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Exercise Is Medicine: Physiologic Benefits of Exercise Ajay N. Kiri, M.D. AAPNA Teleconference December 21, 2009 1 Outline of Seminar Exercise Fundamentals Ayurveda on exercise Benefits of Exercise Exercise Physiology How Exercise Effects Aging Counseling Patients On Exercise Recommended Exercise Regimens Exercise Related Resources 2 Purpose Of The Seminar To teach the main types of exercise & their benefits To understand the physiologic effects of exercise To learn the most effective ways to recommend exercise to your patients To learn what types of exercise protocols to recommend to your patients 3 Why Exercise Is So Important A functional, fit body is the foundation of health Exercising is the only way to get in shape (become fit) “Without Health There Is No Happiness…” Thomas Jefferson 4 Exercise Basics What Is Exercise? Physical activity – Any body movement by the skeletal muscles that results in a substantive increase in resting energy expenditure yard work, shoveling snow, sports, weight lifting Leisure time physical activity – Sports like basketball or soccer Scheduled exercise – Goal oriented activity: jogging or weight lifting Improved fitness or physical performance Weight management or better health 5 Main Types of Purposeful Exercise Aerobic (with oxygen) – Continuous exercise w/elevated heart rate Anaerobic (without oxygen) – Weight lifting, power exercises – Oxygen demand is greater than oxygen supply Core strengthening/stability training Flexibility training Balance training Sport specific training, ie agility, performance 6 What Is Fitness Ability to do physical work over time, using the musculoskeletal & cardiovascular systems Greater degree of fitness leads to reduced risks of overall disease & greater sense of well being & functionality 7 Age-adjusted mortality rates in healthy men categorized by level of fitness (Exercise capacity in METs) Myers, J. Circulation 2003;107:e2-e5 8 How Exercise Impacts Health Improves state of health & fitness Helps manage body weight Improves strength, stamina & energy Improves libido and sexual performance Improves alertness & concentration Improves mood & promotes a positive attitude Promotes restful sleep Delays aging related physiologic changes 9 Patient Asks Why Exercise? Makes you feel better Makes you look better Makes you feel better about yourself Reduces risks of major diseases – Heart disease, diabetes, stroke, cancers Leads to improvement in a great variety of diseases & negative health conditions 10 Ayurveda and Exercise Ayurveda mainly works through nutrition and medications Ayurveda recognizes the benefits of exercise at the physical, mental & spirit Ayurveda’s exercise recommendations are similar to western medicine’s – From thousands of years of wisdom & experience 11 Ayurveda’s Views On Exercise Its Physical Benefits Enhanced circulation Enhanced energy, strength and vitality Enhanced flexibility and coordination Good posture Increased ability to breathe deeper, infusing more prana into the system A feeling of lightness in the body Toned muscles and body Increased efficiency of the digestive system and a balanced appetite and metabolism Increased efficiency in eliminating toxins from the body 12 Ayurveda’s Views On Exercise Benefits for Mind, Heart and Spirit Enhanced mental alertness and agility Enhanced mental strength Enhanced focus and ability to concentrate Sense of emotional equilibrium Enhanced self-esteem and respect for one's body Self-awareness Enhanced ability to manage stress Freedom of spirit 13 Ayurveda’s Views On Exercise Principles to Follow Do not exercise to the point of discomfort – Leads to excessive soreness, fatigue, injury & premature aging – Results in enjoyment of exercise & greater long term commitment to exercise program – Always breath through the nose Concept of balaardh: use half your strength or capacity when exercising If you maintain the exercise program, your exercise capacity will increase 14 Ayurveda’s Views On Exercise Principles to Follow Exercise early in the morning to promote elevated energy levels all day Do not exercise on a completely empty stomach or just after a full meal To enhance circulation and the elimination of toxins, ayurvedic healers recommend that exercise be preceded by abhyanga, the ayurvedic warm oil self-massage 15 Dosha Specific Exercises Vata-Predominant Types Ideal exercises incorporate slow movements for balancing vata Slow dancing Low impact aerobics Tai chi Leisurely swimming in warm water Badminton Walking and yoga 16 Dosha Specific Exercises Pitta-Predominant Types Look for individual activities that require strength, focus and speed Water, ice or snow based activities – Swimming, downhill