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Food is Medicine Lunch Time
Lecture Series

EXERCISE AS AN ADJUNCT TO NUTRITIONAL
COUNSELING

JORDAN FEIGENBAUM MS, CSCS, HFS, CISSN,USAW CC
Quotes for Social Media
 “Let food be thy medicine and medicine be thy food.”-

Hippocrates
 “No citizen has a right to be an amateur in the matter of
physical training…what a disgrace it is for a man to
grow old without ever seeing the beauty and strength of
which his body is capable.”-Socrates
 “Over and above any considerations of performance for
sports, exercise is the stimulus that returns our bodies
for which they were designed. Humans are not
physically normal in the absence of hard physical
effort.”-Mark Rippetoe
Disclaimers
 Bias




Personal
Data interpretation

 Limitations



Time
Asymmetrical Information
Q/A on the FIM Facebook!
 www.barbellmedicine.com


 Evidence Based


Evidence based behavioral practice
Science + Experience
 Biased population?

What Exercise Isn’t
 Weight loss solution
 2007 AHA and ACSM Joint Guidelines on exercise:


“It is reasonable to assume that persons with high daily energy
expenditures would be less likely to gain weight over time
compared to those who have low energy expenditures. So far,
data to support this hypothesis are not particularly
compelling”*

 Exercise is an adjunct to a nutritional intervention

*Haskell W.L

Physical activity and public health: updated recommendation for adults from the American
College of Sports Medicine and the American Heart Association. Circulation. Aug. 2007.
Exercise is Ineffective for Weight Loss
 2000 Finnish study: Does

physical activity prevent
weight gain- a systematic
review. *




Review of 12 studies of successful
dieters’ exercise habits and
subsequent weight maintenance
(e.g. prevention of weight
gain)
Results: In all 12 studies,
participants regained weight






Exercise either decreased rate of
regain by 3.2oz/ month vs
sedentary successful dieters
OR
Increased rate by 1.8oz

*Fogelholm,

M. Kukkonen. K.M. Dose physical activity prevent weight gain- a systematic review.” Obesity
Reviews. 2000 Oct;1(2):95-111.
Conventional Wisdom
 Exercise = Cardiovascular Exercise
 Definition of “Cardio”


LISS vs HIIT
 LISS= Low intensity steady state “cardio”
 HIIT= High intensity interval training
• Work and rest periods
• “The potency of high-intensity interval training to elicit rapid skeletal muscle
remodeling is no doubt related to its high level of muscle fiber recruitment, and
the potential to stress type II fibers in particular”*


HIIT Group: 30s sprints 3x/wk vs LISS Group: 90-120 min of moderate
intensity cycling
• Total volume of training: 2.5 hrs over 2 weeks for HIIT, 10.5 hrs for LISS
• Results: “The two very diverse training protocols induced remarkably similar
changes in weight loss, muscle oxidative capacity, and exercise capacity.
• Thought experiment: What if we increased the volume of HIIT?
• High-intensity Interval Training: A Time-efficient Strategy for Health Promotion?
• Martin Gibala Current Sports Medicine Reports

*Gibala,

Martin. High-Intensity Interval Training: A Time-efficient Strategy for Health Promotion?
Current Sports Medicine Reports. 200
Conventional Wisdom
 “Cardio” is perceived as necessary for health and

longevity


How about Strength?
Study: Association between muscular strength and mortality in men:
prospective cohort study.*
 Results:
 “Muscular strength was significantly and inversely associated
with risk of death from all causes and cancer after controlling for
potential confounders, including cardiorespiratory
fitness...Muscular strength was significantly and inversely
associated with risk of death from cardiovascular disease after
controlling for age….”




