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ACSM’S CERTIFIED
NEWS
J U LY — S E P T E M B E R ,
2 0 1 2
•
V O L U M E
2 2 :
I S S U E
3
Tips for
Training Clients
Who Play Golf
PAGE 3
Exercise
Immunology
PAGE 4
Diabetes
Medications:
Guidelines
for Exercise
Safety PAGE 6
Heart
Sounds
page 10
Resistance
Training and
Diabetes PAGE 9
Exercise and
Bariatric Surgery
PAGE 11
ACSM’S CERTIFIED NEWS
April–June 2012 • Volume 22, Issue 2
In this Issue
Tips for training clients who play golf ................... 3
Exercise Immunology................................................... 4
Diabetes Medications:
Guidelines for Exercise Safety................................ 6
Coaching News........................................................... 8
Resistance Training and Diabetes ............................. 9
Part 3: Heart Sounds...................................................10
Exercise and Bariatric Surgery....................................11
Co-Editors
Peter Magyari, Ph.D.
Peter Ronai, M.S., FACSM
Committee on Certification
and Registry Boards Chair
Deborah Riebe, Ph.D., FACSM
CCRB Publications Subcommittee Chair
Paul Sorace, M.S.
ACSM National Center Certified News Staff
National Director of Certification
and Registry Programs
Richard Cotton
Assistant Director of Certification
Traci Sue Rush
Publications Manager
David Brewer
Editorial Services
Lori Tish
Angela Chastain
Editorial Board
Chris Berger, Ph.D., CSCS
Clinton Brawner, M.S., FACSM
James Churilla, Ph.D., MPH, FACSM
Ted Dreisinger, Ph.D., FACSM
Avery Faigenbaum, Ed.D., FACSM
Riggs Klika, Ph.D., FACSM
Tom LaFontaine, Ed.D., FACSM
Thomas Mahady, M.S.
Paul Sorace, M.S.
Maria Urso, Ph.D.
David Verrill, M.S.
Stella Volpe, Ph.D., FACSM
Jan Wallace, Ph.D.
For More Certification Resources Contact the
ACSM Certification Resource Center:
1-800-486-5643
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ACSM’s Certified News (ISSN# 1056-9677) is published
quarterly by the American College of Sports Medicine
Committee on Certification and Registry Boards (CCRB). All
issues are published electronically and in print. The articles
published in ACSM’s Certified News have been carefully
reviewed, but have not been submitted for consideration as, and
therefore are not, official pronouncements, policies,
statements, or opinions of ACSM. Information published in
ACSM’s Certified News is not necessarily the position of the
American College of Sports Medicine or the Committee on
Certification and Registry Boards. The purpose of this
publication is to provide continuing education materials to the
certified exercise and health professional and to inform these
individuals about activities of ACSM and their profession.
Information presented here is not intended to be information
supplemental to the ACSM’s Guidelines for Exercise Testing and
Prescription or the established positions of ACSM. ACSM’s
Certified News is copyrighted by the American College of
Sports Medicine. No portion(s) of the work(s) may be
reproduced without written consent from the Publisher.
Permission to reproduce copies of articles for noncommercial
use may be obtained from the Certification Department.
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© 2012 American College of Sports Medicine.
ISSN # 1056-9677
2
INTRODUCING
THE EXERCISE IS MEDICINE
(EIM) CREDENTIAL
®
By Richard T. Cotton, National Director of Certification,
American College of Sports Medicine
NEW CREDENTIAL BRIDGES GAP BETWEEN FITNESS PROS AND
PHYSICIANS ENCOURAGING PHYSICAL ACTIVITY TO PATIENTS
There is no bigger decision in managing a certification program than deciding to create a new credential. I use “credential” quite intentionally, because not every credential needs to be a certification.
In fact, in the case of the new Exercise is Medicine® (EIM) Credential, offering a new certification was
not the answer because three out of the five core ACSM certifications (HFS, CES, RCEP) address the
knowledge and skills related to working with special populations, and our personal trainer and group
exercise instructor certifications somewhat address special populations, as well. However, in order
to meet the level of proficiency the EIM Credential Committee felt was appropriate for referral by
physicians, a credential demonstrating specialized knowledge which can enhance any certification was
the solution.
Our team headed into this adventure with a number of objectives:
• Create a credential that will provide physicians with the confidence that the fitness
professional being referred has ability to safely and effectively address the needs of
the referring physician’s patients
• Minimize the barriers to entry to earning this credential and at the same time avoid
duplicating knowledge and skills already addressed by current ACSM certifications
• Address the need for the enhancement of knowledge and skills in the areas of working within the health care system as well as supporting sustainable behavior change
• Grow the number of EIM credentialed fitness professionals as rapidly as possible
The planning meeting to address these objectives was probably one of the most productive and
creative meetings of my entire career. We started by nixing the idea of creating another certification.
We knew we had most of the knowledge and skills covered in three of the five ACSM certifications,
yet we still wanted the holders of those certifications to be able to earn the EIM credential badge to
be able to share with physicians and support the promotion of these important services. Out of this
need came the three levels of credential.
I don’t want to get too much into the details of the levels for all of that can be found at:
http://certification.acsm.org/exercise-is-medicine-credential. The three levels correspond to both the
increasing scope of practice reflected for the most part in the ACSM Certified Personal
Trainer/Certified Group Exercise Instructor certification (Level One) to the ACSM Certified Health
Fitness Specialist certification with a bachelor’s degree (Level Two) to the ACSM Registered Clinical
Exercise Physiologist certification with a master’s degree (Level Three). The ACSM Clinical Exercise
Specialist can either qualify for the Level Two or Level Three credential, depending on education and
experience.
The required education program is intended to enhance the knowledge and skill of those without
bachelor’s degrees in exercise science. The education is provided as follows:
• Working with special populations (60%)
• Working within the health care system (20%)
• Supporting sustainable behavior change (20%)
The exam is composed of 50 questions with the percentage of the questions consistent with the
above.
We are quite proud of the work that we have done and feel confident that this new credential can
meet the needs of healthcare providers as well as enhance our profession to better integrate with
the healthcare system.
ACSM’S CERTIFIED NEWS • JULY–SEPTEMBER 2012 • VOLUME 22: ISSUE 3
WELLNESS ARTICLE
TIPS FOR TRAINING CLIENTS
WHO PLAY GOLF
By Kiran Kanwar, B.S.
Given that more than 25 million Americans play golf, a number
projected by the World Golf Foundation to increase to 55 million by
2020,6 there is a good chance that many of a personal trainer’s typical clientele will include those who play golf — whether to compete at
an elite, amateur or professional level, or simply for the enjoyment of
the game. Such clients can generally benefit from a fitness program
that includes:
• A musculoskeletal screening
• Suggestions for pre-round dynamic warm-up routines
• Suitable exercise regimens
The above three elements will ensure that your client has more
efficient ball-striking in terms of distance, direction and trajectory,
and, at the same time, reduced scope for injury.
Musculoskeletal screening: Screen for neck rotation 80° in either
direction; undesirable excessive cervical or thoracic flexion; pelvic
rotation (belt buckle turns 45°) along with disassociation from thoracic rotation; trail shoulder external rotation; lead arm horizontal
adduction (should be 130° for males, 155° for females); grip strength
and wrist flexibility (specifically radial and ulnar deviation). Other
tests could include those for hamstrings tightness, calf flexibility, pelvic
tilt, leg extension and balance.
Dynamic warmup: A good dynamic warm-up might include pulseraiser exercises which at the same time work the abductor/adductor
muscles of the thigh, the quadriceps and hamstrings, the lateral flexors of the spine and shoulder flexor/extensor muscles.4,5,12
Exercises: A combination of exercises for improving overall and core
strength; flexibility of the spine and upper limb; neuromuscular speed
and positional awareness (including plyometrics and uneven surface proprioception workouts); cardiovascular fitness for the endurance
required to walk 18 holes often carrying a golf bag; balance; and agility.1,2,7,11 A new trend is to include exercises which mimic the core movement patterns of crawling, rolling over and running.
