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Nutrition and ExerciseNutrition and Exercise

Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM

PO Box 27121 – Riyadh 11417Tel: 4912326 – Fax: 4970847

• identify the benefits of exercise and healthy nutrition

• explain the health pyramid

• describe the components of healthy diet counseling

• calculate calories spent in different physical activities

• explain the FITTP acronym in exercise prescription

• explain exercise rules for special groups such as

pregnancy and ASCVD

Objectives

Health Effects of Obesity

Prevalence of Medical Conditions by Body Mass Index (BMI) for Men

Medical Condition Body Mass Index

18.5 to 24.9

25 to 29.9

30 to 34.9

> 40

Prevalence Ratio (%)

Type 2 Diabetes 2.03 4.93 10.10 10.65

Coronary Heart Disease

8.84 9.60 16.01 13.97

High Blood Pressure 23.47 34.16 48.95 64.53

Osteoarthritis 2.59 4.55 4.66 10.04

American Obesity Association .AOA Fact Sheets. Health effects of obesity. http://obesity1.tempdomainname.com/subs/fastfacts/Health_Effects.shtml

10kg Weight Loss in 100kg Patient With Obesity Related Co-morbidities

Mortality 20-25% fall in total mortality

30-40% fall in diabetes related deaths

40-50% fall in obesity related cancer deaths

Blood pressure fall of approximately 10mm/Hg in both systolic and diastolic

values

Reduces the risk of developing diabetes by >50%

Fall of 30-50% F. glucose

Fall of 15% HbAIC

Lipids: Fall of 10% in total cholesterol

Fall of 15% LDL

Fall of 30% triglycerides

Increase of 8% in HDL1Hubert HB et al. Circulation 1996; 93: 1372–9, 2Colditz GA et al. Am J Epidemiol 1990; 132: 501–13, 3Chan JM et

al. Diabetes Care 1994; 17: 961–9, 4Soloman CG, Manson JE. Am J Clin Nutr 1997; 66 (Suppl. 4): 1055S–50S, 5Schapira DV et al. Cancer 1994; 74: 632–9

TreatmentTreatment 25–26.925–26.9 27–29.927–29.9 30–34.930–34.9 35–39.935–39.9 4040

Diet, physicalDiet, physical Yes withYes with Yes withYes with YesYes YesYes YesYes

activity,activity, comorbidities comorbidities comorbidities comorbidities

behaviorbehavior

therapytherapy

Pharmaco-Pharmaco- Yes withYes with YesYes YesYes YesYes

therapytherapy comorbidities comorbidities

Weight-lossWeight-loss Yes with Yes with YesYes

surgerysurgery comorbidities comorbidities

Obesity TreatmentBMI CategoryBMI Category

**YesYes alone indicates that the treatment is indicated regardless of the presence or alone indicates that the treatment is indicated regardless of the presence or absence of comorbidities. The solid arrow signifies the point at which therapy is absence of comorbidities. The solid arrow signifies the point at which therapy is

initiated.initiated.

NIH/NHLBI/NAASO; October 2000. NIH Publication No. 00-4084.

Healthy Diet Pyramid

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Europrev healthy diet, 2005 (modified)

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Healthy diet counseling

• Organization– Arrange for an appointment – Patient’s confidence in the GP and nurses– Consult a dietician if needed– Try to make the healthy lifestyle popular– Arrange discussion meetings with groups

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Healthy diet counseling

• Method– Person’s capacity for understanding– Use appropriate words

– Talk quietly. Do not judge or preach– Explore the person’s knowledge– Explore eating behaviours – Do not set time limits– Answer questions and clarify– Reinforce positive behaviour

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Healthy diet counseling

• Concepts– They are going to feel better – Try to convert persons’ concept – Healthy diet is a way to increase health and well-being.– Use the word ‘food’ instead of ‘diet’– No inflexible ban on some foods– Voluntary and willingly– Encourage people to think about “pros”– In adolescents, do not convey the message: “the thinner

the better”10

Healthy diet counseling

• Techniques– Eat several meals a day– Don’t skip meals– Eat slowly– Avoid lots of salt– Modify the total number of calories consumed

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Healthy diet counseling• The composition of meals

– Increase the amount of fibre – Decrease the amount of refined foods – Eat traditional wholegrain bread and cereals– Eat fruit and vegetables more than twice a day – Reduce the consumption of red meat– Increase the consumption of fish– Eat few eggs a week– Consume skimmed milk and yoghurt – Drink a lot of liquids, especially water

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Healthy diet counseling

• Cooking– Avoid pre-cooked food, fast food, salted meals,

manufactured sweets and cakes.– Roast, boil or grill food instead of frying– Avoid cooking with a lot of salt.– Use olive oil

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Physical activity counseling

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Is your patient ready?

