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Exercise is Medicine:Exercise is Medicine:How to Get You and Your How to Get You and Your

Patients MovingPatients Moving

Getting Men Healthier: A Getting Men Healthier: A Physician’s Playbook Physician’s Playbook

1111thth Annual Symposium on Annual Symposium on

Patients MovingPatients Moving

Men’s HealthMen’s HealthMassachusetts Medical SocietyMassachusetts Medical Society

12 June 201312 June 2013

Edward Edward M. Phillips, MDM. Phillips, MDDirector and Founder, Institute of LifestyleDirector and Founder, Institute of Lifestyle MedicineMedicineDirector and Founder, Institute of Lifestyle Director and Founder, Institute of Lifestyle MedicineMedicine

Assistant Professor, Physical Medicine and RehabilitationAssistant Professor, Physical Medicine and RehabilitationHarvard Harvard Medical School, Boston, Medical School, Boston, MassMass

Director, Outpatient Medical Services Director, Outpatient Medical Services Spaulding Spaulding Rehabilitation Hospital, Boston, Rehabilitation Hospital, Boston, MassMass

Adjunct Scientist, Jean MayerAdjunct Scientist, Jean Mayer--USDA Human Nutrition USDA Human Nutrition Research Center on Aging at Tufts UniversityResearch Center on Aging at Tufts University

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Faculty DisclosureFaculty Disclosure

Member, Scientific Advisory Board, Member, Scientific Advisory Board, OnLifeOnLifeH lth I (A b idi f TH lth I (A b idi f THealth Inc. (A subsidiary of Tennessee Health Inc. (A subsidiary of Tennessee Blue Cross)Blue Cross)

Royalties, ACSM’s Exercise is Medicine: A Royalties, ACSM’s Exercise is Medicine: A Clinician’s Guide to Exercise Prescription, Clinician’s Guide to Exercise Prescription, WoltersWolters--Kluwer, 2009Kluwer, 2009WoltersWolters Kluwer, 2009Kluwer, 2009

Learning ObjectivesLearning Objectives Increase the physical activity of patients Increase the physical activity of patients

by by prescribing exerciseprescribing exercise based on the based on the federal guidelines for weekly physical federal guidelines for weekly physical activity levelsactivity levels

Incorporate the Incorporate the Physical Activity Vital SignPhysical Activity Vital Sign(PAVS) as part of the clinical encounter(PAVS) as part of the clinical encounterImprove personal levels of physical activityImprove personal levels of physical activity Improve personal levels of physical activity Improve personal levels of physical activity for better health and to serve as better for better health and to serve as better role models for patientsrole models for patients

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OverviewOverview

DefinitionsDefinitions Physical activity recommendationsPhysical activity recommendations Physical activity recommendationsPhysical activity recommendations

–– CardiovascularCardiovascular–– Resistance trainingResistance training

InactivityInactivity–– PrevalencePrevalence

Physical activity vital signPhysical activity vital sign Cardiovascular (aerobics)Cardiovascular (aerobics) Cardiovascular (aerobics)Cardiovascular (aerobics) Resistance (strength training)Resistance (strength training) Exercise prescriptionExercise prescription Resources: further education Resources: further education

Physical ActivityPhysical ActivityPhysical Physical activity is any bodily movement activity is any bodily movement

d d b k l t l l th t lt id d b k l t l l th t lt iproduced by skeletal muscles that result in produced by skeletal muscles that result in an expenditure of an expenditure of energy energy

Caspersen CJ et al. Public Health Rep. 1985;100:126-131.

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ExerciseExerciseExercise is physical activity that is Exercise is physical activity that is planned or planned or structuredstructured It involvesIt involves repetitive bodilyrepetitive bodilystructuredstructured. It involves . It involves repetitive bodily repetitive bodily movementmovement done to improve or maintain one or done to improve or maintain one or more of the components of physical fitnessmore of the components of physical fitness——cardiorespiratory endurance (aerobic fitness), cardiorespiratory endurance (aerobic fitness), muscular strength, muscular endurance, muscular strength, muscular endurance, flexibility and body compositionflexibility and body compositionflexibility, and body compositionflexibility, and body composition

Caspersen CJ et al. Public Health Rep. 1985;100:126-131.

