1450466001 Fitness

Seventh Edition

Advanced Fitness Assessment and

Exercise Prescription Vivian H. Heyward, PhD University of New Mexico

Ann L. Gibson, PhD University of New Mexico

Human Kinetics

Library of Congress Cataloging-in-Publication Data Heyward, Vivian H., author. Advanced fitness assessment and exercise prescription / Vivian H. Heyward, Ann L. Gibson. -- Seventh edition. p. ; cm. Includes bibliographical references and index. I. Gibson, Ann L., 1953- author. II. Title. [DNLM: 1. Physical Fitness--physiology. 2. Exercise Movement Techniques. 3. Exercise Test. QT 255] GV436 613.7--dc23 2013040595 ISBN-13: 978-1-4504-6600-4 (print) Copyright © 2014 by Vivian H. Heyward and Ann L. Gibson Copyright © 2010, 2006, 2002, 1998, 1991 by Vivian H. Heyward Copyright © 1984 by Burgess Publishing Company All rights reserved. Except for use in a review, the reproduction or utilization of this work in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including xerography, photocopying, and recording, and in any information storage and retrieval system, is forbidden without the written permission of the publisher. Notice: Permission to reproduce the following material is granted to instructors and agencies who have purchased Advanced Fitness Assessment and Exercise Prescription, Seventh Edition: pp. 366-369, 377-378, 381-383, 386-387, 407-416, 419-427, 430-440, 446-464. The reproduction of other parts of this book is expressly forbidden by the above copyright notice. Persons or agencies who have not purchased Advanced Fitness Assessment and Exercise Prescription, Seventh Edition, may not reproduce any material. The web addresses cited in this text were current as of October, 2013, unless otherwise noted. Acquisitions Editor: Amy N. Tocco; Developmental Editor: Kevin Matz; Managing Editor: Susan Huls; Copyeditor: Joy Wotherspoon; Indexer: Nancy Ball; Permissions Manager: Dalene Reeder; Graphic Designer: Joe Buck; Graphic Artist: Julie L. Denzer; Cover Designer: Keith Blomberg; Photographs (interior): © Human Kinetics unless otherwise noted; Photo Asset Manager: Laura Fitch; Visual Production Assistant: Joyce Brumfield; Photo Production Manager: Jason Allen; Art Manager: Kelly Hendren; Associate Art Manager: Alan L. Wilborn; Illustrations: © Human Kinetics; Printer: Edwards Brothers Malloy We thank the Exercise Physiology Laboratory at the University of New Mexico, Albuquerque, New Mexico, for assistance in providing the location for the photo shoot for this book. Printed in the United States of America   10 9 8 7 6 5 4 3 2 1 The paper in this book is certified under a sustainable forestry program. Human Kinetics Website: www.HumanKinetics.com United States: Human Kinetics P.O. Box 5076 Champaign, IL 61825-5076 800-747-4457 e-mail: [email protected] Canada: Human Kinetics 475 Devonshire Road Unit 100 Windsor, ON N8Y 2L5 800-465-7301 (in Canada only) e-mail: [email protected] Europe: Human Kinetics 107 Bradford Road Stanningley Leeds LS28 6AT, United Kingdom +44 (0) 113 255 5665 e-mail: [email protected]

Australia: Human Kinetics 57A Price Avenue Lower Mitcham, South Australia 5062 08 8372 0999 e-mail: [email protected] New Zealand: Human Kinetics P.O. Box 80 Torrens Park, South Australia 5062 0800 222 062 e-mail: [email protected]

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To those who set high expectations and to those who rise to the challenge.

