1. A presentation at the American
College of Lifestyle Medicine:
Lifestyle 2012 10/1/12
Stephan Esser MD
www.esserhealth.com

2. Disclosures
• None

3. Goals
• Plant Seeds
• Stimulate Dialogue
Have Fun
• Harvest Ideas
• Identify Opportunity
• Unravel a Solution
• Empower you to empower others

4. Goals
• Provide applicable knowledge
• Equip you with tools to promote change
• Practice skills
• Develop a plan of action
• Take it home
• Apply it

5. Goals
• Review foundational ideas in muscle physiology
• Explore concepts in Exercise as medicine
• How your habits affect patient success
• ACSM criteria and patient selection
• Review the basics of patient change and
motivation
• Develop Exercise prescription writing skills

6. What this is NOT!
• The END
• The final word
• Everything you need to know
• For that……..

7. Why none of us do what we know we should do
and want to do ALL the time

8. Reasons NOT to Counsel on Exercise
• Time Limitations
• Inadequate reimbursement
• Personal Fitness
• Don’t feel adequately prepared (lack of confidence,
training, instruments and materials)
• Physician Specialty
• Perceived lack of success at advising exercise
• Lack of confidence in the exercise provider

9. Breakout: 2 minutes
Ask what your neighbor’s reasons are for NOT
counseling on Physical Activity

10. Efficacy of Physician Counseling
• Recent study of hypertensive patients, only a
third received counseling to engage in physical
activity as a way to manage their
hypertension.
• However, 71% of the patients who were
counseled followed the recommendations to
exercise and reduced their blood pressure.
– Halm, Ethnicity and Disease 2008

11. • A recent study showed that diabetic patients
received counseling/referral for nutrition only
36% of the time, and for exercise only 18% of
the time.
Peek, J Gen Intern Med, 2008

12. 1975-Teach medical students about
exercise as preventive medicine
– 74 medical school participated in questionnaire
– 16% offered a course geared to exercise as
preventive medicine
Burke EJ, Hultgren PB. Will Physicians
of the Future Be Able to Prescribe
Exercise? J Med Educ. 1975;50:624-6.

13. Exercise Courses in
Medical Schools
• 2001-Medical school leaders including
Deans and Directors of Medical Education
have reported
– 72 out of 128 medial schools participated in
questionnaire
– 6% of medical schools polled reported having
a core course addressing the exercise
prescription
• Connaughton AV,Weiler RM, Connaughton D. Graduating Medical Students’ Exercise Prescription
Competence as Perceived by Deans and Directors of Medical Education in the United States: Implications
for Healthy People 2010. Public Health Reports. 2001;116:226-234.

14. Deans Report of Medical Student’s
Competency in Exercise Prescription
10%
90%
Connaughton AV,Weiler RM, Connaughton D. Graduating Medical Students’ Exercise Prescription Competence as
Perceived by Deans and Directors of Medical Education in the United States: Implications for Healthy People 2010.
Public Health Reports. 2001;116:226-234.

15. Our Obligation
• The physician is obligated to broach critical
lifestyle areas.
• Avoidance or lack of comment by the
physician may be perceived as tacitly
condoning the unhealthy behaviors.
• The physician has an important opportunity to
promote behavior change and be supportive
of the change process.
• Need to ask about physical activity and to
prescribe exercise.

16. • Effective and efficient delivery of message
from physician to improve health behaviors.
“Talk the Talk.”
• Need to establish physicians as role models of
healthy behaviors. “Walk the Walk.”

17. Goals
• Why this matters?

18. The State of the Nation

19. “A global response to a global
problem: the epidemic of
overnutrition.” WHO
It is estimated that by 2020 2/3rds of the global
burden of disease will be attributable to chronic
non-communicable diseases, most of them strongly
associated with diet. The nutrition transition towards
refined foods, foods of animal origin, and
increased fats plays a major role in the current
global epidemics of obesity, diabetes and
cardiovascular diseases, among other non-
communicable conditions. Sedentary lifestyles and the use
of tobacco are also significant risk factors. …….. A
concerted multi-sectoral approach, involving the use of
policy, education and trade mechanisms, is necessary to
address these matters.