Physical FitnessPhysical Fitness

Outcome of physical activity and exercise:Outcome of physical activity and exercise:–– Strength and powerStrength and power–– Cardiorespiratory fitnessCardiorespiratory fitness–– BalanceBalance–– FlexibilityFlexibility–– Body compositionBody compositionBody compositionBody composition–– Agility, etc. Agility, etc.

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Types of ExerciseTypes of Exercise

Physical Physical activity activity vsvs exerciseexercise–– Structured exerciseStructured exercise–– Lifestyle exercise Lifestyle exercise

Inactivity (sedentary behavior)Inactivity (sedentary behavior) CardioCardio--vascular (aerobic)vascular (aerobic)

R i t t i i ( t th i )R i t t i i ( t th i ) Resistance training (strengthening)Resistance training (strengthening) Flexibility (stretching)Flexibility (stretching)

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Benefits of ExerciseBenefits of Exercise Coronary heart diseaseCoronary heart disease11

Corrects other riskCorrects other risk Improved functional Improved functional

capacitycapacity11Corrects other risk Corrects other risk factors for heart factors for heart disease:disease:11

–– ObesityObesity–– SmokingSmoking–– High blood lipidsHigh blood lipids

StrokeStroke22

HypertensionHypertension11

p yp y Increased bone densityIncreased bone density11

Increased lean body Increased lean body massmass11

Decreased risk for falls in Decreased risk for falls in older peopleolder people22

Decreased anxiety and Decreased anxiety and HypertensionHypertension11

DiabetesDiabetes11

Sexual functioningSexual functioning33

mildmild--moderate moderate depressiondepression11

Decreased total morbidity Decreased total morbidity and mortalityand mortality11

Exercise Break!Exercise Break!

StrengthStrength FlexibilityFlexibility StretchingStretching BalanceBalance

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How Much Physical Activity Should We Recommend?

All Cause Mortality vs Physical All Cause Mortality vs Physical Activity Activity

Adapted from US Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans. http://www.health.gov/PAguidelines; Jonas S, Phillips EM. Exercise is Medicine™: A Clinician’s Guide to Exercise Prescription. Philadelphia, PA: Lippincott Williams & Wilkins; 2009.

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USHHS Physical Activity USHHS Physical Activity Guidelines for Americans: AdultsGuidelines for Americans: Adults 150 minutes of moderate intensity physical 150 minutes of moderate intensity physical

activity per week ORactivity per week ORactivity per week ORactivity per week OR 75 minutes of vigorous physical activity (in bouts 75 minutes of vigorous physical activity (in bouts

of at least 10 minutes)of at least 10 minutes) For more extensive health benefits:For more extensive health benefits:

300 minutes of moderate intensity physical 300 minutes of moderate intensity physical activity OR 150 min vigorous physical activityactivity OR 150 min vigorous physical activityy g p y yy g p y y

Resistance (muscle strengthening) at least Resistance (muscle strengthening) at least twice per weektwice per week

US Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans. http://www.health.gov/PAguidelines.

Physical Activity Statistics Physical Activity Statistics

NHISNHIS-- National Health Interview Survey (1998National Health Interview Survey (1998--2007)2007)2007) 2007) –– 30.2% 30.2% are physically active are physically active –– 40.7%40.7% report no physical activity outside of their report no physical activity outside of their

work work

NHANES NHANES –– National Health and Nutrition National Health and Nutrition E i ti S (1999E i ti S (1999 2006)2006)Examination Survey (1999Examination Survey (1999--2006) 2006) –– 33.5%33.5% are physically active are physically active –– 32.4%32.4% are physically inactiveare physically inactive

NHIS, National Health Interview Survey; NHANES, National Health and Nutrition Examination SurveyCarlson SA et al. J Phys Act Health. 2009;6(Suppl 1):S18-27.

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Sedentary Lifestyle as Risk Sedentary Lifestyle as Risk FactorFactor

The American Heart Association The American Heart Association i d “ d t lif t l ”i d “ d t lif t l ”recognized “sedentary lifestyle” as a recognized “sedentary lifestyle” as a

primary controllable cardiac risk factor in primary controllable cardiac risk factor in 19921992

The prevalence of sedentary lifestyle is at The prevalence of sedentary lifestyle is at least twice that of smoking, hypertensionleast twice that of smoking, hypertensionleast twice that of smoking, hypertension least twice that of smoking, hypertension and elevated total serum cholesteroland elevated total serum cholesterol

Thompson PD et al. Circulation. 2003;107:3109-3116.