Strength + GPA


“The results revealed that those who more frequently engaged in
strength exercise had significantly higher GPA”**

*Ruiz, Jonathan R. Association between muscular strength and mortality in men: prospective cohort study. British Medical Journal. 2008 July 12;
337 (7661): 92-95
*Keating, XD. Association of weekly strength exercise frequency and academic performance among students at a large university in the United
States. Journal of Strength and Conditioning Research. 2013 July Jul;27(7):1988-93.
Conventional Wisdom
 Is achieving a “healthy” BMI really a useful goal?
 Study: Association of All-Cause Mortality With Overweight
and Obesity Using Standard Body Mass Index Categories*
Results: “Relative to normal weight, both obesity (all grades) and
grades 2 and 3 obesity were associated with significantly higher
all-cause mortality. Grade 1 obesity overall was not associated
with higher mortality, and overweight was associated with
significantly lower all-cause mortality.”
 Healthy=18.5-24.9
 Overweight= 25-29.9
 Grade 1= 30-34.9
 Grade 2= 35-39.9
 Grade 3= >40


*Flegal, Katherine M. Association of All-Cause Mortality With Overweight and Obesity Using Standard Body Mass Index
Categories. JAMA. 2013. January. http://jama.jamanetwork.com/article.aspx?articleid=1555137
Practical Uses for Exercise
 Positive feedback loop to

boost compliance




More likely to initiate both at
the same time
Health promotion

 Proper prescription and

application leads to better
outcomes


Improved strength, functional
capacity, HDL, glucose disposal,
etc.
Practical Recommendations
 Resistance Training 3x/wk ~1hr /session
 40 mins RT
 20 mins HIIT
 Progressive overload
Need a stress to elicit a response
 Not all stresses are created equal
 Training economy
 Most muscle mass/largest effective range of motion/most force
production


• why?
 Force production against external resistance= Strength
• Strength is the foundation for all physical characteristics

• Plus it might help you live longer and have a higher GPA
Ten General Physical Characteristics
 Strength
 Power
 Accuracy
 Balance
 Cardiovascular/Respiratory Endurance
 Mobility
 Speed
 Stamina
 Agility
 Coordination
Mechanism unique to RT and HIIT
 High threshold motor unit and fiber recruitment

(e.g. Type II)



Due to increase force production requirements
Anaerobic




Increased Excess Post-Exercise Oxygen Consumption (EPOC)
 Less appropriate term= oxygen debt

Induces mitochondrial biogenesis


More mitochondria facilitates increased BMR and TDEE

 Builds muscle
 Improved glucose disposal via up-regulation of GLUT-4
receptor


Improves insulin sensitivity, blood glucose and lowers HbA1C*

*Ivy JL. Role of exercise training in the prevention and treatment of insulin resistance and non-insulin-dependent diabetes mellitus. Sports Med. 1997
Nov;24(5):321-36. Review.
More on Diabetes
 Type II Diabetes + RT



Improved insulin sensitivity by 48%*
Improved blood glucose levels, Hba1C, etc.


“There was a strong inverse correlation
between HbA1c and muscle cross-sectional
area (knee extensors) after the exercise
period (r = -0.73; p < 0.05)”**

“Aerobic endurance exercise has
traditionally been advocated in the
treatment of non-insulin-dependent diabetes
mellitus (NIDDM). However, the effect of
aerobic endurance exercise programs on
long-term glycaemic control is small to
moderate.”**
*Ishii, T. Resistance training improves insulin sensitivity in NIDDM subjects without altering maximal oxygen uptake.


Diabetes Care. 1998 21:1353-5
**Eriksson, J. Resistance Training in the Treatment of Non-Insulin Dependent Diabetes Mellitus. International Journal of
Sports Medicine. 1997 18:242-6
Conventional Wisdom vs. RT
 It’s dangerous, right?
 Injury per 100 participation hours?




Competitive Weightlifting = 0.006

What’s the physical activity with the highest injury rate?


Soccer= 6.2 injuries per 100 participation hours *

*Hammill, B. Relative Safety of Weightlifting and Weight Training. Journal of Strength and Conditioning Research. 1994. 8 (1): 53-57
Conventional Wisdom vs. RT/HIIT
 But what about populations with pathologies?
 COPD




Heart Failure and Heart Transplant




“The present study documents that a long-term, partly supervised and community-based HIITprogram is an applicable, effective and safe way to improve VO2peak, muscular exercise capacity and
quality of life in HTx recipients. The results indicate that HIIT should be more frequently used among
stable HTx recipients in the future.”**

AAA




“Implementation of interval training has shown to allow lower limb exercise to be sustained at a
high intensity which otherwise would not be tolerable. Interval training can be applied especially to
those patients with advanced COPD, who are unable to sustain exercise intensities sufficiently long
enough to obtain a physiological training effect because of ventilatory limitation.”*

These results support the safety and efficacy of training in patients with small AAA, a population for
which few previous data are available. Despite advanced age and comorbidities, training up to 3
years was well tolerated and sustainable in AAA patients. Training did not influence rate of AAA
enlargement.