21. Top Ten Causes of Death for Men in the United States

22. Actual Causes of Death in US

23. 2 of 3

26. Associated Pathology
• CVD: • Obstetrics:
– Hypertension – Gestational DM
– Congestive Heart Failure – Macrosomia
– Inc. C Section rate
– PVD – Inc. Perinatal Morbidity
– Impotence – Inc. Pre/Eclampsia
– Claudication • Cancer:
• Endocrine: – Prostate
– Colon
– Diabetes
– Breast
– PCOS – Endometrial
– Hypothyroidism – Renal Cell
– Infertility – Gallbladder
• – Esophageal Adeno.
Orthopedics:
• Other:
– Osteoarthritis
• Hyperuricemia, Pancreatitis, Gallstones,
– AVN Sleep Apnea, Alzheimer’s, Dyslipidemia,
• Hepatic: Metabolic Syndrome
– #1 cause of liver dz in US

27. The Problem
1:9 adults

28. The Problem
• High Blood Pressure:
– 1 in 3 adults
1:3 adults

29. 1:6 adults

30. Waist Circumference > 40” M > 35” W
> 34%
Triglycerides > 150 HDL < 40 M or < 50 W
of Americans
BP ≥ 130/85 Fasting Glucose of ≥ 100

32. Perspective
• We eat more
– Sugar, Salt, Fat, Meat, Dairy
– 1970-2006:
• ↑ 24.5 % C/day ≈
617K/day
• We get less then ideal Physical Activity
– 18.8% of adults achieved CDC reccs on
Exercise
– 10% of adults >65 y/o

33. Michelangelo’s David:
12 month 20 city tour of the US

34. “A global response to a global
problem: the epidemic of
overnutrition.” WHO
It is estimated that by 2020 2/3rds of the global
burden of disease will be attributable to chronic
……if…….Lifestyle is the
noncommunicable diseases, most of them strongly
Problem
associated with diet. The nutrition transition towards
refined foods, foods of animal origin, and increased fats
plays a major role in the current global epidemics of
obesity, diabetes and cardiovascular diseases, among
other noncommunicable conditions. Sedentary
What of tobacco are also significant
lifestyles and the use
is the answer……..?
risk factors. …….. A concerted multi-sectoral approach,
involving the use of policy, education and trade
mechanisms, is necessary to address these matters.

35. Surgery
Pharmaceuticals
Physical Modalities
Lifestyle Medicine

36. Lifestyle Medicine
• Nutrition
• Physical Activity
• Emotional Poise
• Avoidance of Toxins

37. Exercise and Physical Health
• Reduces risk of
– Heart Disease ≈ 40%
– Obesity: ≈ 30-100%
– Stroke ≈ 50%
– Type 2 Diabetes ≈ 50%
– Hypertension ≈ 50%
– Disability delayed ≈15 years
– Colon Cancer ≈ 25-40%
– Breast Cancer ≈ 20%-44%
– Osteoporosis ≈ 20+%
• As many as 250,000 deaths per year in the United
States are attributable to a lack of regular
physical activity

38. Physical Health Cont’d
• Improve Balance/Reduce Fall risk
• Reduce/Prevent Disability
• Improve Systemic Circulation
• Accelerate Skin Healing
• Bowel Regularity/  risk diverticulosis
• Improved Energy/Resilience

39. Exercise and Mental Health
• Regular Exercise:
– Reduces risk/severity of:
• Depression
• Anxiety
• ADD/ADHD
• Alzheimers Dementia
– Improves:
• Mental Clarity, test scores, focus

40. Exercise and Emotional Health
• Regular Exercise:
– Increases Self Confidence
– Teaches skills to manage adversity
– Enhances Self Esteem
– Develops Discipline
– Encourages Goal setting and self awareness

41. “Eating alone will not keep a man well; he must
also take exercise. For food and exercise……
work together to produce health.”
Hippocrates
Regimen 400 BC

42. Our Goal
• Support patients in achieving their BEST
Health
• Get patients moving
• Know your stuff Make it FUN
• Patients needs
• Stages of change
• Effectively communicate
• Educate, empower, motivate

43. Mini-Medschool

44. Muscle anatomy and physiology
• Muscle Types:
– Striated: Skeletal, Cardiac
– Smooth: Walls of hollow structures
– Stomach, bladder, intestines, vessels
• Muscle Innervation:
– Voluntary: Skeletal
– Involuntary: Cardiac, Smooth

