Exercise Is Medicine Physiologic Benefits of Exercise Ajay

Exercise Is Medicine: Physiologic Benefits of Exercise Ajay N. Kiri, M. D. AAPNA Teleconference December 21, 2009 1

Outline of Seminar § § § § Exercise Fundamentals Ayurveda on exercise Benefits of Exercise Physiology How Exercise Effects Aging Counseling Patients On Exercise Recommended Exercise Regimens Exercise Related Resources 2

Purpose Of The Seminar § To teach the main types of exercise & their benefits § To understand the physiologic effects of exercise § To learn the most effective ways to recommend exercise to your patients § To learn what types of exercise protocols to recommend to your patients 3

Why Exercise Is So Important § A functional, fit body is the foundation of health § Exercising is the only way to get in shape (become fit) § “Without Health There Is No Happiness…” Thomas Jefferson 4

Exercise Basics What Is Exercise? § Physical activity – Any body movement by the skeletal muscles that results in a substantive increase in resting energy expenditure § yard work, shoveling snow, sports, weight lifting § Leisure time physical activity – Sports like basketball or soccer § Scheduled exercise – Goal oriented activity: jogging or weight lifting § Improved fitness or physical performance § Weight management or better health 5

Main Types of Purposeful Exercise § Aerobic (with oxygen) – Continuous exercise w/elevated heart rate § Anaerobic (without oxygen) – Weight lifting, power exercises – Oxygen demand is greater than oxygen supply § § Core strengthening/stability training Flexibility training Balance training Sport specific training, ie agility, performance 6

What Is Fitness § Ability to do physical work over time, using the musculoskeletal & cardiovascular systems § Greater degree of fitness leads to reduced risks of overall disease & greater sense of well being & functionality 7

Age-adjusted mortality rates in healthy men categorized by level of fitness (Exercise capacity in METs) § Myers, J. Circulation 2003; 107: e 2 -e 5 8

How Exercise Impacts Health § § § § Improves state of health & fitness Helps manage body weight Improves strength, stamina & energy Improves libido and sexual performance Improves alertness & concentration Improves mood & promotes a positive attitude Promotes restful sleep Delays aging related physiologic changes 9

Patient Asks Why Exercise? § § Makes you feel better Makes you look better Makes you feel better about yourself Reduces risks of major diseases – Heart disease, diabetes, stroke, cancers § Leads to improvement in a great variety of diseases & negative health conditions 10

Ayurveda and Exercise § Ayurveda mainly works through nutrition and medications § Ayurveda recognizes the benefits of exercise at the physical, mental & spirit § Ayurveda’s exercise recommendations are similar to western medicine’s – From thousands of years of wisdom & experience 11

Ayurveda’s Views On Exercise Its Physical Benefits § § § § § Enhanced circulation Enhanced energy, strength and vitality Enhanced flexibility and coordination Good posture Increased ability to breathe deeper, infusing more prana into the system A feeling of lightness in the body Toned muscles and body Increased efficiency of the digestive system and a balanced appetite and metabolism Increased efficiency in eliminating toxins from the body 12

Ayurveda’s Views On Exercise Benefits for Mind, Heart and Spirit § § § § Enhanced mental alertness and agility Enhanced mental strength Enhanced focus and ability to concentrate Sense of emotional equilibrium Enhanced self-esteem and respect for one's body Self-awareness Enhanced ability to manage stress Freedom of spirit 13

Ayurveda’s Views On Exercise Principles to Follow § Do not exercise to the point of discomfort – Leads to excessive soreness, fatigue, injury & premature aging – Results in enjoyment of exercise & greater long term commitment to exercise program – Always breath through the nose § Concept of balaardh: use half your strength or capacity when exercising § If you maintain the exercise program, your exercise capacity will increase 14

Ayurveda’s Views On Exercise Principles to Follow § Exercise early in the morning to promote elevated energy levels all day § Do not exercise on a completely empty stomach or just after a full meal § To enhance circulation and the elimination of toxins, ayurvedic healers recommend that exercise be preceded by abhyanga, the ayurvedic warm oil self-massage 15

Dosha Specific Exercises Vata-Predominant Types § Ideal exercises incorporate slow movements for balancing vata § Slow dancing § Low impact aerobics § Tai chi § Leisurely swimming in warm water § Badminton § Walking and yoga 16

Dosha Specific Exercises Pitta-Predominant Types § Look for individual activities that require strength, focus and speed § Water, ice or snow based activities – Swimming, downhill skiing, rowing, surfing and water-skiing – Walking or jogging in a cool shady area – tennis and yoga 17

