1	How Much is Enough? Physical Activity Guidelines for Your Patients CLNN Conference May 2007 Caroline Carr BSc., BSc.PT ACSM Exercise Specialist
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3	Outline Demographics Benefits Contraindications Exercise Program Components FITT Principal Warming up and Cooling down Stretching and Strengthening Exercise in Lipid Management Exercise in Weight Management Behavior Change
4	Accumulate 30-60 minutes of moderate paced activity on most days of the week Health Canada
5	Physical Activity Levels of Nova Scotia Children and Youth
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9	Benefits of Exercise on Risk Factors for CAD Decrease Blood Pressure Improve Glucose Control Improve Fitness/Activity level Coping Strategy in Stress Management Coping Strategy in Smoking Cessation Improve Lipids Decrease or Control Weight
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11	Exercise Program Components Cardiovascular or Aerobic Exercise 4-7 days per week Muscle Strengthening 2-3 days per week Flexibility/Stretching 4-7 days per week Canada’s Healthy Activity Guide
12	FITT Principle F Frequency (how often) I Intensity (how hard) T Type T Time ACSM Guidelines
13	Frequency Aim for 4-7 days per week If deconditioned, recovering from a cardiac event or limited by co-morbidities exercise for short periods several times per day
14	Intensity Intensity Prescription: HR RPE METS Individuals with or at high risk of CAD should have a maximal symptom limited stress test before starting high intensity exercise
15	Intensity Heart Rate Karvonen Equation: THR=40-85% (HR reserve) + HRrest Where HR reserve = HRmax – HRrest Example HRmax 160, HRrest 60 THR=60-75% (HR reserve) + HRrest THR= 60-75% (160-60) + 60 THR=120-135bpm
16	Classification Of Intensity Low Intensity 20-39% of HRR or VO2 Mod Intensity 40-59% of HRR or VO2 High Intensity 60-85% of HRR or VO2
17	Intensity Without a stress test recommendations for low to moderate intensity exercise should be given: Walk and Talk Test RPE Scale Warning Signs of Over Exertion
18	Walk and Talk Test You should be able to walk and talk comfortably If you are not comfortable talking while you are walking or exercising then you are going too fast. Slow down your pace
19	Rate of Perceived Exertion (RPE) CV Health in Motion Program 0 NOTHING 1 VERY LIGHT 2 FAIRLY MODERATE 3 MODERATE 4 SOMEWHAT HARD 5 HARD 6 7 VERY HARD 8 9VERY VERY HARD 10 Modified Borg Scale 0 NOTHING 1 VERY WEAK 2 WEAK 3 MODERATE 4 5 STRONG 6 7 VERY STRONG 8 9 10 EXTREMELY STRONG
20	Classification Of Intensity Low Intensity 20-39% of HRR or VO2 RPE 1-2 Mod Intensity 40-59% of HRR or VO2 RPE 2-4 High Intensity 60-85% of HRR or VO2 RPE 4-6
21	Signs and Symptoms of Over Exertion Feelings of pain, tightness or discomfort in your chest, jaw, arms, neck or back Finding it hard to get your breath Feeling lightheaded, dizzy, confused or sick Having irregular heartbeats Feeling more tired than you expect after exercise Sweating more than usual
22	Type Choose activities that are: Aerobic Use large muscle groups Rhythmic and continuous Enjoyable and motivating Good choices: Walking, cycling, swimming, dancing, skating Leisure activities (golfing, gardening) are good but fitness may not improve
23	Time Aim for 30-60 minutes of aerobic activity If deconditioned, recovering from a cardiac event or have co-morbidities: Start with what can do comfortably (i.e., 2, 3, 5, or 10 minutes) Gradually progress Aim for at least 20 minutes of continuous or intermittent exercise
24	Time Example Start with 5 minutes two times per day Increase by 1 minute every other day to 20 minutes Decrease session to once per day If able increase by 1 minute every other day to 30 minute walk daily Take short rests as needed but total exercise time should be 20-30 minutes May do 2 sessions of 15 minutes or 3 sessions of 10 minutes
25	Volume of Activity Total amount of work or energy expenditure Dependent on the interaction of intensity, frequency and duration of activity ACSM recommends expenditure of 150-400 kcal/day or 1,000-2,000kcal/ week for good health