45. Muscle anatomy and physiology
Sarcomere: The basic
functional unit of a muscle
The A Band does NOT shorten
Z-Lines: Borders of each Sarcomere
http://media.tumblr.com/tumblr_ll9jc5uZcM1qcfmqz.gif

46. Muscle anatomy and physiology
• Fiber Types:
– Type I: slow, oxidative fibers
•  mitochondria, myoglobin, capillaries
•  resistance to fatigue
– Type IIA: fast, oxidative fibers
•  myoglobin
• Intermediate fatigue resistance
– Type IIB: very fast, glycolytic fibers
•  glycogen, anaerobic action
• Rapidly fatigue

47. Basic Principles
• Size Principle:
– Motor units are recruited in order of fiber size,
Type 1 smaller, Type 2 larger
– Inc firing in response to demands

48. Muscle anatomy and physiology
• Fiber Types Continued:
– Force Production:
• Low: Type I
• High: Type IIA
• Very High: Type IIB
– Concentration:
• Average: 60% fast twitch, 40% slow
– Location/Function:
• UE: Fast Para-vertebrals: Slow

49. Muscle anatomy and physiology
• Can you change Fiber Types?
– Endurance Training:
• ’d oxidative potential
• Debatable change in fiber type distribution
– Resistance Training:
• ’d muscle fiber hypertrophy/cross-sectional area
• Debatable change in fiber type distribution

50. What we Know?
• The need for exercise
• The benefits of exercise
• The basic science of muscle

51. Foundational Concepts

52. Defining Exercise
• Exercise:
– movement of the body resulting in the
enhancement of health and/or
improvement of function

54. Exercise
• Leisure time Exercise: organized sports,
running, gym activities, rehabilitation etc.
• Lifestyle Exercise: activity incorporated into our
daily pattern of life
– eg: parking in the distant portion of the parking lot rather then the first
bumper, taking the stairs instead of the elevator etc.

55. Types of Physical Activity
• Cardiovascular
• Strength/Resistance Training
• Core Stability/Balance
• Flexibility/Coordination

56. Cardiovascular Training Adaptations

57. Cardiorespiratory Adaptations
• High, acute stress to the CV system
• Inc HR, SV, CO, BP
• Chronic:
– Inc. Vo2Max, SV
– Decr. Resting HR, BP (HTN -4%/-5%, NT -2%/-1%),

58. Immune System Changes/Adaptations
• Beneficial Effects: Regular, Moderate
• Harmful Effects: Extreme, Excessive
– Decr. neutrophil respiratory burst, lymphocyte
proliferation, monocyte antigen presentation
– >1.5 h, of moderate to high intensity (55–75%
maximum O2 uptake), and performed without
food intake

59. Resistance Training Basics

60. Basic Principle
• Progressive Overload: (Delorme Principle)
– Gradual increase in stress upon the body results in increases
in tolerance and eventual plateau
– SAID (Specific Adaptations to Imposed Demands)
– Greater Demand = Greater Adaptation within genetic
potential

61. Basic Principles
• Hyperplasia: Inc in the number of muscle
fibers within a given muscle ≈ 5%
• Hypertrophy: Inc in the size of individual
muscle fibers/or an entire muscle ≈ 95%

62. Lingo
• Weight: ………
• Repetitions (Reps): Number of times each
motion/exercise performed
• Sets: Number of times a group of repetitions is
performed
• Rep. Max (RM): Highest weight with which an exercise
can be performed (usually one time)

63. Basic Principles
• Low Weight/High Repetition = greater focus on
cardiovascular/endurance benefits
– Eg: > 15 reps
• High Weight/Low Repetition = greater focus on
anabolism, strength
– Eg: 5-8 reps

64. Contraction Types

65. Resistance Training Adaptations

66. Neuromuscular Adaptations
• Early Adaptations: Week 1-8
– Inc. neural drive: motor unit recruitment and rate
of firing, synchronization of motor units,
coordination of agonist/antagonist firing
– Alterations in myosin heavy chains and ATPase
enzymes
– 16 workouts for significant muscle hypertrophy
• Late Adaptations: > 8 weeks
– Primarily muscle hypertrophy

67. Cardiorespiratory Adaptations
• High, acute stress to the CV system
• Inc HR, SV, CO, BP
• Chronic:
– Dec resting HR of 5-12%
– Dec SBP and DBP by 2% and 4%