The personal trainer also can benefit from a basic knowledge of
what aspects of the golf swing deliver better distance, direction and
trajectory; as well as an understanding of the regions of, and main
causes of pain or injury, either caused or exacerbated by golf.
The ‘modern’ golf swing which most golfers today aspire to make
emphasizes a large shoulder turn against a restricted hip turn
(termed X-factor), along with a speedy trail-side lateral trunk flexion
during the downswing (termed ‘crunch factor’), and both these factors require greater joint stability/mobility respectively, while also
resulting in greater chance for injury.6
An efficient golf swing produces power and the resulting club
speed from a combination of:
• Sequential summation of forces - proximal parts leading the distal ones (that is, legs and hips start the
downswing, followed by trunk followed by shoulders,
arms and wrists and finally the club)
• Stretch-shortening cycle (muscles which are stretched
during the backswing — X-factor — or more impor-
tantly during early downswing X-factor stretch — contract more forcefully at impact) and
• Use of ground-reaction forces created by forceful
pushing off of the trail foot.8
A correct sequence of the downswing — proximal to distal — not
only helps to generate greater swing speed, but also delivers the golf
club from the correct direction to produce straight ball-flight.
Conversely, an incorrect downswing sequence is one in which the
upper-body starts the downswing out-of-sequence. Such a downswing
is typically termed an ‘over-the-top’ (OTT) one, and usually results
from a backswing with excessive flexion of lead side trunk and thus
lead knee; excessive thoracic plus hip rotation; internal rotation of
trail shoulder; excessive pronation of trail forearm and early extension of trail wrist. [More efficient and safer backswing joint positions
which reduce the scope for the OTT downswing and thus for injury,
are neutral wrists, semi supine trail forearm, minimal trail elbow flexion, external trail shoulder rotation together with backswing lateral
flexion of the trail side trunk].9,10
Injury in the golf swing is mostly microtrauma, caused by poor
mechanics among the less skilled and occasional golfers; and by
oveuse in the more elite ones.6 Poor-mechanics injury is almost
always the result of the over-the-top downswing, which forces greater
than normal torques and loads on the spine, the lead knee, as well as
on both elbows and the lead wrist.
The most common areas of injury3 are said to be wrist/hand 37%,
low back 24%, shoulder 10%, elbow 7 and knee 7% for professional
golfers. For amateur golfers they are low back 35%, elbow 33%,
wrist/hand 20% shoulder 12% and knee 9%. Most of these injuries
are of the lead side of the body. Avoidance of the OTT downswing
could reduce the scope for all these injuries.
A well-balanced fitness plus nutrition and hydration package based
on a better basic understanding of golf swing mechanics and injury
mechanisms can be an asset to any personal trainer and can add
greatly to his/her repertoire of client services.
The following websites offer golf-specific fitness information:
• www.TitlestPerformanceInstitute.com
• www.backtogolf.com
• www.fitgolf.com
• www.chekinstitute.com
• www.back9fitness.com
• www.golfhelp.com
About the Author
Kiran Kanwar, B.S., has been a golf instructor for
more than 23 years and has worked with every skilllevel of golfer. Based on over 17 years of research,
she has developed The Minimalist Golf Swing which
places all the major golf-swing joints of the body in
positions from which they are designed to perform
optimally, which increases swing efficiency and
decreases scope for injury.
(www.yourgolfguru.com and www.kirankanwargolf.wordpress.com)
Golf (continued on page 15)
ACSM’S CERTIFIED NEWS • JULY–SEPTEMBER 2012 • VOLUME 22: ISSUE 3
3
HEALTH & FITNESS FEATURE
EXERCISE IMMUNOLOGY
By Benjamin T. Gordon, M.S., CES, CSCS
A crippled immune system can impair a training athlete, leaving the
body vulnerable to infection and disease, and subsequently can inhibit exercise training and performance. Furthermore, changes in
immune functioning can have detrimental effects on physiological systems other than the immune system, including the nervous and metabolic systems. In general, the immune response is divided into the
innate immune response (cellular and molecular components that
defend against infection in a non-specific manner, e.g., macrophages
and neutrophils) and the adaptive immune response (specific cellular
and molecular components that defend the body uniquely for each
specific antigen, e.g., T-cells and B-cells). Both innate and adaptive
responses are affected by exercise,32 but, how much of an effect does
exercise have, and how should these desired responses govern exercise prescription? The focus of this article is dedicated to answering
these questions.
INNATE IMMUNE SYSTEM AND EXERCISE
The innate immune response is the first line of defense against
pathogens if they pass surface barriers of the body (e.g., mucous, hair,
skin). Unlike the adaptive immune response, this system does not
adapt to repeated exposures from the same pathogen. Nonetheless,
the innate immune system is able to eliminate most invaders with a
combination of leukocytes (white blood cells derived from multipotent hematopoietic stem cells) and inflammatory mediators (cellderived messenger molecules that propagate inflammation). Innate
immunity relies heavily on four immune cells (neutrophils,
macrophages, dendrites, and natural killer cells), with each responding in a unique manner to exercise. Neutrophils constitute 50% to
60% of all circulating leukocytes and typically are the first to respond
to immune stimuli including exercise.22 Immediately following a single
aerobic exercise session, circulating neutrophils rapidly increase in
number.22 This initial increase is followed by another delayed rise several hours later. Both increases are dependent on the intensity and
duration of the exercise session. However, the increased number of
neutrophils is not necessarily indicative of a heightened immune
response. Rather, following moderate to vigorous aerobic exercise
.
(65 to 85% VO2max), mobilized neutrophils are less responsive to
bacterial stimuli for several hours post exercise, showing that their
function is blunted.25 In contrast to these results to acute exercise,
chronic exercise training appears to leave concentrations of neutrophils unaffected or reduced, while retaining function.8 Neutrophil
response to exercise indicates that while intense acute exercise can
leave the body vulnerable to infection, chronic training may have a
beneficial anti-inflammatory effect. Essentially, exercise training could
cause a more tightly regulated release and sequestering of neutrophils, helping the body control disease and infection.
.
A single aerobic exercise session (65% to 85% VO2max) results in
temporal increases in circulating monocytes approximately 2-h post
exercise.19 If muscle damage is involved macrophages in the muscle tis-
4
sue rise approximately 24-h post exercise.29 Macrophages are monocytes that have left circulation into surrounding tissue and differentiated into phagoctyic immune cells. The increase in circulating monocytes likely is linked to cortisol release from the endothelium during
exercise. Circulating monocytes typically have two predominant phenotypes, based off of surface receptors (Cluster of Differentiation
receptors), CD14+/CD16+ (pro-inflammatory) and CD14+/CD16(homeostatic). Monocytes recruited to circulation within the first 24h post exercise are primarily of CD14+/CD16+ phenotype while the
second wave of monocytes (beyond 24-h post exercise) is composed
mainly of CD14+/CD16- phenotype. Though there is substantial evidence regarding circulating monocytes post exercise, relatively little is
known concerning differentiated tissue macrophages.32 Nonetheless,
animal studies have examined the influence of acute moderate aerobic exercise on tissue macrophages and found some functions such as
phagocytosis and reactive oxygen and nitrogen metabolism are
enhanced by exercise.20,21,33 Conversely, macrophage Major
Histocompatibility Complex II (MHC II) expression and antigen presenting capacity are reduced with a single aerobic exercise session of
.
near exhaustive exercise (70%-90% VO2max for up to 4 h).2,3 MHC
II are a group of proteins that help macrophages present specific antigens to T-helper cells of the adaptive immune system. In contrast to
the conflicting results of single acute exercise session investigations,
chronic exercise training appears to consistently blunt the monocytic
response to exercise. In multiple cross-sectional and longitudinal studies, trained individuals exhibited a smaller monocytic response to
lipopolysaccharide (LPS) than their untrained counterparts.7,14,15,28 LPS
is a component of gram-negative bacteria, and elicits a reputable
immune response in mammals. The typical monocytic response to
LPS was reduced with exercise training. Additionally, some animal
studies show that macrophage infiltration is reduced with exercise
training. Once more, the effects of acute exercise on macrophages
like neutrophils could leave the body susceptible to infection for up to
several days following recovery. Yet, the potential reductions in
macrophage infiltration observed with exercise training are seen as
beneficial in situations of chronic inflammation (i.e., cancer, obesity,
cardiovascular disease, type 2 diabetes).32
Unlike macrophages and neutrophils, the role of dendritic cells has
been vastly under investigated despite the possible large role they
play in the innate and adaptive immune response to exercise.
