From Z Lines to Pt Selection

A presentation at the American College of Lifestyle Medicine:

Lifestyle 2012 10/1/12

Stephan Esser MDwww.esserhealth.com

Disclosures

• None

Goals

• Plant Seeds• Stimulate Dialogue• Harvest Ideas

• Identify Opportunity• Unravel a Solution• Empower you to empower others

Have FunHave Fun

Goals

• Provide applicable knowledge

• Equip you with tools to promote change

• Practice skills

• Develop a plan of action

• Take it home

• Apply it

Goals

• Review foundational ideas in muscle physiology• Explore concepts in Exercise as medicine• How your habits affect patient success• ACSM criteria and patient selection • Review the basics of patient change and

motivation• Develop Exercise prescription writing skills

What this is NOT!

• The END

• The final word

• Everything you need to know

• For that……..

Why none of us do what we know we should do and want to do ALL the time

Reasons NOT to Counsel on Exercise

• Time Limitations • Inadequate reimbursement• Personal Fitness• Don’t feel adequately prepared (lack of confidence,

training, instruments and materials)• Physician Specialty• Perceived lack of success at advising exercise • Lack of confidence in the exercise provider

Breakout: 2 minutes

Ask what your neighbor’s reasons are for NOT counseling on Physical Activity

Efficacy of Physician Counseling

• Recent study of hypertensive patients, only a third received counseling to engage in physical activity as a way to manage their hypertension.

• However, 71% of the patients who were counseled followed the recommendations to exercise and reduced their blood pressure. – Halm, Ethnicity and Disease 2008

• A recent study showed that diabetic patients received counseling/referral for nutrition only 36% of the time, and for exercise only 18% of the time.

Peek, J Gen Intern Med, 2008

1975-Teach medical students about exercise as preventive medicine

– 74 medical school participated in questionnaire– 16% offered a course geared to exercise as

preventive medicine

Burke EJ, Hultgren PB. Will Physicians of the Future Be Able to Prescribe Exercise? J Med Educ. 1975;50:624-6.

Exercise Courses inMedical Schools

• 2001-Medical school leaders including Deans and Directors of Medical Education have reported – 72 out of 128 medial schools participated in

questionnaire– 6% of medical schools polled reported having

a core course addressing the exercise prescription

• Connaughton AV,Weiler RM, Connaughton D. Graduating Medical Students’ Exercise Prescription Competence as Perceived by Deans and Directors of Medical Education in the United States: Implications for Healthy People 2010. Public Health Reports. 2001;116:226-234.

Deans Report of Medical Student’s Competency in Exercise Prescription

Connaughton AV,Weiler RM, Connaughton D. Graduating Medical Students’ Exercise Prescription Competence as Perceived by Deans and Directors of Medical Education in the United States: Implications for Healthy People 2010. Public Health Reports. 2001;116:226-234.

10%

90%

Our Obligation

• The physician is obligated to broach critical lifestyle areas.

• Avoidance or lack of comment by the physician may be perceived as tacitly condoning the unhealthy behaviors.

• The physician has an important opportunity to promote behavior change and be supportive of the change process.

• Need to ask about physical activity and to prescribe exercise.

• Effective and efficient delivery of message from physician to improve health behaviors. “Talk the Talk.”

• Need to establish physicians as role models of healthy behaviors. “Walk the Walk.”

Goals

• Why this matters?

The State of the Nation

“A global response to a global problem: the epidemic of

overnutrition.” WHO

It is estimated that by 2020 2/3rds of the global burden of disease will be attributable to

chronic non-communicable diseases, most of them strongly associated with diet. The nutrition

transition towards refined foods, foods of animal origin, and increased fats plays a major role in the current global epidemics of obesity, diabetes and cardiovascular diseases, among

other non-communicable conditions. Sedentary lifestyles and the use of tobacco are also significant

risk factors. …….. A concerted multi-sectoral approach, involving the use of policy, education and

trade mechanisms, is necessary to address these matters.

Top Ten Causes of Death for Men in the United States

Actual Causes of Death in US

2 of 3 2 of 3

Associated Pathology• CVD:

– Hypertension– Congestive Heart Failure– PVD– Impotence– Claudication

• Endocrine:– Diabetes– PCOS – Hypothyroidism– Infertility

• Orthopedics:– Osteoarthritis– AVN

• Hepatic:– #1 cause of liver dz in US

• Obstetrics:– Gestational DM – Macrosomia– Inc. C Section rate– Inc. Perinatal Morbidity– Inc. Pre/Eclampsia

• Cancer:– Prostate– Colon– Breast– Endometrial– Renal Cell– Gallbladder– Esophageal Adeno.

