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EXERCISE AS AN ADJUNCT TO NUTRITIONAL COUNSELING JORDAN FEIGENBAUM MS, CSCS, HFS, CISSN,USAW CC Food is Medicine Lunch Time Lecture Series

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EXERCISE AS AN ADJUNCT TO NUTRITIONAL COUNSELING

J O R D A N F E I G E N B A U M M S, C S C S, H F S, C I S S N, U S AW C C

Food is Medicine Lunch Time Lecture Series

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Quotes for Social Media

“Let food be thy medicine and medicine be thy food.”-Hippocrates

“No citizen has a right to be an amateur in the matter of physical training…what a disgrace it is for a man to grow old without ever seeing the beauty and strength of which his body is capable.”-Socrates

“Over and above any considerations of performance for sports, exercise is the stimulus that returns our bodies for which they were designed. Humans are not physically normal in the absence of hard physical effort.”-Mark Rippetoe

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Disclaimers

Bias Personal Data interpretation

Limitations Time Asymmetrical Information

Q/A on the FIM Facebook! www.barbellmedicine.com

Evidence Based Evidence based behavioral practice

Science + Experience Biased population?

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What Exercise Isn’t

Weight loss solution 2007 AHA and ACSM Joint Guidelines on exercise:

“It is reasonable to assume that persons with high daily energy expenditures would be less likely to gain weight over time compared to those who have low energy expenditures. So far, data to support this hypothesis are not particularly compelling”*

Exercise is an adjunct to a nutritional intervention

*Haskell W.L Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Circulation. Aug. 2007.

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Exercise is Ineffective for Weight Loss

2000 Finnish study: Does physical activity prevent weight gain- a systematic review. * Review of 12 studies of

successful dieters’ exercise habits and subsequent weight maintenance (e.g. prevention of weight gain)

Results: In all 12 studies, participants regained weight Exercise either decreased rate

of regain by 3.2oz/ month vs sedentary successful dieters

OR Increased rate by 1.8oz

*Fogelholm, M. Kukkonen. K.M. Dose physical activity prevent weight gain- a systematic review.” Obesity Reviews. 2000 Oct;1(2):95-111.

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Conventional Wisdom

Exercise = Cardiovascular Exercise Definition of “Cardio”

LISS vs HIIT LISS= Low intensity steady state “cardio” HIIT= High intensity interval training

• Work and rest periods• “The potency of high-intensity interval training to elicit rapid skeletal muscle

remodeling is no doubt related to its high level of muscle fiber recruitment, and the potential to stress type II fibers in particular”*

HIIT Group: 30s sprints 3x/wk vs LISS Group: 90-120 min of moderate intensity cycling• Total volume of training: 2.5 hrs over 2 weeks for HIIT, 10.5 hrs for LISS• Results: “The two very diverse training protocols induced remarkably similar

changes in weight loss, muscle oxidative capacity, and exercise capacity. • Thought experiment: What if we increased the volume of HIIT?• High-intensity Interval Training: A Time-efficient Strategy for Health

Promotion?• Martin Gibala Current Sports Medicine Reports

*Gibala, Martin. High-Intensity Interval Training: A Time-efficient Strategy for Health Promotion? Current Sports Medicine Reports. 200

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Conventional Wisdom

“Cardio” is perceived as necessary for health and longevity How about Strength?

Study: Association between muscular strength and mortality in men: prospective cohort study.*

Results: “Muscular strength was significantly and inversely associated

with risk of death from all causes and cancer after controlling for potential confounders, including cardiorespiratory fitness...Muscular strength was significantly and inversely associated with risk of death from cardiovascular disease after controlling for age….”

Strength + GPA “The results revealed that those who more frequently engaged in

strength exercise had significantly higher GPA”***Ruiz, Jonathan R. Association between muscular strength and mortality in men: prospective cohort study. British Medical Journal. 2008 July 12; 337 (7661): 92-95

*Keating, XD. Association of weekly strength exercise frequency and academic performance among students at a large university in the United States. Journal of Strength and Conditioning Research. 2013 July Jul;27(7):1988-93.