Metabolic Syndrome


“VO2max increased more after AIT than CME (35% versus 16%; P<0.01) and was associated with
removal of more risk factors that constitute the metabolic syndrome (number of factors: AIT, 5.9
before versus 4.0 after; P<0.01; CME, 5.7 before versus 5.0 after; group difference, P<0.05). AIT
was superior to CME in enhancing endothelial function (9% versus 5%; P<0.001), insulin signaling
in fat and skeletal muscle, skeletal muscle biogenesis, and excitation-contraction coupling and in
reducing blood glucose and lipogenesis in adipose tissue.”****
 AIT= Anaerobic interval training, CME= Continuous moderate exercise

*Kortianou EA. Effectiveness of Interval Exercise Training in Patients with COPD. Cardiopulmonary Physical Therapy Journal. 2010 Sep;21 (3): 12-9
***Myers, Jonathan. A Randomized Trial of Exercise Training in Abdominal Aortic Aneuyrsm Disease. Medicine and Science in Sports and Exercise. 2013.
**Moraes K.L. Fernandes M. Carvalho, V.O. Interval Exercise Training in Adult Heart Transplant Recipients. American Journal of Transplantation. 2013 Jan 13 (2), 526
**** Tjonna, Arnt E. Aerobic Interval Training Versus Continuous Moderate Exercise as a Treatment for the Metabolic Syndrome. Circulation2008.
Practical Recommendations
 Use exercise as adjunct to nutritional intervention


Boosts compliance and can improve results/outcomes




Particularly if applied intelligently

Helps support the patient’s willingness to change

 Don’t criticize the diet


We don’t know that much, really.
Restrictive diets (e.g. Twinkie or Potato diet)
 Low Carbohydrate and Ketogenic diets
 Ketogenic diets in ASD*
 Low carb diet**
 Vegetarian/Vegan/Paleo/DASH/Ornish/Intermittent Fasting, etc.
 If it produces calorie restriction and compliance, it doesn’t matter.
 The Mediterranean Diet is okay too 


**Gardner CD, et al. Comparison of the Atkins, Zone, Ornish, and LEARN diets for change in weight and related risk factors among
overweight premenopausal women: the A TO Z Weight Loss Study. The Journal of The American Medical Association, 2007
*Kossoff EH, Zupec-Kania BA, Rho JM. Ketogenic diets: an update for child neurologists. J Child Neurol. 2009 Aug;24(8):979–88.
Practical Recommendations
 Nutritional interventions

should be simple and
progressive


Easier to build upon habits


e.g. Single ingredient foods first
(address food quality)
 May spontaneously result in
calorie restriction
 Resulting intake may higher
satiety index rating*
 Likely reduces food reward**
• More positive feedback

*Holt SH, Miller JC, Petocz P, Farmakalidis E. A Satiety index of common foods. European Journal of Clinical Nutrition. 1995
Sep; 49 (9); 675-90
**Hans-Rudolf Berthoud, Natalie R. Lenard, Andrew C Shin. Food Reward, hyperphagia, and obesity. American Journal of
Physiology. June 2011. Vol. 300.
Wrap Up/TL;DR
 Exercise won’t work in a bubble
 Resistance Training and HIIT would be the

modalities of choice




3x/wk 40 mins RT + 20 mins HIIT is a good place to start
Don’t be afraid of the weights
Use as adjunct to dietary intervention

 Dietary counseling should be simple and supportive
 Many approaches “work” even if suboptimal




Requiring eating “clean” is borderline Orthorexia*

Encourage high food quality within the framework of an
approach that increases compliance