• Other:• Hyperuricemia, Pancreatitis, Gallstones,

Sleep Apnea, Alzheimer’s, Dyslipidemia, Metabolic Syndrome

The Problem

1:9 adults 1:9 adults

The Problem

• High Blood Pressure:– 1 in 3 adults

1:3 adults1:3 adults

1:6 adults1:6 adults

Waist Circumference > 40” M > 35” W

Triglycerides > 150 HDL < 40 M or < 50 W

BP ≥ 130/85 Fasting Glucose of ≥ 100

> 34% of Americans

Perspective• We eat more

– Sugar, Salt, Fat, Meat, Dairy– 1970-2006:

• 24.5 % C/day 617K/day

• We get less then ideal Physical Activity– 18.8% of adults achieved CDC reccs on Exercise– 10% of adults >65 y/o

Michelangelo’s David: 12 month 20 city tour of the US

“A global response to a global problem: the epidemic of overnutrition.” WHO

It is estimated that by 2020 2/3rds of the global burden of disease will be attributable to chronic noncommunicable diseases, most of them strongly associated with diet. The

nutrition transition towards refined foods, foods of animal origin, and increased fats plays a

major role in the current global epidemics of obesity, diabetes and cardiovascular diseases,

among other noncommunicable conditions. Sedentary lifestyles and the use of tobacco

are also significant risk factors. …….. A concerted multi-sectoral approach, involving the use of policy, education and trade mechanisms,

is necessary to address these matters.

……if…….Lifestyle is the Problem

……if…….Lifestyle is the Problem

What is the answer……..?What is the answer……..?

Lifestyle Medicine

Physical Modalities

Pharmaceuticals

Surgery

Lifestyle Medicine

• Nutrition

• Physical Activity

• Emotional Poise

• Avoidance of Toxins

Exercise and Physical Health• Reduces risk of

– Heart Disease ≈ 40%– Obesity: ≈ 30-100%– Stroke ≈ 50%– Type 2 Diabetes ≈ 50%– Hypertension ≈ 50%– Disability delayed ≈15 years– Colon Cancer ≈ 25-40%– Breast Cancer ≈ 20%-44%– Osteoporosis ≈ 20+%

• As many as 250,000 deaths per year in the United States are attributable to a lack of regular physical activity

Physical Health Cont’d

• Improve Balance/Reduce Fall risk

• Reduce/Prevent Disability

• Improve Systemic Circulation

• Accelerate Skin Healing

• Bowel Regularity/ risk diverticulosis

• Improved Energy/Resilience

Exercise and Mental Health

• Regular Exercise:– Reduces risk/severity of:

• Depression• Anxiety• ADD/ADHD• Alzheimers Dementia

– Improves:• Mental Clarity, test scores, focus

Exercise and Emotional Health

• Regular Exercise:– Increases Self Confidence

– Teaches skills to manage adversity

– Enhances Self Esteem

– Develops Discipline

– Encourages Goal setting and self awareness

“Eating alone will not keep a man well; he must also take exercise. For food and exercise……

work together to produce health.”Hippocrates

Regimen 400 BC

Our Goal

• Support patients in achieving their BEST Health

• Get patients moving

• Know your stuff• Patients needs• Stages of change• Effectively communicate• Educate, empower, motivate

Make it FUNMake it FUN

Mini-Medschool

Muscle anatomy and physiology

• Muscle Types:– Striated: Skeletal, Cardiac– Smooth: Walls of hollow structures

– Stomach, bladder, intestines, vessels

• Muscle Innervation:– Voluntary: Skeletal– Involuntary: Cardiac, Smooth


http://media.tumblr.com/tumblr_ll9jc5uZcM1qcfmqz.gif

Z-Lines: Borders of each SarcomereZ-Lines: Borders of each Sarcomere

Sarcomere: The basic functional unit of a muscle

Sarcomere: The basic functional unit of a muscle

The A Band does NOT shortenThe A Band does NOT shorten


• Fiber Types:– Type I: slow, oxidative fibers

• mitochondria, myoglobin, capillaries• resistance to fatigue

– Type IIA: fast, oxidative fibers• myoglobin• Intermediate fatigue resistance

– Type IIB: very fast, glycolytic fibers• glycogen, anaerobic action• Rapidly fatigue