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Prescribing physical activity

• Caloric threshold– The optimal caloric threshold for a healthy adult is

2000 kcal/week. • Calories spent in physical activity:

16American College of Sport Medicine

Prescribing physical activity

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Prescribing physical activity

• F - frequency (how many days per week)

• I - intensity (mild, moderate, intense)

• T - time (quantity of physical activity/day)

• T - type of activity (aerobic, anaerobic, for strength, stretching…)

• P - progression

18EUROPREV Guide on Promoting Health through Physical Activity

A Guide to Physical Activity Counselling in Daily Practice, 2007

Prescribing physical activity

• F- Frequency– It is advisable that the patients are active every day,

no matter what type of activity they choose. – Physical activity gives beneficial effects when done

regularly,– the minimum being 30 minutes for 3-5 days per week

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Prescribing physical activity

• I – Intensity– Mild:

• strolling, walking slowly, doing moderate housekeeping,

• The heart rate (pulse) in mild exercise is less than 50% of the maximal pulse

– Moderate:• walking briskly, mowing the lawn...

• heart rate is 50-70% of the maximal pulse.

– Intensive:• jogging, engaging in heavy yard work...

• heart rate is more than 70% of the maximal pulse. 20

Prescribing physical activity

• Intensity assessment– One can count his/her heart beats or observe his/her

reaction to exercise.

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Prescribing physical activity

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Subjective evaluation of intensity

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Prescribing physical activity

• T- Type– Anaerobic

• Without air ie energy exchange in living tissue independent of oxygen

• brief, strength-based activities such as sprinting or bodybuilding, weight lifting, sprinting, jumping ...

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Prescribing physical activity

• T- Type– Aerobic

• Aerobic meaning requiring air/oxygen

• Aerobic exercise is generally activity performed over a long period of time, typically 20 min. Or more

• Continuous activities that involve using the large muscles in the arsm or legs are called indurance or aeorbic exercise

• endurance activities such as marathon running or long-distance cycling, swimming, dancing, walking, running, climbing stairs...

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Typical Aerobic Exercise session

ACSM (2006) p.137

Prescribing physical activity

• Balanced physical activity

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Prescribing physical activity

• Start the exercise session with a gradual warm-up– During this time (about 5 to 10 minutes), one should

slowly stretch muscles first, and then gradually increase the level of activity.

– For example, one should begin walking slowly and then pick up the pace.

• When the exercise is finished, cool down for about 5 to 10 minutes, stretch the muscles and let the heart rate slow down gradually.

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Prescribing physical activity

• T- Time

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Prescribing physical activity

• P- Progression

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Exercise advice and tips

1. Start by talking with your doctor

2. Start out slowly

3. Choose the activity you like to do

4. Get a partner

5. Vary your routine

6. Choose a comfortable time of day

7. Don't get discouraged

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Exercise advice and tips

8. Forget "no pain, no gain“

9. Make exercise fun

10.Use appropriate clothes and footwear.

11.Drink plenty of fluids.

12.Warm up before starting

13.Do not forget to cool down

14.Self-monitoring– Record food intake daily– Check body weight 1 x/wk

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Special Considerations

• Pregnancy – target HR < 140 – (60-70% MaxHR)– Duration 30-45 minutes

• Breastfeeding – reports of failure of milk production in strenuously exercising women

ASCVD

Risk categories for exercise • Class A — Individuals who are apparently healthy and in

whom there is no clinical evidence of increased cardiovascular risk with exercise.

• Class B — Individuals with established CHD that is clinically stable. These individuals are at low risk of cardiovascular complications of vigorous exercise.

• Class C — Individuals who are at moderate or high risk of cardiovascular complications during exercise. Examples of people who would be in this category are those who have had several heart attacks and those who have chest pain at a relatively low level of exercise. Patients with certain positive findings on an exercise test may also be in this group.

• Class D — Individuals with unstable disease who should not participate in an exercise program.

ASCVD

• Class A – No prescreening recommended• Class B – ECG monitored for the first 6 sessions• Class C – Monitored exercise until 8-12 weeks.• Class D – not able to exercise

* Warm up and cool down periods should be monitored for B & C.