Dosha Specific Exercises Kapha-Predominant Types § Excel at activities requiring endurance and doggedness § They like team sports § Might not always be motivated to exercise, preferring a more sedentary lifestyle § Good balancing activities include distance walking or running, basketball, racquetball, football, aerobics, ice skating, cross country skiing and cycling 18

Exercise Physiology and Its Specific Benefits § Discuss benefits by body system and physiology – Cardiovascular – Respiratory – Endocrine – Musculoskeletal & overall body composition – Mental health – Aging related physiology 19

§ § § Cardiovascular Benefits of A Sustained Exercise Program Strengthens the heart muscle Improves blood flow (circulation) Reduces risk of heart attack – If occurs, occurs later in life, less severe event § § Lowers blood pressure Promotes weight loss Raised HDL (good) cholesterol Lowers LDL (bad) cholesterol 20

Exercise Physiology Cardiovascular Effects & Benefits § Benefit derived primarily from aerobic exercise § Changes occur to accommodate increased blood flow to skeletal muscles for increased oxygen requirements 21

Exercise Physiology Cardiovascular Effects & Benefits § What happens when you exercise – Heart rate increases linearly with work rate – Stroke volume increases – Cardiac output increases – Blood flow to muscles improves – Blood pressure increases with exercise – Tissue oxygen extraction improves – Pulmonary ventilation increases 22

How Cardiac Output Increases § § § Cardiac output (CO)= HR x SV Increase in heart rate leads to higher CO Stroke volume increases from resting HR up to 50% of aerobic capacity – Enhanced venous return – Increasing force of contraction § Increased ventricular contractility (Frank-Starling mechanism) § Catecholamine mediated sympathetic stimulation – Increase in ejection fraction § EF = [SV/EDV] x 100 – SV may decrease at higher heart rates b/c of less diastolic filling time 23

Stroke Volume Increases Up to 50% Aerobic Capacity 24

Cardiovascular Effects of Exercise Conditioning § Exercise conditioning leads to increased aerobic capacity (fitness) § Ability to circulate blood and provide oxygen improves § The heart muscles enlarges and becomes stronger § Results in higher stroke volume – Lower resting pulse § Greater response (increase in cardiac output) to exercise 25

Cardiovascular Effects of Exercise Conditioning: Sedentary Man Vs World Class Athlete § Resting/maximal (exercise) heart rate – Sedentary man: 70/190 bpm – World class athlete: 45/190 bpm § Resting/maximal stroke volume – Sedentary man: 85/93 m. L/beat – World class athlete: 136/184 m. L/beat 26

Cardiovascular Effects of Exercise Conditioning: Sedentary Man Vs World Class Athlete § Resting/maximal cardiac output – Sedentary man: 6. 1/17. 7 L/min – World class athlete: 6. 1/35. 0 L/min § Arteriovenous O 2 difference: rest/maximal – Sedentary man: 4. 0/14. 0 m. L/d. L blood – World class athlete: 4. 0/16. 0 m. L/d. L blood 27

How Exercise Lowers Blood Pressure § § Aerobic exercise does this Takes 3 months to have an effect Last as long as exercise is continued Results from – Stronger heart muscle – Improved vasomotor responsiveness – Blood vessels are able to “relax” when not exercising – Less effort for blood circulation 28

The Respiratory System § Pulmonary ventilation is typically not the limiting factor in maximal aerobic capacity § Minute ventilation increases 15 to 25 fold with increasing exercise/work – Via increase in tidal volume – Respiratory rate § Generally pulmonary respiration is directly proportional to O 2 consumption and C 02 production – Also increases with lactate production 29

Exercise & the Endocrine System § Exercise makes the metabolism more efficient, increase in enzymes for energy production § Increases insulin sensitivity – Improves type 2 diabetes § Combined with aggressive dietary changes can “cure” type 2 diabetes § Promotes weight loss 30

Aerobic Exercise & Energy Metabolism § Glucose is the preferred energy source – ATP (energy) generated via glycolysis & Kreb cycle § Comes from glycogen breakdown in liver and skeletal muscle; glycogenolysis § Fat stores are also mobilized for energy – Ratio of glucose: fat metabolism is initially 1: 1, can change to 1: 4 with prolonged submaximal V 02 <60% intensity exercise, takes 90 minutes to reach this effect – Increased fat metabolism with low to moderate intensity activities after 10 minutes of steady state exercise § Proteins may also be broken down for energy if needed 31