Basic Principles

• Size Principle:– Motor units are recruited in order of fiber size,

Type 1 smaller, Type 2 larger– Inc firing in response to demands


• Fiber Types Continued:– Force Production:

• Low: Type I• High: Type IIA• Very High: Type IIB

– Concentration:• Average: 60% fast twitch, 40% slow

– Location/Function:• UE: Fast Para-vertebrals: Slow


• Can you change Fiber Types?– Endurance Training:

• ’d oxidative potential • Debatable change in fiber type distribution

– Resistance Training:• ’d muscle fiber hypertrophy/cross-sectional area• Debatable change in fiber type distribution

What we Know?

• The need for exercise

• The benefits of exercise

• The basic science of muscle

Foundational Concepts

Defining Exercise

• Exercise:– movement of the body resulting in the

enhancement of health and/or improvement of function

Exercise

• Leisure time Exercise: organized sports, running, gym activities, rehabilitation etc.

• Lifestyle Exercise: activity incorporated into our daily pattern of life – eg: parking in the distant portion of the parking lot rather then the first

bumper, taking the stairs instead of the elevator etc.

Types of Physical Activity

• Cardiovascular

• Strength/Resistance Training

• Core Stability/Balance

• Flexibility/Coordination

Cardiovascular Training Adaptations

Cardiorespiratory Adaptations

• High, acute stress to the CV system

• Inc HR, SV, CO, BP

• Chronic:

– Inc. Vo2Max, SV

– Decr. Resting HR, BP (HTN -4%/-5%, NT -2%/-1%),

Immune System Changes/Adaptations

• Beneficial Effects: Regular, Moderate

• Harmful Effects: Extreme, Excessive – Decr. neutrophil respiratory burst, lymphocyte

proliferation, monocyte antigen presentation

– >1.5 h, of moderate to high intensity (55–75% maximum O2 uptake), and performed without food intake

Resistance Training Basics

Basic Principle• Progressive Overload: (Delorme Principle)

– Gradual increase in stress upon the body results in increases in tolerance and eventual plateau

– SAID (Specific Adaptations to Imposed Demands)

– Greater Demand = Greater Adaptation within genetic potential

Basic Principles

• Hyperplasia: Inc in the number of muscle fibers within a given muscle ≈ 5%

• Hypertrophy: Inc in the size of individual muscle fibers/or an entire muscle ≈ 95%

Lingo• Weight: ………

• Repetitions (Reps): Number of times each motion/exercise performed

• Sets: Number of times a group of repetitions is performed

• Rep. Max (RM): Highest weight with which an exercise can be performed (usually one time)

Basic Principles

• Low Weight/High Repetition = greater focus on cardiovascular/endurance benefits

– Eg: > 15 reps

• High Weight/Low Repetition = greater focus on anabolism, strength

– Eg: 5-8 reps

Contraction Types

Resistance Training Adaptations

Neuromuscular Adaptations

• Early Adaptations: Week 1-8– Inc. neural drive: motor unit recruitment and rate

of firing, synchronization of motor units, coordination of agonist/antagonist firing

– Alterations in myosin heavy chains and ATPase enzymes

– 16 workouts for significant muscle hypertrophy

• Late Adaptations: > 8 weeks– Primarily muscle hypertrophy

Cardiorespiratory Adaptations

• High, acute stress to the CV system

• Inc HR, SV, CO, BP

• Chronic:

– Dec resting HR of 5-12%

– Dec SBP and DBP by 2% and 4%

Connective Tissue Adaptations

• Bone is dynamic responding to compression, strain– Increased intensity = increased response– Goal > 60% 1RM– Stress results in inc. BMD– Takes time ≈ 6 months, begins with Inc serum alk

phos. and osteocalcin at 1 month

• Soft Tissue:– Inc. collagen size, number and packing density

Endocrine Adaptations• Testosterone/ GH/ IGF/ Insulin / Cortisol • Acute Changes:

– Inc T and GH during and for 15-30 minutes post in men– Affects in women less studied/less clear– Magnitude of change greatest when large muscle mass is

exercised at mod/high intensity and volume with short rest periods

• Chronic Changes:– Resting T [] variable– No change in resting GH, however various sizes/forms– Inc IGF-1 at rest. – No clear change in resting cortisol

Immune System Changes/Adaptations

• Inc circulating Leukocytes 8-14% over next 24 hrs

• Inc circulating Lymphocytes 50-200%

– NK cell cytotoxic activity by 40% 2 hrs post

Comparative Benefits

Types of Physical Activity

• Cardiovascular

• Strength/Resistance Training

• Core Stability/Balance

• Flexibility/Coordination

What we know!