*Bratman, Steven. What is Orthorexia? www.orthorexia.com. June 4, 2010

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Fi mpresentation

  • 1. Food is Medicine Lunch Time Lecture Series EXERCISE AS AN ADJUNCT TO NUTRITIONAL COUNSELING JORDAN FEIGENBAUM MS, CSCS, HFS, CISSN,USAW CC
  • 2. Quotes for Social Media  “Let food be thy medicine and medicine be thy food.”- Hippocrates  “No citizen has a right to be an amateur in the matter of physical training…what a disgrace it is for a man to grow old without ever seeing the beauty and strength of which his body is capable.”-Socrates  “Over and above any considerations of performance for sports, exercise is the stimulus that returns our bodies for which they were designed. Humans are not physically normal in the absence of hard physical effort.”-Mark Rippetoe
  • 3. Disclaimers  Bias   Personal Data interpretation  Limitations   Time Asymmetrical Information Q/A on the FIM Facebook!  www.barbellmedicine.com   Evidence Based  Evidence based behavioral practice Science + Experience  Biased population? 
  • 4. What Exercise Isn’t  Weight loss solution  2007 AHA and ACSM Joint Guidelines on exercise:  “It is reasonable to assume that persons with high daily energy expenditures would be less likely to gain weight over time compared to those who have low energy expenditures. So far, data to support this hypothesis are not particularly compelling”*  Exercise is an adjunct to a nutritional intervention *Haskell W.L Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Circulation. Aug. 2007.
  • 5. Exercise is Ineffective for Weight Loss  2000 Finnish study: Does physical activity prevent weight gain- a systematic review. *   Review of 12 studies of successful dieters’ exercise habits and subsequent weight maintenance (e.g. prevention of weight gain) Results: In all 12 studies, participants regained weight    Exercise either decreased rate of regain by 3.2oz/ month vs sedentary successful dieters OR Increased rate by 1.8oz *Fogelholm, M. Kukkonen. K.M. Dose physical activity prevent weight gain- a systematic review.” Obesity Reviews. 2000 Oct;1(2):95-111.
  • 6. Conventional Wisdom  Exercise = Cardiovascular Exercise  Definition of “Cardio”  LISS vs HIIT  LISS= Low intensity steady state “cardio”  HIIT= High intensity interval training • Work and rest periods • “The potency of high-intensity interval training to elicit rapid skeletal muscle remodeling is no doubt related to its high level of muscle fiber recruitment, and the potential to stress type II fibers in particular”*  HIIT Group: 30s sprints 3x/wk vs LISS Group: 90-120 min of moderate intensity cycling • Total volume of training: 2.5 hrs over 2 weeks for HIIT, 10.5 hrs for LISS • Results: “The two very diverse training protocols induced remarkably similar changes in weight loss, muscle oxidative capacity, and exercise capacity. • Thought experiment: What if we increased the volume of HIIT? • High-intensity Interval Training: A Time-efficient Strategy for Health Promotion? • Martin Gibala Current Sports Medicine Reports *Gibala, Martin. High-Intensity Interval Training: A Time-efficient Strategy for Health Promotion? Current Sports Medicine Reports. 200
  • 7. Conventional Wisdom  “Cardio” is perceived as necessary for health and longevity  How about Strength? Study: Association between muscular strength and mortality in men: prospective cohort study.*  Results:  “Muscular strength was significantly and inversely associated with risk of death from all causes and cancer after controlling for potential confounders, including cardiorespiratory fitness...Muscular strength was significantly and inversely associated with risk of death from cardiovascular disease after controlling for age….”   Strength + GPA  “The results revealed that those who more frequently engaged in strength exercise had significantly higher GPA”** *Ruiz, Jonathan R. Association between muscular strength and mortality in men: prospective cohort study. British Medical Journal. 2008 July 12; 337 (7661): 92-95 *Keating, XD. Association of weekly strength exercise frequency and academic performance among students at a large university in the United States. Journal of Strength and Conditioning Research. 2013 July Jul;27(7):1988-93.