Sitting Time and Mortality from All Causes,Cardiovascular Disease and Cancer1

Sitting Time and Mortality from All Causes, Cardiovascular Disease, and Cancer.KATZMARZYK, PETER; CHURCH, TIMOTHY; CRAIG, CORA; BOUCHARD, CLAUDE

Medicine & Science in Sports & Exercise. 41(5):998‐1005 May 200941(5):998 1005, May 2009.DOI: 10.1249/MSS.0b013e3181930355

FIGURE 1 ‐Kaplan‐Meier survival curve for all‐cause mortality across categories of daily sitting time in 17,013 men and women 18‐90 yr of age, in the Canada Fitness Survey, 1981‐1993. Log‐rank [chi]2 = 174.4, df = 4, P < 0.0001. The sample sizes across the categories were 3022

©2009The American College of Sports Medicine.  Published by Lippincott Williams & Wilkins, Inc.

across the categories were 3022 (17.8%), 6652 (39.1%), 4379 (25.7%), 2138 (12.6%), and 822 (4.8%), for the categories of almost none of the time, one fourth of the time, half of the time, three fourths of the time, and almost all of the time, respectively.

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Does Clinician Prescription of Exercise

Make a Difference?

Evidence Base: Exercise RxEvidence Base: Exercise Rx

Exercise prescription for brisk walking resulted in Exercise prescription for brisk walking resulted in statistically significant, long term improvements in statistically significant, long term improvements in cardiopulmonary fitness (cardiopulmonary fitness (PP< .01)< .01)

Study limitations:Study limitations: Study limitations: Study limitations: –– absence of a “no treatment” control groupabsence of a “no treatment” control group–– patients with abnormal lipid profiles were excludedpatients with abnormal lipid profiles were excluded–– Comparison group intervention (physician advice) may not Comparison group intervention (physician advice) may not

parallel the impact of advice from a patient’s personal physicianparallel the impact of advice from a patient’s personal physician

Duncan GE et al. Arch Intern Med. 2005;165:2362-2369.

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Efficacy of Exercise PrescriptionEfficacy of Exercise Prescription

TwoTwo--year randomized, controlled trialsyear randomized, controlled trialsdd Women given exercise prescription increased Women given exercise prescription increased

physical activity from 10% at baseline to physical activity from 10% at baseline to 43% at 12 months, and 39% at 24 months 43% at 12 months, and 39% at 24 months ((PP<0.001)<0.001)

Limitations: inability to blind participants to the Limitations: inability to blind participants to the i t ti i i t ti ith i th t di t ti i i t ti ith i th t dintervention, ongoing interaction with nurse in the study intervention, ongoing interaction with nurse in the study group may have acted as an intervention, sample size group may have acted as an intervention, sample size not large enough to detect significant difference in not large enough to detect significant difference in clinical outcomesclinical outcomes

Lawton BA et al. BMJ. 2009;43:120-123.

Do Physicians Regularly Prescribe Exercise?

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Dearth of Physician CounselingDearth of Physician Counseling National prevalence of lifestyle counseling or National prevalence of lifestyle counseling or

referral among Africanreferral among African--Americans and whites Americans and whites with diabeteswith diabeteswith diabeteswith diabetes

A recent study showed that diabetic patients A recent study showed that diabetic patients received counseling/referral for nutrition only received counseling/referral for nutrition only 36% of the time, and for exercise only 18% of 36% of the time, and for exercise only 18% of the time the time

Limitations: Limitations: t f li t t l t lt f li t t l t l–– rates of counseling may not accurately assess actual rates of counseling may not accurately assess actual

practice; inability practice; inability to detect racial differences in to detect racial differences in counseling counseling quality; findings quality; findings may not be generalizable may not be generalizable to the most vulnerable Africanto the most vulnerable African--American patientsAmerican patients

Peek ME et al. J Gen Intern Med. 2008;23:1858-1864.

Efficacy of Physician CounselingEfficacy of Physician Counseling

Study of hypertensive patients, only a Study of hypertensive patients, only a third received counseling to engage inthird received counseling to engage inthird received counseling to engage in third received counseling to engage in physical activity as a way to manage their physical activity as a way to manage their hypertensionhypertension

However, 71% of the patients who were However, 71% of the patients who were counseled followed the recommendations counseled followed the recommendations to exercise and reduced their bloodto exercise and reduced their bloodto exercise and reduced their blood to exercise and reduced their blood pressurepressure

Limitations: Study data may be old, selfLimitations: Study data may be old, self--reported data reported data may be limitedmay be limited

Halm J, Amoaka E. Ethnicity and Disease. 2008;18:278-282.