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27	Warming-Up and Cooling-Down Once participant can exercise for 20 minutes at a moderate pace add a warm-up and cool-down Warm-up: Exercise at a slower pace for 5 minutes at the start of session Cool-down: Exercise at a slower pace for 5 minutes at the end of session Why? To make exercise session SAFE
28	Stretching To minimize muscle soreness and improve your flexibility Most effective if done at the end of session, after cooling down Do not bounce and do not hold breath 2-3 reps per stretch Hold each stretch for 15-30 seconds
29	Strengthening Exercises Strengthening exercises are an important part of a well rounded exercise program Strengthen muscles and bone Reduce bone loss Increase metabolic rate to assist with weight loss Safe protocol: Low weights (2-10 lbs) High reps (8-15) One set, progressing to 2-3 sets 2-3 sessions per week Major muscle groups No breath holding RPE not to exceed 5 (hard)
30	Pedometer Good Health-10,000 steps per day (equivalent to300-400 kcal/day) Weight loss-Up to 14,000 steps per day If elderly, deconditioned, or have limitations to exercise, gradually progress from baseline as tolerated Inaccurate if walk slower than 2mph, shuffle or are obese
31	Exercise and Lipid Management Lipid Abnormality Effect of Exercise Cholesterol Little or no effect LDL Cholesterol Little or no effect HDL Cholesterol Mild to Moderate An increase in HDL requires a substantial volume of activity (greater than 1,000 to 1,500 kcal per week) for 6 months or more 180 pound person: walking 3mph- 45 min,5/wk ACSM’s Resource Manual For Guidelines For Exercise Testing and Prescription, 5^th Edition, 2006
32	Exercise and Lipid Managment Leon and Sanchez, 2001 Meta-analysis of 52 exercise training studies HDL-average increase 4.6% Triglycerides-average decrease 3.7% LDL cholesterol-average decrease 5.0%
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37	Exercise and Lipid Management Halverstadt, 2007 100 sedentary, healthy 50-75 years olds Followed standardized diet 24 weeks of aerobic exercise training F 3/week I 50%VO2 progressing to 70%VO2max T Various types of aerobic training equipment (treadmill, bike, elliptical) T 40 minutes
38	Exercise and Lipid Management Results: VO2 increased (15%) TC decreased significantly Trig decreased significantly LDL decreased significantly HDL increased significantly (7%) Changes independent of diet, baseline body composition or change in body composition with training
39	Exercise and Lipid Management Slentz, 2007 240 Sedentary, overweight subjects randomized to 6 month: Control group High amount (23 kcal/kg)/vigorous intensity (65-80% VO2)–averaged 60 minutes 3.5/week Low amount (14kcal/kg)/vigorous intensity (65-80% VO2)-averaged 45 min- 3/week Low amount (14kcal/kg)/moderate intensity (40-55% VO2)-averaged 60 minutes-3.5/week Plasma measurements at baseline, 24 hrs, 5 days, and 15 days after exercise session
40	Exercise and Lipid Management Results: Continued inactivity resulted in significant increase in LDL Modest activity prevented this deterioration Moderate intensity, not vigorous intensity resulted in reduction of LDL and Trig that was sustained for 15 days of detraining Low intensity exercise (walking) about 11 miles per week reduced triglycerides by 25% Vigorous intensity (high and low amounts) resulted in increase in HDL that was sustained for 15 days of detraining High intensity exercise (brisk walking or running)
41	Exercise and Weight Management 5-10% reduction in body weight associated with significant improvements in lipids, BP and insulin sensitivity Start with lower intensity exercise (40-60% of VO2 or HRR, RPE 2-3), progressing to moderate intensities (50-75% of VO2 or HRR, RPE 3-5) Frequency of training: 5-7 days per week Duration of training session:45-60 minutes May do 2 sessions of 20-30 minutes, 3 sessions of 15-20 minutes etc.