Dendritic cells are named after their resemblance of neuronal dendrites, and serve largely as mediators between the innate and adaptive immune response. Currently, only two studies have investigated
dendritic cell responses to exercise, and both found that a single exer.
cise session of moderate aerobic exercise (60%-85% VO2max)
increased circulating levels.5,9 Aside from these results, little else is
known about the dendritic cell response or function following acute
exercise. Only two animal studies have investigated exercise training
and effects on dendritic cells.4,12 Liao et al.12 found an increase in circulating dendritic cells in exercise trained rats. Chiang et al.4 found that
MHC II expression and Interleukin 12 (IL-12) production were signifi-
ACSM’S CERTIFIED NEWS • JULY–SEPTEMBER 2012 • VOLUME 22: ISSUE 3
cantly increased in dendritic cells. MHC II and IL-12 are heavily
involved in the development of T-cells and the adaptive immune
response. These investigations support a potentially large dendritic
cell role in exercise recovery. Exercise training possibly aids in dendritic function, but additional clinical trials are needed before conclusive
statements are made.
Circulating natural killer (NK) cells, much like other innate leukocytes, are rapidly increased in response to exercise. Following a single
.
session of aerobic exercise (65%-95% VO2max for up to 4 h) a 50%100% increase in circulating NK cells10 has been reported. As is the
case with monocytes, the NK cell exercise response is phenotype specific. NK cells can be grouped by their relative expression of CD56,
a membrane adhesion molecule. CD56bright and CD56dim are the
two common phenotypes of NK cell, and it appears CD56bright NK
cells are less responsive to acute exercise than CD56dim. This could
indicate that NK cells have a reduced ability to defend against
pathogens following acute exercise, because CD56dim NK cells are
less cytotoxic. In addition, with prolonged exercise, circulating NK
cells decrease, which is likely a result of tissue infiltration.10
Nonetheless, the health implications following acute exercise-mediated changes in NK cells are unknown, and the effects of exercise training on NK cell functioning are complex. Fairey et al. completed a 15week clinical trial and found increased NK cytotoxicity.6 Other clinical
trials including a 12-month trial by Campbell et al. found no exercise
training effect.1 Inter-study differences such as subject variability may
contribute as confounding factors. However, more decisive evidence
regarding NK cell functioning in response to exercise training is needed before conclusions are made.
THE ADAPTIVE IMMUNE SYSTEM
AND EXERCISE
Adaptive immunity is the second division of the immune system
and uniquely responds to individual pathogens. The adaptive immune
system almost always is activated by the presentation of an antigen
(any foreign object that provokes the immune system to create antibodies), typically by a member of the innate immune system T helper
cells (CD4+). T-cells are lymphocytes like NK cells and neutrophils,
but all T-cells are distinguished by T-cell Receptors (TCR). CD4+ cells
are not the only T-cells in the immune system. There are several subdivisions of T-cells including, Regulatory T-cells (Tregs), cytotoxic Tcells (CD8+), memory T-cells, and Natural Killer T-cells (NKT).
However unlike CD4+ cells, other T-cells do not initiate the adaptive
immune response. Furthermore, CD4+ cells are subdivided into type
1(Th1) and type 2 (Th2) phenotypes. CD4+ cells and have no specific mechanism for defending against pathogens, but may help other
immune cells do so. CD4+ cell phenotype is determined by what activates them and what pathways are followed after activation. Th1 cells
are activated by the presence of intracellular pathogens such as bacteria or viruses. This activation usually is caused by CD4+ cell detection of infected macrophages.32 In turn, Th2 cells are activated by the
presence of extracellular pathogens and toxins, which typically results
in B-cell production of antibodies. Along with their adaptive immune
system counterparts, B-cells another lymphocyte, make up the majority of the system and function in immune surveillance. These circulating cells do not fully proliferate without CD4+ cells releasing soluble
mediators including cytokines (e.g., IL-4, IL-5, IL-6, and IL-13), which
differentiate the B-cells into plasma cells or memory cells. Plasma cells
release large amounts of specific antibody (Immunoglobulin, (Ig)) that
help mark pathogens in the immune phagocytic destruction process.
A single exercise session substantially changes function of the adaptive immune response.32 Typically, with moderate to vigorous exercise
.
(60%-85% VO2max), T- and B-cells show a biphasic response with a
rapid increase in circulation followed by a dip below baseline values a
few hours post-exercise. The decrease of T- and B-cells is dependent
on how intense and how long the exercise is, meaning with increases
in intensity and duration there are larger decreases below baseline.13,26 Epinephrine interaction appears to cause much of the mobilization of these cells into circulation via direct and indirect mechanisms. Lymphocytes naturally express a high percentage of adrenergic receptors causing them to react to the release of epinephrine.
With exercise, both the activity and density of these receptors are
increased.27 CD4+ cells have the lowest expression of adrenergic
receptors with the CD8+ expressing the highest. The decrease following initial mobilization of T-cells likely is due to an exaggerated
decrease in Th1 cells, whereas exercise seems to have little or no
effect on Th2 cells. Most likely the decrease in Th1 cells is a result of
redistribution of cells and not apoptosis. Similar to acute exercise
studies involving the innate immune system, the decrease in T-cell
number may be indicative of immune suppression during exercise
recovery. However, T-cell function also must be analyzed.
Without proper functioning T-cells, which can happen with intense
acute exercise, the body is susceptible to all types of intracellular
invaders. This may explain why intense training and competition (e.g.,
near maximal effort) leaves athletes temporarily more susceptible to
upper respiratory tract infections (URTI).17 However, analysis of T-cell
activity following exercise is extremely difficult. In addition, T-cell functioning is measured only in vitro from blood samples obtained during
recovery. The cell composition of blood samples taken before and
after exercise is often dramatically different making analysis more difficult because the ratios of immune cells are not consistent between
the two measurements. Nonetheless, T- and B-cell function appear
susceptible to increases of greater that 15% per week in training load
(duration, intensity, and frequency)31 of exercise training. T-cell proliferative responses and decreases in stimulated B-cell Ig synthesis have
been reported with increases in intensity of exercise training.11,30
Further investigations are needed to clarify and fully understand the
impact of exercise training upon T-cell functioning.
B-cells, when properly stimulated by CD4+ cells, can differentiate
into plasma cells or memory cells. Following differentiation, plasma Bcells generally are localized in lymphoid and mucosal tissue with their
main role being the secretion of Ig (antibody). The effects of exercise
on plasma cells have been measured through Ig mucosal concentrations in vivo and serum Ig creation following in vitro stimulation.
Mucosal Ig concentrations allow for an estimation of plasma cell
release of Ig, while serum Ig synthesis allows for the analysis of the
plasma cells to create Ig outside of the body. Mucosal Ig concentrations following a single session of exercise and exercise training
remain unchanged.18,23 However, Ig production following in vitro stimulation increases in response to both a single exercise session and
exercise training,26 showing that B-cell functioning is potentially positively influenced by exercise.30
Exercise Immunology (continued on page 13)
ACSM’S CERTIFIED NEWS • JULY–SEPTEMBER 2012 • VOLUME 22: ISSUE 3
5
WELLNESS ARTICLE
DIABETES MEDICATIONS:
GUIDELINES FOR EXERCISE SAFETY
By Mary Lobb Oyos, RN, MS, BC-ADM, CDE, and Sherry Barkley, Ph.D., CES, RCEP
Diabetes mellitus is a chronic disease that is quickly
becoming an epidemic. Based on current data, 25.8 million
American children and adults (or 8.3% of the United States
population) have diabetes. Another 79 million Americans
have pre-diabetes.5 U.S. data released in 2010 predict that
1 in 3 American adults could have diabetes by 2050 if current trends continue.6 Diabetes is the seventh leading cause
of death in the United States, and individuals with diabetes
are two to four times more likely to develop cardiovascular disease than those without diabetes.5 Despite these
alarming statistics, there is a great deal that people can do
to prevent diabetes and that those with the disease can do
to avoid complications and stay healthy.
