Activity and Health

Physical activity is an often-overlooked, powerful tool in lowering the risk for chronic degenerative illnesses which plague so many of us. As an effective “anti-aging” technique, exercise is hard to beat. Finding time, opportunity and motivation to exercise consistently is admittedly difficult for most of us. Adding small bits of activity to our daily schedule is an excellent beginning, since it all adds up. We have prepared lists of such small steps that virtually anyone can fit into their schedules.

Always talk to your physician before starting an exercise program.

Most people favor walking, because it requires no special equipment, can be done anytime and anywhere, and is effective. For those who are interested, with measurements of basal and resting metabolism, we can fashion an individualized “exercise prescription” to help you achieve a greater degree of fitness scientifically, and in the shortest possible time.

What we do about your exercise program

Our approach to physical activity is similar to our approach to other components of our health services:  it has to work for you.

1. We assess your need for exercise in relation to your entire health picture, your lifestyle, and your goals
2. We do baseline measurements of your body composition, including weight, height, body mass index, percent body fat, percent body water, percent lean body mass (primarily muscle), numerical indices of abdominal (visceral) fat, bone mass, and overall physical index. A written report with normal values and comparisons is furnished upon your request.
3. Given your exercise history and capability, we suggest a structured exercise program to achieve your goals in each component of fitness: aerobic fitness, muscular fitness (strength and endurance), flexibility, and body composition. 
4. You receive specific instructions, including illustrated materials, about the particular aerobic activities best for your lifestyle that will be most successful for you.  Your target heart rate will be given to you with the range best for your goals, with tips about monitoring heart rate.
5. You will also be given, after an exercise-by-exercise discussion, a plan for strength training, again with illustrated materials so you can easily follow things along.
6. We review the relationship between physical activity and energy production and energy needs in your body with you.  This includes the composition, timing, caloric needs that will support the activities we chose together for the new you.
7. Specifically, we give you easy-to-follow instructions about how much protein, carbohydrate, and fat to eat, vitamins, minerals, fluids, and other components of your nutrition that will bring you the best returns for your effort.  This advice is personalized to your eating habits.
8. If weight is of concern, we give you a projection of how much weight you will lose, based upon the caloric expenditure of your exercise program.
9. We review other topics which are of concern, especially “ergogenic aids”, which are intended to increase your ability to do more, either with greater power/strength, or endurance.
10. We discuss the bewildering world of supplements for building and taking care of muscle and bone for athletes, tell you those with solid evidence behind them, and those that will probably not help you.
11. We provide motivational materials in print during visits, and electronically by emails and fax.
12. According to your goals, we monitor your progress with periodic reassessments of performance and body composition at regular intervals, assisting you to reap the great benefits physical activity offers, and the “look” you desire.

Ask for our review of the many basic science benefits of physical activity, together with the latest recommendations from the American College of Sports Medicine (links listed in Resources & Links).

Our office supports the ACSM initiative: Exercise is Medicine, and Physical Activity Guidelines for Americans and we are enrolled in that Supporter Network. A full copy of those Guideliness is available with other tools and an online adult fitness evaluation. A brief two-page Summary of the Guidelines is available as well. We also support the Get Active America initiative as well as the President’s Council on Physical Fitness and Sports.

Fitness Through Regular, Moderately Intense, Exercise 
Research studies have shown that most of the health benefits from exercise are achieved when an individual transitions from not exercising to becoming moderately active.

Slightly more benefits are gained from increasing the duration or intensity of the exercise. But, there is a risk-benefit ratio that may be different for each person. Therefore, the comprehensive lifestyle change program encourages participants to exercise aerobically a minimum of 30 minutes a day or for an hour every other day for a total of 3-5 hours of aerobic exercise per week. More intense exercise is allowed if medically appropriate and if desired by the participant. Resistive or strength training exercise is also crucial to maintaining health. If medically appropriate, participants are also encouraged to engage in strength training exercise 2-3 times per week.