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Conventional Wisdom

Is achieving a “healthy” BMI really a useful goal? Study: Association of All-Cause Mortality With Overweight

and Obesity Using Standard Body Mass Index Categories* Results: “Relative to normal weight, both obesity (all grades)

and grades 2 and 3 obesity were associated with significantly higher all-cause mortality. Grade 1 obesity overall was not associated with higher mortality, and overweight was associated with significantly lower all-cause mortality.”

Healthy=18.5-24.9 Overweight= 25-29.9 Grade 1= 30-34.9 Grade 2= 35-39.9 Grade 3= >40

*Flegal, Katherine M. Association of All-Cause Mortality With Overweight and Obesity Using Standard Body Mass Index Categories. JAMA. 2013. January. http://jama.jamanetwork.com/article.aspx?articleid=1555137

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Practical Uses for Exercise

Positive feedback loop to boost compliance More likely to initiate both

at the same time Health promotion

Proper prescription and application leads to better outcomes Improved strength,

functional capacity, HDL, glucose disposal, etc.

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Practical Recommendations

Resistance Training 3x/wk ~1hr /session 40 mins RT 20 mins HIIT Progressive overload

Need a stress to elicit a response Not all stresses are created equal

Training economy Most muscle mass/largest effective range of

motion/most force production• why?

Force production against external resistance= Strength• Strength is the foundation for all physical characteristics

• Plus it might help you live longer and have a higher GPA

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Ten General Physical Characteristics

StrengthPowerAccuracyBalanceCardiovascular/Respiratory EnduranceMobilitySpeedStaminaAgilityCoordination

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Mechanism unique to RT and HIIT

High threshold motor unit and fiber recruitment (e.g. Type II) Due to increase force production requirements Anaerobic

Increased Excess Post-Exercise Oxygen Consumption (EPOC) Less appropriate term= oxygen debt

Induces mitochondrial biogenesis More mitochondria facilitates increased BMR and TDEE

Builds muscle Improved glucose disposal via up-regulation of GLUT-4

receptor Improves insulin sensitivity, blood glucose and lowers HbA1C*

*Ivy JL. Role of exercise training in the prevention and treatment of insulin resistance and non-insulin-dependent diabetes mellitus. Sports Med. 1997 Nov;24(5):321-36. Review.

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More on Diabetes

Type II Diabetes + RT Improved insulin sensitivity by 48%* Improved blood glucose levels, Hba1C,

etc. “There was a strong inverse correlation

between HbA1c and muscle cross-sectional area (knee extensors) after the exercise period (r = -0.73; p < 0.05)”**

“Aerobic endurance exercise has traditionally been advocated in the treatment of non-insulin-dependent diabetes mellitus (NIDDM). However, the effect of aerobic endurance exercise programs on long-term glycaemic control is small to moderate.”**

**Eriksson, J. Resistance Training in the Treatment of Non-Insulin Dependent Diabetes Mellitus. International Journal of Sports Medicine. 1997 18:242-6

*Ishii, T. Resistance training improves insulin sensitivity in NIDDM subjects without altering maximal oxygen uptake. Diabetes Care. 1998 21:1353-5

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Conventional Wisdom vs. RT

It’s dangerous, right? Injury per 100 participation hours?

Competitive Weightlifting = 0.006 What’s the physical activity with the highest injury

rate? Soccer= 6.2 injuries per 100 participation hours *

*Hammill, B. Relative Safety of Weightlifting and Weight Training. Journal of Strength and Conditioning Research. 1994. 8 (1): 53-57

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But what about populations with pathologies? COPD

“Implementation of interval training has shown to allow lower limb exercise to be sustained at a high intensity which otherwise would not be tolerable. Interval training can be applied especially to those patients with advanced COPD, who are unable to sustain exercise intensities sufficiently long enough to obtain a physiological training effect because of ventilatory limitation.”*

Heart Failure and Heart Transplant “The present study documents that a long-term, partly supervised and community-based HIIT-program is

an applicable, effective and safe way to improve VO2peak, muscular exercise capacity and quality of life in HTx recipients. The results indicate that HIIT should be more frequently used among stable HTx recipients in the future.”**

AAA These results support the safety and efficacy of training in patients with small AAA, a population for which

few previous data are available. Despite advanced age and comorbidities, training up to 3 years was well tolerated and sustainable in AAA patients. Training did not influence rate of AAA enlargement.

