Designing exercise programs by Dr. Nayanjeet

Designing Physical Activity

Intervention

Dr. Nayanjeet Chaudhury, M.D., M.P.H.

Certified Personal Trainer (ACSM)

Certified Aerobics Trainer (Reebok)

Director for M&E and Health Services Delivery,

Population Services International, New Delhi

Feb’ 2014

Flow of the presentation

• Basic Exercise Physiology

• Risk Stratification

• Physical Activity Guidelines

• Physical Activity Design

• Special populations

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Total energy expenditure(TEE)

or total metabolic rate

= (1) the basal metabolic rate (BMR)

+ (2) the activity energy costs,

+ (3) diet-induced thermogenesis

TEE = BMR when measured

(a) in the morning

(b) 20 h after the last meal,

(c) resting, reclining,

(d) at normal body temp., and

(e) at a comfortable ambient temperature

The BMR varies according to sex, age, body size and weight.

Basic Exercise Physiology: Principles

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• ATP is produced in the cells (except the RBCs). Usually the

mitochondria of the cell does so by burning fat and

carbohydrate into carbon dioxide and water

(metabolism)

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Sites of Energy generation/ATP

production during muscular activity

Anaerobic

Aerobic Occurs in Mitochondria. Burns fats, carbs and amino

acids in presence of Oxygen to produce large no. of ATPs

Occurs in Cytoplasm. Breaks only glucose or glycogen

without Oxygen to produce small number of ATPs

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Muscle fibre types

• In humans, 3 myosin isomorph fiber types I, IIA & IIB

• Type I – Slow twitch, high oxidative capacity.

• Type IIB – Fast twitch, low oxidative

• Type IIA – Intermediate

Long-term effects of training

• Resistance or endurance training, IIB IIA

• Prolonged resistance training - Hypertrophy

Source: American College of Sports Medicine

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Cardiovascular adaptations to chronic exercise

• No change on Max Heart Rate(H.R.) and Resting Cardiac

Output (C.O.). Rather, Resting H.R. may lower.

• Max C.O. increases due to Increased Stroke Volume (S.V.) in

trained people

• Remember, S.V. in supine posture (swimming) is higher than in

upright position (running)

Prolonged Endurance Training - reduced systolic, diastolic, and

mean arterial pressures (therapeutically effective on mild

hypertensives only)



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• Endurance training

• - Capacity of the oxidative

system to produce ATP by

increasing mitochondrial density

in muscle

• - Amplify the storage of energy

substrates(glycogen, lipids)

• - lipid depots more pronounced

• Resistance Training

• - Increased capacity of muscle

to produce ATP anaerobically by

increasing glycolytic enzymes &

glycogen stored in muscle



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Major Energy Systems in the Body

• Phosphagen system

– ATP and phosphocreatine

(PCr) stored in muscle

• Non-Oxidative system

– "anaerobic“ only Carb

pathway.

– End product = lactate

• Oxidative system

– "aerobic“- lipid/carb

pathway,

– End product= CO2 + H20

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Energy systems used in various sports Phosphagen system, almost

entirely (4 m ATP/min for 8-10 sec)

100 meter dash

Jumping

Weight lifting

Diving

Football dashes

Phosphagen and Glycogen

lactic acid system

200 m dash

Basketball

Base ball home run

Glycogen lactic acid system, mainly (2.5 m ATP/min for 1.3 to 1.6 min)

400 m dash

100 m swim

Tennis

Soccer Glycogen-lactic A & Aerobic

system

800 m dash/ 1500 m run

200/400 m swim

2000 m rowing

Boxing Aerobic system (1 m ATP/min

for unlimited time (nutrient limited)

10000 m skating

Cross country skiing

Marathon

jogging

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Age and Exercise • Resting B.P. and exercise B.P. are lower in children

• Both resting H.R. and exercise H.R. are higher in children

• C.O. at a submax oxygen consumption (V02) is lower in adults.

• Children have poor thermoregulation– high sweating threshold

• Men start losing bone mass in 50-55 yrs, women start in 30-35

yrs with increase after menopause

• Muscle strength declines by 15% per decade from 50-80yrs

and by 30% thereafter.

• Joint stiffness and loss of flexibility are common in elderly.

• Healthy older adults walk at a preferred speed that is 20%

slower than that of younger adults.