Benefits of Regular Aerobic Exercise
Activity and aerobic exercise can improve one’s physical health in many ways. As stated earlier, most of the health benefits of physical activity are gained with only moderate levels of activity. A proper aerobic exercise program will:

1. increase the efficiency of the heart by making it able to pump more blood (increased stroke volume) with fewer beats (decreased heart rate) resulting in increased oxygen availability to the heart
2. increase the ability of muscles to pick up, carry and use oxygen efficiently
3. decrease the oxygen requirements of the heart during rest and activity
4. decrease resting blood pressure such that blood pressure medications may be decreased
5. increase the ability to exercise at higher workloads for longer periods of time, before being limited by fatigue, shortness of breath or chest pain
6. decrease triglyceride levels in the blood and increase the HDL-Cholesterol (good cholesterol) levels, thus making it harder for fats to collect inside artery walls
7. decrease blood sugar and triglyceride levels in the blood such that the types and amounts of blood sugar lowering drugs may be decreased or changed for those individuals with diabetes
8. decrease the blood’s ability to clot and stick to blood vessel walls which decreases the risk for blood clots to block small arteries
9. increase one’s ability to move, thus making it easier to perform daily activities
10. decrease body fat and increase muscle mass
11. increase metabolism
12. increase tolerance to stress by improving one’s outlook on life
13. decrease hostility
14. increase control of stress hormones
15. increase one’s self-confidence and general sense of well-being
16. decrease risk for osteoporosis

Aerobic Exercise Guidelines

The comprehensive lifestyle change program exercise recommendations are based on the distinction of three levels of exertion: inactivity, activity and exercise.

Inactivity involves no effort and is illustrated by sedentary pastimes such as watching television or sitting at the computer. The effects of inactivity on the body are negative. In fact, most of the benefits of exercise previously discussed are reversed with inactivity.

The next level of exertion is activity. This category includes stop-and-go or low intensity movements such as gardening or golfing.
The third level is exercise, or more specifically, “aerobic” exercise. Aerobic exercise is continuous movement, using arms and/or legs at a moderate to high level of intensity, and lasts at least 20 minutes. Some examples of aerobic exercise are swimming, biking and walking.

While it is best to minimize the amount of inactivity and important to increase our general level of activity, it is essential that exercise be an integral part of our daily lives.

The “FITT Principle” of Aerobic Exercise

There are four conditions that must be met for aerobic exercise to produce the desired cardiovascular training benefits. These conditions are adjusted according to the interests and level of fitness of each individual.

F – Frequency (How often to exercise)

• This will vary from several times per day to 3-6 times per week depending on the exercise intensity and time.

I – Intensity (How hard to exercise)

• 65%-80% of an individual’s maximal functional capacity determined by a treadmill test.

T – Time (How long to exercise)

• Exercise should be sustained for 30-60 minutes, for a minimum of 3 hours per week up to 5 hours per week.

T – Type (The type of exercise)

• Walking, jogging, aerobic dance, bicycling, swimming, rowing, cross-country skiing, etc.
• Activities in which you move only intermittently or that are “stop and go”, such as golf, basketball, baseball or bowling, tend to activate the anaerobic system and thus do not help to achieve as much of a training effect.

The Components of Each Aerobic Exercise Session

1. Warm-up. 5-10 minutes of several range-of-motion exercises and slow aerobic activity designed to prepare the muscular and cardiovascular system for exercise. If you begin exercising too quickly, without warming up, you’ll draw too heavily on your anaerobic system, a system that is relatively inefficient due to a lack of oxygen available for the working muscles. As a result, you increase the risk for angina (pain in the chest or another part of the body) and you’ll fatigue quickly and build up a lot of lactic acid, which causes muscle cramps and pain.
2. Aerobic Activity. 30-60 minutes consisting of continuous, rhythmic exercise performed at the target heart rate and perceived exertion level prescribed by the staff and your physician.
3. Cool Down. 8-10 minutes of slower aerobic activity and stretching designed to allow the body to gradually return to its pre-exercise state and increase the body’s flexibility. If the body does not have enough time to “cool-down,” it generates large amounts of lactic acid (the same problem outlined in “Warm-up”), which causes muscle soreness and pain. This is the easiest area to cut short when “hurrying” from exercise to your next activity. It is very important to allow the body enough time to return to its pre-exercise state. In order to achieve the effects of the relaxation response that occur after exercise — the sense of calmness and well-being — you need to cool down fully.

Now that your heart and lungs are developing strength, stamina and efficiency, it’s time to start working on the other muscles of the body!

In the past, we have emphasized the value of cardiovascular (cardio or aerobic) exercise, but we are becoming aware of how crucial resistive or strength training is in maintaining muscle tone and function. Incorporating strength training into your daily routine will allow you to continue doing the things you’ve always done, from carrying groceries and climbing stairs, to playing tennis and dancing till dawn.