Metabolic Syndrome “VO2max increased more after AIT than CME (35% versus 16%; P<0.01) and was associated with

removal of more risk factors that constitute the metabolic syndrome (number of factors: AIT, 5.9 before versus 4.0 after; P<0.01; CME, 5.7 before versus 5.0 after; group difference, P<0.05). AIT was superior to CME in enhancing endothelial function (9% versus 5%; P<0.001), insulin signaling in fat and skeletal muscle, skeletal muscle biogenesis, and excitation-contraction coupling and in reducing blood glucose and lipogenesis in adipose tissue.”**** AIT= Anaerobic interval training, CME= Continuous moderate exercise

Conventional Wisdom vs. RT/HIIT

*Kortianou EA. Effectiveness of Interval Exercise Training in Patients with COPD. Cardiopulmonary Physical Therapy Journal. 2010 Sep;21 (3): 12-9***Myers, Jonathan. A Randomized Trial of Exercise Training in Abdominal Aortic Aneuyrsm Disease. Medicine and Science in Sports and Exercise. 2013.

**** Tjonna, Arnt E. Aerobic Interval Training Versus Continuous Moderate Exercise as a Treatment for the Metabolic Syndrome. Circulation2008.

**Moraes K.L. Fernandes M. Carvalho, V.O. Interval Exercise Training in Adult Heart Transplant Recipients. American Journal of Transplantation. 2013 Jan 13 (2), 526

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Practical Recommendations

Use exercise as adjunct to nutritional intervention Boosts compliance and can improve results/outcomes

Particularly if applied intelligently Helps support the patient’s willingness to change

Don’t criticize the diet We don’t know that much, really.

Restrictive diets (e.g. Twinkie or Potato diet) Low Carbohydrate and Ketogenic diets

Ketogenic diets in ASD* Low carb diet**

Vegetarian/Vegan/Paleo/DASH/Ornish/Intermittent Fasting, etc. If it produces calorie restriction and compliance, it doesn’t

matter. The Mediterranean Diet is okay too

*Kossoff EH, Zupec-Kania BA, Rho JM. Ketogenic diets: an update for child neurologists. J Child Neurol. 2009 Aug;24(8):979–88.

**Gardner CD, et al. Comparison of the Atkins, Zone, Ornish, and LEARN diets for change in weight and related risk factors among overweight premenopausal women: the A TO Z Weight Loss Study. The Journal of The American Medical Association, 2007

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Practical Recommendations

Nutritional interventions should be simple and progressive Easier to build upon habits

e.g. Single ingredient foods first (address food quality) May spontaneously result in

calorie restriction Resulting intake may higher

satiety index rating* Likely reduces food reward**

• More positive feedback

*Holt SH, Miller JC, Petocz P, Farmakalidis E. A Satiety index of common foods. European Journal of Clinical Nutrition. 1995 Sep; 49 (9); 675-90**Hans-Rudolf Berthoud, Natalie R. Lenard, Andrew C Shin. Food Reward, hyperphagia, and obesity. American Journal of Physiology. June 2011. Vol. 300.

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Wrap Up/TL;DR

Exercise won’t work in a bubbleResistance Training and HIIT would be the

modalities of choice 3x/wk 40 mins RT + 20 mins HIIT is a good place to start Don’t be afraid of the weights Use as adjunct to dietary intervention

Dietary counseling should be simple and supportive Many approaches “work” even if suboptimal

Requiring eating “clean” is borderline Orthorexia* Encourage high food quality within the framework of an

approach that increases compliance

*Bratman, Steven. What is Orthorexia? www.orthorexia.com. June 4, 2010