skiing, rowing, surfing and water-skiing – Walking or jogging in a cool shady area – tennis and yoga 17 Dosha Specific Exercises Kapha-Predominant Types Excel at activities requiring endurance and doggedness They like team sports Might not always be motivated to exercise, preferring a more sedentary lifestyle Good balancing activities include distance walking or running, basketball, racquetball, football, aerobics, ice skating, cross country skiing and cycling 18 Exercise Physiology and Its Specific Benefits Discuss benefits by body system and physiology – Cardiovascular – Respiratory – Endocrine – Musculoskeletal & overall body composition – Mental health – Aging related physiology 19 Cardiovascular Benefits of A Sustained Exercise Program Strengthens the heart muscle Improves blood flow (circulation) Reduces risk of heart attack – If occurs, occurs later in life, less severe event Lowers blood pressure Promotes weight loss Raised HDL (good) cholesterol Lowers LDL (bad) cholesterol 20 Exercise Physiology Cardiovascular Effects & Benefits Benefit derived primarily from aerobic exercise Changes occur to accommodate increased blood flow to skeletal muscles for increased oxygen requirements 21 Exercise Physiology Cardiovascular Effects & Benefits What happens when you exercise – Heart rate increases linearly with work rate – Stroke volume increases – Cardiac output increases – Blood flow to muscles improves – Blood pressure increases with exercise – Tissue oxygen extraction improves – Pulmonary ventilation increases 22 How Cardiac Output Increases Cardiac output (CO)= HR x SV Increase in heart rate leads to higher CO Stroke volume increases from resting HR up to 50% of aerobic capacity – Enhanced venous return – Increasing force of contraction Increased ventricular contractility (Frank-Starling mechanism) Catecholamine mediated sympathetic stimulation – Increase in ejection fraction EF = [SV/EDV] x 100 – SV may decrease at higher heart rates b/c of less diastolic filling time 23 Stroke Volume Increases Up to 50% Aerobic Capacity 24 Cardiovascular Effects of Exercise Conditioning Exercise conditioning leads to increased aerobic capacity (fitness) Ability to circulate blood and provide oxygen improves The heart muscles enlarges and becomes stronger Results in higher stroke volume – Lower resting pulse Greater response (increase in cardiac output) to exercise 25 Cardiovascular Effects of Exercise Conditioning: Sedentary Man Vs World Class Athlete Resting/maximal (exercise) heart rate – Sedentary man: 70/190 bpm – World class athlete: 45/190 bpm Resting/maximal stroke volume – Sedentary man: 85/93 mL/beat – World class athlete: 136/184 mL/beat 26 Cardiovascular Effects of Exercise Conditioning: Sedentary Man Vs World Class Athlete Resting/maximal cardiac output – Sedentary man: 6.1/17.7 L/min – World class athlete: 6.1/35.0 L/min Arteriovenous O2 difference: rest/maximal – Sedentary man: 4.0/14.0 mL/dL blood – World class athlete: 4.0/16.0 mL/dL blood 27 How Exercise Lowers Blood Pressure Aerobic exercise does this Takes 3 months to have an effect Last as long as exercise is continued Results from – Stronger heart muscle – Improved vasomotor responsiveness – Blood vessels are able to “relax” when not exercising – Less effort for blood circulation 28 The Respiratory System Pulmonary ventilation is typically not the limiting factor in maximal aerobic capacity Minute ventilation increases 15 to 25 fold with increasing exercise/work – Via increase in tidal volume – Respiratory rate Generally pulmonary respiration is directly proportional to O2 consumption and C02 production – Also increases with lactate production 29 Exercise & the Endocrine System Exercise makes the metabolism more efficient, increase in enzymes for energy production Increases insulin sensitivity – Improves type 2 diabetes Combined with aggressive dietary changes can “cure” type 2 diabetes Promotes weight loss 30 Aerobic Exercise & Energy Metabolism Glucose is the preferred energy source – ATP (energy) generated via glycolysis & Kreb cycle Comes from glycogen breakdown in liver and skeletal muscle; glycogenolysis Fat stores are also mobilized for energy – Ratio of glucose:fat metabolism is initially 1:1, can change to 1:4 with prolonged submaximal V02 <60% intensity exercise, takes 90 minutes to reach this effect – Increased fat metabolism with low to moderate intensity activities after 10 minutes of steady state exercise Proteins may also be broken down for energy if needed 31 Anaerobic Exercise & Energy Metabolism Energy for a 400m sprint – 70% anaerobic (without oxygen) ATP-CP creatine phosphate system ATP generated by glycolysis – 30% aerobic Kreb cycle in mitochondria Continued conditioning will