After the age of 20, people who don’t engage in physical activity will begin to lose muscle. The most significant loss comes after the age of 60. Aging may contribute to some of this loss, but it is primarily caused by a decrease in physical activity. Cardiovascular exercise such as walking may be good for the heart, but it will have little effect on muscle mass. Only strength training has been shown to dramatically slow down the process of muscle loss. Two research studies by Dr. Maria Fiatarone and colleagues at the Center for Aging at Tufts University demonstrated that people in their 80’s and 90’s can make strength gains in just a few months of resistance training. Study results showed that subjects increased their strength by at least 100%, and improved their walking speed and stair-climbing ability. So remember, it’s never too late to start.

Strength training works on the “overload principle,” which involves making the muscles work a little harder than they are accustomed to by increasing the resistance to movement or the frequency and duration of an activity. In the past, strength training was used primarily by athletes to improve performance, or for physical rehabilitation after an injury. This kind of training used to be considered unsafe for populations like the elderly or people with cardiovascular disease, but recent studies have shown that strength training can be safe and effective for both of these groups when appropriately prescribed and supervised.

Strength training does NOT require expensive equipment and large amounts of time. It can be practiced at home, for 20-30 minutes per session, 2-3 times per week, using a minimum amount of resources. Hand weights, resistive bands and tubing, calisthenics and even plain old water jugs or soup cans can be used to provide the needed resistance.

Create a balanced exercise program by combining cardiovascular exercise, resistive/strength training and stretching for flexibility.

Benefits of Regular Strength Training Exercise

• increased strength and flexibility of muscles, tendons and ligaments
• increased functional capacity
• increased lean tissue and metabolism
• increased bone density (which may help prevent bone loss)
• better balance and stability
• injury prevention
• increased self-confidence, improved self-image
• improved ability to perform occupational and
• leisure time activities
• improved exercise adherence (because of the diversity of exercises)

Strength Training Guidelines

• Breathe! Exhale (blow out) during the exertion phase of the lift. Remember this: Exhale on Effort.
• Maintain proper speed of motion with slow, controlled movements.
• A repetition is the lifting and lowering of the weight. Lift on a 2 count and lower on a 4 count.
• Exercise through the full range of motion but within your comfort level. Emphasize complete extension of the limbs when lifting.
• Pause for a brief moment at the end of a movement (extension) to avoid using momentum (swinging).
• Never sacrifice form for resistance. Stay within your limits!
• Use a partner to help you when necessary.
• Select exercises for both the upper and lower extremities.
• Loosely hold handgrips when possible; sustained, tight gripping may evoke an excessive blood pressure response to lifting.
• Because resistance training is muscle specific, each exercise may require a different weight.
• Stop exercise in the event of warning signs or symptoms, especially dizziness, arrhythmias, unusual shortness of breath and/or angina pectoris (chest pain).
• Do not perform strength-training exercises with any kind of musculoskeletal pain or injury.

The “FITT Principle” of Strength Training

F – Frequency (How often to exercise)

• Weight train a minimum of 2-3 times per week with one rest day between sessions.

I – Intensity (How hard to exercise)

• To prevent soreness and injury, initially choose a weight that will allow the performance of 12-15 repetitions (1 set) comfortably.
• Avoid straining. Ratings of perceived exertion (6-20 scale) should not exceed fairly light (10) to somewhat hard (15) during lifting.

T – Time (How long to exercise)

• Initially, perform 1 set of each exercise.
• Keep rest periods between sets relatively short (30-90 seconds).
• Complete 10-15 repetitions of 8-10 different types of resistive exercises that concentrate on large muscle groups of the upper and lower body.

T – Type (The type of exercise)

• Free weights/barbells/heavy hands/ankle weights
• machines
• resistance bands/ surgical tubing
• calisthenics (body weight)
• household items (water jugs, canned food)

Pollock, ML, et al. Resistance Exercise in Individuals With and Without Cardiovascular Disease. Circulation. 2000; 101; 828.

Progression in Your Strength Training Routine

• After the initial training phase is completed (2-4 weeks), select a weight that provides a challenge without sacrificing form at the completion of each set.
• Increase the weight gradually by 1-5 pounds when 12-15 repetitions can be comfortably completed. This is important in order to see continuing improvements in muscle strength.

The Components of Each Strength Training Session

Warm-up/Cool-down
5-10 minutes of general, rhythmical-type exercise with some stretching and range of motion movements should be done before and after each session. Your aerobic exercise can be your “warm-up” for your strength training.

Strength Training Activity
15-30 minutes consisting of 12-15 types of resistive exercises that concentrate on large muscle groups of the upper and lower body. Perform 1-3 sets of each exercise. Keep rest periods between sets relatively short (30-90 seconds).

