Section 6: Physical Activity Science and Prescription

Question 1

Physical Inactivity and All Cause Mortality

Answer 1

1 in 10 premature deaths
6% coronary heart disease
7% type 2 DB
10% Breast Cancer
10% Colon Cancer
Only 1 in 3 adults reach recommended physical activity in a week

Question 2

Prolonged activity and sitting

Answer 2

Blood glucose is reduced if walking every 20min when sitting, both light or moderate intensity of walking

Question 3

NEAT

Answer 3

Non Exercise Activity Thermogenesis

Question 4

Fitness

Answer 4

ability to perform one’s activity of daily life with sufficient energy and vitality without excess fatigue

Question 5

Physical fitness includes:

Answer 5

cardio respiratory endurance
Muscle strength
Muscle Endurance
Body Composition
Flexibility

Question 6

FITT

Answer 6

Frequency: number of days
Intensity: light, moderate, vigorous
Type (of exercise): aerobic, strength, balance, flexibility
Time (duration): how long, hours and min.
Volume (amount): how much total exercise per week or month
Progression

Example: walk (type) at 60 steps per min. or pace where you feel like you are breathing faster than normal (intensity) for 30 min (time) 5 days per week (frequency)`

Question 7

Physical Activity Guidelines for Americans (PAGA)

Answer 7

• 150 min per week of moderate intensity physical activity OR 75 min. vigorous intensity activity or an equivalent combination
• The more physically active, the more benefits, and any amount of exercise is better than none.

Question 8

Physical Activity benefits in children 3-6 yrs age

Answer 8

Improved bone health and weight status

Question 9

Physical Activity benefits in children 6-13 yrs age

Answer 9

Improved cognitive function

Question 10

PA Benefits in Adults, All ages (Main Ones)

Answer 10

Lower incidence of cancer:
- Bladder, breast, colon, prostate, endometrium, esophagus, kidney, stomach, lung cancers

Brain:
- reduce dementia, improve cognitive function following bouts of aerobic activity, improved quality of life, improved sleep, reduced feelings of anxiety and depression

• Reduce incidence of fall related injuries
• Reduce risk of gestational diabetes
• Reduce risk of postpartum depression
• improved walking and fitness in multiple sclerosis

Question 11

Updates form 2018 Guidelines

Answer 11

• Single episodes of PA imbrove brain executive function, etc.
• Within days to weeks of initiating regular exercise, the risk of disease starts decreasing

Question 12

PA Guidelines in Different Ages

Answer 12

3-5 yrs:
- Physically active throughout the day, encourage active play

6-17 yrs:
- 60min or more per day of mod to vigorous intensity (vigorous at least 3 days per week)

Adults 18-64 yrs:
- 150 min mod per week or 75 min vigorous per week, or combination
- 10min per session or less is also beneficial

Age 65 yrs and older:
- Should follow guidelines, if unable, should be physically active as possible

Woman during pregnancy or postpartum without exercise contraindications:
- 150min moderate intensity exercise per week
- Vigorous activity is okay if exercised before pregnancy

Adults with chronic conditions or diseases:
- 150-300 min of moderate per week or 75-150min of vigorous per week
- If unable, as much exercise as possible to avoid sedentary

Question 13

Strength Training Guidelines

Answer 13

6-17 yrs:
- participate in strengthening and bone strengthening activities that place force or impact on bones for at least 1 hours or 3 days a week (tug of war, jumps, climbing)
- Resistance training with heavy loads done under supervision

18-64 yrs:
- 2-3 times a week on non consecutive days

Adults age 65 or older:
- 2 times a week or can follow guidelines

Adults with chronic condition:
- 2-3 times a week

Question 14

Flexibility Guidelines

Answer 14

• Benefits of flexibility to reduce injury are unproven, but can help perform activities requiring greater flexibility
• Healthy adults: 10 min 2-3 days per week, greatest benefit if performed daily

Adults age 65 or older:
- Should do balance training 3 or more days per week

Question 15

Isreali Health Study

Answer 15

Physicians health screening and vaccination practices influence the practices of their pxs

Question 16

MET

Answer 16

(Metabolic Equivalent of a Task)

Ratio of metabolic rate of task vs resting metabolic rate. Ratio is metabolic rate of task divided by standard metabolic rate of 1 MET

Sitting: 1.0 MET
Sleeping: 0.9 METs
3mph walking: 3 METs
Climbing two flight of stairs: 5 METs
Running at 10.9 mph (17.5 kmph): 18 MET

Question 17

MET

Answer 17

(Metabolic Equivalent of a Task)

One MET is defined as 3.5 mL O2/kg/min and is the amount of oxygen consumed during quiet rest or sitting. Sleeping is considered 0.9 METs.

Ratio of metabolic rate of task vs resting metabolic rate. Ratio is metabolic rate of task divided by standard metabolic rate of 1 MET

Sitting: 1.0 MET
Sleeping: 0.9 METs
3mph walking: 3 METs
Climbing two flight of stairs: 5 METs
Running at 10.9 mph (17.5 kmph): 18 MET

Moderate intensity: 3-5.9 METs
Vigorous intensity: >6 METs

METs are absolute. If px adapts, they can be lower.