increase the lactic acid threshold – Improved anaerobic energy production 32 Lipoprotein Profile and Exercise Researchers are unsure as to exact mechanisms that do this Exercise may release enzymes that clear LDL from blood vessels and bring it back to liver for processing Exercise is able to change the lipoprotein profile – Low density lipoproteins are bad – High density lipoproteins are good – Exercise reduces former, increases latter 33 Lipoprotein Profile and Exercise Aerobic exercise is needed to improve lipid profile Greater intensity exercise leads to greater improvement – Can lower LDL by 10 – 15% – Increase HDL by 20% – Combine efforts with nutritional changes 34 Exercise & the Musculoskeletal System Exercise training results in improvements in muscle strength & size up to that required for exercise – Muscles adapt to increasing resistance load by hypertrophy – Increases in contractile proteins actin & myosin – Also there is gradual strengthening of tendons, ligaments and joints 35 Exercise & the Musculoskeletal System Strength or resistance training (ie weight lifting) leads to greatest muscle mass gains Leads to increased overall strength, power, joint stability, basal metabolism Can also improve neuromuscular control 36 Strength Training is Rehabilitative For Joints & Muscles Leads to restructuring of collagen fibers in tendons & ligaments Strengthens resulting soft tissues & joints Process takes time & requires consistent effort on the part of the pt Refer to a qualified physical therapist when needed 37 Exercise and Bone Health Bone is constantly remodeling via – Osteoblastic formation – Osteoclastic resorption Process is affected by mechanical stresses – Exercise is a stimulus for skeletal adaptation – Bones become stronger with exercise – Leads to maintenance or increase in density Reminder – Women begin to lose bone mass between age 30 – 35 Rate of about 0.75% to 1% per year – Men begin to lose bone mass between age 50 – 55 Rate of about 0.4% per year 38 Exercise and Bone Health Once bone is demineralized, remineralization with exercise is a slow process – Slower than building strength – Be careful when working out elderly because of weak bones Best to take calcium & Vitamin D supplements & exercise throughout life to prevent bone mass & density loss 39 Exercise & Mental Health Exercise promotes positive changes in mood Increases brain blood flow Increase in nerve growth factors Increases concentrations of neurotransmitters that support cognition – Dopamine, glutamate, norepinephrine, serotonin Release of opioid like endorphins – Runner’s high 40 Exercise & Mental Health Exercise is a very effective treatment for depression – Improvement in serotonin levels – Weight loss – Increased confidence & self worth Improvements in other mental disorders are possible – improved cognition in dementia – Stress reduction in anxiety states 41 Exercise And Sleep Exercise improve ability to fall asleep and remain asleep When the physical body is exhausted it slips into REM more quickly & for a longer period of time – Muscles recovery during sleep & REM Leads to more restful sleep & increased energy during the day 42 Exercise and Aging Aging is inevitable Some changes can be mitigated or ameliorated via – Exercise – Proper nutrition – Proper supplementation – Lifestyle factors: stress reduction, sleeping habits, weight management 43 Cardiovascular Changes With Aging Are changes normal or due to cardiovascular disease Maximal heart rate decreases with age – Decrease in pacemaker cells and responsiveness to stimulation Maximal heart rate formula – 220 minus age 44 Cardiovascular Changes With Aging Increase in interstitial fibrosis & calcium in myocardium – Collagen crosslinking and elasticity loss – Left ventricle hypertrophies Cardiac output is 10 to 30% less at age 65 than at young adulthood – Decrease in both HR & SV – Decreases about 1% per year Arterial stiffening & elasticity loss which increases SBP – Increases heart’s workload (afterload) Overall circulation decreases with aging 45 Exercise and Cardiovascular Aging Exercise can minimize loss in stroke volume Heart rate changes are less responsive Exercise can help maintain & minimize loss in aerobic capacity Exercise can also reduce blood pressure & improve circulation 46 Pulmonary Changes With Aging Lung compliance increases with aging Ability for chest to expand decreases 20% increase in work to breath by age 65 Vital capacity decreases by 40 to 50% by age 70 – May be due to loss of elastic recoil of lung 47 Pulmonary Changes With Aging Respiratory changes do not limit exercise capacity – Unless there is severe lung disease 48 Body Composition Changes With Aging Approximately 1/3 of the population is obese – Childhood