Rule of Thumb

You should always be able to carry on a conversation while exercising. If you can’t, there is not enough oxygen available for the working muscles.  Slow down. Remember the phrase: “You should be able to talk while you walk”—barely.

Physical activity and your heart

A proper amount of exercise may lower risk for heart disease by 50%. The cost may be minimal, and benefits are many—improved mood, greater productivity, self-confidence, and a lower risk for many degenerative/inflammatory diseases: diabetes, hypertension, osteoporosis, memory and cognitive loss, preservation of muscle mass and fewer colon, breast, and other cancers. Physical activity (or exercise) is one of the best health bargains in today’s world. If it were available in pill form, that pill might sell for thousands of dollars.

About 25,000 original studies have been published in peer-reviewed, indexed journals showing that physical activity lowers the risk for heart disease, excluding the reviews and commentaries.

• Very brisk walking (4 mph) 30-60 min daily lowers risk up to 49%
• Brisk walking 30 min/day lowers risk by 18%
• Running for an hour or more several times per week lowers risk by 42%
• Running for an hour once/week lowers risk by 18%
• In a study of 710 men, those with low fitness levels were more likely to have calcium identified in fatty plaques in coronary arteries
• In men with documented heart disease, a group who exercised survived longer than a group who received angioplasty. Angioplasty is an accepted minimally invasive intervention (technique) for breaking up plaques that narrow coronary arteries.

To be sure, the death rate during exercise is 1 in 15,000-18,000 healthy exercisers, but this must be compared to the much higher risk of remaining sedentary.

Recommendations for activity  

In August, 2007, and again in October, 2008, the AHA and the American College of Sportsmedicine released the latest recommendations for exercise for adults (this is the 4^th by the ACSM, the last one being in 1995):

1. Do moderately intense aerobic exercise* (“cardio”) 30 minutes a day, five days a week. Moderately intense means working hard at a level 6 intensity on a scale of 10 as the hardest, but still be able to carry on a conversation during exercise. This is equivalent to walking about 1.5 miles at 3-4 mph                          (or do vigorously intense cardio 20 min/day, 3 days a week)
2. The exercise may be accumulated in 10 minute sessions,           and
3. Do 8-10 strength-training* exercises, 8-12 repetitions of each exercise twice a week. Resistance exercise provides health benefits beyond those received after aerobic exercise.
4. Moderate-intensity physical activity means working hard enough to raise your heart rate and break a sweat, yet still being able to carry on a conversation. It should be noted that to lose weight or maintain weight loss, 60 to 90 minutes of physical activity may be necessary. The 30-minute recommendation is for the average healthy adult to maintain health and reduce the risk for chronic disease.

The guidelines for adults over age 65, or adults 50-64 with chronic conditions, such as arthritis, are somewhat less. It is important to remember that these are basic, minimal guidelines, and that more strenuous, frequent, and longer exercise sessions will produce additional benefits. One could not expect everyone will lower their risk for heart disease maximally by doing the amounts mentioned. However, there are definite heart benefits from doing even lighter activity, compared with not doing any at all. Some is much better than none.  For weight loss, one hour of aerobics six days per week is best.  The ACSM and AHA guidelines are somewhat reflected in Uncle Sam’s Guidelines (see below, and visit http://www.informz.net/acsm/data/images/acsmahanewsrelease and www.acsm.org/physicalactivity.  Some additional links are

• Tips for meeting the guidelines  
• Starting an exercise program  
• Improvements from the 1995 recommendation 
• Frequently Asked Questions 
• Read the healthy adults manuscript  
• Read the older adults manuscript

Exercise as the real Fountain of Youth

There is another significant return from investing in exercise—rolling back the clock on aging. A study in Circulation in 2001 confirmed what many cardiologists and exercise physiologists suspected for many years: moderate aerobic exercise reverses some markers of aging. In only 6 months, middle aged people who exercise can reverse the effects of decades of aging on cardiovascular fitness, which is considered to slow fatty deposits in arteries, lower the risk of heart attack, stroke, and diabetes, control weight, reduce levels of LDL-cholesterol and triglycerides in the blood, and increase levels of protective HDL-cholesterol. Aerobic exercises appear to benefit cholesterol the most, by lowering LDL by 5 to 10% and raising HDL cholesterol by 3 to 6%. Generally more intense and longer amounts of exercise are necessary for such a full effect. Aerobic exercise is one of the best ways to raise protective HDL-cholesterol. Space does not allow a full discussion of all the many benefits of exercise on the cardiovascular system. For example, data from the Cardiovascular Health Study (Circulation Aug 19, 2008) suggest that light to moderate physical activity is associated with a lower risk of atrial fibrillation (AF) in older adults.