Question 18

Physical Activity Guidelines for Obese from American College of Sports Medicine

Answer 18

Weight Maintenance
- >250 min. per week of moderate intensity (to prevent weight re-gain)
- 60-90 min per day of mod intensity daily exercise

Question 19

Minimum level of exercise

Answer 19

• The most benefit is 10-20 MET hours per week of physical activity
• Mortality decreases with increased in MET, but plateau around 80 MET per hour
• Standing for 2 hours per day is associated with a 10% reduction in mortality of all causes

Shanghai Women’s Health Study:
-20-40% risk reduction among active individuals (standing, taking stairs, etc)

Nurse Health Study
- 1-1.9 hours of vigorous PA per week, significant reduction in all cause mortality

Week end warrior
- 1-2 days per week of activity there is decreased mortality
- But 150min of PA in a day may increase injury

Question 20

Maximum level of exercise

Answer 20

Additional activity has further and extensive health benefits

• Further reduction in all cause mortality beyond 150min of mod or 75 min vigorous activity per week (or 300 min mod per week/150 min vig per week)

Years of life gained brisk walk vs sedentary:
- 75 min brisk walk per week: 1.8 years of life gained
- 90-150 min per week: 2.5 years
- 200 min. per week: 3 years
- 400 min per week: 4 years
- 500 min per week: 4.5 years

• Participating in PA provides:
  1 hour mod intensity - 2.6 hours of life
  1 hour vig intensity - 5.2 hours of life

Question 21

Physical Activity Assessment Tools

Answer 21

PAV - Physical Activity Vital Signs

Equation: days per week with PA x min of PA per day= min of physical activity per week

Interpret:
If standard PA met - congratulate px
If insufficient - guide them to acknowledge insufficiency
If sedentary - lead px to acknowledge sedentary behavior, related health problems to physical inactivity, etc.

Question 22

Exercise intensity assessment Tools

Answer 22

1. Talk test - least objective, but easiest to measure.
   a. Very light to light intensity: heart rate 63% or less of maximum, able to talk and sing

b. moderate intensity: heart rate 64-76% maximum, able to talk but not sing
c. vigorous to max intensity exercise - 77-100% of max, unable to talk

2. Respiratory rate - overlaps with talk test
3. Rating of perceived exertion (RPE)
   - Borg Scale: 12-13 moderate intensity, 14 and above up to 20 only - vigorous
4. Heart rate reserve (HRR)
   - HRR = max heart rate - resting heart rate
   - recommended exercise intensity is 40-85% of HRR
5. Maximal heart rate % (refer to no. 1)
6. Meabolic Equvalents of a Task (METs)

Question 23

Assessing Functional Capacity

Answer 23

6 min. walk test
- walk as far as possible within 6 min. at submax level
- How to: long hallway (30 meters or 100 feet), stopwatch. Monitor px as they walk as far as possible for 6 min.
- Most useful when comparing with previous test before and after an intervention

Question 24

Assessing components of Fitness

Answer 24

1. Cardiorespiratory fitness test:
   a. Step testing: 12 inch step, metronome, stopwatch. Subject steps for 3 min. to the timing of metronome and then rests for 1 min. Then HR is auscultated and palpated. Then compared to calculated norms for age and gender.
2. Submaximal talk test for ventilatory threshold (VTG1) - requires machine monitoring
3. Rockport fitness walking test (1 mile or 1.6 km), Walk as fast as possible then pulse recorded and estimated with equation.

Question 25

Body Composition

Answer 25

Gold standard:

Hydrodensitometry (underwater weighing) and Dual Energy X-Ray Absorptiometry (DEXA) scan

Question 26

Medical Screening for Exercise by Health Care Provider

Answer 26

• Risk of death during PA is very rare except with px with known diseasee.

ACSM recommends PAR-Q (Physical Activity Readiness Questionnaire for Everyone)

Guidelines: px that should receive medical clearance before initiating exercise or increasing intensity:

• Group 1: Those with clinically significant diseases who would benefit from medically supervised exercise programs.
• Group 2: Those with uncontrolled medical conditions that require tx or control before further exercise should be initiated
  Goal of screening: reduce exercise related CV events

ACSM guidelines:
- If person is physically inactive + signs or symptoms of cardiovascular, metabolic, renal disease - medical clearance is recommended before initiating mod to vigorous intensity PA.