• The value of movement• The basic science of muscle• Foundational terms and principles

Next• Goals• Patient Selection

Our Goals

• For the overwhelming majority of patients the benefits of exercise outweigh risk

• We must identify those at risk and appropriately screen and select them

• We must help establish goals and assist in their achievement

Phases of Activity

• Phase I: Contemplation, screening and motivation

• Phase II: From start to ACSM/AHA exercise recommendations

• Phase III: Maintaining or going beyond ACSM/AHA recommendations

Up Next

• Risk Stratification

• Readiness for Change

• Exercise Prescription Writing

• Motivation: Improving Engagement

SimpleMinimal CostOne step screenValidated

Patient answered NO to all seven questions on the

PAR-Q

Low risk:Client can begin exercise program

unsupervised

Symptomatic or known

cardiovascular, pulmonary or

metabolic disease

Patient completes the

PAR-Q

Moderate risk:Client requires supervision or

modifications to exercise program

High risk:Client requires further medical assessment

prior to initiating exercise program

RISK STRATIFICATION FOR SEDENTARY PATIENTS

Patient answered YES to one or

more questions on the PAR-Q

< 2 risk factors for CV, pulmonary or metabolic disease

≥ 2 risk factors for CV, pulmonary or metabolic disease

Uncomplicated pregnancy

Complicated Pregnancy

Other medical conditions

Risk Factors

• Family History– Relative with early CAD (M<55, W<65)

• Smoking: present or last 6 months• Dyslipidemia: LDL >130, HDL<40, Tch>200• Hypertension: SBP>140, DBP>90• Elevated Blood Glucose: > 100 2x’s• Obesity

Low Risk

• Men < 45 y/o • With ≤ 1 risk factor

• Women < 55 y/o– With ≤ 1 risk factor

Moderate Risk

• Men ≥ 45 and Women ≥ 55

• ≥ 2 risk factors

High Risk

• Known CAD, CVD, PVD

• Known Pulmonary Disease

• Signs/Symptoms suggestive of the above

CARDIOVASCULAR/METABOLIC RISK FACTORS: <2 risk factors = LOW RISK; ≥2 = MODERATE RISK• male > 45 years old• female > 55 year old, or has had hysterectomy, or is post menopausal• smoker (or quit within past 6 months)• BP > 140/90mmHg • on BP medication• blood cholesterol >200mg/dL• close blood relative who had heart attack or heart surgery before age 55 (male) or 65 (female)• >20 pounds overweight• pre-diabetes• sedentary lifestyle

CARDIOVASCULAR/METABOLIC RISK FACTORS: <2 risk factors = LOW RISK; ≥2 = MODERATE RISK• male > 45 years old• female > 55 year old, or has had hysterectomy, or is post menopausal• smoker (or quit within past 6 months)• BP > 140/90mmHg • on BP medication• blood cholesterol >200mg/dL• close blood relative who had heart attack or heart surgery before age 55 (male) or 65 (female)• >20 pounds overweight• pre-diabetes• sedentary lifestyle


OTHER RISK FACTORS (MODERATE RISK)• pregnancy• musculoskeletal problems that limit physical activity• client takes prescription medication that may influence exercise tolerance• client has concerns about the safety of exercise

OTHER RISK FACTORS (MODERATE RISK)• pregnancy• musculoskeletal problems that limit physical activity• client takes prescription medication that may influence exercise tolerance• client has concerns about the safety of exercise


CARDIOVASCULAR and PULMONARY S/S (HIGH RISK):• heart attack or heart failure• heart surgery or transplantation• cardiac catheterization• coronary angioplasty• pacemaker/implantable cardiac• defibrillator/rhythm disturbance• heart valve disease• congenital heart disease• chest discomfort with exertion• unreasonable breathlessness• dizziness, fainting or blackouts• takes heart medications• burning or cramping sensation in lower legs when walking short distances• asthma or other lung disease

