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Exercise Prescription from Eight to Eighty

Activity. Exercise Prescription from Eight to Eighty. Brian K. Unwin, M.D. Anthony Beutler, M.D. Jeff Goodie, Ph.D. Department of Family Medicine Uniformed Services University Bethesda, MD. Overview. Obesity & chronic disease epidemic Motivational counseling technique

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Exercise Prescription from Eight to Eighty

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  1. Activity Exercise Prescription from Eight to Eighty 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

  5. Obesity Epidemic Modifiable Risk Factors“Actual Causes of Death” 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. Overview Shifting the Paradigm: Exercise Activity Exercise = Training Activity = Play, Fun, Functional Fitness Stephens, USUHS, 2001

  9. 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

  10. Exercise prescription doesn’t work without addressing the behavior!

  11. Motivational CounselingTool #1: Scaling Questions 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 Completely Not at all 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

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

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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

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

  19. 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)

  20. 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

  21. 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

  22. 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

  23. 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

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

  25. 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

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

  27. 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

  28. 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

  29. 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

  30. NHANESPrevalence of Overweight Youth Ages 2-19 National Center for Health Statistics, Prevalence of Overweight Among Children and Adolescents: United States, 2003-2004

  31. 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 ANYother age “Train up a child in the way he should go: and when he is old, he will not depart from it.” - Proverbs 22:6 Allen, J Pediatr, 2007 Flegal, PhysiolBehav, 2005

  32. 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 obesity…low intensity, long duration exercise • Aerobic exercise combined with resistance training Med Sci Sports Exerc, 2002

  33. Exercise (Activity) Prescription for KidsWhy Exercise Works in Kids

  34. 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

  35. 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

  36. 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

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

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

  39. 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

  40. 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

  41. Exercise (Activity) Prescription for Older Adults“Dis-fitness” Cycle Age Related Change Illness Risk Factors New or Existing Illness Increased Disease Risk Reduced Physical Activity

  42. 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, 1994;49(3):M109-15

  43. Exercise (Activity) Prescription for Older Adults Exercise and Aerobic Capacity Active Active + Aging Reduced Activity + Weight Gain VO2 Max Sedentary Exercise Intervention 20 80 Age

  44. Exercise (Activity) Prescription for Older Adults Strength: Use It & Lose Less of it Losses Gains Lean body mass increases 1-3 kg Resistance training improves strength by a range of 40-150% Muscle fiber area 10-30% • Sedentary people lose large amounts of muscle mass (20-40%) • 6% per decade loss of Lean Body Mass (LBM) Aerobic Activity IS NOT sufficient to stop this loss! BOTTOM LINES: MUSCLE STRENGTHENING EXERCISES REQUIRED MUST INCLUDE BALANCE+FLEXIBILITY IN OLDER ADULTS FEWER FALLS, FRACTURES, DISUSE, FRAILTY AND SARCOPENIA

  45. Exercise (Activity) Prescription for Older AdultsWhat’s 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

  46. Exercise (Activity) Prescription for Older AdultsA little more about balance Dynamic Static Intensity=sensory or time

  47. The “MD FITT” Prescription (for the older adult) • Mode: Aerobic+Strength +Balance+Flexibility • Duration • Frequency • Intensity: • Touch > No Touch > Eyes Closed for balance • 5-6/10 self-perceived exertion • Timely Follow Up • Therapy (Preventive and/or Therapeutic)

  48. 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

  49. Finish Line! • Obesity and chronic disease epidemic • “Ours” and “Theirs” Problem • Motivational counseling technique • Scaled Questions • Importance and Confidence

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