Chapter 17
Scott K. Powers • Edward T. Howley
Obesity Trends* Among U.S. Adults
BRFSS, 2007
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
Theory and Application to Fitness and Performance
SEVENTH EDITION
Chapter
Exercise for Special Populations
Presentation prepared by:
Brian B. Parr, Ph.D.
University of South Carolina Aiken
No Data
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Chapter 17
<10%
10%–14%
29%
15%–19%
≥30%
20%–24%
25%–
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Chapter 17
Scope and Prevalence
• 33 % of adult males and 35% of females are
borderline obese America
• Children Overweight =BMI at or above the 85th percentile ;
Obesity =BMI at or above the 95th percentile for children of
the same age and
th
d sex.
– 1976 -2006 = ages 6 to 11 – from 6.5 to 17.5 %
– 1976 -2006 = ages 12 to 17 – from 5.5 to 17 %
• $30 to 50 billion spent on weight loss gimmicks and
remedies
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Consequences of obesity
• Comorbid conditions
– Coronary Heart Disease
– Hyperlipidemia
– Cancers
– Type II Diabetes Mellitus
– Hypertension
– Orthopedic conditions
• Mortality
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1
Chapter 17
Chapter 17
Causes
• Low-economic status
• Endocrine regulators of food intake
– Leptin – secreted by fat cells and regulates body weight in
mice (inject leptin in deficient mice, reduce weight
• Genetic
– Regulation of food intake, fat storage, etc
– Body fat distribution
• Set –point theory – after weight loss individuals
require 15% fewer calories to maintain weight
• Energy expenditure –
– RMR – 70% of energy expeniditure
– 10% is metabolic cost of digestion,
– remainder is physical activity
Exercise Testing
• Screening should include
– Assessment
– Medical – causes, co-morbidities
– Psychological – patterns as well as eating
disorders
– Nutritional
• General population training may also be
appropriate, leg or arm ergometer may be better
• Watch for ability to adjust to the workload
• Proper blood pressure cuff size
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Chapter 17
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Chapter 17
Obesity: Exercise Training
• Acute exercise response
– Reduced functional capacity
– Increased cardiac work for a given submaximal load.
– Exercise intolerance due to orthopedic
p
limitations
and/or hyperthermia
• Exercise training
– Cardiovascular system
Decreased blood pressure response, improved blood lipid
profile
– Respiratory system
Obesity: Exercise Training
• Exercise Training (con’t) –
– Metabolism
Lowering of insulin concentrations (improved sensitivity)
gy
increased HDL
Lower VLDL and triglycerides,
– General Health
Best improvements in those who move out of severe obesity
status
Bray et al. – procedures that reduce intake were shown to
have greater potential for reducing weight and stored fat
than those that increased energy expenditure
In the grossly obese, may see some improvement in ERV
and blood gasses
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2
Chapter 17
Chapter 17
Obesity: Exercise Testing and
Prescription
• Mode (Peak Met level = 6 – 8 METs)
– Cycle ergometer
– Treadmill – use very low intensity warm – up with 12 MET increases
• Prescription
– F – 5 days/week +
– I – low to moderate intensity (50 to 70% of peak
capacity)
– Time – 40 to 60 minutes total
– Type – walking, cycle ergometer, water exercise
– Strength Training – maintain or gain lean body
weight
Obesity: Special Considerations
• Injury
– History
– Adequate, warm-up, and cool-down
– Gradual progression
– Low or non-weight bearing exercises
• Thermoregulation
– Exercise at cool times of the day with adequate
water and loose fitting clothing
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Chapter 17
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Diabetes
Chapter 17
Progaming issues
• Do it yourself programs –
• Non-clinical programs
• Clinical programs
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Diabetes
• Characterized by hyperglycemia
– Due to:
Defect in insulin secretion (Type 1 diabetes)
Defect in insulin action (Type 2 diabetes)
• A major health problem and leading cause of death
– More than 20.8 million have diabetes
– Only 14.6 million are diagnosed
• Warning signs:
– Frequent urination/unusual thirst
– Extreme hunger
– Rapid weight loss, weakness, and fatigue
– Irritability, nausea, and vomiting
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3
Diabetes
Chapter 17
Diabetes
Chapter 17
Characteristics of Type 1 and Type 2
Diabetes
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
Can occur in overweight children
– Associated with upper-body obesity
– 90–95% diabetic population
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Diabetes
Chapter 17
Exercise and the Diabetic
Diabetes
Chapter 17
Effect of Prolonged Exercise in Diabetics
• Control of blood glucose is important
– Blood glucose close to normal
• Adequate insulin is required
– To increase glucose uptake by muscle
• Ketosis
– Metabolic acidosis from accumulation of
ketone bodies
Due to excessive fat metabolism
– May result from a lack of insulin
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Figure 17.1
4
Diabetes
Chapter 17
Diabetes
Chapter 17
Effect of Plasma Insulin Levels in Type 1
Diabetics During Exercise
Exercise and Type 1 Diabetes
• Exercise is part of treatment
– Along with insulin and diet
• Exercise itself does not improve blood glucose
control
– Improved
p
CHD risk factors
• Hypoglycemia is major concern
– May result in insulin shock
• Must maintain regular exercise schedule
– Intensity, frequency, and duration
– Altering diet and insulin
– May require fine-tuning
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Diabetes
Chapter 17
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 light 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
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Figure 17.2
Diabetes
Chapter 17
In Summary
A sedentary type 1 diabetic has to juggle diet and insulin
to achieve control of the blood glucose concentration. An
exercise program may complicate matters, and therefore
is not viewed as a primary means of achieving “control.”