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OverviewOverview

DefinitionsDefinitions Physical activity recommendationsPhysical activity recommendations Physical activity recommendationsPhysical activity recommendations

–– CardiovascularCardiovascular–– Resistance trainingResistance training

InactivityInactivity–– PrevalencePrevalence

Physical activity vital signPhysical activity vital sign Cardiovascular (aerobics)Cardiovascular (aerobics) Exercise prescriptionExercise prescription Resources: further education Resources: further education

Physical Activity Vital Sign at Kaiser Physical Activity Vital Sign at Kaiser PermanentePermanente

1.1. “How many days per week (on average) “How many days per week (on average) d i t d t l ld i t d t l ldo you exercise at a moderate level or do you exercise at a moderate level or greater (like a brisk walk)?” greater (like a brisk walk)?” Followed by a pull down 0 to 7 daysFollowed by a pull down 0 to 7 days

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2.2. “How long (on average) do you spend “How long (on average) do you spend i i t thi l l ( d ti i t thi l l ( d t

Physical Activity Vital Sign at Kaiser Permanente

exercising at this level (moderate or exercising at this level (moderate or greater) when you do exercise (in greater) when you do exercise (in minutes)?” minutes)?” Followed by a pull down Followed by a pull down 10/20/30/40/50/60/90/120/150 or more10/20/30/40/50/60/90/120/150 or more10/20/30/40/50/60/90/120/150 or more 10/20/30/40/50/60/90/120/150 or more minutesminutes

Kaiser Permanente Exercise Vitals Screen Shots

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Kaiser Permanente Exercise Vitals Screen Shot

Activity: Physical Activity Vital Sign Activity: Physical Activity Vital Sign

Turn to your neighbor, colleague, client, Turn to your neighbor, colleague, client, ti t ( lf)ti t ( lf)patient (or yourself)patient (or yourself)

Assess their PAVS Assess their PAVS

PAVS, physical activity vital sign

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Physical Activity Vital Sign Physical Activity Vital Sign

How many days (over the last week), did How many days (over the last week), did you participate in physical activity such asyou participate in physical activity such asyou participate in physical activity such as you participate in physical activity such as a brisk walk?a brisk walk?

(On average), how many minutes per day (On average), how many minutes per day did you accumulate of physical activity at did you accumulate of physical activity at this level? this level? M lti l th 2 b t tM lti l th 2 b t t Multiply the 2 numbers to get a Multiply the 2 numbers to get a minute/week averageminute/week average

Greenwood JL et al. J Phys Act Health. 2010;7:571-576.

Results Results

Inactive (0Inactive (0--75 minutes per week)75 minutes per week)Ti t t i B ildi i 10 i t fTi t t i B ildi i 10 i t f Time to get moving. Building in 10 minutes of Time to get moving. Building in 10 minutes of exercise each day would benefit your health exercise each day would benefit your health

Somewhat active (75Somewhat active (75--149 minutes per week) 149 minutes per week) There is room for improvement but you are There is room for improvement but you are

almost there almost there Active (Active (>>150 minutes per week) 150 minutes per week)

Congratulations! Keep up your healthy Congratulations! Keep up your healthy lifestyle and getting more out of life lifestyle and getting more out of life

Greenwood JL et al. J Phys Act Health. 2010;7:571-576.

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Exercise PrescriptionExercise Prescription

ScreeningScreening PrecautionsPrecautions FrequencyFrequency Intensity Intensity TypeType TimeTime ProgressionProgression

Exercise PrescriptionExercise Prescription

ScreeningScreening PrecautionsPrecautions FrequencyFrequency Intensity Intensity TypeType TimeTime ProgressionProgression

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Screening for Exercise Screening for Exercise The screening process The screening process

should not be a barrier should not be a barrier for for lowlow level of physical level of physical activityactivityactivityactivity

The risks of death are The risks of death are rare:rare:–– sudden onset sudden onset

vigorous intensity vigorous intensity –– patients with knownpatients with knownpatients with known patients with known

disease or signs and disease or signs and symptomssymptoms

The risks of sedentary The risks of sedentary behavior are universalbehavior are universalJonas S, Phillips EM. Exercise is Medicine: A Clinician’s Guide to Exercise Prescription. Philadelphia, Pa: Lippincott Williams & Wilkins; 2009.