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Contents Preface ix Acknowledgments xii Accessing the Online Video  xiii

Chapter 1

Physical Activity, Health, and Chronic Disease

1

Physical Activity, Health, and Disease: An Overview . . . . . . . . . . . . . . . . . 2 Cardiovascular Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Hypercholesterolemia and Dyslipidemia . . . . . . . . . . . . . . . . . . . . . . 10 Tobacco . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Obesity and Overweight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Metabolic Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Musculoskeletal Diseases and Disorders . . . . . . . . . . . . . . . . . . . . . . 18 Aging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Review Material . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Chapter 2 Preliminary Health Screening and Risk Classification

23

Preliminary Health Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Testing Procedures for Blood Pressure, Heart Rate, and Electrocardiogram . . . . 32 Review Material . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44

Chapter 3 Principles of Assessment, Prescription, and Exercise Program Adherence

47

Physical Fitness Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Basic Principles for Exercise Program Design . . . . . . . . . . . . . . . . . . . 56 Exercise Program Adherence . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Using Technology to Promote Physical Activity . . . . . . . . . . . . . . . . . . .63 Exercise Science as a Profession . . . . . . . . . . . . . . . . . . . . . . . . . .69 Review Material . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

Chapter 4 Assessing Cardiorespiratory Fitness

79

Definition of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Graded Exercise Testing: Guidelines and Procedures . . . . . . . . . . . . . . . 81 Maximal Exercise Test Protocols . . . . . . . . . . . . . . . . . . . . . . . . . .84 Submaximal Exercise Test Protocols . . . . . . . . . . . . . . . . . . . . . . . .99 Field Tests for Assessing Aerobic Fitness . . . . . . . . . . . . . . . . . . . . . 109 Exercise Testing for Children and Older Adults . . . . . . . . . . . . . . . . . . 112 Review Material . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 v

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Chapter 5 Designing Cardiorespiratory Exercise Programs

121

The Exercise Prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Aerobic Training Methods and Modes . . . . . . . . . . . . . . . . . . . . . . 135 Personalized Exercise Programs . . . . . . . . . . . . . . . . . . . . . . . . . 140 Review Material . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150

Chapter 6 Assessing Muscular Fitness

153

Definition of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 Strength and Muscular Endurance Assessment . . . . . . . . . . . . . . . . . 155 Sources of Measurement Error in Muscular Fitness Testing . . . . . . . . . . . 169 Additional Considerations for Muscular Fitness Testing . . . . . . . . . . . . . . 171 Muscular Fitness Testing of Older Adults . . . . . . . . . . . . . . . . . . . . . 173 Muscular Fitness Testing of Children . . . . . . . . . . . . . . . . . . . . . . . 178 Review Material . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179

Chapter 7 Designing Resistance Training Programs

181

Types of Resistance Training . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 Developing Resistance Training Programs . . . . . . . . . . . . . . . . . . . . 192 Common Questions About Resistance Training . . . . . . . . . . . . . . . . . 201 Effects of Resistance Training Programs . . . . . . . . . . . . . . . . . . . . . 209 Muscular Soreness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214 Review Material . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217

Chapter 8 Assessing Body Composition

219

Classification and Uses of Body Composition Measures . . . . . . . . . . . . . 220 Body Composition Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221 Reference Methods for Assessing Body Composition . . . . . . . . . . . . . . 223 Field Methods for Assessing Body Composition . . . . . . . . . . . . . . . . . 235 Review Material . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264

Chapter 9 Designing Weight Management and Body Composition Programs

267

Obesity, Overweight, and Underweight: Definitions and Trends . . . . . . . . . . 267 Obesity: Types and Causes . . . . . . . . . . . . . . . . . . . . . . . . . . . 271 Weight Management Principles and Practices . . . . . . . . . . . . . . . . . . 274 Well-Balanced Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276 Designing Weight Management Programs: Preliminary Steps . . . . . . . . . . 282 Designing Weight Loss Programs . . . . . . . . . . . . . . . . . . . . . . . . 287 Designing Weight Gain Programs . . . . . . . . . . . . . . . . . . . . . . . . . 299 Designing Programs to Improve Body Composition . . . . . . . . . . . . . . . 300 Review Material . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302