68. Connective Tissue Adaptations
• Bone is dynamic responding to compression, strain
– Increased intensity = increased response
– Goal > 60% 1RM
– Stress results in inc. BMD
– Takes time ≈ 6 months, begins with Inc serum alk
phos. and osteocalcin at 1 month
• Soft Tissue:
– Inc. collagen size, number and packing density

69. Endocrine Adaptations
• Testosterone/ GH/ IGF/ Insulin / Cortisol
• Acute Changes:
– Inc T and GH during and for 15-30 minutes post in men
– Affects in women less studied/less clear
– Magnitude of change greatest when large muscle mass is
exercised at mod/high intensity and volume with short rest
periods
• Chronic Changes:
– Resting T [] variable
– No change in resting GH, however various sizes/forms
– Inc IGF-1 at rest.
– No clear change in resting cortisol

70. Immune System Changes/Adaptations
• Inc circulating Leukocytes 8-14% over next 24
hrs
• Inc circulating Lymphocytes 50-200%
– NK cell cytotoxic activity  by 40% 2 hrs post

71. Comparative Benefits

72. Types of Physical Activity
• Cardiovascular
• Strength/Resistance Training
• Core Stability/Balance
• Flexibility/Coordination

73. What we know!
• The value of movement
• The basic science of muscle
• Foundational terms and principles
Next
• Goals
• Patient Selection

74. Our Goals
• For the overwhelming majority of patients the
benefits of exercise outweigh risk
• We must identify those at risk and
appropriately screen and select them
• We must help establish goals and assist in
their achievement

75. Phases of Activity
• Phase I: Contemplation, screening and
motivation
• Phase II: From start to ACSM/AHA exercise
recommendations
• Phase III: Maintaining or going beyond
ACSM/AHA recommendations

76. Up Next
• Risk Stratification
• Readiness for Change
• Exercise Prescription Writing
• Motivation: Improving Engagement

77. Simple
Minimal Cost
One step screen
Validated

78. RISK STRATIFICATION FOR SEDENTARY PATIENTS
Patient answered
NO to all seven Low risk:
questions on the
Client can begin
PAR-Q < 2 risk factors for exercise program
CV, pulmonary or unsupervised
metabolic disease
Patient
completes the
PAR-Q
≥ 2 risk factors for
CV, pulmonary or
metabolic disease Moderate risk:
Client requires
Uncomplicated supervision or
Patient answered
YES to one or pregnancy modifications to
more questions Other medical exercise program
on the PAR-Q conditions
Complicated
Pregnancy High risk:
Client requires further
Symptomatic or medical assessment
known cardiovascular,
prior to initiating
pulmonary or
metabolic disease
exercise program

79. Risk Factors
• Family History
– Relative with early CAD (M<55, W<65)
• Smoking: present or last 6 months
• Dyslipidemia: LDL >130, HDL<40, Tch>200
• Hypertension: SBP>140, DBP>90
• Elevated Blood Glucose: > 100 2x’s
• Obesity

80. Low Risk
• Men < 45 y/o
• With ≤ 1 risk factor
• Women < 55 y/o
– With ≤ 1 risk factor

81. Moderate Risk
• Men ≥ 45 and Women ≥ 55
• ≥ 2 risk factors

82. High Risk
• Known CAD, CVD, PVD
• Known Pulmonary Disease
• Signs/Symptoms suggestive of the above

83. RISK STRATIFICATION FOR SEDENTARY
PATIENTS
CARDIOVASCULAR/METABOLIC RISK FACTORS:
<2 risk factors = LOW RISK; ≥2 = MODERATE RISK
• male > 45 years old
• female > 55 year old, or has had hysterectomy, or is post menopausal
• smoker (or quit within past 6 months)
• BP > 140/90mmHg
• on BP medication
• blood cholesterol >200mg/dL
• close blood relative who had heart attack or heart surgery before
age 55 (male) or 65 (female)
• >20 pounds overweight
• pre-diabetes
• sedentary lifestyle

84. RISK STRATIFICATION FOR SEDENTARY PATIENTS
OTHER RISK FACTORS (MODERATE RISK)
• pregnancy
• musculoskeletal problems that limit physical activity
• client takes prescription medication that may influence
exercise tolerance
• client has concerns about the safety of exercise