Anaerobic Exercise & Energy Metabolism § Energy for a 400 m sprint – 70% anaerobic (without oxygen) § ATP-CP creatine phosphate system § ATP generated by glycolysis – 30% aerobic § Kreb cycle in mitochondria § Continued conditioning will increase the lactic acid threshold – Improved anaerobic energy production 32

Lipoprotein Profile and Exercise § Researchers are unsure as to exact mechanisms that do this § Exercise may release enzymes that clear LDL from blood vessels and bring it back to liver for processing § Exercise is able to change the lipoprotein profile – – – Low density lipoproteins are bad High density lipoproteins are good Exercise reduces former, increases latter 33

Lipoprotein Profile and Exercise § Aerobic exercise is needed to improve lipid profile § Greater intensity exercise leads to greater improvement – Can lower LDL by 10 – 15% – Increase HDL by 20% – Combine efforts with nutritional changes 34

Exercise & the Musculoskeletal System § Exercise training results in improvements in muscle strength & size up to that required for exercise – Muscles adapt to increasing resistance load by hypertrophy – Increases in contractile proteins actin & myosin – Also there is gradual strengthening of tendons, ligaments and joints 35

Exercise & the Musculoskeletal System § Strength or resistance training (ie weight lifting) leads to greatest muscle mass gains § Leads to increased overall strength, power, joint stability, basal metabolism § Can also improve neuromuscular control 36

Strength Training is Rehabilitative For Joints & Muscles § Leads to restructuring of collagen fibers in tendons & ligaments § Strengthens resulting soft tissues & joints § Process takes time & requires consistent effort on the part of the pt § Refer to a qualified physical therapist when needed 37

Exercise and Bone Health § Bone is constantly remodeling via – Osteoblastic formation – Osteoclastic resorption § Process is affected by mechanical stresses – Exercise is a stimulus for skeletal adaptation – Bones become stronger with exercise – Leads to maintenance or increase in density § Reminder – Women begin to lose bone mass between age 30 – 35 § Rate of about 0. 75% to 1% per year – Men begin to lose bone mass between age 50 – 55 § Rate of about 0. 4% per year 38

Exercise and Bone Health § Once bone is demineralized, remineralization with exercise is a slow process – Slower than building strength – Be careful when working out elderly because of weak bones § Best to take calcium & Vitamin D supplements & exercise throughout life to prevent bone mass & density loss 39

Exercise & Mental Health § § Exercise promotes positive changes in mood Increases brain blood flow Increase in nerve growth factors Increases concentrations of neurotransmitters that support cognition – Dopamine, glutamate, norepinephrine, serotonin § Release of opioid like endorphins – Runner’s high 40

Exercise & Mental Health § Exercise is a very effective treatment for depression – Improvement in serotonin levels – Weight loss – Increased confidence & self worth § Improvements in other mental disorders are possible – improved cognition in dementia – Stress reduction in anxiety states 41

Exercise And Sleep § Exercise improve ability to fall asleep and remain asleep § When the physical body is exhausted it slips into REM more quickly & for a longer period of time – Muscles recovery during sleep & REM § Leads to more restful sleep & increased energy during the day 42

Exercise and Aging § Aging is inevitable § Some changes can be mitigated or ameliorated via – Exercise – Proper nutrition – Proper supplementation – Lifestyle factors: stress reduction, sleeping habits, weight management 43

Cardiovascular Changes With Aging § Are changes normal or due to cardiovascular disease § Maximal heart rate decreases with age – Decrease in pacemaker cells and responsiveness to stimulation § Maximal heart rate formula – 220 minus age 44

Cardiovascular Changes With Aging § Increase in interstitial fibrosis & calcium in myocardium – Collagen crosslinking and elasticity loss – Left ventricle hypertrophies § Cardiac output is 10 to 30% less at age 65 than at young adulthood – Decrease in both HR & SV – Decreases about 1% per year § Arterial stiffening & elasticity loss which increases SBP – Increases heart’s workload (afterload) § Overall circulation decreases with aging 45

Exercise and Cardiovascular Aging § § § Exercise can minimize loss in stroke volume Heart rate changes are less responsive Exercise can help maintain & minimize loss in aerobic capacity § Exercise can also reduce blood pressure & improve circulation 46

Pulmonary Changes With Aging § § Lung compliance increases with aging Ability for chest to expand decreases 20% increase in work to breath by age 65 Vital capacity decreases by 40 to 50% by age 70 – May be due to loss of elastic recoil of lung 47

Pulmonary Changes With Aging § Respiratory changes do not limit exercise capacity – Unless there is severe lung disease 48