  • 8. Conventional Wisdom  Is achieving a “healthy” BMI really a useful goal?  Study: Association of All-Cause Mortality With Overweight and Obesity Using Standard Body Mass Index Categories* Results: “Relative to normal weight, both obesity (all grades) and grades 2 and 3 obesity were associated with significantly higher all-cause mortality. Grade 1 obesity overall was not associated with higher mortality, and overweight was associated with significantly lower all-cause mortality.”  Healthy=18.5-24.9  Overweight= 25-29.9  Grade 1= 30-34.9  Grade 2= 35-39.9  Grade 3= >40  *Flegal, Katherine M. Association of All-Cause Mortality With Overweight and Obesity Using Standard Body Mass Index Categories. JAMA. 2013. January. http://jama.jamanetwork.com/article.aspx?articleid=1555137
  • 9. Practical Uses for Exercise  Positive feedback loop to boost compliance   More likely to initiate both at the same time Health promotion  Proper prescription and application leads to better outcomes  Improved strength, functional capacity, HDL, glucose disposal, etc.
  • 10. Practical Recommendations  Resistance Training 3x/wk ~1hr /session  40 mins RT  20 mins HIIT  Progressive overload Need a stress to elicit a response  Not all stresses are created equal  Training economy  Most muscle mass/largest effective range of motion/most force production  • why?  Force production against external resistance= Strength • Strength is the foundation for all physical characteristics • Plus it might help you live longer and have a higher GPA
  • 11. Ten General Physical Characteristics  Strength  Power  Accuracy  Balance  Cardiovascular/Respiratory Endurance  Mobility  Speed  Stamina  Agility  Coordination
  • 12. Mechanism unique to RT and HIIT  High threshold motor unit and fiber recruitment (e.g. Type II)   Due to increase force production requirements Anaerobic   Increased Excess Post-Exercise Oxygen Consumption (EPOC)  Less appropriate term= oxygen debt Induces mitochondrial biogenesis  More mitochondria facilitates increased BMR and TDEE  Builds muscle  Improved glucose disposal via up-regulation of GLUT-4 receptor  Improves insulin sensitivity, blood glucose and lowers HbA1C* *Ivy JL. Role of exercise training in the prevention and treatment of insulin resistance and non-insulin-dependent diabetes mellitus. Sports Med. 1997 Nov;24(5):321-36. Review.
  • 13. More on Diabetes  Type II Diabetes + RT   Improved insulin sensitivity by 48%* Improved blood glucose levels, Hba1C, etc.  “There was a strong inverse correlation between HbA1c and muscle cross-sectional area (knee extensors) after the exercise period (r = -0.73; p < 0.05)”** “Aerobic endurance exercise has traditionally been advocated in the treatment of non-insulin-dependent diabetes mellitus (NIDDM). However, the effect of aerobic endurance exercise programs on long-term glycaemic control is small to moderate.”** *Ishii, T. Resistance training improves insulin sensitivity in NIDDM subjects without altering maximal oxygen uptake.  Diabetes Care. 1998 21:1353-5 **Eriksson, J. Resistance Training in the Treatment of Non-Insulin Dependent Diabetes Mellitus. International Journal of Sports Medicine. 1997 18:242-6
  • 14. Conventional Wisdom vs. RT  It’s dangerous, right?  Injury per 100 participation hours?   Competitive Weightlifting = 0.006 What’s the physical activity with the highest injury rate?  Soccer= 6.2 injuries per 100 participation hours * *Hammill, B. Relative Safety of Weightlifting and Weight Training. Journal of Strength and Conditioning Research. 1994. 8 (1): 53-57
  • 15. Conventional Wisdom vs. RT/HIIT  But what about populations with pathologies?  COPD   Heart Failure and Heart Transplant   “The present study documents that a long-term, partly supervised and community-based HIITprogram is an applicable, effective and safe way to improve VO2peak, muscular exercise capacity and quality of life in HTx recipients. The results indicate that HIIT should be more frequently used among stable HTx recipients in the future.”** AAA   “Implementation of interval training has shown to allow lower limb exercise to be sustained at a high intensity which otherwise would not be tolerable. Interval training can be applied especially to those patients with advanced COPD, who are unable to sustain exercise intensities sufficiently long enough to obtain a physiological training effect because of ventilatory limitation.”