85. RISK STRATIFICATION FOR SEDENTARY PATIENTS
CARDIOVASCULAR and PULMONARY S/S (HIGH RISK):
• heart attack or heart failure
• heart surgery or transplantation
• cardiac catheterization
• coronary angioplasty
• pacemaker/implantable cardiac
• defibrillator/rhythm disturbance
• heart valve disease
• congenital heart disease
• chest discomfort with exertion
• unreasonable breathlessness
• dizziness, fainting or blackouts
• takes heart medications
• burning or cramping sensation in lower legs when walking short distances
• asthma or other lung disease

86. Risk Stratification Algorithm
MAJOR SIGNS and SYMPTOMS of CARDIOVASCULAR, PULMONARY or METABOLIC
DISEASE (HIGH RISK):
•chest discomfort with exertion
• dizziness, fainting or blackouts
• takes heart medications
• bilateral ankle edema
• unreasonable breathlessness (at rest, with mild exercise, or when recumbent)
• burning or cramping sensation in lower legs when walking short distances
• pain or discomfort in the chest, neck, jaw, arms, or elsewhere that may be d/t ischemia
Adapted from: American College of Sports Medicine. ACSM's Guidelines for Exercise
Testing and Prescription, 8th edition. Philadelphia: Lippincott Williams & Wilkins; 2009.
(chapter 2)

87. Risk Stratification
• Low Risk: No additional testing needed
• Moderate Risk: Exercise testing if planning for
vigorous intensity activity
• High Risk: Exercise testing prior to engaging in
moderate or vigorous

88. Cases

89. Cases
62 y/o plays doubles tennis regularly
On HCTZ 12.5 for SBP and low dose Statin
Wants to train for a charity ½ marathon for
breast cancer

90. Case

91. • Evaluating your patient’s activity

92. Present Recommendations
• Cardiovascular:
– 150 minutes of moderate-intensity exercise per
week.
– 30-60 minutes of moderate-intensity exercise (five
days per week) or 20-60 minutes of vigorous-
intensity exercise (three days per week).

93. Present Recommendations
• Resistance Training:
– 2-3 days per week
– All major muscle groups
– 2-4 sets of each exercise
– 48 hours in between sessions
http://www.acsm.org/about-acsm/media-room/news-releases/2011/08/01/acsm-issues-new-
recommendations-on-quantity-and-quality-of-exercise

94. Present Recommendations
• Flexibility:
– 2-3 days/week to improve range of motion
• Balance:
– 2-3 days/week
– Eg: Tai Chi, Yoga

95. • What are they already doing?

96. Physical Activity Vital Sign
• “Over the last week on how many days did
you do at least 30 minutes of moderate
physical activity?”
• 0-2 Days: Sedentary
• 3-4 Days: Somewhat active
• 5-7 Days: Meets recommended levels

97. Other Basics
• Type of Exercise they perform
• What they enjoy/don’t enjoy
• Why/Why not
• What have they tried
• What would they like to try

98. • Your Patients and Change

99. Stages of change
1: Pre-contemplation
2: Contemplation
3: Preparation/planning
4: Action
5: Maintenance
6: Permanent Maintenance (Termination)

100. The Pre-contemplators
• Ask if the patient would
like to hear about or
read about the benefits
of exercise
• “I understand that you
are not ready to change,
but please know that
when you are ready, I will
be here to help.”
• “I think that it is
important for your
health….”
Key: Empathy

101. Physicians’ Empathy Influences Clinical
Outcomes
• 891 Diabetic patients
• 29 Family physicians
• Hgb-A1c, LDL-C
• Jefferson Scale of Empathy
• High empathy scores for MD correlated with good control
of Hgb A1c and LDL-C in patients
Hojat et al. Acad Med. 2011;86:359-364

102. Contemplators
• Ask the patient to consider
what things would be like if
they did not begin an
exercise program
• Ask the patient how
important exercise is to
them
• Work with the patient to
identify a powerful, intrinsic
motivator
Key: Vision and Motivators

103. My Reasons to Exercise
• Feel good in my skin
• Increase energy, Reduce stress
• Increase my confidence, discipline
• Be a role model, socialize, family time
• It’s fun, I love to sweat and work hard
• I love challenges
• Reduce disease risk
• Lower disability risk
• Maintain independence

104. What are your reasons?

105. Defining Success
• What is success for you?
• Are such goals achievable, legitimate?
• What will you do if you fail to “succeed”?