CARDIOVASCULAR and PULMONARY S/S (HIGH RISK):• heart attack or heart failure• heart surgery or transplantation• cardiac catheterization• coronary angioplasty• pacemaker/implantable cardiac• defibrillator/rhythm disturbance• heart valve disease• congenital heart disease• chest discomfort with exertion• unreasonable breathlessness• dizziness, fainting or blackouts• takes heart medications• burning or cramping sensation in lower legs when walking short distances• asthma or other lung disease


MAJOR SIGNS and SYMPTOMS of CARDIOVASCULAR, PULMONARY or METABOLIC DISEASE (HIGH RISK):

•chest discomfort with exertion• dizziness, fainting or blackouts• takes heart medications• bilateral ankle edema • unreasonable breathlessness (at rest, with mild exercise, or when recumbent)• burning or cramping sensation in lower legs when walking short distances• pain or discomfort in the chest, neck, jaw, arms, or elsewhere that may be d/t ischemia

MAJOR SIGNS and SYMPTOMS of CARDIOVASCULAR, PULMONARY or METABOLIC DISEASE (HIGH RISK):

•chest discomfort with exertion• dizziness, fainting or blackouts• takes heart medications• bilateral ankle edema • unreasonable breathlessness (at rest, with mild exercise, or when recumbent)• burning or cramping sensation in lower legs when walking short distances• pain or discomfort in the chest, neck, jaw, arms, or elsewhere that may be d/t ischemia

Risk Stratification Algorithm

Adapted from: American College of Sports Medicine. ACSM's Guidelines for Exercise Testing and Prescription, 8th edition. Philadelphia: Lippincott Williams & Wilkins; 2009.(chapter 2)

Risk Stratification

• Low Risk: No additional testing needed

• Moderate Risk: Exercise testing if planning for vigorous intensity activity

• High Risk: Exercise testing prior to engaging in moderate or vigorous

Cases

Cases

62 y/o plays doubles tennis regularly

On HCTZ 12.5 for SBP and low dose Statin

Wants to train for a charity ½ marathon for breast cancer

Case

• Evaluating your patient’s activity

Present Recommendations

• Cardiovascular:– 150 minutes of moderate-intensity exercise per

week.

– 30-60 minutes of moderate-intensity exercise (five days per week) or 20-60 minutes of vigorous-intensity exercise (three days per week).


• Resistance Training:– 2-3 days per week– All major muscle groups– 2-4 sets of each exercise– 48 hours in between sessions

http://www.acsm.org/about-acsm/media-room/news-releases/2011/08/01/acsm-issues-new-recommendations-on-quantity-and-quality-of-exercise


• Flexibility:– 2-3 days/week to improve range of motion

• Balance:– 2-3 days/week– Eg: Tai Chi, Yoga

• What are they already doing?

Physical Activity Vital Sign

• “Over the last week on how many days did you do at least 30 minutes of moderate physical activity?”

• 0-2 Days: Sedentary

• 3-4 Days: Somewhat active

• 5-7 Days: Meets recommended levels

Other Basics

• Type of Exercise they perform

• What they enjoy/don’t enjoy

• Why/Why not

• What have they tried

• What would they like to try

• Your Patients and Change

Stages of change

1: Pre-contemplation2: Contemplation3: Preparation/planning4: Action5: Maintenance6: Permanent Maintenance (Termination)

The Pre-contemplators

• Ask if the patient would like to hear about or read about the benefits of exercise

• “I understand that you are not ready to change, but please know that when you are ready, I will be here to help.”

• “I think that it is important for your health….”

Key: Empathy

Physicians’ Empathy Influences Clinical Outcomes

• 891 Diabetic patients

• 29 Family physicians

• Hgb-A1c, LDL-C

• Jefferson Scale of Empathy

• High empathy scores for MD correlated with good control of Hgb A1c and LDL-C in patients

Hojat et al. Acad Med. 2011;86:359-364

Contemplators

• Ask the patient to consider what things would be like if they did not begin an exercise program

• Ask the patient how important exercise is to them

• Work with the patient to identify a powerful, intrinsic motivator

Key: Vision and Motivators

My Reasons to Exercise

• Feel good in my skin• Increase energy, Reduce stress• Increase my confidence, discipline• Be a role model, socialize, family time• It’s fun, I love to sweat and work hard• I love challenges• Reduce disease risk• Lower disability risk• Maintain independence

What are your reasons?