Type 1 diabetes is a disease of absolute insulin deficiency characterized by beta cell failure; it affects 5% to 10% of
individuals with diabetes. Type 2 diabetes involves relative
insulin deficiency and is characterized by some combination
of three main metabolic problems: 1) decreased beta cell
function with reduced insulin production, 2) insulin resistance in the peripheral tissues, and 3) increased hepatic glucose production. Of the people with diabetes, 90% to 95%
have type 2.1,7
Diabetes treatment components include healthy eating,
regular physical activity, medication (if needed), blood glucose monitoring, and education on diabetes self-management.1,4 Medication options for diabetes treatment continue
to expand and include oral medications, insulin, and other
injectable preparations. Some of these medications may
cause hypoglycemia (low blood glucose), particularly when
combined with increased activity. The remainder of this
article explores the various types of diabetes medications
and implications for exercise/fitness professionals to help
ensure a safe exercise experience for their clients.
Table 1: Oral Diabetes Medications1,4
CLASS
HOW THEY WORK NAMES –
Generic & (Brand)
Name
Sulfonylurea
Stimulate pancreas to
make more insulin,
both right after a meal
and for several hours
later
- Glimepiride (Amaryl) Yes
- Glipizide (Glucotrol,
Glucotrol XL)
- Glyburide (Diabeta,
Micronase, Glynase)
Meglitinides
Stimulate pancreas to
release more insulin
right after a meal
- Nateglinide (Starlix) Yes
- Repaglinide (Prandin)
Biguanides
Decrease amount of - Metformin,
glucose released from metformin XR
liver
Not likely, but possible
Alpha-Glucosidase
Inhibitors
Slow carbohydrate
digestion
- Acarbose (Precose)
- Miglitol (Glyset)
Yes, if used with
sulfonylurea or insulin
Thiazolidinediones
(TZDs)
Increase insulin
sensitivity in muscle
and fat tissue
- Pioglitazone (Actos)
- Rosiglitasone
(Avandia)
No
Dipeptidyl peptidase-4 Enhance insulin
(DPP-4) inhibitors
secretion & decrease
amount of glucose
released from liver
after a meal
RISK OF
HYPOGLYCEMIA
- Linagliptin
No
(Tradjenta)
- Saxagliptin (Onglyza)
- Sitagliptin (Januvia)
Note: Several of these medications are available in combination preparations.
Table 2: Insulin Types and Actions4
TYPE
NAME
Generic & (Brand)
Name
ONSET
PEAK
DURATION
Rapid-acting
Aspart (NovoLog)
Glulisine (Apidra)
Lispro (Humalog)
5-15 minutes
30-90 minutes
<5 hours
Short-acting
Regular
30-60 minutes
2-3 hours
5-8 hours
Intermediateacting
NPH
2-4 hours
4-10 hours
10-16 hours
Long-acting
Detemir (Levemir)
Glargine (Lantus)
2-4 hours
None
24 hours
ORAL DIABETES MEDICATIONS
Note: Several pre-mixed insulin combinations also are available.
Oral diabetes medications may be used to control blood
sugar in persons with type 2 diabetes. The oral medications
are divided into six classes based on how they work to
affect blood glucose levels. These may or may not increase
the risk for hypoglycemia during exercise (Table 1).
INSULIN
Insulin is always used in the treatment of type 1 diabetes, and sometimes in the treatment of type 2 diabetes.
All types of insulin can cause hypoglycemia. The peak
insulin time is when an individual is at greatest risk for
hypoglycemia. It is suggested that exercise be avoided dur-
Table 3: Carbohydrate Options
for Treatment
of Hypoglycemia4
TREATMENT
AMOUNT (15 grams carbohydrate)
Fruit juice
½ cup
Milk (skim preferred)
1 cup
Regular soda pop
½ cup (4 oz.)
Glucose tablets
3-4 (depends on brand)
Glucose gel
Check package information for amount equal
to 15 grams
Note: High fat foods/drinks slow gastric emptying and carbohydrate absorption and therefore
take longer to raise blood glucose levels.
6
ACSM’S CERTIFIED NEWS • JULY–SEPTEMBER 2012 • VOLUME 22: ISSUE 3
Table 4: Recommended Pre-Exercise Carbohydrate Intake
Based on Blood Glucose Levels
GLUCOSE
PRE-EXERCISE
INTENSITY AND DURATION EXTRA FOOD NEEDED
OF EXERCISE
Less than 100 mg/dl
Low
(< 30 minutes)
Moderate
(30-60 minutes)
Strenuous
(>1 hour)
15 gms carbohydrate
30 gms carbohydrate
60 gms carbohydrate
101-170 mg/dl
Low
Moderate
Strenuous
No extra food needed 15 gms carbohydrate
30 gms carbohydrat
171-300 mg/dl
Low
Moderate Strenuous
No extra food needed No extra food needed 15 gms carbohydrate
Over 300 mg/dl
**Don’t begin exercise until blood sugar is under better control.
ing peak insulin action. See Table 2 for a summary of insulin types and
duration of action.
NON-INSULIN INJECTABLE MEDICATIONS
There are other injectable diabetes medications that are not
insulin, but affect glucose control in other ways. These include exenatide (Byetta & Bydureon), liraglutide (Victoza) and pramlintide
(Symlin). These medications do not cause hypoglycemia by themselves, but can do so if combined with other medications that may
lead to low glucoses.4
• Administer insulin injections in a part of the body that
will not be used actively for exercise. The abdomen is
often a good site. Injecting into the subcutaneous tissue near a muscle that is being used during activity
may cause hypoglycemia. The increased blood flow to
the area causes more rapid insulin absorption with
possible resultant hypoglycemia.4,7
• Always check the blood glucose level before, during,
and after exercise, at least until the effects of a specific type and duration of activity are monitored for several exercise sessions.2,3
• Watch for delayed post-exercise hypoglycemia in
people who take insulin. Because metabolism remains
increased for several hours after exercise, people
may experience lows several hours after exercise,
especially during the night. Advise people to check
glucose at bedtime and take a snack of 15-30 grams
carbohydrate plus protein if the glucose is <100
mg/dl. A glucose check at 1–2:00 a.m. also is advisable following a day of significantly increased activity.4
• Individuals who take a diabetes medication that can
cause hypoglycemia should plan for increased activity
by either increasing carbohydrate intake or decreasing insulin intake. These guidelines are a helpful starting point for additional carbohydrate prior to exercise. All extra food should be eaten before exercise
and is in addition to the regular meal plan (Table 4). SUMMARY
HYPOGLYCEMIA SYMPTOMS
AND TREATMENT
Anyone with diabetes who is taking insulin or an oral medication
that can cause hypoglycemia should be aware of hypoglycemia symptoms and have rapid-acting glucose available at all times, particularly
during exercise. Hypoglycemia is defined as a glucose <70 mg/dl.4
Symptoms of hypoglycemia include:
• Sweating
• Shaking
• Dizziness
• Headache
• Confusion/irritability
• Personality change
• Hunger
• Weakness
• Vision changes
• Seizures or loss of
consciousness
If hypoglycemia is suspected, check blood glucose. If blood glucose
is below 70 mg/dl, treat the low blood sugar using the Rule of 15.