42	Exercise and Weight Management Volume of training: 150 minutes/week (1000 kcal/week) of moderate exercise Progressing to 200-300 minutes/week (2,000 kcal/week) Non weight bearing activities (i.e. cycling) may be necessary and more comfortable Physical activity is best predictor of long term weight maintenance ACSM Guidelines for Exercise Testing and Prescription, 7^th edition, 2006
43	Counting Calories Remember, you need to burn 3,500 calories to lose 1 pound
44	How Much is Enough? General Good Health/Risk Factor Control including control of LDL, Trig Accumulate 30-60 minutes of moderate intensity activity most days of the week Accumulate 10,000 Steps per day RPE 2-4 (some what moderate to somewhat hard)
45	How Much is Enough? Improve HDL At least 1,000 to 1,500 kcal/week Continuous moderate to high intensity activity RPE 4-5 (somewhat hard to hard)
46	How Much is Enough? Weight Loss Accumulate 45-60 minutes of moderate intensity activity 5-7 days per week Accumulate 14,000 steps per day Expand 1000-2000 kcal/week RPE 2-5(somewhat moderate to hard)
47	How Much is Enough? Improve Fitness Level At least 20-30 minutes of continuous, moderate to high intensity activity, 3-4 days per week RPE 3-5 (moderate to hard)
48	Tom 200 pounds Goals: Lose weight and improve cholesterol Physical Activity Cal/min Total Time Total Calories Walking 3mph 5.3 225 (45min 5/wk) 1200 Mowing Lawn 7.2 30 216 Raking Lawn 6.4 30 192 Vacuuming 5.6 20 112 Fishing from a bank 5.6 45 252 Total Calories/Volume 1972
49	Tom Successful? Tom expands about 2000 calories per week Pounds lost in one week: 0.5 pounds 3500 calories in 1lbs/1975 calories expanded=0.55 pound Tom has sufficient energy expenditure to increase HDL and improve LDL, Trig
50	Accumulate 30-60 minutes of moderate paced activity on most days of the week
51	Motivating Behavior Change Assess barriers and strength of barriers Assess motivators and strength of motivators Develop an action plan: Choose behaviors that are specific, realistic and can be maintained over the long term.
52	Barriers to Physical Activity I am not motivated I don’t have the time I don’t know how to exercise I don’t have any support I have too many aches and pains
53	Motivators to Physical Activity Look better Feel better Improve health Live longer Have more energy Lose weight Control risk factors
54	Keeping Motivated Think of the benefits Exercise with a buddy Join a gym or a group Keep a dairy Reward yourself Find some support Schedule your exercise Consider home equipment Use a pedometer
55	Questions?
56	References ACSM’s Guidelines for Exercise Testing and Prescription, American College of Sports Medicine; 7^th Edition; 2006. ACSM's Resource Manual for Guidelines for Exercise Testing and Prescription American College of Sports Medicine; 5th Edition; 2005. Canada’s Physical Activity Guide to Healthy Living, Canadian Society for Exercise Physiology and Public Health Agency of Canada Halverstadlt A et al, Endurance exercise training raises high density lipoprotein cholesterol and lowers small low density lipoprotein and very low-density lipoprotein independent of body fat phenotypes in older men and women. Metabolism Clinical and Experimental 56(2007) 444-450 Leon AS, Sanchez O. Meta-analysis of the effects of aerobic exercise training on blood lipids. Circulation 2001; 104 (Suppl II):II414-5 Slentz J et al, Inactivity, exercise training and detraining, and plasma lipoproteins. STRIDE: a randomized, controlled study of exercise intensity and amount. Articles in Press. J Appl Physiol (2007)