Defining Success

• What is success for you?

• Are such goals achievable, legitimate?

• What will you do if you fail to “succeed”?

The People in Preparation• Ask the patient how confident she is in her ability to perform

exercise

• Ask how the patient can increase her confidence in her ability to perform exercise

• Develop a SMART exercise goal for the patient

• Identify possible obstacles and brainstorm strategies around them

Key: A solid plan with SMART goals

What are your reasons NOT

to Exercise?

My Reasons NOT to Exercise

• Time• I’m tired or lazy• Inconvenience (I forgot my clothes etc…)• Money (shoes, travel, racquets) • Other priorities• Hate Change• Don’t know what to do• I’m Injured

GROW

• Goals

• Reality today

• Options

• Will

• Specific

• Measureable

• Achievable

• Realistic

• Timely

4 minute breakout

• Identify a Physical Activity Goal for yourself!

• Using the SMART acronym write a plan for achieving it!

• Share it with your neighbor

The People in Action

• Review physical activity guidelines

• Write an exercise prescription

• Follow up on the patient’s progress

• Congratulate patients on their exercise

• Encourage patients to meet the guidelines

• Ask about walks or runs for non-profits (AHA)

Key: Motivators, rewards, goals

The People in Maintenance

• Discuss the patients exercise routine

• Consider recommending cross training

• Review health benefits with patient

• Congratulate patient

• Write an exercise prescription

• Recommend becoming a mentor to family or friends

Key: Motivators, rewards, goals +variety and mentoring

• Why Prescribe?

Physician Prescribed Exercise

• Acceptable, familiar format for physicians

• Limited time required

• Elevates from recommendation to “order”

• Supports metaphor that exercise is indeed the best medicine

Medication Prescription:Medicine: Ibuprofen Strength: 600mg tabletsRoute: By mouthDispense: 90 tabletsFrequency: Three times per dayPrecautions: Discontinue for stomach upsetRefills: 3

Exercise Prescription: Exercise: Walk 30 minutes per day to improve mood and

general health.Strength: Moderate intensityFrequency: Five days per weekPrecautions: Increase duration of walking slowly to avoid

injuryRefills: Refill at next visit.

Exercise Prescription

• Screening• Precautions• Frequency• Intensity • Type• Time• Progression

Frequency

• Cardiovascular:– 150 minutes of moderate-intensity exercise per

week.

– 30-60 minutes of moderate-intensity exercise (five days per week) or 20-60 minutes of vigorous-intensity exercise (three days per week).

1: As much as they will2: Gradually Increase3: Achieve the reccs.


Ask for a confidence rating? 0-10 Document it in the chart

Ask for a confidence rating? 0-10 Document it in the chart

Intensity of Exercise

Maximal Heart Rate:220-Age or 206.9-(0.67x age)

Heart Rate Reserve (HRR):Max. HR- Resting HR = HRR

Target HR=HRR x % intensity + HR @ rest

Maximal Heart Rate:220-Age or 206.9-(0.67x age)

Heart Rate Reserve (HRR):Max. HR- Resting HR = HRR

Target HR=HRR x % intensity + HR @ rest

Talk Test:-Easy: Can Talk and Sing-Moderate: Can Talk but not sing-Intense: Can’t talk or sing

Talk Test:-Easy: Can Talk and Sing-Moderate: Can Talk but not sing-Intense: Can’t talk or sing

Exercise Progression

0

5

10

15

20

25

30

35

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Exercise level

To

tal

min

ute

s o

f ex

erci

se (p

er d

ay)

EXERCISE INTENSITYn Low

n Moderate

n High/vigorous

TARGET / THRESHOLD ZONE: 30 min of moderate intensity ≥5x/week, OR

20 min high intensity ≥3x/week, OR

20-30 min combined moderate and high intensity 3-5x/week

<3x/

wee

k

TO DETERMINE STARTING LEVEL: Determine how many minutes (see X-axis) you are comfortable exercising at least 3x/week. This is your starting level. Increase to 5x/week before progressing to the next level.

PROGRESS: to the next level (move 1 bar to the right) every week. Ensure that you continue exercising 5x/week. If you begin the program very deconditioned or sedentary and over the age of 65, then progress every 2-4 weeks.