• Old age = Decreased visual acuity, hearing loss, deterioration

of short-term memory, slow processing of multiple information

& slow reaction time, gradual decrease in B.M.R.

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Oxygen consumption and Age • VO2 Max– a function

of C.O. and A.V.

Oxygen difference.

• Genetically limited

• May increase 5-30%

with training

• Inversely related to

body mass

• Declines by 5-15%

per decade after age

25, - can be slowed

by regular physical

activity


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Atherosclerotic CVD Risk Factor Thresholds Positive Risk Factors

•Age: Men ≥45 yr; Women ≥55 yr

•Family history of Myocardial infarction, coronary revascularization, or sudden death

before 55 yr of age in father or other male first-degree relative, or before 65 yr of age in

mother or other female first-degree relative

•Current cigarette smoker or those who quit within the previous 6 months

•Sedentary lifestyle :

•Obesity:

•Hypertension: SBP ≥140 mm Hg and/or DBP ≥90 mm Hg, or on antihypertensive drugs

•Dyslipidemia: LDL-cholesterol ≥130 mg·dL-1 (3.37 mmol·L-1) or HDL- cholesterol <40

mg·dL-1 (1.04 mmol·L-1) or on lipid-lowering drug. If total serum cholesterol only available,

use ≥200 mg·dL-1 (5.18 mmol·L-1)

•Pediabetes: Impaired fasting glucose (IFG) = fasting plasma glucose ≥100 mg·dL-1

(5.50 mmol·L-1) but <126 mg·dL-1 (6.93 mmol·L-1) or impaired glucose tolerance (IGT) =

2-hour values in oral glucose tolerance test (OGTT) ≥140 mg·dL-1 (7.70 mmol· L-1) but

<200 mg·dL-1 (11.00 mmol·L-1) confirmed by measurements on at least two separate

occasions

Negative Risk factor: HDL Cholesterol ≥60 mg·dL-1 (1.55 mmol·L-1). If HDL is high,

subtract one risk factor from the sum of positive risk factors.

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ACSM Risk Stratification Low Risk Moderate Risk High Risk

(Asymptomatic

<2 risk Factors)

Asymptomatic ≥ 2 Risk

Factors

Symptomatic/ known

cardiac, pulmonary or

metabolic ds

Med Exam & Graded Ex

test

(not necessary)


test

(necessary for Vigorous

Ex)


test

(Necessary for both

moderate and Vigorous

Ex)

Medical Supervision

necessary for Maximum

stress test

Medical Supervision

necessary for both submax

and max test

Moderate exercise - 40-60% of V02max; 3-6 METs; "an intensity well within the

individual's capacity, one which can be comfortably sustained for a prolonged

period of time (-45 minutes)"

Vigorous exercise - > 60% of V02max; > 6 METs; "exercise intense enough to

represent a substantial cardiorespiratory challenge"


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Pre-exercise Evaluation

• Detailed personal and medical history

• Pre-exercise Test Physical Examination

• Recommended Laboratory Tests

• Low/Moderate risk individuals

• Lipid profile, fasting glucose, thyroid profile

• High risk individuals

• Appropriate lab tests (refer to ACSM)


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Health-Related Physical Fitness Testing • Body composition assessment:

– Anthropometry – BMI, circumferences,

– skin fold measurements

– Bio-electrical impedence analysis

– Platysmography, DXA etc

• Cardiorespiratory fitness assessment

– Maximal or Submaximal exercise testing (clinic based or field tests)

• Muscular Fitness: Muscular Strength (the ability of the muscle to exert force) and Muscular Endurance (muscle's ability to continue to perform for successive exertions or many repetitions)

• Flexibility or Range of Movement Tests

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Available Guidelines for Indians

Age group WHO Guidelines Physical activity guidelines for

Asian Indians (conensus

statement. Mishra et al 2011)

Duration Intensity Duration Intensity

0-5 Years None None None None

5-17 years

old

60 min daily Moderate to

vigorous

intensity

60 min / day Moderate to

vigorous intensity

18-64 years

old

150 min per

week / 70 min

week

Moderate /

vigorous /

combination of

both

60 min / day Moderate intensity

65 years

and above

150 min per

week / 70 min

week

Moderate /

vigorous /

combination of

both

60 min / day Moderate intensity

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Children and Adolescents Type Frequency Duration