106. The People in Preparation
• Ask the patient how confident she is in her ability to perform
exercise
• Ask how the patient can increase her confidence in her ability
to perform exercise
• Develop a SMART exercise goal for the patient
• Identify possible obstacles and brainstorm strategies around
them
Key: A solid plan with SMART goals

107. What are your reasons
NOT
to Exercise?

108. My Reasons NOT to Exercise
• Time
• I’m tired or lazy
• Inconvenience (I forgot my clothes etc…)
• Money (shoes, travel, racquets)
• Other priorities
• Hate Change
• Don’t know what to do
• I’m Injured

109. GROW
• Goals
• Reality today
• Options
• Will

110. • Specific
• Measureable
• Achievable
• Realistic
• Timely

111. 4 minute breakout
• Identify a Physical Activity Goal for yourself!
• Using the SMART acronym write a plan for
achieving it!
• Share it with your neighbor

112. The People in Action
• Review physical activity guidelines
• Write an exercise prescription
• Follow up on the patient’s progress
• Congratulate patients on their exercise
• Encourage patients to meet the guidelines
• Ask about walks or runs for non-profits (AHA)
Key: Motivators, rewards, goals

113. The People in Maintenance
• Discuss the patients exercise routine
• Consider recommending cross training
• Review health benefits with patient
• Congratulate patient
• Write an exercise prescription
• Recommend becoming a mentor to family or friends
Key: Motivators, rewards, goals +
variety and mentoring

114. • Why Prescribe?

115. Physician Prescribed Exercise
• Acceptable, familiar format for physicians
• Limited time required
• Elevates from recommendation to “order”
• Supports metaphor that exercise is indeed the
best medicine

116. Medication Prescription:
Medicine: Ibuprofen
Strength: 600mg tablets
Route: By mouth
Dispense: 90 tablets
Frequency: Three times per day
Precautions: Discontinue for stomach upset
Refills: 3
Exercise Prescription:
Exercise: Walk 30 minutes per day to improve mood and
general health.
Strength: Moderate intensity
Frequency: Five days per week
Precautions: Increase duration of walking slowly to avoid
injury
Refills: Refill at next visit.

117. Exercise Prescription
• Screening
• Precautions
• Frequency
• Intensity
• Type
• Time
• Progression

118. Frequency
Ask for a confidence
• Cardiovascular: rating? 0-10
Document it in the chart
– 150 minutes of moderate-intensity exercise per
week.
– 30-60 minutes of moderate-intensity exercise (five
1: As days peras they will minutes of vigorous-
much week) or 20-60
2: Gradually exercise (three days per week).
intensity Increase
3: Achieve the reccs.

119. Intensity of Exercise
Talk Test:
-Easy: Can Talk and Sing
-Moderate: Can Talk but not sing
Maximal Heart Rate:
-Intense: Can’t age) or sing
220-Age or 206.9-(0.67x talk
Heart Rate Reserve (HRR):
Max. HR- Resting HR = HRR
Target HR=HRR x % intensity + HR @ rest

120. Exercise Progression Once the threshold is
reached, exercise
35
intensity can be
TARGET / THRESHOLD ZONE: increased, enabling total
Total minutes of exercise(per day)
30
 30 m in of m oderate intensity ≥5x/w eek, OR exercise time to
 20 m in high intensity ≥3x/w eek, OR decrease (from 150
 20-30 m in combined m oderate and high min/week to 60
25 intensity 3-5x/w eek min/week if all exercise
is high intensity)
20 The average healthy,
inactive adult should
start here
15
10
EXERCISE
INTENSITY
5 n Low
<3x/week
n Moderate
<−−−−−− Ε xercise 3-5x/w eek, w orking up to 150 m in/w eek) −−−−−−
0 n High/vigorous
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Exercise level
TO DETERMINE STARTING LEVEL: Determine PROGRESS: to the next level (move 1 bar to the right)
how many minutes (see X-axis) you are comfortable every week. Ensure that you continue exercising 5x/week.
exercising at least 3x/week. This is your starting level. If you begin the program very deconditioned or sedentary
Increase to 5x/week before progressing to the next level. and over the age of 65, then progress every 2-4 weeks.

121. Time
• As little as 10 minutes per session has shown
benefit
1: As much as they will
2: Gradually Increase
3: Achieve the reccs.