Exercise also gives people energy, reversing inward signs of aging, such as feeling fatigued washed up, and “old”, as well as the outward signs of aging, such as looking good, and appearing vigorous. Physical fitness definitely contributes to successful mental aging.

Also in October, 2008, the U.S. Department of Health and Human Services issued their new physical activity guidelines.

Main recommendations are:

• Adults should get at least 2½ hours of moderate-intensity physical activity each week, such as brisk walking, or 1¼ hours of a vigorous-intensity activity, such as jogging or swimming laps, or a combination of the two types, to get the most health benefits from exercise. These aerobic activities should be done in at least 10-minute bouts.
• To get even more health benefits, people should do five hours of moderate-intensity physical activity each week or 2½ hours of vigorous activity.
• Adults should do muscle-strengthening (resistance) activities at a moderate- or high-intensity level for all major muscle groups two or more days a week. This should include exercises for the chest, back, shoulders, upper legs, hips, abdomen and lower legs. The exercises can be done with free weights or machines, resistance bands, calisthenics that use body weight for resistance (push-ups, pull-ups, sit-ups), or carrying heavy loads or doing heavy gardening such as digging or hoeing.
• Children and adolescents should do an hour or more of moderate-intensity to vigorous aerobic physical activity each day. That should include vigorous activity at least three days a week, and it should include bone-strengthening activities such as running, jumping rope, skipping, playing hopscotch and muscle-strengthening activities such as tug of war, modified sit-ups and push-ups.
• Older Americans should follow the guidelines for other adults if they are able. If not, they should be as active as their physical condition or disabilities, allow. If they are at risk of falling, they should do exercises that improve balance.

Previous federal recommendations advised adults to do at least 30 minutes of moderate activity most days of the week. They did not include specific muscle-strengthening recommendations.

Some links for further information are

• 2008 Physical Activity Guidelines for Americans (Report)
• Be Active Your Way:A Guide for Adults For adults aged 18—64
• 2008 Physical Activity Guidelines for Americans Toolkit
• 2008 Physical Activity Guidelines Advisory Committee Report  (Full report)

Pathways to Success with Exercise:

Fulfill the 3 C’s: Comprehension, Commitment and Confidence.

• Comprehension – understand the reason why it is important for you to exercise on a regular basis by talking with a health care professional or by reading educational exercise materials. This will provide a strong base for your commitment.
• Commitment – make a personal decision to place exercise as a priority in your day’s activities. Make exercise a ritual. Write time for exercise in your appointment book — in ink.
• Confidence – set small, reasonable goals. Reward and praise yourself when reaching the steps that will lead you to your ultimate objective. Don’t let small setbacks sabotage your long-term success.

Bring Physical Activity Into Daily Life

The most efficient way to increase your physical activity is to make it part of your daily routines.

• Instead of driving, walk or bicycle to work or to the store. If that’s not practical, park a little farther away (where the parking places are usually easier to find, thereby also reducing your stress level).
• Take the stairs instead of an elevator, especially if you’re going only one or two floors.
• If you use the moving sidewalks at airports, don’t just stand there — walk!
• If you play golf, walk instead of using an electric cart.
• Exercise with family or friends to provide social support, for more motivation and a double benefit.
• On a vacation, walk rather than drive to see and experience the sights.

The components of health that drive our purpose and methods are summarized in our logo:

Leonardo da Vinci (1452–1519) combined art and science to create the perfectly proportioned human (c1492). Building on Greek mathematical principles, the Vitruvian Man is an illustration of how balance and symmetry in health can produce extraordinary results from several core principles. The most basic of these components were emphasized by Hippocrates, the Father of Medicine. Years later this was expressed as Sit mens sana in corpore sano.

The original work is stored in the Gallerie dell’Accademia, Venice. One of Da Vinci’s most memorable quotes was: “Simplicity is the ultimate sophistication.” This is a variant of Occam’s razor [William Ockham (c. 1285–1349)]: Entia non sunt multiplicanda praeter necessitatem, or “Don’t make things unnecessarily complicated.” Razor refers to shaving off unnecessary assumptions to get to the simplest explanation, which has been used to guide scientists to basic explanations. Unfortunately, the pendulum has swung the other way, since the more science advances, the more we see that Mother Nature is extremely complex.

Commitment includes personal responsibility and ownership of your own health.