Take 15 grams of carbohydrate, wait 15 minutes, then re-treat with
15 grams of carbohydrate if symptoms have not improved (Table 3).
In individuals with either type 1 or type 2 diabetes, exercise is not
recommended for blood glucose below 100 mg/dl until a carbohydrate has been consumed, the glucose level has been rechecked, and
has increased to a safe level.2
Hypoglycemia prevention is key to a safe exercise experience for
the person with diabetes. Some tips for avoiding hypoglycemia
include:
Regular physical activity is an essential tool in glycemic control and
overall health for everyone with diabetes. Exercise professionals who
are prepared to provide advice and assist with hypoglycemia treatment can help to ensure that persons with diabetes have a safe and
beneficial exercise experience.
About the Authors
Mary Lobb Oyos RN, MS, BC-ADM, CDE, is diabetes
program manager at avera McKennan Hospital and
University Health Center, Sioux Falls, SD.
Sherry Barkley, Ph.D., CES, RCEP, is an assistant
professor and chair of the HPER Department at
Augustana College, Sioux Falls, SD. She has many
years of experience with exercise prescription for
persons with heart disease, diabetes, and other
clinical conditions. Sherry is past-president of
NACSM and current member of the CCRB
Publications Subcommittee.
Suggested Resources
• MedlinePlus.gov Drugs and Supplements:
http://www.nlm.nih.gov/medlineplus/druginformation.html
• X-Plain Patient Education Videos Available from MedlinePlus.gov:
http://www.nlm.nih.gov/medlineplus/tutorials/diabetesintroduction/htm/_yes_0_no_0.htm
Diabetes Medications (continued on page 14)
ACSM’S CERTIFIED NEWS • JULY–SEPTEMBER 2012 • VOLUME 22: ISSUE 3
7
COACHING NEWS
By Margaret Moore (Coach Meg), M.B.A.
THIS COLUMN CONTINUES THE NEW FORMAT FOR OUR COACHING
NEWS COLUMN. WE ARE EXPLORING A VARIETY OF CLIENT SCENARIOS, ONE SCENARIO FOR EACH COLUMN. I DESCRIBE A FEW TIPS FROM
MY SCIENCE-BASED COACHING TOOLBOX TO HELP YOU HELP YOUR
CLIENTS ENGAGE FULLY IN A FIT LIFESTYLE THAT ALLOWS THEM TO
THRIVE, WHATEVER THRIVING MEANS IN THEIR LIVES.
Today we explore how to work with a client who is not engaged
in following evidence-based or scientif ic guidelines, including preventive tests, and is not seeking out reputable sources on the
Web and beyond. Instead, s/he hunts down information and recommendations from non-reputable sources, while not listening to
your well-informed advice.
It goes without saying that those reading this article honor and
respect the scientific method, are skeptical of recommendations that
lack a scientific foundation, and stay within the bounds of evidencebased guidelines that are worthy of publication in a peer-reviewed
journal or textbook. The construct of evidence-based medicine has
been around for about 20 years and is a relatively new, but essential
paradigm in exercise program design and implementation.1 We are
taught to refrain from making recommendations that are not firmly
rooted in well-designed research studies, the more the better.
However, our clients may not be like us. They may not trust or
respect science-based recommendations. Perhaps they think of themselves as right-brain types who didn’t enjoy science courses in their
education, and value intuition and creativity more than the scientific
method. Maybe they are frustrated with the limitations of the scientific method, which generates recommendations based upon averages and bell curves that don’t seem relevant to their personal circumstances. They may be more interested in what complementary
and alternative practitioners have to say because these practitioners
treat people who have been failed by conventional medicine.
Some are justifiably concerned about how medical guidelines
change dramatically over time.
Lively debates have emerged recently among scientists and in the
media about the pros/cons of mammograms, PSA tests for prostate
cancer, and the value of annual physicals. Not long ago high carb/low
fat diets were the universal recommendation for heart health; this is
no longer valid as the evidence for low carb/moderate healthful fat
diets is now compelling. The landmark June 2012 JAMA paper on
weight loss maintenance by Ludwig et al., has overturned the sciencebased wisdom that a “calorie is a calorie” when it comes to energy
expenditure.2 It turns out that high carb diets lead to an average of
300 fewer calories expended daily than low carb diets, a critical issue
for weight loss maintenance. No wonder our clients may have
become cynical about evidence-based guidelines.
So how do we bridge the gap between our science-based wisdom
and guidelines and our clients who don’t trust our science-based
guidelines and resist our recommendations?
8
1. APPRECIATE WITHOUT JUDGMENT
The only way a helping professional can
defuse resistance is to get fully onto your
clients’ side of the fence. Get down from
your expert pedestal and honor your clients’
biological drive for autonomy, to choose their
own path. Inquire openly and without even the tiniest whiff of judgment or expectation about how they make decisions on what to do
to protect and improve their personal health. What is their approach
to investigating options, whose advice do they trust most, how do
they weigh up their options and decide? What do they think about
evidence-based medical guidelines? Perhaps they will share painful stories about how they or close others have experienced difficulties with
recommendations of reputable health care providers. Validate and
show respect for their perspectives with authentic sincerity, however
uncomfortable that might be.
2. COACH DON’T PREACH
Once your clients trust that you appreciate and
respect their viewpoints, bringing down the walls
of resistance, you have created an opening to facilitate their finding a new and improved decisionmaking process. Move into a collaborative coaching conversation
where you encourage clients to generate new ideas on how best to
make health decisions, and get permission to offer your ideas and wisdom. While it’s tough for our expert minds to give up control of having the right answers, it is human nature for your clients to value what
they discover more than what has been imposed. Allowing your
clients to discover a better path for themselves will, in fact, dramatically increase your impact and your clients’ success. And the bonus is
that they will be more likely to be interested in your best advice.
About the Author
Margaret Moore (Coach Meg), M.B.A., is the
founder & CEO of Wellcoaches Corporation, a
strategic partner of the ACSM, widely recognized
as setting a gold standard for professional
coaches in healthcare and wellness. She is codirector of the Institute of Coaching, at McLean
Hospital, an affiliate of Harvard Medical School and co-directs the
annual Coaching in Leadership & Healthcare Conference offered by
Harvard Medical School. She co-authored the ACSM-endorsed
Lippincott, Williams & Wilkins Coaching Psychology Manual, the first
coaching textbook in healthcare and the Harvard Health Book published
by Harlequin: Organize Your Mind, Organize Your Life.
References
1. Donald A. Evidence-Based Medicine: Key Concepts. MedGenMed 4(2),
2002 [formerly published in Medscape Psychiatry & Mental Health
eJournal 7(2), 2002].
2. Ebbeling CB, Swain JF, Feldman HA, et al. Effects of Dietary
Composition on Energy Expenditure in Weight Loss Maintenance.
JAMA. 2012;307(24):2627-34.
ACSM’S CERTIFIED NEWS • JULY–SEPTEMBER 2012 • VOLUME 22: ISSUE 3
HEALTH & FITNESS COLUMN
RESISTANCE TRAINING AND DIABETES
By Wayne L. Westcott, Ph.D.
Age-related muscle loss is associated with a variety of physiological
problems including metabolic decline,21 fat gain,20 and diabetes.8
Studies show muscle mass reductions of 3% to 8% each decade after
age 30,8 and 5% to 10% each decade after age 50,15 averaging
approximately one pound of muscle tissue every year following the
fifth decade of life.16 According to an excellent research review by
Flack et al.,8 decreased muscle mass directly influences the risk of
developing glucose intolerance and diabetes because muscle tissue is
the primary site of glucose deposit and utilization.
Muscle Gain
Numerous studies have shown that gains in lean weight resulting
from resistance training are associated with greater glucose tolerance
in adults with type 2 diabetes,6 older adults with type 2 diabetes,4
men with type 2 diabetes,2 and women with type 2 diabetes.7
According to Phillips and Winett,17 resistance exercise is associated
with improved glucose and insulin homeostasis due to increases in
lean body mass and muscle cross-sectional area. Flack et al.8 also
found that increased lean body mass was associated with improved
insulin sensitivity and glucose tolerance.