122. Type
• Ask….don’t tell
• Disclose your own habits
– Physicians who exercise are most likely to
encourage pts to exercise
– You are most likely to counsel about the form of
exercise you perform
• Be relatable and maintain optimism
• Consider keeping a folder of “successes”
• Take a lesson from Big Pharma
Personal Exercise Habits and Counseling Practices of Primary Care Physicians: A National Survey Clinical Journal of Sport
Medicine:January 2000 - Volume 10 - Issue 1 - pp 40-48
Physician disclosure of healthy personal behaviors improves credibility and ability to motivate.
Archives of Family Medicine [2000, 9(3):287-290]

123. Breakout: 4 minutes
• Ask your neighbor about their physical activity
goal
• With this in mind, write an Exercise
Prescription for your neighbor using the FITT
approach

124. Practical Advice:
• Not counseling the benefits of exercise may be
perceived as condoning a sedentary lifestyle.
• Do not emphasize exercise threshold.
• Change the emphasis from vigorous to moderate
intensity e.g. walking 3-4 miles per hour.
• Sedentary patients should not be counseled to
initially exercise at a hard level as this leads to higher
dropout rates.

125. Motivating your patients
• Set realistic goals- accumulating moderate
activity (e.g., pedometer)
• Talk about general and mental health benefits
of exercise and risks of remaining sedentary,
but also about the pleasure of exercise
• Ask about physical activity levels.
• Write exercise recommendations on a script

126. Motivating your patients
at each visit:
• Ask about exercise just as inquiries about
sleep, concentration, etc.
• Document details in chart note
• Explore barriers to exercise
• Positive reinforcement
• Incorporate socialization

127. “Physical fitness can neither be
achieved by wishful thinking nor
outright
purchase.”
Joseph Pilates

128. • Exercise and Aging

129. The Graying of America

130. The Graying of America

133. CDC Exercise Stats
• <20% of all adults achieve recc. Levels
• > 60% of adults are not regularly active
• By age 75 1:3 men and 1:2 women engage in NO
physical exercise

134. • “You have to work at living, period. You’ve got
to train like you are training for an athletic
event. Most older people just give up. They
think, “I’m too old for that,” because they
have an ache here or a pain there. Life is a
pain in the butt; you’ve got to work at it.”
- Jack LaLanne -

135. The Physiology of Aging
• Cardiovascular:
– 20-30%  in CO by 65
– Max. 02 uptake  by 9-5% per
decade, for sedentary men and
women
–  Vascular elasticity = 10-40 mm Hg
SBP/DBP
– Maximum HR  app.10 bpm/decade

136. Physiology of Aging
• Respiratory:
– FVC of 40 to 50% by age 70
– in chest wall compliance
– Maximum Ventilation
– in Alveolar size and conc.

137. Physiology of Aging
• Muscles
–40%  in muscle mass by 70
–  muscle fiber size & #
–30%  in strength by 70

138. Physiology of Aging
• Skeletal health:
– 1%  in bone mass/yr after 35
– Post-menopause 2-3%  per year for 5-
10 yrs
–  rates of OA, sponylo-arthropathy,
general joint dysfunction and
degeneration

139. Physiology of Aging
• Connective Tissue:
–  elasticity
– shortened muscle fibers
–  synovial fluid volume
– Up to 15% reduction in nerve cond.
–  Hgb, Hct, RCM

140. Disuse
• Bedrest:
–  BMD, increased bone resorption
–  muscle mass and strength
–  muscle fiber size
–  fatty infiltration of muscle
– Impaired O2 exchange
–  Cardiac function, efficiency

141. • “A review of biologic changes commonly
attributed to the process of aging demonstrates
the close similarity of most of these to changes
subsequent to a period of enforced physical
Disuse and Aging
inactivity. The coincidence of these changes from
the subcellular to the whole-body level of
organization, and across a wide range of body
systems, prompts the suggestion that at least a
portion of the changes that are commonly
attributed to aging is in reality caused by disuse
and, as such, is subject to correction. There is no
drug in current or prospective use that holds as
much promise for sustained health as a lifetime
Walter Bortz MD program of physical exercise.”(JAMA
1982;248:1203-1208)