Contents • vii

Chapter 10 Assessing Flexibility

305

Basics of Flexibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305 Assessment of Flexibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308 Flexibility Testing of Older Adults . . . . . . . . . . . . . . . . . . . . . . . . . 320 Review Material . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324

Chapter 11 Designing Programs for Flexibility and Low Back Care

325

Training Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325 Stretching Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 326 Designing Flexibility Programs: Exercise Prescription . . . . . . . . . . . . . . . 331 Designing Low Back Care Exercise Programs . . . . . . . . . . . . . . . . . . 337 Review Material . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339

Chapter 12 Assessing Balance and Designing Balance Programs

341

Definitions and Nature of Balance . . . . . . . . . . . . . . . . . . . . . . . . 342 Factors Affecting Balance and Risk of Falling . . . . . . . . . . . . . . . . . . . 342 Assessment of Balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343 Designing Balance Training Programs . . . . . . . . . . . . . . . . . . . . . . 353 Review Material . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 360 Appendix A

Health and Fitness Appraisal

363

A.1 Physical Activity Readiness Questionnaire (PAR-Q) . . . . . . . . . . . . . . 364 A.2 Medical History Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . 366 A.3 Checklist for Signs and Symptoms of Disease . . . . . . . . . . . . . . . . 368 A.4 Physical Activity Readiness Medical Examination (PARmed-X) . . . . . . . . 370 A.5 SCORE High and Low CVD Risk Charts . . . . . . . . . . . . . . . . . . . 374 A.6 Relative Risk Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376 A.7 Lifestyle Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377 A.8 Fantastic Lifestyle Checklist . . . . . . . . . . . . . . . . . . . . . . . . . 379 A.9 Informed Consent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381 A.10 Websites for Selected Professional Organizations and Institutes . . . . . . 383 Appendix B

Cardiorespiratory Assessments

385

B.1 Summary of Graded Exercise Test and Cardiorespiratory Field Test Protocols . . . . . . . . . . . . . . . . . . . . . . . . . . . . 386 B.2 Rockport Fitness Charts . . . . . . . . . . . . . . . . . . . . . . . . . . . 388 B.3 Step Test Protocols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .390 B.4 OMNI Ratings of Perceived Exertion Scales . . . . . . . . . . . . . . . . . 393 B.5 Analysis of Sample Case Study in Chapter 5 . . . . . . . . . . . . . . . . . 397

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Appendix C

Muscular Fitness Exercises and Norms

401

C.1 Standardized Testing Protocols for Digital, Handheld Dynamometry . . . . . 402 C.2 Average Strength, Endurance, and Power Values for Isokinetic (Omni-Tron) Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 403 C.3 1-RM Squat and Bench Press Norms for Adults . . . . . . . . . . . . . . . 405 C.4 Isometric Exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 407 C.5 Dynamic Resistance Training Exercises . . . . . . . . . . . . . . . . . . . . 411 Appendix D

Body Composition Assessments

417

D.1 Prediction Equations for Residual Volume . . . . . . . . . . . . . . . . . . 418 D.2 Standardized Sites for Skinfold Measurements . . . . . . . . . . . . . . . . 419 D.3 Skinfold Sites for Jackson’s Generalized Skinfold Equations . . . . . . . . . 424 D.4 Standardized Sites for Circumference Measurements . . . . . . . . . . . . 425 D.5 Standardized Sites for Bony Breadth Measurements . . . . . . . . . . . . . 426 D.6 Ashwell Body Shape Chart . . . . . . . . . . . . . . . . . . . . . . . . . . 427 Appendix E

Energy Intake and Expenditure

429

E.1 Food Record and RDA Profile . . . . . . . . . . . . . . . . . . . . . . . . . 430 E.2 Sample Computerized Analysis of Food Intake . . . . . . . . . . . . . . . . 432 E.3 Physical Activity Log . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437 E.4 Gross Energy Expenditure for Conditioning Exercises, Sports, and Recreational Activities . . . . . . . . . . . . . . . . . . . . . . . . . 438 E.5 Healthy Eating Pyramids . . . . . . . . . . . . . . . . . . . . . . . . . . . 441 Appendix F