Fat Loss
The primary result of resistance training is muscle gain, which
appears to have a positive impact on factors related to diabetes risk.
However, a secondary outcome of resistance exercise is fat loss,
which also may be advantageous with respect to diabetes risk.8
Although the duration of activity time in standard resistance exercise
sessions is relatively low compared to standard aerobic exercise sessions, the training intensity is relatively high. A standard circuit
strength training workout (typically 10 to 15 exercises arranged so
that participants perform one set of an exercise then move quickly to
an exercise for a different muscle group with minimal non-activity
time) uses approximately 6.7 to 8.5 calories per minute, or up to 170
calories for a 20-minute exercise session.10 However, post-training
muscle tissue remodeling processes appear to be responsible for
increasing resting energy expenditure by 5% to 9% for 72 hours following the strength workout.9,11 Using an average 7% increase in
resting energy expenditure and a resting energy expenditure of
1,600 calories/day, this would represent about 110 additional calories used on a daily basis for people who perform at least two resistance training sessions/week.
Consequently, the cumulative calorie-burning benefit of regular
resistance exercise could total about 4,800 calories/month (8 training
sessions x 170 calories/session + 31 days x 110 calories/day = 4,770
calories). The increased resting energy expenditure may be largely
responsible for the approximately 4-pound reduction in fat weight
reported following 10 to 12 weeks of regular strength training.3, 22
More specifically, resistance exercise has been shown to decrease
intra-abdominal fat in older men and women12 and in people with diabetes.13 This is important because research has revealed an association between abdominal fat and insulin resistance.5, 14 Based on their
2010 meta-analysis of related studies, Strasser et al.19 concluded that
“resistance training reduces total body fat mass and visceral adipose
tissue independently from dietary restriction.” Based on their 2011
review of related research, Flack et al.8 concluded that “resistance
training alone may reduce abdominal and visceral fat, which is known
to increase with advancing age and influence insulin resistance.”
Resistance Training Recommendations
The American College of Sports Medicine (ACSM) guidelines for
resistance exercise provide a sound basis for strength training that is
appropriate for most people who are capable of performing muscular activity.1 The general recommendations call for doing 8 to 10
exercises per session, performing 2 to 4 sets of exercise for each
muscle group, using a resistance that permits 8 to 12 repetitions,
emphasizing complete movement range and controlled movement
speed, and training 2 or 3 non-consecutive days a week (1 page 172).
This could be accomplished by performing two to four sets of a single exercise for a given muscle group (e.g., three sets of bench presses for the pectoralis major muscles), or by performing one set of two
to four exercises for the same muscle group (e.g., one set each of
bench presses, incline presses, and dumbbell flies for the pectoralis
major muscles). The resistance training guidelines for older adults are
similar, but recommend beginning with a resistance that permits 10
to 15 repetitions at a lower effort level (1 page 172). With respect to
glycemic control, Strasser et al.19 report that improvements have
resulted from a range of training volumes (4 to 9 exercise sets per
muscle group per week) and training intensities (50% to 85% of maximum resistance).
The American Diabetes Association (ADA) supports resistance exercise for people with type 2 diabetes, and recommends a training protocol consistent with the ACSM guidelines. The ADA encourages resistance training for all the major muscle groups, progressing to three sets
of 8 to 10 repetitions, performed at high intensity, three times a week.18
Upon examining the strength training research and recommendations,
Flack et al.8 have proposed a progressive program of resistance exercise
for older diabetic and pre-diabetic individuals. They suggest beginning
with low intensity and low volume workouts (one set of 10 to 12 repetitions performed two days a week), with gradual increases in the training variables (intensity, volume, and frequency). All of these suggested
resistance training protocols appear to be appropriate for people with
diabetes, and, therefore, may be recommended for the prevention and
management of type 2 diabetes.19
Resistance Training (continued on page 14)
ACSM’S CERTIFIED NEWS • JULY–SEPTEMBER 2012 • VOLUME 22: ISSUE 3
9
CLINICAL COLUMN
PART 3:
HEART SOUNDS
By Paul Visich, Ph.D., MPH
The first two heart sound articles, in this series of three,
reviewed the anatomical positions to listen to the different valves
of the heart, correct use of the stethoscope and the rationale for
common heart sounds. To recap briefly, systole (S1) “lub” and diastole (S2) “dub” are the typical healthy heart sounds. Less common
sounds that should be considered include (S3), caused by rapid ventricular filling and (S4), the onset of atrial contraction. The third
heart sound may be an innocent normal variant in younger populations and in pregnancy; however, as with a fourth heart sound it
may be associated with cardiac pathologies and would need further
evaluation.
This third article in the heart sound series will describe the sounds
associated with the more common valvular diseases that produce
murmurs. Murmurs are longer duration sounds that are attributed to
turbulent blood flow. The two common valvular abnormalities are
stenosis and regurgitation. Stenosis is reflective of a partially obstructive valve that causes blood to be ejected through a smaller orifice
than normal. Regurgitation is reflective of a valve that allows blood
to flow in a “retrograde” or opposite direction. Identifying the murmurs associated with the possible presence of stenosis or regurgitation is based on determining where to best listen on the chest wall
(previously described) and the ability to determine when they occur
in the cardiac cycle.
Aortic Stenosis
Blood is being ejected through a smaller than normal opening in
the aortic valve, which creates a higher than normal pressure in the
left ventricle (LV). This creates a “nozzle” effect during systole. The
sound is greatest immediately following S1 and decreases to S2
(decrescendo murmur). The turbulent blood flow against the aortic
walls is responsible for causing the vibration and loud murmur
(Figure).
Figure: Phonocardiograms from normal and
abnormal heart sounds
Adapted from: ttp://en.wikipedia.org/wiki/File:Phonocardiograms_from_normal_and_abnormal_heart_sounds.png
which usually doesn’t exceed 35mmHg. Because there is very little
blood in the LV at the onset of LA contraction, a vibration sound may
not occur until the LV is partially full. The increased amount of blood
in the LV will stretch the LV, which allows a vibration sound to be produced when blood is ejected into the LV. Therefore, mitral stenosis
may not be heard until 2/3 of the way through diastole. Because
mitral stenosis produces lower pitch sounds, using the bell side of the
stethoscope may be helpful to hear this abnormality.
Mitral Regurgitation
The murmur is heard during diastole (between S2 and S1). The murmur is caused by turbulent blood flow traveling retrograde from the
aorta through the aortic valve into the blood in the left ventricle. This
murmur has been described as a “blowing” high pitch sound, but typically not as loud as aortic stenosis due to a lesser pressure difference.
Blood flow will travel retrograde through the mitral valve during
systole, and will be heard as a “blowing” swishing sound in the LA.
However, the LA is very deep in the chest wall and difficult to hear,
and, therefore, it is best to identify this sound through the LV, at the
apex of the heart. The murmur sound is produced by turbulent blood
being pushed back through the mitral valve into the blood in the LA
or against the atrial wall. This sound is very similar to aortic regurgitation; however it occurs during systole versus diastole, making it very
important to recognize where the sound is heard in the cardiac cycle.
