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
DesigningPhysicalActivitybyNayanjeetChaudhury-

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

• 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)

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

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

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)

• 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

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
DesigningPhysicalActivitybyNayanjeetChaudhury

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

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.

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 Source: American College of Sports Medicine

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.

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"

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)

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

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

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

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
f

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)

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-
up or cool-down phase

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

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

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

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.

• 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

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

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.

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.

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

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.

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.

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.

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

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

Thanks !

Designing exercise programs by Dr. Nayanjeet

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