Moderate- or vigorous-

intensity aerobic

physical activity (such as

running, hopping,

skipping, jumping rope,

swimming, dancing, and

bicycling)

At least 3 days a week

(Preferably daily),

60+ min per day

Muscle-strengthening

physical activity (playing

on playground

equipment, climbing

trees, tug-of-war, weight

lifting or working with

resistance bands)

3 days a week

20-30 min

Bone-strengthening

physical activity (such as

running, jumping,

basketball, tennis)

3 days a week 20-30 min


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Examples of activities for Older Adults

• Aerobic • Walking

• Dancing

• Swimming

• Jogging

• Aerobic exercise classes

• Bicycle riding (stationary or on a path)

• Some activities of gardening, Tennis

• Muscle-Strengthening

• Exercises using exercise

bands, weight machines, hand-

held weights

• Calisthenic exercises (body

weight provides resistance to

movement)

• Digging, lifting, and carrying as

part of gardening

• Carrying groceries

• Some yoga exercises

Source:http://www.health.gov/paguidelines/pdf/paguide.pd

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Physical Activity design: Pre-requisites

• Depends on

health status,

physical ability,

and age, or

athletic and

performance

goals

• FITT principle –

Frequency,

Intensity,

• Type (modes)

and

• Time (Period)


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Components of the Exercise Training Session

• Warm-up: Min 5 to 10 min of low- (<40% VO2R) to moderate-

(40%–<60% [VO2R) intensity cardiovascular and muscular

endurance activities

• Conditioning: 20 to 60 mins of aerobic, resistance, and/or sport

activities

• bouts of 10 minutes are Ok if one accumulates min 20-60 min/ day of daily

exercise)

• Cool-down: Min. 5 -10 mins of low- (<40% VO2R) to moderate-

(40%–<60% VO2R) intensity cardio-vascular and muscular

endurance activities

• Stretching: Min. 10 minutes of stretching exercises after warm-

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Cardiovascular endurance • Most effective when large muscle groups are engaged in

continuous, rhythmic (aerobic) activity.

• Frequency: ACSM recommends 3-5 days/wk (most days).

– - attenuation of improvement in physical fitness with exercise

frequencies >3 d·wk-1 and a plateau beyond 5 wk

• Intensity: For minimum health benefits, moderate

intensity activity (40-60% VO2R*) that visibly

increases H.R. and breathing.

• Duration: a dose-response relationship between

calories per week health benefits

* VO2R = VO2Max – VO2rest Source: American College of Sports Medicine

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Rate of perceived exertion Original Borg’s scale

• 6 No exertion at all

• 7 Extremely light

• 8

• 9 Very light

• 10

• 11 Light

• 12

• 13 Somewhat hard

• 14

• 15 Hard (heavy)

• 16

• 19 Extremely hard

• 20 Maximal Exertion

Modified Borg’s Scale

• 0 Nothing at all

• 0.5 Very, very weak

• 1 Very weak

2 Weak

3 Moderate

4 Somewhat strong

5 Strong

6

7 Very strong

8

9

10 Very, very strong

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Muscular strength and endurance

• Muscular strength = the maximal amount of resistance that

a muscle can overcome.

• Muscular endurance = the ability of muscle to overcome a

submaximal resistance several times consecutively.

• Frequency: untrained should train each major muscle group

(of the chest, shoulders, upper and lower back, abdomen,

hips, and legs) 2–3 days/wk with at least 48 hours between

two sessions

• Type: multijoint or compound exercises.

– (chest press, shoulder press, pull-down, dips, lower-back extension,

abdominal crunch/curl-up, and leg press)

• Volume = Beginners 8-10 Reps, 2-4 sets


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Some more principles Specificity: Exercise programs are specific to the

exercise performed and to the muscles involved.

Overlaod: put a demand on muscle greater than that in

the previous workout session. Overload can be

achieved by:

– a. Increasing the resistance or weight.

– b. Increasing repetitions.

– c. Increasing sets.

– d. Decreasing the rest period between sets

Progression: an increase in workload to maintain

overload.


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• Stretching most effective when muscles are warm.

• Should be done before and after conditioning phase.

• Stretching may not prevent injury.