Mitral Stenosis
Personal Note
There is an increased challenge in blood flow from the left atrium
(LA) to LV due to stenosis of the mitral valve. Typically, this is a lower
pitch sound in diastole because of a decreased pressure in the LA,
Becoming proficient at recognizing different heart sounds in your
Clinical Exercise Physiology (CEP) academic training can be challenging. Hopefully, the concepts of detecting heart sounds are being introHeart Sounds (continued on page 15)
Aortic Regurgitation
10
ACSM’S CERTIFIED NEWS • JULY–SEPTEMBER 2012 • VOLUME 22: ISSUE 3
CLINICAL FEATURE
EXERCISE AND
BARIATRIC SURGERY
By Kelly Drew, M.S., ACSM RCEP
BACKGROUND
Bariatric surgery is becoming more and more prevalent as the number of obese and morbidly obese adults increases. Currently, 35.5% of
adult men and 35.8% of adult women are considered obese (have a
body mass index (BMI) greater than or equal to 30.0 kg/m2).5 When
surgical treatment of obesity is contemplated, obesity and clinically
severe obesity need to be differentiated. Clinically severe obesity (or
morbid obesity) is defined by the American Society for Metabolic and
Bariatric Surgery (ASMBS) as a disease of excess energy stores in the
form of fat, correlating with a BMI of 40 kg/m2 or greater or with being
100 pounds over ideal weight.3 The physical, emotional, and financial
burden of obesity is now being recognized.3 Well-documented consequences of obesity include cardiac and pulmonary problems, metabolic
disease, endocrine disorders, digestive problems, orthopedic issues, and
an increased rate of developing some cancers. However, the most alarming consequence is the direct increase in mortality due to an increase in
weight. In a 12-year follow-up study of approximately 750,000 men and
women, mortality rates for those who were 50% over their average
weight were twice as high as those who were an average weight.7
Surgical treatment for obesity has become medically necessary for
the morbidly obese as being the only proven method of long-term
weight control.3 Surgical treatment is not a form of cosmetic surgery but
a tool to help reduce a person’s weight and improve or eliminate the
associated co-morbidities. There are several different types of bariatric
surgery, all decreasing the size of the stomach pouch, with or without
some sort of malabsorption. The changed anatomy from surgery makes
life-long vitamin treatment necessary for bariatric patients. The most
popular procedure is the gastric bypass, with laparoscopic adjustable gastric banding as the second most popular procedure.4 More detailed
information about the specific surgeries can be found through ASMBS
(www.asmbs.org).
Candidates for bariatric surgery include patients who have a BMI
over 40 kg/ms2 and have a decreased quality of life due to obesity.
Less obese patients who have BMI between 35 and 40 kg/m2 may
be considered for surgery if they have high risk co-morbid conditions
related to their obesity. All patients must clearly understand the procedure and life-changes that are necessary and must undergo psychological evaluation of readiness for surgery. They must prove they have
tried and failed at other weight loss attempts. They also usually go
through some form of supervised weight loss with the bariatric team,
which includes the surgeon, registered dietician, exercise physiologist,
and behavioral coach, for a period of between 2 and 6 months prior
to being cleared for surgery.3
As exercise professionals, we have to understand the bariatric patient
and how exercise intervention can not only help with weight loss and
weight maintenance, but also help improve the quality of life for these
patients. We also must be compassionate and understanding, not judg-
mental, towards these individuals. A 2009 study of exercise science students showed that the students endorsed attitudes that “fat people” are
lazy, physically unattractive, buy too much junk food, and could lose
weight if they really wanted to.9 This perception must change if an exercise professional is to be successful at working with bariatric patients. As
more bariatric centers are employing exercise physiologists as part of
the multidisciplinary teams, and more clients that have undergone
bariatric surgery present at fitness centers, we need to understand how
to best manage these patients and help them on the path to improved
fitness.
THE PRE-OPERATIVE BARIATRIC PATIENT
Working with a bariatric patient pre-operatively can be a challenging
task. These patients usually have tried and failed at many weight loss
attempts, including diet and exercise, and, therefore, may have a very
negative view of the efficacy of an exercise program. They also present
with a myriad of co-morbidities that need to be addressed by the exercise physiologist. These include, but are not limited to, orthopedic problems, metabolic diseases, pulmonary disease such as asthma or COPD,
cardiac conditions and risk factors, and sleep apnea. Common barriers
to exercise for the pre-operative patient include lack of motivation, pain
with exercise, feeling uncomfortable while exercising, and severe deconditioning. The goal for the exercise intervention is to establish a consistent habit (3-5 times per week) of performing some sort of very low
intensity physical activity (35%-40% of heart rate reserve or VO2
reserve). Patients should be encouraged to engage in at least 10 minutes
of continuous aerobic exercise in the pre-operative phase, with a goal of
achieving 30 minutes of aerobic exercise per session. Weight bearing
exercise such as treadmill walking is preferred if tolerated, but due to the
physical limitations of morbidly obese patients, nonweight bearing exercise may be the best option.
POST-OPERATIVE EXERCISE PRESCRIPTION
The exercise prescription for the post-operative bariatric patient is
consistent with the recommendations for obesity by the American
College of Sports Medicine’s (ACSM) Guidelines for Exercise Testing
and Prescription, eighth edition. Increasing caloric expenditure and fat
loss, as well as managing co-morbid conditions, is the main goal of exercise for these patients.
Cardiorespiratory
The primary mode for cardiorespiratory exercise for these patients
should be aerobic activity that involves large muscle groups, with walking being the most common mode utilized. Usually weight bearing exercise is tolerated to some degree by most patients after a modest weight
loss, but nonweight bearing options should be considered. The goal
Bariatric Surgery (continued on page 12)
ACSM’S CERTIFIED NEWS • JULY–SEPTEMBER 2012 • VOLUME 22: ISSUE 3
11
Bariatric Surgery (continued from page 11)
should be a frequency of 5-6 days per week of moderately intense
(40%-60% heart rate reserve or VO2 reserve) cardiorespiratory activity, with fat loss being a primary goal. Duration is emphasized over intensity, with a minimum goal of 150 minutes per week and a long term
objective of achieving 300 minutes per week.2 A typical progression is
presented in Table 1.
used has a sufficient weight limit to accommodate larger patients, and
that exercise machines have larger seats. If bariatric chairs are not available, make sure you offer chairs with no arms. If you are doing exercise
on the floor, make sure to use a thicker and wider mat to make sure the
patient is more comfortable.
NUTRITIONAL CONSIDERATIONS
Table 1: Cardiorespiratory Exercise Progression
Time Post
Surgery
Frequency
Duration
0-2 weeks
Several times per day as tolerated
2-4 weeks
5-6 days per week
20-30 minutes in 10 minute increments
4-6 weeks
5-6 days per week
30-40 minutes
6+ weeks
5-6 days per week
40-60 minutes
Resistance
It has been observed that during a significant weight loss, fat-free
mass is lost,5 which can be detrimental for long term success of weight
maintenance by bariatric patients. Exercise, especially resistance training,
can help preserve fat-free mass after bariatric surgery. Bariatric patients
also show a higher incidence of bone mineral deficiency post-surgery
due to the malabsorptive nature of certain bariatric procedures, specifically Roux-en-Y gastric bypass,8 and resistance training is recommended
to reduce the risk of developing osteoporosis.
Resistance training should not be started until clearance from the surgeon is obtained, which can be anywhere from 6 weeks to 6 months
post bariatric surgery. After clearance, higher repetition exercise is usually better tolerated. A typical progression is provided in Table 2.
Table 2: Resistance Exercise Progression
Resistance
Training
Repetitions
Frequency
Muscle Groups
0-4 weeks
1 set of 20
2-3 days per week
8-10
4-8 weeks
2 sets of 15
2-3 days per week
8-10
8+ weeks
3 sets of 12-15
2-3 days per week
8-10
A brief overview of the diet a bariatric patient follows will be discussed, with understanding that as exercise professionals we should not
offer dietary advice to bariatric patients due to the specific nature of the
post-operative diet. We do, however, need to be aware of what the
patient is experiencing so we can tailor an exercise program to fit within their nutritional status.
The diet progression post-surgery is as follows: clear liquids, full liquids,
soft/puree diet, then very small portions of protein-focused meals.1 The
length of time and contents of this diet can be found within the ASMBS
guidelines. This restrictive caloric intake should be considered by the
exercise professional in terms of energy levels and exercise timing. The
patient should exercise after a meal or snack. Due to the limited calories
consumed, reasonable expectations as far as muscle gains should be
acknowledged. Another exercise consideration should be the hydration
status of the individual. Because the stomach pouch is much smaller after
surgery, staying hydrated can be difficult for the patient.1 This is of concern if they are participating in an exercise program. Having the patient
take small sips of water during an exercise session can help prevent dehydration. We need to encourage the patient to stay hydrated, and discontinue exercise if severe dehydration is present.