142. “There may be no single feature of age-related
decline that could more dramatically affect
ambulation, mobility, calorie intake, and
overall nutrient intake and status,
independence, breathing, etc. than the
decline in lean body mass.”
Aging, Atrophy and Apoptosis:Failing “A’s” for Frailty
National Conference on Aging

143. Sports Med. 2000 Oct;30(4):249-68.
Strength training in the elderly: effects on risk factors for age-related diseases.
• (i) produces substantial increases in the strength, mass, power and quality of
skeletal muscle
• (ii) can increase endurance performance
• (iii) normalizes blood pressure in those with high normal values
• (iv) reduces insulin resistance
• (v) decreases both total and intra-abdominal fat
• (vi) increases resting metabolic rate in older men
• (vii) prevents the loss of BMD with age
• (viii) reduces risk factors for falls
• (ix) may reduce pain and improve function in those with osteoarthritis in the knee
region
Influence of Resistance Exercise on Lean Body Mass in Aging Adults: A Meta-Analysis Med Sci Sports
Exerc. 2011 February; 43(2): 249–258.

145. What we know!
• The value of movement
• The basic science of muscle
• Foundational terms and principles
• How to Evaluate Readiness for Change
• ACSM Risk Stratification and Pt Selection
• How to Write and Exercise Script
• Exercise and Aging

146. Goals
• Provide applicable knowledge
• Equip you with tools to promote change
• Practice skills
• Develop a plan of action
• Take it home Have Fun
• Apply it

147. Now What
• You are powerful
• Our collective message is one of optimism and
opportunity
• We can empower our patients
• Together we can alter the course of American
healthcare

148. Now What
• Develop 3 actionable items you can
incorporate in your practice when you return
• Develop 3 actionable items you can
incorporate in your practice over the next 6
months

149. With Thanks!
• The Institute of Lifestyle Medicine
– Dr Edward Philips MD
– Dr Elizabeth Frates MD
• My Wife

150. Thank You!

151. References
• Bull World Health Organ. 2002;80(12):952-8. Epub 2003 Jan 23. Chopra M et al
• http://www.cdc.gov/nccdphp/publications/factsheets/Prevention/pdf/obesity.pdf
• http://www.heart.org/idc/groups/heart-public/@wcm/@sop/@smd/documents/downloadable/ucm_319587.pdf
• http://www.ers.usda.gov/Publications/EIB33/EIB33_Reportsummary.pdf
• http://www.springerlink.com/content/w26525u488gq2024/
• http://www.ingentaconnect.com/content/nrc/cjpp/2001/00000079/00000005/art00003
• http://biomedgerontology.oxfordjournals.org/content/55/7/B347.short
• http://www.ingentaconnect.com/content/adis/smd/2007/00000037/00000002/art00004
• http://www.ncbi.nlm.nih.gov/pubmed/2311599
• http://onlinelibrary.wiley.com/doi/10.1111/j.1520-037X.2001.00529.x/full
• http://jap.physiology.org/content/103/2/693.short
• American College of Sports Medicine. ACSM's Guidelines for Exercise Testing and Prescription, 8th edition. Philadelphia: Lippincott Williams & Wilkins;
2009.(chapter 2)
• James O. Prochaska and Wayne F. Velicer (1997) The Transtheoretical Model of Health Behavior Change. American Journal of Health Promotion:
September/October 1997, Vol. 12, No. 1, pp. 38-48.
• http://www.nationalatlas.gov/articles/people/a_age2000.html
• Influence of Resistance Exercise on Lean Body Mass in Aging Adults: A Meta-Analysis Med Sci Sports Exerc. 2011 February; 43(2): 249–258.
• Changes in skeletal muscle with aging: effects of exercise training.Exercise and Sports Science Reviews 1993, 21:65-102
• Physician disclosure of healthy personal behaviors improves credibility and ability to motivate. Archives of Family Medicine[2000, 9(3):287-290]
• Disuse and AgingWalter M. Bortz II, MD JAMA. 1982;248(10):1203-1208.
• http://www.plosone.org/article/fetchArticle.action?articleURI=info:doi/10.1371/journal.pone.0000465

152. A few Resources
• ACLM: www.lifestylemedicine.org
• ILM: www.instituteoflifestylemedicine.org
• ACSM: www.acsm.org
• Abeforfitness.com
• Let’s Move: www.letsmove.gov
• President’s Challenge: www.presidentschallenge.org
• Body and Mind: www.bam.gov