Body Composition Changes With Aging § Approximately 1/3 of the population is obese – Childhood obesity is becoming an epidemic § Basal metabolic rate decrease by 5% per decade § Loss of lean muscle mass, atrophy with aging – Loss depends on activity level § Exercise, both aerobic and strength training is the key to minimizing weight gain and muscle atrophy 49

Joint Degeneration With Aging § Progressive loss of flexibility with aging – Loss of collagen fibers – Deterioration of joint soft tissues § Increase in knee and back problems with aging § Significant degeneration of the spine with aging – Excessive weight bearing may play a role § Exercise is great for minimizing rate of joint degeneration & strengthening soft tissues 50

Overview of How to Counsel Patients on Exercise § Key is to form a partnership with your patient § Teach them to become self motivated – Your role is to teach them how to motivate themselves § Numerous counseling techniques are available and are physician dependent 51

Several Models for Exercise Counseling § 3 Ms model § Mentioning exercise – Identify which patient can benefit from exercise § Modeling: being a role model – Discuss your experiences with exercise § Motivating: teaching patients to motivate themselves § AVOID NAGGING YOUR PATIENT 52

Several Models for Exercise Counseling § § § Five As Model Assess (pt’s need for exercise) Advise (exercise recommendations) Agree (agreement by patient) Assist (pt to engage in the activity) Arrange (follow up) 53

Screening History & Physical Exam § Talk to your physician if you have – Heart disease or severe lung disease § Chest pain § Abnormal heart beat § Circulation problems – Joint disease § Prior injuries, severe arthritis – Poor balance § History of falls – Other related medical issue as note by your doctor 54

ACSM & AHA Exercise Recommendation: Adults Under 65 § Moderate intensity exercise for 30 minutes, 5 x/week § Or § High intensity exercise for 20 minutes, 3 x/week § And § 8 to 10 repetitions of 10 strength training exercises 2 x/week 55

ACSM & AHA Exercise Recommendation: Adults Over 65 § Moderate intensity exercise for 30 minutes, 5 x/week § Or § High intensity exercise for 20 minutes, 3 x/week § And § 10 - 15 repetitions of 10 strength training exercises 2 x/week § Balance training if there is a risk of falling 56

US Dept of Health & Human Services Physical Activity Guidelines § Moderate intensity exercise for 30 minutes, 5 x/week § Or § High intensity exercise for 20 minutes, 3 x/week § Or § Combination of moderate & high intensity exercise to reach recommended level 57

Types of Aerobic Exercises § § § § Walking Brisk walking Jogging Cycling Stairmaster Elliptical rowing § Jump roping § Superset without rest between sets § Circuit training § Swimming § Various sporting activities 58

Main Strength Exercises § Chest muscles – Bench press § Flat, incline, decline § Shoulders – Shoulder press – Lateral or front raises § Upper back – Chin up – Rows § Arms – Bicep & forearm curls – Tricep extensions § Abdominals – Sit ups & crunches – Leg raises § Obliques – – Side bends Torso twists § Lower Back – Back extension – deadlifts § Legs – Squats, lunges – Leg press – Leg extensions & curls 59

Exercise Intensities § Level of physical exertion to raise your heart rate & break a sweat – Should be able to carry on a conversation – Level 6 on scale of 1 to 10 § Vigorous intensity – Level 8 or higher – Requires higher focus – Difficult to carry conversation 60

Complete Exercise Protocols § § § Should have all 5 components Aerobic exercise Muscular, strength or resistance training Core strength & stability training Stretching & flexibility training Balance training 61

Principles of Weight Loss § § § Expend more calories than you consume Typically requires a lifestyle change Eating lower calories and exercising to burn calories § During weight loss period – Requires more strict adherence to calorie restriction – Higher levels of exercise § During maintenance period: goal wt is attained 62

Principles of Weight Loss § § § Expend more calories than you consume Typically requires a lifestyle change Eating lower calories and exercising to burn calories § During weight loss period – Requires more strict adherence to calorie restriction – Higher levels of exercise § During maintenance period: goal wt is attained 63

Calorie Restriction Techniques § Drink lots of water and/or low calorie drinks § Eat lots of fruits and vegetables – – Bulky and low calorie Phytonutrients boost metabolism Fruits are convenient & ready to eat Learn tasty & palatable recipes to cook veges § Increase protein intake to preserve lean tissue § Limit high calorie foods like fried food, nuts, candies, empty calories § Take supplements as directed 64

Exercise Resources § § § American College of Sports Medicine American Heart Association US Department of Health & Human Services – Physical Activities Guidelines Advisory Committee § National Academy of Sports Medicine § American College of Cardiology 65