obesity is becoming an epidemic Basal metabolic rate decrease by 5% per decade Loss of lean muscle mass, atrophy with aging – Loss depends on activity level Exercise, both aerobic and strength training is the key to minimizing weight gain and muscle atrophy 49 Joint Degeneration With Aging Progressive loss of flexibility with aging – Loss of collagen fibers – Deterioration of joint soft tissues Increase in knee and back problems with aging Significant degeneration of the spine with aging – Excessive weight bearing may play a role Exercise is great for minimizing rate of joint degeneration & strengthening soft tissues 50 Overview of How to Counsel Patients on Exercise Key is to form a partnership with your patient Teach them to become self motivated – Your role is to teach them how to motivate themselves Numerous counseling techniques are available and are physician dependent 51 Several Models for Exercise Counseling 3 Ms model Mentioning exercise – Identify which patient can benefit from exercise Modeling: being a role model – Discuss your experiences with exercise Motivating: teaching patients to motivate themselves AVOID NAGGING YOUR PATIENT 52 Several Models for Exercise Counseling Five As Model Assess (pt’s need for exercise) Advise (exercise recommendations) Agree (agreement by patient) Assist (pt to engage in the activity) Arrange (follow up) 53 Screening History & Physical Exam Talk to your physician if you have – Heart disease or severe lung disease Chest pain Abnormal heart beat Circulation problems – Joint disease Prior injuries, severe arthritis – Poor balance History of falls – Other related medical issue as note by your doctor 54 ACSM & AHA Exercise Recommendation: Adults Under 65 Moderate intensity exercise for 30 minutes, 5x/week Or High intensity exercise for 20 minutes, 3x/week And 8 to 10 repetitions of 10 strength training exercises 2x/week 55 ACSM & AHA Exercise Recommendation: Adults Over 65 Moderate intensity exercise for 30 minutes, 5x/week Or High intensity exercise for 20 minutes, 3x/week And 10 - 15 repetitions of 10 strength training exercises 2x/week Balance training if there is a risk of falling 56 US Dept of Health & Human Services Physical Activity Guidelines Moderate intensity exercise for 30 minutes, 5x/week Or High intensity exercise for 20 minutes, 3x/week Or Combination of moderate & high intensity exercise to reach recommended level 57 Types of Aerobic Exercises Walking Brisk walking Jogging Cycling Stairmaster Elliptical rowing Jump roping Superset without rest between sets Circuit training Swimming Various sporting activities 58 Main Strength Exercises Chest muscles – Bench press Flat, incline, decline Shoulders – Shoulder press – Lateral or front raises Upper back – Chin up – Rows Arms – Bicep & forearm curls – Tricep extensions Abdominals – Sit ups & crunches – Leg raises Obliques – Side bends – Torso twists Lower Back – Back extension – deadlifts Legs – Squats, lunges – Leg press – Leg extensions & curls 59 Exercise Intensities Level of physical exertion to raise your heart rate & break a sweat – Should be able to carry on a conversation – Level 6 on scale of 1 to 10 Vigorous intensity – Level 8 or higher – Requires higher focus – Difficult to carry conversation 60 Complete Exercise Protocols Should have all 5 components Aerobic exercise Muscular, strength or resistance training Core strength & stability training Stretching & flexibility training Balance training 61 Principles of Weight Loss Expend more calories than you consume Typically requires a lifestyle change Eating lower calories and exercising to burn calories During weight loss period – Requires more strict adherence to calorie restriction – Higher levels of exercise During maintenance period: goal wt is attained 62 Principles of Weight Loss Expend more calories than you consume Typically requires a lifestyle change Eating lower calories and exercising to burn calories During weight loss period – Requires more strict adherence to calorie restriction – Higher levels of exercise During maintenance period: goal wt is attained 63 Calorie Restriction Techniques Drink lots of water and/or low calorie drinks Eat lots of fruits and vegetables – – – – Bulky and low calorie Phytonutrients boost metabolism Fruits are convenient & ready to eat Learn tasty & palatable recipes to cook veges Increase protein intake to preserve lean tissue Limit high calorie foods like fried food, nuts, candies, empty calories Take supplements as directed 64 Exercise Resources American College of Sports Medicine American Heart Association US Department of Health & Human Services – Physical Activities Guidelines Advisory Committee National Academy of Sports Medicine American College of Cardiology 65