Transcript Exercise Is Medicine

Exercise Is Medicine:
Physiologic Benefits of
Exercise
Ajay N. Kiri, M.D.
AAPNA Teleconference
December 21, 2009
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Outline of Seminar
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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
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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
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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
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Age-adjusted mortality rates in healthy men categorized by
level of fitness (Exercise capacity in METs)
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Myers, J. Circulation 2003;107:e2-e5
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How Exercise Impacts Health
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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
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Patient Asks Why Exercise?
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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
 Ayurveda’s exercise recommendations are similar
to western medicine’s
– From thousands of years of wisdom & experience
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Ayurveda’s Views On Exercise
Its Physical Benefits
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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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Ayurveda’s Views On Exercise
Benefits for Mind, Heart and Spirit
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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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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
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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
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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
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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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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 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
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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
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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
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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 heart’s 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
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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
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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)
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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
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 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
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 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
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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
 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
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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
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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
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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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