-4.4 4.5-5.9 6.0-8.4  8.5 RPE <10 10-11 12-13 14-16  17 Low Moderate High

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

  25. Exercise prescription doesn’t work without addressing behavioral aspects!

  26. Motivational CounselingTool #1: Scaling Questions How important is it for you to change__? 0 1 2 3 4 5 6 7 8 9 10 Most important Not at all 0 1 2 3 4 5 6 7 8 9 10 How confident are you that you can change__? Completely Not at all Rollnick S. Health Behavior Change: a guide for practitioners. Edinburgh: Churchill Livingstone; 2000

  27. Motivational Counseling SMART Goal Setting Specific Where, when, how Measurable How much? How many? Attainable Realistic Track

  28. 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

  29. The Exercise (Activity) Prescription#1 - Assess Baseline Fitness Ways to Establish Patient’s Baseline Fitness Tool #3 - Americans In Motion • SCE (Sub-maximal Cycle Ergometry) • GXT/ETT • AIM • LOOK-501

  30. The Exercise (Activity) Prescription#1 - Assess Baseline Status Establish Patient’s Baseline Fitness • AIM • LOOK-501 • Establish Goals, Realities & Outcomes • What does the patient want? • What does the patient need? • What does the patient already do? • SCE • GXT

  31. The Exercise (Activity) Prescription#1 - Assess Baseline Status Establish Patient’s Baseline Fitness • 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 • SCE • GXT

  32. The Exercise (Activity) Prescription#2 - Assess Cardiovascular Risk Does My Patient Need A Treadmill Test?

  33. The Exercise (Activity) Prescription#2 - Assess Cardiovascular Risk ACSM Guidelines • Low Risk • Men < 45, Women <55 • No cardiac symptoms • 1 risk factor • Moderate Risk • “Older” individuals •  2 risk factors • High Risk • Signs/Symptoms of cardiac dz • Known cardiac, pulmonary or metabolic (DM) disease • Cardiac Risk Factors • Cigarette smoking • FamHx. of early CAD • LDL >130 or HDL <35 • Hypertension • Impaired fasting gluc • (>110mg/dL) • Obesity (BMI >30) • Sedentary lifestyle “Positive” Factor:High serum HDL (>60)

  34. The Exercise (Activity) Prescription#2 – 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

  35. The Exercise (Activity) Prescription#3 – 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

  36. The Exercise (Activity) Prescription The “MD FITT” Prescription • Mode • Duration • Frequency • Intensity • Timely Follow Up • Therapy (Preventive and/or Therapeutic)

  37. The Exercise (Activity) Prescription#3 – Write the Prescription 2007 ACSM Guidelines For Adults 18-65 Moderate Intensity (brisk walk) 30 minutes 5 times per week Vigorous Intensity (jogging) 20 minutes 3 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

  38. The Exercise (Activity) Prescription#3 – Write the Prescription 2007 ACSM Guidelines For Adults 18-65 Intensity Vigorous (>6 METs) Jogging Heavy loads “Competitive”: Swimming Tennis Volleyball Skiing Bicycling Etc Light (< 3 METs) Walking in home Light household Leisure Moderate (3-6 METs) Brisk walking Heavy household “Recreational”: Basketball Bicycling Dancing Swimming Volleyball

  39. The Exercise (Activity) Prescription • Mode • Duration • Frequency • Intensity • Timely Follow Up • Therapy (Preventive and/or Therapeutic) The “MD FITT” Prescription

  40. Exercise Duration Exercise Frequency Minutes per Session Sessions per Week Orthopedic Injury VO2max Gain Exercise (Activity) Prescription in Adults Orthopedic Injury vs. VO2max GainIn Vigorous Exercise Gettman, Med Sci Sports Exerc, 1977

  41. The Exercise (Activity) PrescriptionTool # 4 The AIM Fitness Prescription Mode Duration + Frequency + Intensity Paradigm: Kids: Activity Adults: Fitness Older Adults: Functional Fitness Timely Followup

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

  43. X Exercise Prescription in AdultsNational Health Interview Survey: 2006 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% @ 75 and older) www.cdc.gov/nchs/data/nhis/earlyrelease/earlyrelease200706.pdf

  44. By 2015: 75% of adults overwt or obese 41% will be frankly obese Exercise (Activity) Prescription for AdultsNew Hopkins Projections Epidemiologic Reviews. 2007. 29(1): 6-28

  45. Merry Christmas Exercise (Activity) Prescription for AdultsThe Adult Weight Cycle

  46. 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”

  47. Good News for Your Patients Unfit (no exercise) 5.7 Fit (regular exercise) 3.8 3.2 1.9 1.4 1.0 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

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

  49. 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

  50. TV watching Biking Smoking Obesity Exercise (Activity) Prescription for KidsTrends in Youth Exercise How are we doing over the past 15 years? 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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