Exercise Is Medicine: Physiologic Benefits of Exercise

Ajay N. Kiri, M.D. AAPNA Teleconference December 21, 2009

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

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
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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
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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

Age-adjusted mortality rates in healthy men categorized by level of fitness (Exercise capacity in METs)

Myers, J. Circulation 2003;107:e2-e5

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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

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

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Ayurveda and Exercise

Ayurveda mainly works through nutrition and medications Ayurveda recognizes the benefits of exercise at the physical, mental & spirit Ayurvedas exercise recommendations are similar to western medicines
From thousands of years of wisdom & experience
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Ayurvedas 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

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Ayurvedas 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

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Ayurvedas 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
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Ayurvedas 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
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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
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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

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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
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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
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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
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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
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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
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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
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Stroke Volume Increases Up to 50% Aerobic Capacity

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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

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 Resting/maximal (exercise) heart rate

Sedentary man: 70/190 bpm World class athlete: 45/190 bpm

Cardiovascular Effects of Exercise Conditioning: Sedentary Man Vs World Class Athlete

Resting/maximal stroke volume

Sedentary man: 85/93 mL/beat World class athlete: 136/184 mL/beat

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Cardiovascular Effects of Exercise Conditioning: Sedentary Man Vs World Class Athlete

Resting/maximal cardiac output
Sedentary man: 6.1/17.7 L/min World class athlete: 6.1/35.0 L/min

Arteriovenous O2 difference: rest/maximal

Sedentary man: 4.0/14.0 mL/dL blood World class athlete: 4.0/16.0 mL/dL blood
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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
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The Respiratory System

Pulmonary ventilation is typically not the limiting factor in maximal aerobic capacity Minute ventilation increases 15 to 25 fold with increasing exercise/work
Via increase in tidal volume Respiratory rate

Generally pulmonary respiration is directly proportional to O2 consumption and C02 production

Also increases with lactate production
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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
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Aerobic Exercise & Energy Metabolism

Glucose is the preferred energy source
ATP (energy) generated via glycolysis & Kreb cycle

Comes from glycogen breakdown in liver and skeletal muscle; glycogenolysis Fat stores are also mobilized for energy
Ratio of glucose:fat metabolism is initially 1:1, can change to 1:4 with prolonged submaximal V02 <60% intensity exercise, takes 90 minutes to reach this effect Increased fat metabolism with low to moderate intensity activities after 10 minutes of steady state exercise

Proteins may also be broken down for energy if needed

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Anaerobic Exercise & Energy Metabolism

Energy for a 400m sprint
70% anaerobic (without oxygen)
ATP-CP creatine phosphate system ATP generated by glycolysis

30% aerobic
Kreb cycle in mitochondria

Continued conditioning will increase the lactic acid threshold

Improved anaerobic energy production
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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
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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

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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

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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

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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

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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

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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
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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

Runners high

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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
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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
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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
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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

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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 hearts workload (afterload)

Overall circulation decreases with aging

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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

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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

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Pulmonary Changes With Aging

Respiratory changes do not limit exercise capacity
Unless there is severe lung disease

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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

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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

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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

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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

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Several Models for Exercise Counseling

Five As Model Assess (pts need for exercise) Advise (exercise recommendations) Agree (agreement by patient) Assist (pt to engage in the activity) Arrange (follow up)

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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

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ACSM & AHA Exercise Recommendation: Adults Under 65

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

Moderate intensity exercise for 30 minutes, 5x/week Or High intensity exercise for 20 minutes, 3x/week And 10 - 15 repetitions of 10 strength training exercises 2x/week Balance training if there is a risk of falling

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US Dept of Health & Human Services Physical Activity Guidelines

Moderate intensity exercise for 30 minutes, 5x/week Or High intensity exercise for 20 minutes, 3x/week Or Combination of moderate & high intensity exercise to reach recommended level
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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

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Main Strength Exercises

Chest muscles
Bench press
Flat, incline, decline

Abdominals
Sit ups & crunches Leg raises

Shoulders
Shoulder press Lateral or front raises

Obliques
Side bends Torso twists

Upper back
Chin up Rows

Lower Back
Back extension deadlifts

Arms
Bicep & forearm curls Tricep extensions

Legs
Squats, lunges Leg press Leg extensions & curls

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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
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Complete Exercise Protocols

Should have all 5 components Aerobic exercise Muscular, strength or resistance training Core strength & stability training Stretching & flexibility training Balance training

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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

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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

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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
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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

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