Once the threshold is reached, exercise intensity can be

increased, enabling total exercise time to

decrease (from 150 min/week to 60

min/week if all exercise is high intensity)

<- - - - - - Exercise 3-5x/week, working up to 150 min/week) - - - - - -

The average healthy, inactive adult should

start here

Time

• As little as 10 minutes per session has shown benefit



Type

• Ask….don’t tell• Disclose your own habits

– Physicians who exercise are most likely to encourage pts to exercise

– You are most likely to counsel about the form of exercise you perform

• Be relatable and maintain optimism• Consider keeping a folder of “successes”• Take a lesson from Big Pharma

Personal Exercise Habits and Counseling Practices of Primary Care Physicians: A National Survey Clinical Journal of Sport Medicine:January 2000 - Volume 10 - Issue 1 - pp 40-48Physician disclosure of healthy personal behaviors improves credibility and ability to motivate.Archives of Family Medicine [2000, 9(3):287-290]

Breakout: 4 minutes

• Ask your neighbor about their physical activity goal

• With this in mind, write an Exercise Prescription for your neighbor using the FITT approach

Practical Advice:

• Not counseling the benefits of exercise may be perceived as condoning a sedentary lifestyle.

• Do not emphasize exercise threshold. • Change the emphasis from vigorous to moderate

intensity e.g. walking 3-4 miles per hour. • Sedentary patients should not be counseled to

initially exercise at a hard level as this leads to higher dropout rates.

Motivating your patients

• Set realistic goals- accumulating moderate activity (e.g., pedometer)

• Talk about general and mental health benefits of exercise and risks of remaining sedentary, but also about the pleasure of exercise

• Ask about physical activity levels.• Write exercise recommendations on a script

Motivating your patients at each visit:

• Ask about exercise just as inquiries about sleep, concentration, etc.

• Document details in chart note• Explore barriers to exercise• Positive reinforcement• Incorporate socialization

“Physical fitness can neither be achieved by wishful thinking nor

outright purchase.”

Joseph Pilates

• Exercise and Aging

The Graying of America

The Graying of America

CDC Exercise Stats• <20% of all adults achieve recc. Levels

• 60% of adults are not regularly active

• By age 75 1:3 men and 1:2 women engage in NO physical exercise

• “You have to work at living, period. You’ve got to train like you are training for an athletic event. Most older people just give up. They think, “I’m too old for that,” because they have an ache here or a pain there. Life is a pain in the butt; you’ve got to work at it.”

- Jack LaLanne -

The Physiology of Aging

• Cardiovascular:–20-30% in CO by 65 –Max. 02 uptake by 9-5% per

decade, for sedentary men and women

– Vascular elasticity = 10-40 mm Hg SBP/DBP

– Maximum HR app.10 bpm/decade

Physiology of Aging

• Respiratory:– FVC of 40 to 50% by age 70– in chest wall compliance– Maximum Ventilation– in Alveolar size and conc.

Physiology of Aging

• Muscles–40% in muscle mass by 70– muscle fiber size & #–30% in strength by 70

Physiology of Aging

• Skeletal health:–1% in bone mass/yr after 35–Post-menopause 2-3% per year for 5-

10 yrs– rates of OA, sponylo-arthropathy,

general joint dysfunction and degeneration

Physiology of Aging

• Connective Tissue:– elasticity –shortened muscle fibers– synovial fluid volume–Up to 15% reduction in nerve cond.– Hgb, Hct, RCM

Disuse

• Bedrest:– BMD, increased bone resorption

– muscle mass and strength

– muscle fiber size

– fatty infiltration of muscle

– Impaired O2 exchange

– Cardiac function, efficiency

• “A review of biologic changes commonly

attributed to the process of aging demonstrates the close similarity of most of these to changes

subsequent to a period of enforced physical inactivity. The coincidence of these changes from

the subcellular to the whole-body level of organization, and across a wide range of body

systems, prompts the suggestion that at least a portion of the changes that are commonly

attributed to aging is in reality caused by disuse and, as such, is subject to correction. There is no drug in current or prospective use that holds as much promise for sustained health as a lifetime

program of physical exercise.”(JAMA 1982;248:1203-1208)

Walter Bortz MD

Disuse and Aging

“There may be no single feature of age-related decline that could more dramatically affect

ambulation, mobility, calorie intake, and overall nutrient intake and status,

independence, breathing, etc. than the decline in lean body mass.”