• Different stretching methods- Static, dynamic or

ballistic, proprioceptive neuromuscular facilitation

(PNF), and dynamic range of motion.

• Should involve major muscle tendon groups of body.

• ≥4 repetitions per muscle group is recommended.

• Static stretches should be held for 15 to 60 seconds.

Flexibility training

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Exercise in Pregnancy Relative Contraindications

• Severe anemia

• Maternal cardiac dysrhythmia

• Chronic bronchitis

• Poorly controlled type 1 diabetes

mellitus

• Extreme morbid obesity

• Extreme underweight

• Extremely sedentary lifestyle

• IUGR in current pregnancy

• Poorly controlled hypertension

• Orthopedic limitations

• Poorly controlled seizure disorder

• Poorly controlled hyperthyroidism

• Heavy smoker

Absolute Contraindications

• Hemodynamically significant heart ds

• Restrictive lung disease

• Incompetent cervix/cerclage

• Multiparity at risk of premature labor

• Persistent 2nd or 3rd trimester bleeding

• Placenta previa after 26 weeks of

gestation

• Premature labor during the current

pregnancy

• Ruptured membranes

• Preeclampsia/pregnancy-induced

hypertension


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Exercise in Pregnancy

• After 1st trimester, pregnant women should

avoid exercising in the supine position

• Aerobic – 3-7 days/wk, RPE 11-13, 30-40 min

• Resistance – Decrease intensity; No Valsalva

maneuver.

• Adjust hydration and clothing.

• Exercise in post-ostpartum period may begin

~4 to 6 weeks after delivery

• Consult physician if Gestational DM or HT. Source: American College of Sports Medicine

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Exercise in Older adults

• Instead of MET levels, use RPE scale

• Moderate intensity = 5-6 RPE

• Evaluate for medical conditions

• Neuromuscular training, combining balance,

agility, and proprioceptive training,

• Aerobic – start with low intensity, increase

duration and then intensity

• Resistance – under 100% supervision.


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Osteoporosis • Weight-bearing exercise is most effective in

maintaining or increasing bone density

• Include exercises that direct the load over the

long axis of the bone (e.g., leg press,

shoulder press)

• Include functional exercises (e.g., balance).

• a. Exercise is contraindicated when in pain.

• b. Avoid high-impact or ballistic activity.

• c. Excessive trunk flexion & twisting activities

• increase compressive forces


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Hypertension • Primary form of exercise = aerobic not anaerobic

• If resting BP >160/100 mm Hg, drug therapy is

indicated either before or coincident with initiation of

an exercise program.

• Multiple bouts of short-duration (l0-15 minutes), low-

intensity activity (e.g., walking) are encouraged.

• Exercise is contraindicated if pre-exercise SBP > 200

mm Hg or DBP >> 11OmmHg.

• Patients on vasodilators need prolonged cool-down

and should avoid abrupt postural change.


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Diabetes • - “Insulin like" effect on blood glucose

• - DM-II should aim at least 1,000 kcal/week.

• - Aerobic 3-7 days, 50-80% HRR, 20-60min

• - Resistance = Lower intensity

• - Exercise contraindicated if FBS > 250 mgldL with

ketones or >300 mgldL without ketones

• - Carbohydrate intake and insulin dosage should be

adjusted before exercise

• - Maintain adequate hydration.


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Obesity

• - Aim 7,000-10,500 Kcal loss per week

• - Primary mode of calorie expense –

through Aerobic activity.

• - Anaerobic work out only adjunct to an

aerobic exercise program.


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Planning to coach • Understand your Client better

Use Prochaska’s stages of change model to assess

Understand students’ learning styles & personalities.

• Develop SMART goals and tools for ongoing

assessment and progress.

• Pros & cons of behavior change – decisional

balance

Ask the client to identify at least one reason each for

change as well as no change


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Building relationship between the

trainer and the trainee

• The trainer and the Client – partners in change.

• Maintain confidentiality

• Ask powerful, open questions, but empathise

• Show that you care.

• Be an active listener

• Respect genuinely, be non-judgmental

• Demonstrate understanding

• Ask for open/honest feedback

• Engage client in planning process


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Thanks !

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Designing exercise programs by Dr. Nayanjeet

Health & Medicine

Transcript of Designing exercise programs by Dr. Nayanjeet