Flexibility and Low Back Care Exercises

445

F.1 Selected Flexibility Exercises . . . . . . . . . . . . . . . . . . . . . . . . . 446 F.2 Exercise Do's and Don’ts . . . . . . . . . . . . . . . . . . . . . . . . . . . 455 F.3 Exercises for Low Back Care . . . . . . . . . . . . . . . . . . . . . . . . . 460

List of Abbreviations  465 Glossary 467 References 477 Index 527 About the Authors  537

Preface A

dvanced Fitness Assessment and Exercise Prescription, Seventh Edition is written primarily for exercise science students in advanced professional courses dealing with physical fitness appraisal and exercise prescription. This book is also a resource for exercise physiologists or personal trainers working in the public or private sector. Previous editions of this text have been adopted for course use by numerous universities and colleges and have been translated into Chinese, Greek, Italian, Korean, Portuguese, and Spanish. Also, the seventh edition is now available as an electronic book, potentially allowing it to reach a wider audience worldwide. This book provides exercise scientists with the knowledge and skills needed to assess the physical fitness of apparently healthy individuals rather than individuals who have suspected or documented cardiovascular disease. Since this text is not clinically oriented, it provides limited information on the etiology and pathophysiology of chronic diseases, on clinical exercise testing, and on exercise prescriptions for clinical populations. Exercise scientists working with clinical populations are encouraged to consult clinically oriented books that provide detailed information for exercise testing and prescriptions for these populations. In its well-balanced approach to the assessment of physical fitness, Advanced Fitness Assessment and Exercise Prescription addresses five components: •• Cardiorespiratory endurance •• Muscular fitness •• Body weight and composition •• Flexibility •• Balance This text is unique in its scope and in the depth of its content, organization, and approach to the subject matter. Introductory texts typically focus on field testing for evaluating physical fitness. Although this text includes some field tests, it emphasizes labora-

tory techniques for assessment. The scope and depth of information make this text an important resource for practitioners, especially those employed in health and fitness settings. Generally, the text is organized around physical fitness components, providing for each of them one chapter on assessment followed by one chapter on exercise prescription. The multidisciplinary approach of this text synthesizes concepts, principles, and theories based on research in exercise physiology, kinesiology, measurement, psychology, and nutrition. The result is a direct and clear-cut approach to physical fitness assessment and exercise prescription. The scope and organization of the seventh edition of Advanced Fitness Assessment and Exercise Prescription are not substantially different from previous editions. Pedagogical tools include Key Questions at the beginning of each chapter and Key Points, Review Questions, and Key Terms at the end of each chapter. Each of the key terms is defined in the glossary at the end of the book. These tools will help you identify the key terms and concepts and test your knowledge and understanding of the material in each chapter. Pertinent information from the latest edition (2014) of ACSM’s Guidelines for Exercise Testing and Prescription is incorporated throughout the text. Updated phone numbers and websites for equipment manufacturers and suppliers are included. The following list highlights some of the changes in the chapters of Advanced Fitness Assessment and Exercise Prescription, Seventh Edition:

Chapter 1 •• Recent global and U.S. statistics on the prevalence of chronic diseases •• New research substantiating the link between physical activity and disease risk •• Expanded information on prediabetes, overweight/obesity, metabolic syndrome, and osteoporosis •• New physical activity recommendations from the U.S. government, the American Heart

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Association, and the American College of Sports Medicine (ACSM) •• Information about beneficial effects of physical activity on life expectancy

Chapter 2 •• Updated information on risk factor identification and risk stratification •• Inclusion of SCORE system to estimate 10 yr risk of fatal cardiac event due to atherosclerosis •• Latest (2014) ACSM guidelines regarding medical exam and exercise testing requirements prior to beginning exercise programs •• Updated information on automated and hybrid sphygmomanometers •• New information on white coat hypertension and masked hypertension