Exercise PrescriptionExercise Prescription

ScreeningScreening PrecautionsPrecautions FrequencyFrequency Intensity Intensity TypeType TimeTime ProgressionProgression

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Age HRmaxVIGOROUS INTENSITY

LOW INTENSITY

MODERATE INTENSITY

The ranges were calculated using the formula: [206.9 The ranges were calculated using the formula: [206.9 –– (0.67 x age] x %HR (0.67 x age] x %HR maxmax Low intensity: <64% HR Low intensity: <64% HR rmaxrmax

Moderate intensity: 64%Moderate intensity: 64%--76% HR max76% HR maxVigorous intensity: >76% HR max Vigorous intensity: >76% HR max

Heart Rate Ranges

15 < 126 126 − 150 > 150 19720 < 124 124 − 147 > 147 19425 < 122 122 − 145 > 145 19030 < 120 120 − 142 > 142 18735 < 117 117 − 139 > 139 18340 < 115 115 − 137 > 137 18045 < 113 113 − 134 > 134 17750 < 111 111 − 132 > 132 17355 < 109 109 − 129 > 129 17060 < 107 107 − 127 > 127 16765 < 105 105 − 124 > 124 16370 < 102 102 − 122 > 122 16075 < 100 100 − 119 > 119 15780 < 98 98 − 117 > 117 15385 < 96 96 − 114 > 114 15095 < 92 92 − 109 > 109 143

ACSM’s Guidelines for Exercise Testing and Prescription, 8th Edition. Baltimore, MD: Lippincott Williams & Wilkins; 2009.

“Talk“Talk--Test”Test”

The least objective but easiest measure of The least objective but easiest measure of intensity is the “talk test” intensity is the “talk test” yy

When performing physical activity at a low When performing physical activity at a low intensity, an individual should be able to talk or intensity, an individual should be able to talk or sing while exercising sing while exercising

At a moderate intensity, talking is comfortable,At a moderate intensity, talking is comfortable,but singing, which requires a longer breath, but singing, which requires a longer breath, becomes more difficult becomes more difficult

At vigorous intensity, neither singing nor At vigorous intensity, neither singing nor prolonged talking is possibleprolonged talking is possible

Persinger R et al. Med Sci Sports Exerc. 2004;36:1632-1636.

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Intensity "Talk Test"Perceived

Exertion (10 point HRR (%) Maximal

HR (%)MET

VO R (%) VO

Exercise Intensity

yscale)

HR (%)

Very light <20 <50Light 20–39 50–63Moderate Able to talk but

not sing 3 -4 40–59 64–76

Vigorous/hard 5 - 6 60–84 77–93

Very hard 7 -9 85 94Difficulty talking >6

<3 > 3

3 -6

Able to talk and/or sing

VO R (%)2 VO2max

Maximal 10 100 100Abbreviations: METs = metabolic equivalent units (1 MET = 3.5 mL×kg–1×min–1); = oxygen uptake reserve; HRR = heart rate reserve.VO R,2

Jonas S, Phillips EM. Exercise is Medicine™: A Clinician’s Guide to Exercise Prescription. Philadelphia, Pa: Lippincott Williams & Wilkins; 2009:102.

OverviewOverview

DefinitionsDefinitions Physical activity recommendationsPhysical activity recommendations

–– CardiovascularCardiovascular–– Resistance trainingResistance training

Cardiovascular (aerobics)Cardiovascular (aerobics)St th i ( i t t i i )St th i ( i t t i i ) Strengthening (resistance training)Strengthening (resistance training)

Exercise prescriptionExercise prescription Exercise: further education Exercise: further education

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Medication Prescription:Medicine: Ibuprofen Strength: 600 mg tabletsRoute: By mouthDispense: 90 tablets

Medication vs Exercise Prescriptions

Dispense: 90 tabletsFrequency: 3 times per dayPrecautions: Discontinue for stomach upsetRefills: 3

Exercise Prescription: Exercise: Walk 30 minutes per day to improve mood

d l h lthand general healthStrength: Moderate intensityFrequency: 5 days per weekPrecautions: Increase duration of walking slowly to avoid

injuryRefills: Forever

Jonas S, Phillips EM. Exercise is Medicine™: A Clinician’s Guide to Exercise Prescription. Philadelphia, Pa: Lippincott Williams & Wilkins; 2009:102.