I spite
In
it off this,
thi th
the di
diabetic
b ti iis encouraged
d tto participate
ti i t
in a regular exercise program to experience its healthrelated benefits.
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5
Diabetes
Chapter 17
In Summary
Diabetes
Chapter 17
Exercise and Type 2 Diabetes
The diabetic may have to increase carbohydrate intake
and/or decrease the amount of insulin prior to activity to
maintain the glucose concentration close to normal
during the exercise. The extent of these alterations is
d
dependent
d t off a number
b off ffactors,
t
including
i l di th
the iintensity
t
it
and duration of the physical activity, the blood glucose
concentration prior to the exercise, and the physical
fitness of the individual.
• Exercise is a primary treatment
– Help treat obesity
– Help control blood glucose
Reduces insulin resistance
– Help treat cardiovascular disease risk factors
• Combination of diet and exercise may eliminate
need for drug treatment
• May need to adjust medication dosages
– Prevent hypoglycemia during exercise
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Diabetes
Chapter 17
Exercise and Type 2 Diabetes
• Exercise prescription
– Dynamic aerobic activity at 50–90% HRmax
– 20–60 min
– 4–7 times/week
Promote sustained increase in insulin sensitivity
Promote weight loss and maintenance
– Strength training is also recommended
– Goal to expend a minimum of 1,000 kcal/week
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Diabetes
Chapter 17
American Diabetes Association Goals for
Nutrition Therapy
• Achieve and maintain:
– Blood glucose in normal range
– Improved lipid and lipoprotein profile
– Blood pressure in the normal range
• Prevent and treat chronic diabetes complications
– By modifying nutrient intake and lifestyle
• Address individual nutritional needs
– Personal and cultural preferences
• Limit food choices when indicated by scientific
evidence
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6
Diabetes
Chapter 17
Research Focus 17.1
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
Hypertension
• Classification
– Normal
Systolic BP <120 and diastolic BP <80 mmHg
– Prehypertension
75 g g
glucose
Systolic BP 120–139 or diastolic BP 80–89 mmHg
– 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
– Hypertension (stage 1)
Systolic BP 140–159 or diastolic BP 90–99 mmHg
• Prevalence
– 50 million US adults
– Majority have stage 1 hypertension
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Hypertension
Chapter 17
Hypertension Treatment
• Nonpharmalogical approaches for mild or
borderline hypertension
– Diet and exercise
• Diet
– Reduction in sodium
Reduction in BP: 5 mmHg systolic, 3 mmHg diastolic
– Reduction in caloric intake
1 kg weight loss = –1.6 mmHg systolic, –1.3 mmHg
diastolic
• Exercise
– 10 mmHg reduction in resting BP
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Hypertension
Chapter 17
Hypertension
Chapter 17
Exercise for Hypertension
• Recommendations:
– Moderate intensity exercise
40–60% HR reserve
– 30 minutes on most,, preferably
p
y all,, days
y
– Goal of expending 700–2000 kcal/week
– ACSM recommendation for improving VO2 max can
also be followed
• Precautions
– Blood pressure should be monitored for those on
medications
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7
Hypertension
Chapter 17
Cardiac Rehabilitation
Chapter 17
Cardiac Rehabilitation: Patient
Population
Hypertension Treatment
• Additional 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
• 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 using
saphenous vein or internal mammary artery
– Angioplasty (PTCA)
Balloon-tipped catheter used to open occluded arteries
May insert a stent to keep artery open
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Cardiac Rehabilitation
Chapter 17
Common Medications
β-blockers
– Reduce HR and/or BP
– Reduce work of the heart
• Anti-arrhythmia medications
– Control
C t ld
dangerous h
heartt rhythms
h th
• Nitroglycerin
– Relax smooth muscle in veins to reduce venous
return
– Reduce angina symptoms
•
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Cardiac Rehabilitation
Chapter 17
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)
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8
Cardiac Rehabilitation
Chapter 17
Exercise Programs
Cardiac Rehabilitation
Chapter 17
Effects of Cardiac Rehabilitation
• Phase I
– Inpatient exercise program
• Phase II
– Outpatient exercise, close supervision
• Phase III
– Less supervision, may be home-based
• Exercise prescription
– Based on GXT results
MET level, heart rate, signs/symptoms
• Improved cardiovascular function
– Higher VO2 max
– Higher work rate without ischemia
– Greater capacity for prolonged exercise
• Improved risk factor profile
– Lower total and higher HDL cholesterol
• Secondary prevention programs
– Reduce risk of subsequent cardiac event
– Whole-body, dynamic exercise
– Intensity, duration, and frequency based on severity
of disease
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Exercise During Pregnancy
Chapter 17
Exercise During Pregnancy
• Major adaptations to pregnancy
– Blood volume increases 40–50%
– Oxygen uptake and heart rate are higher at rest and
g exercise
during
– Cardiac output is higher at rest and during exercise
in first two trimesters
Lower in third trimester
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Exercise During Pregnancy
Chapter 17
Exercise During Pregnancy
• Regular endurance exercise poses little risk to the
fetus and is beneficial for the mother
– Reduced risk of gestational diabetes and
preeclampsia
• Pregnant women should consult their physician
prior to beginning any exercise program
– Absolute and relative contraindications
• Effect of exercise training
– VO2 max is increased or maintained
– Combination of training and pregnancy results in
greater adaptations than training alone
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9
Exercise During Pregnancy
Chapter 17
Exercise Recommendations
• Follow ACSM/CDC recommendation
– 30 min/day of moderate-intensity activity on most,
preferably all, days
• Intensity determined by:
– Heart
H
rate
May not be the best method
– Rating of perceived exertion
– “Talk test”
• No supine exercise after first trimester
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