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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

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
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


Overview1
Overview

  • Obesity & chronic disease epidemic

  • Motivational counseling technique

  • Basics of the exercise Rx

  • Exercise Rx for youth and adults

  • The exercise Rx for seniors


Obesity epidemic nhanes adult obesity
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


Obesity epidemic modifiable risk factors actual causes of death
Obesity Epidemic Modifiable Risk Factors“Actual Causes of Death”

Mokdad, JAMA, 2004


Obesity epidemic why providers don t discuss behavior change
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


Overview physicians their patients exercise
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


Overview shifting the paradigm
Overview Shifting the Paradigm:

Exercise

Activity

Exercise = Training

Activity = Play, Fun, Functional Fitness

Stephens, USUHS, 2001


Overview2
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



Motivational counseling tool 1 scaling questions
Motivational Counseling behavior!Tool #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


Motivational counseling smart goal setting
Motivational Counseling behavior!SMART Goal Setting

Specific

Where, when, how

Measurable

How much? How many?

Attainable

Realistic

Track


Motivational counseling tool 2 importance and confidence
Motivational Counseling behavior!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


Overview3
Overview behavior!

  • Obesity and chronic disease epidemic

  • Motivational counseling technique

  • Basics of the exercise Rx

  • Exercise Rx for youth and adults

  • The exercise Rx for seniors


The exercise activity prescription 1 assess baseline fitness
The Exercise behavior!(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


The exercise activity prescription 1 assess baseline status
The Exercise behavior!(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


The exercise activity prescription 1 assess baseline status1
The Exercise behavior!(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


The Exercise behavior!(Activity) Prescription#2 - Assess Cardiovascular Risk

Does My Patient Need

A Treadmill Test?


The Exercise behavior!(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)


The exercise activity prescription 2 does my patient need an ett
The Exercise behavior! (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


The Exercise behavior!(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


The Exercise behavior!(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


The exercise activity prescription 3 write the prescription
The Exercise behavior!(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


The Exercise behavior!(Activity) Prescription

  • Mode

  • Duration

  • Frequency

  • Intensity

  • Timely Follow Up

  • Therapy (Preventive and/or Therapeutic)

The “MD FITT” Prescription


Exercise activity prescription in adults orthopedic injury vs vo2max gain in vigorous exercise

Exercise Duration behavior!

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


The exercise activity prescription tool 4 the aim fitness prescription
The Exercise behavior!(Activity) PrescriptionTool # 4 The AIM Fitness Prescription

Mode

Duration + Frequency + Intensity

Paradigm:

Kids: Activity

Adults: Fitness

Older Adults: Functional Fitness

Timely Followup


Overview4
Overview behavior!

  • Obesity epidemic: the “Big” problem

  • Motivational counseling technique

  • Basics of the exercise Rx

  • Exercise Rx for youth and adults

  • The exercise Rx for seniors


Exercise behavior!(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


TV watching behavior!

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


Nhanes prevalence of overweight youth ages 2 19
NHANES behavior!Prevalence of Overweight Youth Ages 2-19

National Center for Health Statistics, Prevalence of Overweight Among Children and Adolescents: United States, 2003-2004


Exercise behavior!(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


Exercise behavior!(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


Exercise behavior!(Activity) Prescription for KidsWhy Exercise Works in Kids


Exercise behavior!(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


Overview5
Overview behavior!

  • Obesity epidemic: the “Big” problem

  • Motivational counseling technique

  • Basics of the exercise Rx

  • Exercise Rx for youth and adults

  • The exercise Rx for seniors


Exercise prescription in adults national health interview survey 2006

X behavior!

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


Exercise behavior!(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


Merry Christmas behavior!

Exercise (Activity) Prescription for AdultsThe Adult Weight Cycle


Good News for Your Patients behavior!

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


Overview6
Overview behavior!

  • Obesity epidemic: the “Big” problem

  • Motivational counseling technique

  • Basics of the exercise Rx

  • Exercise Rx for youth and adults

  • The exercise Rx for seniors


Exercise activity prescription for older adults dis fitness cycle
Exercise behavior!(Activity) Prescription for Older Adults“Dis-fitness” Cycle

Age

Related

Change

Illness

Risk

Factors

New or Existing

Illness

Increased

Disease

Risk

Reduced

Physical

Activity


Exercise activity prescription for older adults fitness and functional status
Exercise behavior!(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


Exercise activity prescription for older adults exercise and aerobic capacity
Exercise behavior!(Activity) Prescription for Older Adults Exercise and Aerobic Capacity

Active

Active +

Aging

Reduced

Activity +

Weight Gain

VO2 Max

Sedentary

Exercise Intervention

20

80

Age


Exercise activity prescription for older adults strength u se it lose less of it
Exercise behavior!(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


Exercise activity prescription for older adults what s different for older adults
Exercise behavior!(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


Exercise activity prescription for older adults a little more about balance
Exercise behavior!(Activity) Prescription for Older AdultsA little more about balance

Dynamic

Static

Intensity=sensory or time


The “MD FITT” Prescription behavior!

(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)


Exercise activity prescription for older adults tool 5
Exercise behavior!(Activity) Prescription for Older Adults Tool #5

http://www.nia.nih.gov/NR/rdonlyres/8E3B798C-237E-469B-A508-94CA4E537D4C/0/NIA_Exercise_Guide407.pdf


Finish line
Finish Line! behavior!

  • Obesity and chronic disease epidemic

    • “Ours” and “Theirs” Problem

  • Motivational counseling technique

    • Scaled Questions

    • Importance and Confidence


Finish line1
Finish Line! behavior!

  • 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)


Finish line2
Finish Line! behavior!

  • Exercise Rx for youth and adults

    • Flexible Paradigm (FP):

      • Children: “Train up”

      • Adults: Fitness

      • Seniors: Functional Fitness

    • Components:

      • Aerobic + Strength


Finish line3
Finish Line! behavior!

  • The exercise Rx for seniors

    • Aerobic + strength

    • Balance and flexibility

  • Tools to Use


Questions
Questions? behavior!

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


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