BEGIN WITH:Frequency F __________ times each weekIntensity I __________ intensity (ie, an intensity where you

can talk/sing while active)

Activity: Exercise Prescription

can talk/sing while active)Time/duration T __________ minutes each day

(circle)Type T __________ type of exercise (eg, walking,

gardening, swimming, etc) This corresponds to level ______ on the graph aboveMaintain this level for _______ weeks before starting your progression

PROGRESSIONPROGRESSION:Every week/2 weeks, progress to the next level on the graph above

(circle)PRECAUTIONS:OTHER NOTES:

Jonas S, Phillips EM. Exercise is Medicine™: A Clinician’s Guide to Exercise Prescription. Philadelphia, Pa: Lippincott Williams & Wilkins; 2009.

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25

30

35(p

er d

ay) TARGET / THRESHOLD ZONE:

30 min of moderate intensity ≥5x/week, OR 20 min high intensity ≥3x/week, OR

20-30 min combined moderate and highintensity 3-5x/week

Once the threshold is reached, exercise

intensity can be increased, enabling

total exercise time to decrease (f rom 150

min/week to 60

Exercise Progression

0

5

10

15

20

ota

l min

ute

s o

f ex

erci

se

EXERCISE INTENSITYLow Moderate

High/vigorous <3x/

wee

k

min/week to 60 min/week if all exercise

is high intensity)

xercise 3-5x/week, working up to 150 min/week)

The average healthy, inactive adult should

0

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17To

Exercise level

g g<

TO DETERMINE STARTING LEVEL: Determinehow many minutes (see X-axis) you are comfortable exercising at least 3x/week. This is your starting level.Increase to 5x/week before progressing to the next level.

PROGRESS: to the next level (move 1 bar to the right)every week. Ensure that you continue exercising 5x/week. If you begin the program very deconditioned or sedentary and over the age of 65, then progress every 2-4 weeks.

Jonas S, Phillips EM. Exercise is Medicine™: A Clinician’s Guide to Exercise Prescription. Philadelphia, Pa: Lippincott Williams & Wilkins; 2009.

Sample Exercise Prescription

Jonas S, Phillips EM. Exercise is Medicine™: A Clinician’s Guide to Exercise Prescription. Philadelphia, Pa: Lippincott Williams & Wilkins; 2009.

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Sample Exercise Prescription

Jonas S, Phillips EM. Exercise is Medicine™: A Clinician’s Guide to Exercise Prescription. Philadelphia, Pa: Lippincott Williams & Wilkins; 2009.

Source: Lydia Siegel, MD

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Activity: Exercise Prescription Activity: Exercise Prescription

The exercise prescriptionThe exercise prescription–– Turn to your colleague, client, patient etc.Turn to your colleague, client, patient etc.–– Assess their readiness for exerciseAssess their readiness for exercise–– Negotiate:Negotiate: FrequencyFrequency IntensityIntensity Time Time TypeType

–– Write a prescription for cardiovascular (and Write a prescription for cardiovascular (and resistance training for extra credit)resistance training for extra credit)

Activity: Exercise PrescriptionBEGIN WITH:Frequency F __________ times each weekIntensity I __________ intensity (ie, an intensity where you

can talk/sing while active)can talk/sing while active)Time/duration T __________ minutes each day

(circle)Type T __________ type of exercise (eg, walking,

gardening, swimming, etc) This corresponds to level ______ on the graph aboveMaintain this level for _______ weeks before starting your progression

PROGRESSION

Jonas S, Phillips EM. Exercise is Medicine™: A Clinician’s Guide to Exercise Prescription. Philadelphia, Pa: Lippincott Williams & Wilkins; 2009.

PROGRESSION:Every week/2 weeks, progress to the next level on the graph above

(circle)PRECAUTIONS:OTHER NOTES:

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http://www.exerciseismedicine.org

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Follow Up

Email: ephillips1@partners.org Connect with the Institute of Lifestyle Connect with the Institute of Lifestyle

Medicine (ILM) Website: www.instituteoflifestylemedicine.org/ Facebook:

https://www.facebook.com/InstituteofLifestyleMedicine

LinkedIn: http://www.linkedin.com/groups/Institute-Lifestyle-Medicine-4598141

Twitter: @ILMLifestyleMed