Aging, Atrophy and Apoptosis:Failing “A’s” for FrailtyNational Conference on Aging

Sports Med. 2000 Oct;30(4):249-68.

Strength training in the elderly: effects on risk factors for age-related diseases.

• (i) produces substantial increases in the strength, mass, power and quality of skeletal muscle

• (ii) can increase endurance performance• (iii) normalizes blood pressure in those with high normal values• (iv) reduces insulin resistance• (v) decreases both total and intra-abdominal fat • (vi) increases resting metabolic rate in older men• (vii) prevents the loss of BMD with age• (viii) reduces risk factors for falls• (ix) may reduce pain and improve function in those with osteoarthritis in the knee

region

Influence of Resistance Exercise on Lean Body Mass in Aging Adults: A Meta-Analysis Med Sci Sports Exerc. 2011 February; 43(2): 249–258.

What we know!

• The value of movement• The basic science of muscle• Foundational terms and principles• How to Evaluate Readiness for Change• ACSM Risk Stratification and Pt Selection• How to Write and Exercise Script• Exercise and Aging

Goals

• Provide applicable knowledge

• Equip you with tools to promote change

• Practice skills

• Develop a plan of action

• Take it home

• Apply it

Have FunHave Fun

Now What

• You are powerful

• Our collective message is one of optimism and opportunity

• We can empower our patients

• Together we can alter the course of American healthcare

Now What

• Develop 3 actionable items you can incorporate in your practice when you return

• Develop 3 actionable items you can incorporate in your practice over the next 6 months

With Thanks!

• The Institute of Lifestyle Medicine– Dr Edward Philips MD– Dr Elizabeth Frates MD

• My Wife

Thank You!

References

• Bull World Health Organ. 2002;80(12):952-8. Epub 2003 Jan 23. Chopra M et al• http://www.cdc.gov/nccdphp/publications/factsheets/Prevention/pdf/obesity.pdf• http://www.heart.org/idc/groups/heart-public/@wcm/@sop/@smd/documents/downloadable/ucm_319587.pdf• http://www.ers.usda.gov/Publications/EIB33/EIB33_Reportsummary.pdf• http://www.springerlink.com/content/w26525u488gq2024/• http://www.ingentaconnect.com/content/nrc/cjpp/2001/00000079/00000005/art00003• http://biomedgerontology.oxfordjournals.org/content/55/7/B347.short• http://www.ingentaconnect.com/content/adis/smd/2007/00000037/00000002/art00004• http://www.ncbi.nlm.nih.gov/pubmed/2311599• http://onlinelibrary.wiley.com/doi/10.1111/j.1520-037X.2001.00529.x/full• http://jap.physiology.org/content/103/2/693.short• American College of Sports Medicine. ACSM's Guidelines for Exercise Testing and Prescription, 8th edition. Philadelphia: Lippincott Williams & Wilkins;

2009.(chapter 2)• James O. Prochaska and Wayne F. Velicer (1997) The Transtheoretical Model of Health Behavior Change. American Journal of Health Promotion:

September/October 1997, Vol. 12, No. 1, pp. 38-48.• http://www.nationalatlas.gov/articles/people/a_age2000.html• Influence of Resistance Exercise on Lean Body Mass in Aging Adults: A Meta-Analysis Med Sci Sports Exerc. 2011 February; 43(2): 249–258.• Changes in skeletal muscle with aging: effects of exercise training.Exercise and Sports Science Reviews 1993, 21:65-102• Physician disclosure of healthy personal behaviors improves credibility and ability to motivate. Archives of Family Medicine[2000, 9(3):287-290]• Disuse and AgingWalter M. Bortz II, MD JAMA. 1982;248(10):1203-1208.• http://www.plosone.org/article/fetchArticle.action?articleURI=info:doi/10.1371/journal.pone.0000465

A few Resources

• ACLM: www.lifestylemedicine.org

• ILM: www.instituteoflifestylemedicine.org

• ACSM: www.acsm.org

• Abeforfitness.com

• Let’s Move: www.letsmove.gov

• President’s Challenge: www.presidentschallenge.org

• Body and Mind: www.bam.gov

Documents

From Z Lines to Pt Selection