• Pulmonary disease does not require medical clearance, BUT with uncontrolled lung disease should be evaluated to see if changes in medical therapy is needed
• there is lack of evidence that clearance mitigates risk

Question 27

Exercise Stress Testing

Answer 27

US Preventive Services Task Force recommends against routine testing or exercise electrocardiography in asymptomatic individuals

Unless: symptoms suggestive of ischemic heart disease, chest pain but negative cardiac enzymes, to evaluate heart function in at risk px with syncope. avlavular disease, arrhytmias, medical or surgical intervention

• Not recommended for px who are low risk or high risk
• contrindicated in recent MI, hypertensive emergency, acute infections, decompensated heart failure, stenosis

Question 28

Algorithm for exercise pre participation screening process

Answer 28

1. Px currently exercises regularly
   - Asymptomatic wit no know CV, metabolic, renal disease - NO CLEARANCE NEEDED. may participate in mod to vig intensity exercise

• Asymptomatic with KNOWN CV, metablic, renal disease - NO CLEARANCE for MODERATE intensity, with gradual progression to vigorous intensity if one remains asymptomatic
• If signs or symptoms occur, then it’s REQUIRED
• Symptomatic regardless of diseases status: SEEK MEDICAL CLEARANCE, if cleared, px may continue exercise program

2. Px DOES NOT exercise regularly
   - Asymptomatic with no disease - NO CLEARANCE NEEDED, light to moderate exercise recommended

• Asymptomatic with KNOWN disease - NEED CLEARANCE. Once cleared, light to mod intensity recommended the progress as needed
• Symptomatic regardless of disease - NEED CLEARANCE,

Question 28

Algorithm for exercise pre participation screening process

Answer 28

1. Px currently exercises regularly
   - Asymptomatic wit no know CV, metabolic, renal disease - NO CLEARANCE NEEDED. may participate in mod to vig intensity exercise

• Asymptomatic with KNOWN CV, metablic, renal disease - NO CLEARANCE for MODERATE intensity, with gradual progression to vigorous intensity if one remains asymptomatic
• If signs or symptoms occur, then it’s REQUIRED
• Symptomatic regardless of diseases status: SEEK MEDICAL CLEARANCE, if cleared, px may continue exercise program

2. Px DOES NOT exercise regularly
   - Asymptomatic with no disease - NO CLEARANCE NEEDED, light to moderate exercise recommended

• Asymptomatic with KNOWN disease - NEED CLEARANCE. Once cleared, light to mod intensity recommended the progress as needed
• Symptomatic regardless of disease - NEED CLEARANCE, Once cleared, light to mod intensity recommended the progress as needed

Question 29

ACSM 3 Stages of Exercise Progression

Answer 29

Initial stage: 1-6 weeks - designed to minimize muscle soreness, discomfort, and injury. 3-4 times a week

Improvement stage (4-8 months)
- HRR = MHR - RHR
- MHR = 220 minus a person’s age (220- age)
- Maximum heart rate per exercise should be increased no more than 5% of one’s heart rate reserve every 6th session

Maintenance stage (indefinitely)

Question 30

5A’s in Practice

Answer 30

1. Assess: beliefs, behaviors, knowledge
2. Advise: provide specific information about health benefits of chagne
3. Agree: collaboratively set goals based on patient’s interest and confidence in their ability to change behavior (use SMART goal)
4. Assist: identify personal barriers, strategies, problem solving techniques or social/environmental support
5. Arrange follow up plan.

Question 31

Resource for Sustainable behavior change

Answer 31

1. Self monitoring: pedometer, etc.
2. Problem solve:
   - Identify barriers as to why goals were not met
   - ABC: Antecedent, behavior, consequence
   - Develop solutions
   - Act and assess
3. Relapse prevention
   - Identify high risk situations (i.e. holidays, travel)
   - Plan for potential lapses
   - Cognitive restructuring (identify unhelpful thought patterns, encourage px not to abandon goals
4. Health promotion clinic, wellness programs. worksite wellness

Question 32

Exercise as medication

Answer 32

Randomized control trial by DIabetes PRevention PRogram Research
- 150 min physical activity per week (7% weight loss goal)
- metformin decreased incidence of DB by 31%, while LM intervention reduced by 58%

Question 33

PA in special population

Answer 33

• Even 100 year old px can increase muscle mass
• Pregnancy without contraindication: 150 min of mod intensity per week

DM:
150 min per week of moderate intensity of PA is sufficient to reduce risk of T2DM

• Colon cancer: 17-30% decrease in risk with PA
  Breast cancer
• Breast cancer: 25% risk reduction , PA prevents reoccurence and primary onset

Question 34

Smoking vs PA

Answer 34

Smoking no. 1 preventable cause of death
Physical Inactivity - 4th

Question 35

Aerobic Center Longitudinal Study

Answer 35

Findings: In this prospective study of 56,175 healthy participants at baseline, followed-up for a mean of 14.5 years, ≥100 PAI score/week was associated with significant 21% lower risk of all-cause and 30% lower risk of CVD mortality in comparison with inactive people.

Question 36

PA Vital Sign

Answer 36

1) On average, how many days/week do you engage in moderate to strenuous exercise?

2) On average, how many minutes do you engage in exercise at this level?

Question 37

Min. Recommended MET of PA

Answer 37

The amount of weekly time engaged in exercise is important with a goal exercise load of approximately 500-1000 MET-min/week.