SUMMARY
Working with bariatric patients is both a rewarding and challenging
undertaking. It is our responsibility as exercise professionals to understand the bariatric patient, both physically and emotionally, so we can
help them achieve a healthy lifestyle. Remember the surgery is only a
tool; the lifestyle changes made are the best predictors of success!
About the Author
Flexibility
Flexibility training increases or maintains joint range of motion, which
can alleviate aches and pains associated with obesity.2 Stretching exercises should be incorporated after a brief warm-up or after an exercise session when muscles are warm. The recommendation by ACSM’s
Guidelines for Exercise Testing and Prescription, eighth edition, is
2-4 days per week and holding each stretch for at least 15 seconds.2
Special Considerations
Exercise professionals should pay special attention to exercises that
require balance (e.g., unsupported lunges, squats) in the first year after
surgery due to a changing center of mass associated with rapid weight
loss. Many patients are not able to get on the floor to do resistance
exercises due to body habitus or musculoskeletal issues associated with
obesity, so care and tact must be taken by the exercise professional to
ensure the patient is doing a safe routine that they are comfortable completing. Other considerations should include ensuring the equipment
12
Kelly Drew, M.S., ACSM RCEP, is a clinical exercise
physiologist with Community Bariatric Surgeons at
Community Health Network in Indianapolis, IN.
Kelly is currently a member of ACSM RCEP Practice
Board.
References
1. Allis L, Blankenship J, Buffington C, Furtado M, Parrott J. ASMBS
Allied Health Nutritional Guidelines for the Surgical Weight Loss
Patient. Surgery for Obesity and Related Diseases 4. 2008:S73-S108.
2. American College of Sports Medicine. ACSM’s Guidelines for
Exercise Testing and Prescription, 8th ed. Thompson WR, Gordon
NF, Pescatello LS, editors. Baltimore (MD): Lippincott Williams &
Wilkins; 2009.
3. American Society for Metabolic and Bariatric Surgery. Rationale for
the Surgical Treatment of Morbid Obesity [Internet]. Updated Nov
23, 2005. [cited 2012 Jun 18]. Available from:
http://asmbs.org/rationale-for-surgical-treatment/.
Bariatric Surgery (continued on page 15)
ACSM’S CERTIFIED NEWS • JULY–SEPTEMBER 2012 • VOLUME 22: ISSUE 3
Exercise Immunology (continued from page 5)
Exercise for Immune Health
While some general aspects of the immune response to exercise
are known, more discoveries need to be made regarding specific
events following exercise. Mechanisms for leukocytosis (elevated concentrations of neutrophils and monocytes, NK cells, dendritic cells, Tcells, and B-cells), which occurs directly following a single exercise session and reasoning for decreased concentrations of leukocytes following leukocytosis 24 h after exercise needs elucidation. This depression
could be a result of leukocytes leaving circulation to differentiate in
surrounding tissue, and not actual apoptosis (cell death). Regardless
of the mechanism, following acute exercise the body appears vulnerable to infection because of depression in leukocyte cell number and
function. However, if the immune system is allowed complete recovery following each exercise session, there are no long term detrimental effects of exercise training upon the system. Moreover, with moderate intensity (moderate is relative to the individual and the range
for this value can vary with characteristics of the individual) exercise
training beneficial anti-inflammatory effects and improvements in
immunosurveillance are achieved.16
Regular exercise and physical activity will, in most cases, positively
influence immune function.16,31 While exercise training does influence
the immune system, other lifestyle behaviors, such as proper sleep
and nutrition, also are influential and must be considered. In addition,
overtraining can devastate the immune system. When starting an
exercise program, moderate intensity and low exercise volume
should be the foundation for the exercise prescription.31
Furthermore, using the same training mode for long durations often
can cause decreased levels of circulating immune cells leading to
decreased immune surveillance, so varying exercise modes is recommended.24 Between-athlete variability makes it difficult to predict how
hard any individual athlete can train before immune function is compromised. However, the more physically fit an individual is the more
likely they will be able to endure high exercise volume and high intensity (near maximal effort) workouts. Regardless of fitness level, there
should be a heightened awareness during times of increased risk (e.g.,
high intensity training, competition, and recovery periods immediately following competition) with an emphasis on good hygiene, rest, and
recovery. If trainers and coaches actively monitor these criteria, the
likelihood of having a healthy immune system is enhanced.
About the Author
Benjamin T. Gordon, M.S., CES, CSCS, is currently
pursuing a Ph.D. in applied physiology from the
University of South Carolina.
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Exercise Immunology (continued on page 14)
ACSM’S CERTIFIED NEWS • JULY–SEPTEMBER 2012 • VOLUME 22: ISSUE 3
13
Resistance Training (continued from page 9)
About the Author
Wayne L. Westcott, Ph.D., teaches exercise science
and conducts fitness research at Quincy College in
Quincy, MA.
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Exercise Immunology (continued from page 13)
Diabetes Medications (continued from page 7)
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14
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ACSM’S CERTIFIED NEWS • JULY–SEPTEMBER 2012 • VOLUME 22: ISSUE 3
bers of the health care team the valuable contribution that the CEP
can make toward patient recovery and helps to further develop a
respect of the role of the CEP in a variety of clinical settings.
duced into your didactic training. Integrating your didactic experience with your clinical rotations is critical in developing proficiency at
recognizing heart sounds. An important tip in learning heart sounds
is to listen to the heart sounds of someone with a known heart valve
abnormality or other heart condition. While doing so, try to identify
and describe the sounds that you are hearing, the location of where
they are best heard and when they occur in the cardiac cycle.
Hospital (Phase 1) settings as well as diagnostic exercise settings
allow the learner opportunities to listen to normal heart sounds,
heart sounds associated with cardiac disease and heart sounds that
may change in relationship to exercise. Making these correlations is
the key in developing a clear understanding of the disease process
and its impact on the individual.
Becoming knowledgeable about and proficient in the assessment
of heart sounds enables the clinician to identify significant findings,
communicate findings to the health care team, and create appropriate exercise treatment plans that best contribute to the improvement of the health of the patient. This process demonstrates to mem-
Paul Visich, Ph.D., MPH, is the current chair and
professor of the Exercise and Sports Performance
Department at the University of New England in
Biddeford, Maine. Paul served as a team editor of
the textbook, Clinical Exercise Physiology, published
by Human Kinetics. Paul served as a member of the
Practice Board for ACSM’s Registered Clinical
Exercise Physiologist (RCEP) credential, the
chairperson of the ACSM Professional Education Committee, and a
member of ACSM’s Committee on Certification and Registry Boards
(CCRB).
Golf (continued from page 3)
Bariatric Surgery (continued from page 12)
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stretching and golf swing performance. Int J Sports Med. 2009
Feb;30(2):113-8. Epub 2009 Jan 28.
AUTHOR’S NOTE: The author would like to thank Joyce O’Connor
M.S., RN, NP-C, for reviewing and providing comments to improve
the quality of this article.
About the Author
4. Buchwald H, Consensus Conference Statement; Bariatric surgery
for morbid obesity: Health implications for patients, health professionals, and third-party payers. Surgery for Obesity and Related
Diseases 1. 2008:71-381
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Obesity (London). 2007; 31(5):743-50.
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Trends in the Distribution of Body Mass Index Among US Adults,
1999-2010. JAMA. 2012;307(5):491-97.
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750,000 men and women. Journal of Chronic Disease.
1979;31:563-7.6
8. Ming S, Gornichec R, Therapeutic Treatment Options for
Osteoporosis in the Surgical Weight Loss Population. Bariatric
Times. 2011;8(4): 8-10
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Obesity. 2009;17:941-64.
ACSM’S CERTIFIED NEWS • JULY–SEPTEMBER 2012 • VOLUME 22: ISSUE 3
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