* These results support the safety and efficacy of training in patients with small AAA, a population for which few previous data are available. Despite advanced age and comorbidities, training up to 3 years was well tolerated and sustainable in AAA patients. Training did not influence rate of AAA enlargement. Metabolic Syndrome  “VO2max increased more after AIT than CME (35% versus 16%; P<0.01) and was associated with removal of more risk factors that constitute the metabolic syndrome (number of factors: AIT, 5.9 before versus 4.0 after; P<0.01; CME, 5.7 before versus 5.0 after; group difference, P<0.05). AIT was superior to CME in enhancing endothelial function (9% versus 5%; P<0.001), insulin signaling in fat and skeletal muscle, skeletal muscle biogenesis, and excitation-contraction coupling and in reducing blood glucose and lipogenesis in adipose tissue.”****  AIT= Anaerobic interval training, CME= Continuous moderate exercise *Kortianou EA. Effectiveness of Interval Exercise Training in Patients with COPD. Cardiopulmonary Physical Therapy Journal. 2010 Sep;21 (3): 12-9 ***Myers, Jonathan. A Randomized Trial of Exercise Training in Abdominal Aortic Aneuyrsm Disease. Medicine and Science in Sports and Exercise. 2013. **Moraes K.L. Fernandes M. Carvalho, V.O. Interval Exercise Training in Adult Heart Transplant Recipients. American Journal of Transplantation. 2013 Jan 13 (2), 526 **** Tjonna, Arnt E. Aerobic Interval Training Versus Continuous Moderate Exercise as a Treatment for the Metabolic Syndrome. Circulation2008.
  • 16. Practical Recommendations  Use exercise as adjunct to nutritional intervention  Boosts compliance and can improve results/outcomes   Particularly if applied intelligently Helps support the patient’s willingness to change  Don’t criticize the diet  We don’t know that much, really. Restrictive diets (e.g. Twinkie or Potato diet)  Low Carbohydrate and Ketogenic diets  Ketogenic diets in ASD*  Low carb diet**  Vegetarian/Vegan/Paleo/DASH/Ornish/Intermittent Fasting, etc.  If it produces calorie restriction and compliance, it doesn’t matter.  The Mediterranean Diet is okay too   **Gardner CD, et al. Comparison of the Atkins, Zone, Ornish, and LEARN diets for change in weight and related risk factors among overweight premenopausal women: the A TO Z Weight Loss Study. The Journal of The American Medical Association, 2007 *Kossoff EH, Zupec-Kania BA, Rho JM. Ketogenic diets: an update for child neurologists. J Child Neurol. 2009 Aug;24(8):979–88.
  • 17. Practical Recommendations  Nutritional interventions should be simple and progressive  Easier to build upon habits  e.g. Single ingredient foods first (address food quality)  May spontaneously result in calorie restriction  Resulting intake may higher satiety index rating*  Likely reduces food reward** • More positive feedback *Holt SH, Miller JC, Petocz P, Farmakalidis E. A Satiety index of common foods. European Journal of Clinical Nutrition. 1995 Sep; 49 (9); 675-90 **Hans-Rudolf Berthoud, Natalie R. Lenard, Andrew C Shin. Food Reward, hyperphagia, and obesity. American Journal of Physiology. June 2011. Vol. 300.
  • 18. Wrap Up/TL;DR  Exercise won’t work in a bubble  Resistance Training and HIIT would be the modalities of choice    3x/wk 40 mins RT + 20 mins HIIT is a good place to start Don’t be afraid of the weights Use as adjunct to dietary intervention  Dietary counseling should be simple and supportive  Many approaches “work” even if suboptimal   Requiring eating “clean” is borderline Orthorexia* Encourage high food quality within the framework of an approach that increases compliance *Bratman, Steven. What is Orthorexia? www.orthorexia.com. June 4, 2010

Editor's Notes

  1. Personal Bias
  2. Current recs= 150 minutes of moderate intensity exercise per week- up to 90 minutes a day most days for weight loss.
  3. *Reduces seizure frequency by &gt; 50% in ½ patients and by &gt; 90% in 1/3 of pts**311 overweight/obese premenopausal women were randomized to 4 diets: A low-carb Atkins diet, a low-fat vegetarian Ornish diet, the Zone diet and the LEARN diet. Zone and LEARN were calorie restricted.“The Atkins group lost the most weight, although the difference was not statistically significant (though it was at least double). The Atkins group had the greatest improvements in blood pressure, triglycerides and HDL. LEARN and Ornish (low-fat) had decreases in LDL at 2 months, but then the effects diminished.”
  4. Satiety&gt; ate 240kCal of 38 foods- based on how much they would eat within 120 minutes after eating standard bolus. Protein, fiber, water= more satiating. Fat was negatively associated with satiety.