effective physical activity for cardiovascular disease prevention jeremy pomeroy ms, rcep
Post on 19-Dec-2015
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Effective Physical Activity Effective Physical Activity for Cardiovascular Disease for Cardiovascular Disease
PreventionPrevention
Jeremy Pomeroy MS, RCEPJeremy Pomeroy MS, RCEP
Past ExperiencePast Experience
• Physical activity programs in Gila River– Diabetes secondary and tertiary
prevention– Diabetes primary prevention– Medical fitness programs
Gila River Physical Activity Gila River Physical Activity ProgramsPrograms
• Hospital-based at a medical fitness center– Facility with specialized equipment and
staff to provide safe and effective physical activity programs to individuals with a variety of medical conditions
• Community-based– Trained CHRs met with participants at
locations throughout the community• Including homes
Gila River Physical Activity Gila River Physical Activity ProgramsPrograms
• Goals– Increase / maintain quality of life
• Reduce incidence of diabetes• Reduce incidence of diabetes complications• Increase / maintain physical function
Gila River Physical Activity Gila River Physical Activity ProgramsPrograms
• Outcomes– Primary prevention
• participants with NGT and IGT lost significant amounts of weight
Gila River Physical Activity Gila River Physical Activity ProgramsPrograms
• Outcomes– Primary prevention
• participants with NGT and IGT lost significant amounts of weight
– Secondary prevention• Average HbA1c reduction was 2.1%
– Baseline 8.6%, follow up 6.5%– >95% of long-term participants maintain HbA1c
≤7.0%
Glycemic control for individuals with type 2 Glycemic control for individuals with type 2 diabetes participating in GRHCC’s physical activity diabetes participating in GRHCC’s physical activity
programsprograms
44.5
55.5
66.5
77.5
88.5
99.5
Time (months of participation)
Hb
A1
c
Intervention HbA1c
Glycemic control and body mass for individuals with type 2 Glycemic control and body mass for individuals with type 2 diabetes participating in GRHCC’s physical activity diabetes participating in GRHCC’s physical activity
programsprograms
4
4.5
5
5.5
6
6.5
7
7.5
8
8.5
9
Time (months of participation)
Hb
A1
c
32333435363738394041424344
BM
I
Intervention HbA1c
Intervention BMI
Gila River Physical Activity Gila River Physical Activity ProgramsPrograms
• Outcomes– Diabetes related complications
• 1 new complication for long term participants
– Quality of life• Dramatic increases for nearly all participants
Gila River Physical Activity Gila River Physical Activity ProgramsPrograms
• Average exercise frequency, intensity, and type– Individuals with diabetes exercised on
average for 45 min/wk at low-moderate intensity using a combination of cardiorespiratory exercise and resistance exercise
ProcessProcess
Define the goal, design the plan Define the goal, design the plan to achieve the goal, evaluate, to achieve the goal, evaluate,
modifymodify
Define the goalDefine the goal
• Increase energy expenditure?– Any activity above resting – Cumulative effect
• Increase fitness?– Fitness is a physiologic adaptation to
stress– Requires moderate intensity and moderate
frequency
Define the GoalDefine the Goal
• Weight loss?– Individuals can use physical activity to
achieve weight loss without any changes in fitness
• Reduce diabetes-related risk factors?– Improvements in HbA1c have been shown
at levels of physical activity that are not sufficient to improve fitness or promote weight loss
Glycemic control and body mass for individuals with Glycemic control and body mass for individuals with type 2 diabetes participating in GRHCC’s physical type 2 diabetes participating in GRHCC’s physical
activity programsactivity programs
4
4.5
5
5.5
6
6.5
7
7.5
8
8.5
9
Time (months of participation)
Hb
A1
c
32333435363738394041424344
BM
I
Intervention HbA1c
Intervention BMI
ProcessProcess
Design the planDesign the plan
Exercise and RiskExercise and Risk
• Cardiovascular events– Largely related to intensity
• As intensity increases so does risk
Intensity CurveIntensity Curve
6
8
10
12
14
16
18
20
10min 20min 30min 40min 50min 60min
Time
RP
E
RPE
• As time increases so does relative intensity even at the same absolute intensity
Upper limit for safetyUpper limit for safety
6
8
10
12
14
16
18
20
10min 20min 30min 40min 50min 60min
Time
RP
E
RPE
Conservative upper limit for Conservative upper limit for safetysafety
6
8
10
12
14
16
18
20
10min 20min 30min 40min 50min 60min
Time
RP
E
RPE
Exercise and RiskExercise and Risk
• Cardiovascular events– Largely related to intensity
• As intensity increases so does risk
• Other adverse events– Dehydration– Falls– Blisters / ulcers– Overuse injuries
Minimize riskMinimize risk
• Participants with peripheral neuropathy– Don’t recommend walking long distances
for exercise• +30 min
– Instruct in appropriate foot care
