Title: Exercise Prescription from Eight to Eighty
1Exercise 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
2Overview
- 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
3Overview
- Obesity chronic disease epidemic
- Motivational counseling technique
- Basics of the exercise Rx
- Exercise Rx for youth and adults
- The exercise Rx for seniors
-
4Obesity 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
5Obesity Epidemic Modifiable Risk FactorsActual
Causes of Death
Mokdad, JAMA, 2004
6Obesity 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
7Overview 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(No Transcript)
9Overview Shifting the Paradigm
Exercise
Activity
Activity Play, Fun, Functional Fitness
Stephens, USUHS, 2001
10Overview
- Obesity and chronic disease epidemic
- Motivational counseling technique
- Basics of the exercise Rx
- Exercise Rx for youth and adults
- The exercise Rx for seniors
-
11Exercise prescription doesnt work without
addressing the behavior!
12 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
13Motivational Counseling SMART Goal Setting
- Specific
- Where, when, how
- Measurable
- How much? How many?
- Attainable
- Realistic
- Track
14Motivational 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
15Overview
- Obesity and chronic disease epidemic
- Motivational counseling technique
- Basics of the exercise Rx
- Exercise Rx for youth and adults
- The exercise Rx for seniors
-
16The 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
17The Exercise (Activity) Prescription1 - Assess
Baseline Status
- Establish Patients Baseline Fitness
- Establish Goals, Realities Outcomes
- What does the patient want?
- What does the patient need?
- What does the patient already do?
18The Exercise (Activity) Prescription1 - Assess
Baseline Status
- Establish Patients Baseline Fitness
- 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
19The Exercise (Activity) PrescriptionOrthopedic
Risk
- Kids/Teens Dont you ignore
- Adults Dont let patients ignore
- Older Adults
Be positive!
20The Exercise (Activity) Prescription2 - Assess
Cardiovascular Risk
Does My Patient Need A Treadmill Test?
21The 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)
22The 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
23The 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
24The 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
25The 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
26The Exercise (Activity) Prescription
- Mode
- Duration
- Frequency
- Intensity
- Timely Follow Up
- Therapy (Preventive and/or Therapeutic)
The MD FITT Prescription
27Exercise (Activity) Prescription in Adults
Orthopedic Injury vs. VO2max GainIn Vigorous
Exercise
Gettman, Med Sci Sports Exerc, 1977
28The Exercise (Activity) PrescriptionTool 4 The
AIM Fitness Prescription
Mode
Duration Frequency Intensity
Paradigm Kids Activity Adults Fitness Older
Adults Functional Fitness
Timely Followup
29Overview
- Obesity epidemic the Big problem
- Motivational counseling technique
- Basics of the exercise Rx
- Exercise Rx for youth and adults
- The exercise Rx for seniors
-
30Exercise (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
31Exercise (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
32NHANESPrevalence of Overweight Youth Ages 2-19
33Exercise (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
34Exercise (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
35Exercise (Activity) Prescription for KidsWhy
Exercise Works in Kids
36Exercise (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
37Exercise (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
38Overview
- Obesity epidemic the Big problem
- Motivational counseling technique
- Basics of the exercise Rx
- Exercise Rx for youth and adults
- The exercise Rx for seniors
39Exercise 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)
40Exercise (Activity) Prescription for AdultsNew
Hopkins Projections
- By 2015
- 75 of adults overwt or obese
- 41 will be frankly obese
41Exercise (Activity) Prescription for AdultsThe
Adult Weight Cycle
42Good 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
43Overview
- Obesity epidemic the Big problem
- Motivational counseling technique
- Basics of the exercise Rx
- Exercise Rx for youth and adults
- The exercise Rx for seniors
-
44Exercise (Activity) Prescription for Older
AdultsDis-fitness Cycle
45Exercise (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
46Exercise (Activity) Prescription for Older Adults
Exercise and Aerobic Capacity
Active
Active Aging
Reduced Activity Weight Gain
VO2 Max
Sedentary
Exercise Intervention
80
20
Age
47Exercise (Activity) Prescription for Older Adults
Strength Use It Lose Less of it
- 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
48Exercise (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
49Exercise (Activity) Prescription for Older
AdultsA little more about balance
Dynamic
Static
Intensitysensory or time
50The 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)
51Exercise (Activity) Prescription for Older Adults
Tool 5
http//www.nia.nih.gov/NR/rdonlyres/8E3B798C-237E-
469B-A508-94CA4E537D4C/0/NIA_Exercise_Guide407.pdf
52Finish Line!
- Obesity and chronic disease epidemic
- Ours and Theirs Problem
- Motivational counseling technique
- Scaled Questions
- Importance and Confidence
53Finish 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) -
54Finish Line!
- Exercise Rx for youth and adults
- Flexible Paradigm (FP)
- Children Train up
- Adults Fitness
- Seniors Functional Fitness
- Components
- Aerobic Strength
55Finish Line!
- The exercise Rx for seniors
- Aerobic strength
- Balance and flexibility
- Tools to Use
56Questions?
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