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Chapter 17 Exercise for Special Populations EXERCISE PHYSIOLOGY Theory and Application to Fitness and Performance, 6th edition Scott K.Presentation Powersrevised & Edward T. Howley and updated by Brian B. Parr, Ph.D. University of South Carolina Aiken Diabetes • Characterized by an absolute (type 1) or relative (type 2) insulin deficiency that results in hyperglycemia • A major health problem and leading cause of death in the United States – More than 18.2 million have diabetes – Only 11.1 million are diagnosed • Warning signs: – Frequent urination/unusual thirst – Extreme hunger – Rapid weight loss, weakness, and fatigue – Irritability, nausea, and vomiting Diabetes • Type 1 – Lack of insulin • Dependent on exogenous insulin – Develops early in life – Associated with viral infections – 5–10% diabetic population • Type 2 – Resistance to insulin – Develops later in life – Associated with upper-body obesity – 90–95% diabetic population Characteristics of Type 1 and Type 2 Diabetes Table 17.1 Exercise and the Diabetic • Control of blood glucose is important • Adequate insulin is required • Ketosis – Metabolic acidosis from accumulation of ketone bodies – May result from a lack of insulin Effect of Prolonged Exercise in Diabetics Figure 17.1 Exercise and Type 1 Diabetes • Metabolic control before physical activity – Avoid exercise if fasting glucose is >300 mg/dl (or >250 mg/dl with ketosis) – Ingest carbohydrates if glucose is <100 mg/dl • Blood glucose monitoring before and after exercise – Identify when changes in insulin or food intake is needed – Learn how blood glucose responds to different types of exercise • Food intake – Consume carbohydrates to prevent hypoglycemia – Carbohydrates should be readily available during and after exercise Effect of Plasma Insulin Levels in Type 1 Diabetics During Exercise Figure 17.2 Exercise Prescription for Type 1 Diabetes • Exercise 20–60 min, 3–4 days per week, 50–85% heart rate reserve • May use non-weight bearing, low-impact activities – If weight-bearing activities are contraindicated • Use lighter weights (40–60% 1RM), 15–20 reps – Avoid the Valsalva maneuver – Heavier weights for athletes • Drink extra fluids and have carbohydrates available • Exercise with someone in case of emergency Exercise and Type 2 Diabetes • Exercise is a primary treatment – Help treat obesity – Help control blood glucose • Combination of diet and exercise may eliminate need for drug treatment • Exercise prescription – Dynamic aerobic activity at 50–90% HRmax – 20–60 min, 4–7 times/week – Strength training is also recommended – Goal to expend a minimum of 1,000 kcal/week • May need to reduce dosage of medications to maintain blood glucose American Diabetes Association Goals for Nutrition Therapy • Attain and maintain optimum metabolic outcomes to reduce risk of complications – Blood glucose in normal range – Improved lipid and lipoprotein profile – Lower blood pressure • Prevent and treat chronic diabetes complications • Improve health through healthy food choices and physical activity • Address individual nutritional needs Prevention or Delay of Type 2 Diabetes • Impaired fasting glucose (IFG) – Fasting BG 100–125 mg/dl • Impaired glucose tolerance (IGT) – Oral glucose tolerance test – 2-hour blood glucose 140–199 mg/dl • Prediabetes – Having IFG or IGT – Likely to develop type 2 diabetes – 150 min/week of physical activity and losing 5-10% of body weight reduces risk • Better approach than using drugs Asthma • A respiratory problem characterized by a shortness of breath accompanied by a wheezing sound • Due to: – Contraction of smooth muscle of airways – Swelling of mucosal cells – Hypersecretion of mucus • 20 million are affected by asthma – 1.9 million emergency room visits – 4,000 deaths – Direct and indirect costs of $16.1 billion Asthma: Diagnosis and Causes • Diagnosed using pulmonary-function testing – Low maximal expiratory flow rate • Triggers – Dust, chemicals, antibodies, exercise • Causes influx of Ca+2 into mast cells – Release of chemical mediators that cause: • Increased smooth muscle contraction leading to bronchoconstriction • Bronchoconstrictor reflex via vagus nerve • Inflammatory response Proposed Mechanism by Which an Asthma Attack Is Initiated Figure 17.3 Prevention and Relief of Asthma • Prevention – Avoidance of allergens – Immunotherapy • Medications – Cromolyn sodium – 2-agonists – Theophylline – Corticosteroids – Leukotriene inhibitors Exercise-Induced Asthma • More common in asthmatics • Does not necessarily impair performance if controlled • Caused by drying of respiratory tract – Increases osmolarity on surface of mast cell – Triggers Ca+2 influx and airway narrowing • Reducing the chance of an attack – Warm-up – Short-duration exercise • Treatment – -agonist in case of attack during exercise – Other medications to prevent attack Chronic Obstructive Pulmonary Disease (COPD) • Includes chronic bronchitis, emphysema, and bronchial asthma – Can create irreversible changes in the lung – Can severely limit normal activities • Testing for COPD – FEV1 – Graded exercise test • VO2max • Maximal exercise ventilation • Changes in arterial PO2 and PCO2 Treatment of COPD • Goals: – Reduced reliance on O2 and medications – Improved ability to complete daily activities • Treatments: – Medications (including supplemental O2) – Breathing exercises – Dietary therapy – Exercise – Counseling • Outcomes: – Increased exercise tolerance without Hypertension • Classifications: – Normal <120/<80 mmHg – Prehypertension 120–139/80–89 mmHg – Hypertension (stage I) 140–159/90–99 mmHg • Recommendations – Lose weight if overweight – Limit alcohol intake – Reduce sodium intake – Maintain adequate dietary K+, Ca+2, Mg+2 – Stop smoking – Reduce dietary fat, saturated fat, and cholesterol intake Exercise for Hypertension • Exercise can be used as a non-drug treatment • Recommendations: – Moderate intensity exercise (40–60% HR reserve) – 30 minutes on most, preferably all, days – Goal of expending 700–2000 kcal/week – ACSM recommendation for improving VO2max can also be followed • Precautions – Blood pressure should be monitored for those on medications Cardiac Rehabilitation: Patient Population • Those who have or have had: – Angina pectoris • Chest pain due to ischemia – Myocardial infarction (MI) • Heart damage due to coronary artery occlusion – Coronary artery bypass graft surgery (CABGS) • Bypass one or more blocked coronary arteries saphenous vein or internal mammary artery – Angioplasty (PTCA) • Balloon tipped catheter used to open occluded arteries • May insert a stent to keep artery open Cardiac Rehabilitation: Medications -blockers – Reduce work of the heart • Anti-arrhythmics – Control dangerous heart rhythms • Nitroglycerine – Reduce angina symptoms Cardiac Rehabilitation: Testing • Graded exercise testing – ECG monitoring (12-lead) • Heart rate and rhythm • Signs of ischemia (ST segment depression) – Blood pressure – Rating of perceived exertion (RPE) – Signs or symptoms • Chest pain – May include radionuclide imaging • Evaluate perfusion (201Thallium) • Evaluate ventricular ejection (99Technetium) Cardiac Rehabilitation: Exercise Programs • Exercise prescription – Based on GXT results • MET level, heart rate, signs/symptoms – Whole body, dynamic exercise – Intensity, duration, and frequency based on severity of disease • Effects – Increased functional capacity (VO2max) – Reduced signs/symptoms of ischemia – Improved risk factor profile Exercise For Older Adults • VO2max declines ~1% per year – Regular exercise may reduce rate of decline • Benefits of participation – Improved risk factor profile – Increased strength and VO2max – Increased bone mass • Recommendations – Similar to younger subjects – Medical exam and risk factor screening is essential Exercise and Bone Health • Osteoporosis results in reduced bone mineral density and increased fracture risk – More common in women over fifty due to lack of estrogen • Prevention and treatment – Dietary calcium • >1000 mg/day through food and supplements – Hormone replacement therapy (HRT) • Prevents bone loss and reduces fracture risk • May increase risk of cardiovascular disease and cancers – Exercise • Weight-bearing activities and resistance training • 2–3 hours per week Exercise During Pregnancy • Regular endurance exercise poses no risk to the fetus and is beneficial for the mother • Recommendations – Pregnant women should consult their physician prior to beginning any exercise program • Absolute and relative contraindications – Follow ACSM/CDC recommendation • 30 min/day of moderate-intensity activity on most, preferably all, days – Intensity determined by: • Heart rate, Rating of perceived exertion, or “talk test” – No supine exercise after first trimester