• Participants with osteoarthritis– Pain free range of motion– If OA is in knees instruct in low weight
bearing activities
Minimize riskMinimize risk
• ESRD / HTN– Avoid activities that greatly increase blood
pressure• Heavy weight lifting• High intensity cardiorespiratory exercise
– Do encourage resistance exercise• Low weight moderate repetition• Maintain lean tissue
ProcessProcess
Facilitate utilizationFacilitate utilization
Change TheoriesChange Theories
• Transtheoretical Model
• Health Belief Model
• Self Determination Theory
Transtheoretical Model Transtheoretical Model Stage of Change TheoryStage of Change Theory
• 5 Stages– Precontemplation– Contemplation– Preparation– Action– Maintenance
Transtheoretical ModelTranstheoretical Model
• Role in promoting health behavior– Target education to participant’s stage of
change• Attempts to increase awareness appropriate
for individuals in precontemplation stage• Strategies to reduce environmental barriers
appropriate for individuals in action stage
– Also useful for designing interventions to target subsets of a population
Health Belief ModelHealth Belief Model
• Perceived susceptibility
• Perceived seriousness
• Perceived benefits of adopting new behavior
• Barriers to adopting behavior
• Cues to action
Successfully adopting new Successfully adopting new behaviorsbehaviors
• Desire to change behavior
• Belief that new behavior will result in desired outcome
• Belief that new behavior can be accomplished
Self-Determination TheorySelf-Determination Theory
• Focus is on extent that behavior is adopted volitionally– Classifies motivation as ranging on a
continuum from lack of motivation (amotivation) to intrinsic motivation
Self-Determination ContinuumSelf-Determination Continuum
Behavior Non self-determined Self-determined
Motivation Amotivation Extrinsic Intrinsic
Regulatory Non- External Introjected Identified Integrated Intrinsic
Styles Regulation
Regulatory Lack of Compliance Congruence
Processes Control Enjoyment
Self-Determination ContinuumSelf-Determination Continuum
Behavior Non self-determined Self-determined
Motivation Amotivation Extrinsic Intrinsic
Regulatory Non- External Introjected Identified Integrated Intrinsic
Styles Regulation
Regulatory Lack of Compliance Congruence
Processes Control Enjoyment
Self-Determination ContinuumSelf-Determination Continuum
Behavior Non self-determined Self-determined
Motivation Amotivation Extrinsic Intrinsic
Regulatory Non- External Introjected Identified Integrated Intrinsic
Styles Regulation
Regulatory Lack of Compliance Congruence
Processes Control Enjoyment
Promoting Integrated RegulationPromoting Integrated Regulation
• Recognize the participant as a physically active person
• Link the behavior to the desired outcomes– Feeling good because of exercise
Increasing the chance of Increasing the chance of successsuccess
• Provide a full spectrum of social support – Emotional support (concern)– Esteem support (encouragement)– Informational support (education)– Network support (sense of belonging)
Reducing psychological barriersReducing psychological barriers
• Empowerment – Focus on helping the client to understand
their own power to create self-change
• Self-efficacy– People estimate the chance of future
success on past performance so make sure initial experiences are successful
Increasing the chance of Increasing the chance of successsuccess
• Acknowledge barriers– Show empathy– Don’t start off by offering advice to
overcome barrier• If it was that easy the client probably would
have thought of it• Work with the client to teach the skills to
overcome barriers
Maximize effectivenessMaximize effectiveness
• Resistance training– Muscle weakness often the most
significant limitation to functional capacity– Can be done a variety of ways in a variety
of settings• Machines• Resistive bands / tubing• Body weight
Maximize effectivenessMaximize effectiveness
• Encourage lifestyle activity– Parking at the far end of the lot– Walking instead of driving– Gardening
• Every bit helps and focus on that instead of “not enough”
-10
-8
-6
-4
-2
0
Equivalence of lifestyle physical activity versus Equivalence of lifestyle physical activity versus programmed exerciseprogrammed exercise
Wei
ght C
hang
e (k
g)
Time (months)
Diet + programmed activity
Diet + lifestyle activity
P=0.06
Andersen et al. JAMA 1999;281:335.
0 8 36 52 6816 28 44 60
TreatmentTreatmentPhasePhase Maintenance PhaseMaintenance Phase
Gila River Physical Activity Gila River Physical Activity ProgramsPrograms
• Average exercise frequency, intensity, and type– Individuals with diabetes exercised on
average for 45 min/wk at low-moderate intensity using a combination of cardiorespiratory exercise and resistance exercise
ResourcesResources
• American College of Sports Medicine– www.acsm.org
• American Heart Association– www.americanheart.org
• North American Society for the Study of Obesity– www.obesityonline.org