Chapter 3 •• Expanded information about the use of technology and wireless body area networks to monitor physical activity and physiological responses to exertion •• Updated information on the use of exergaming to promote physical activity and exercise for children and older adults •• New information on the use of social networking media to promote physical activity and increase adherence to an exercise program •• Updated information about the certification and licensure of exercise professionals •• Comparison of selected professional certifications

Chapter 4 •• Updated statistics on the risk of adverse cardiac events during exercise testing •• Latest (2014) ACSM guidelines for exercise testing •• New field method for predicting maximum heart rate •• New information on the importance of monitoring participants during bench-step tests •• Recumbent stepper submaximal exercise test protocol •• New protocols for assessing the cardiorespiratory fitness level of children •• Expanded number of OMNI pictorial scales for ratings of perceived exertion during exercise

Chapter 5 •• Latest (2014) ACSM FITT-VP principle for designing aerobic exercise programs •• Use of kettlebell exercises to improve aerobic fitness •• New information on monitoring exercise intensity with rating of perceived exertion (RPE) scales •• Updated information on high-intensity interval · training to improve VO2max

Chapter 6 •• Clinical methods of isometric muscle testing with endurance norms •• Core stability muscle tests •• Tips for spotting resistance exercises

Chapter 7 •• Updated guidelines for developing resistance training programs for novice, intermediate, and advanced weightlifters •• Updated information on designing resistance training programs for older adults •• Whole-body vibration training as an adjunct to resistance training •• Kettlebell training for improving strength, muscle endurance, and cardiorespiratory fitness •• New information about the transcriptome signature of resistance training •• Updated information about the effectiveness of supplements for increasing strength

Chapter 8 •• New underwater weighing technique for decreasing amount of time client is fully submerged •• Updated information about air displacement plethysmography and dual-energy X-ray absorptiometry as reference methods for body composition assessment •• Use of bioimpedance spectroscopy and multifrequency bioimpedance analysis to estimate body composition •• Updated information on digital skinfold caliper systems •• Updated information on using populationspecific anthropometric indices to classify disease risk

Preface • xi

Chapter 9 •• Updated statistics on the global prevalence of obesity in children and adults •• New dietary guidelines for Americans •• MyPlate replaces healthy eating pyramid •• Evaluation of dietary and nutrition supplements for weight loss

Chapter 10 •• Updated information on dynamic stretching and constant tension stretching •• Use of stretching and active warm-up for increased flexibility

Chapter 11 •• Updated guidelines for designing stretching programs •• Physiological mechanisms underlying improvements in range of motion •• Whole-body vibration training as an adjunct to flexibility training •• Updated information about stretching and its effect on maximal muscle performance •• Comparison of active and passive stretching

Chapter 12 •• Definition of neuromotor training and ACSM recommendations for neuromotor training •• Reactive balance tests •• Effects of preactivity stretching on balance performance •• Gait-velocity testing •• Sample progressive balance training program

Appendixes •• Updated websites for professional organizations •• OMNI pictorial scales for assessing ratings of perceived exertion of adults and children •• Age-gender squat and bench press norms for novice to elite lifters These updates and additions provide a comprehensive approach to physical fitness appraisal and exercise prescription. We hope you will use Advanced Fitness Assessment and Exercise Prescription, Seventh Edition to improve your knowledge, skill, and professional competence as an exercise scientist.

Ancillary Support To ensure fully integrated support for every faculty member, the following ancillaries are available to adopters of Advanced Fitness Assessment and Exercise Prescription, Seventh Edition at www. HumanKinetics.com/AdvancedFitnessAssessment AndExercisePrescription. •• Instructor guide. Includes sample syllabi, course outlines, a class project, and activity and lab suggestions. •• Test package. Includes more than 250 true-orfalse, multiple-choice, fill-in-the-blank, and shortanswer questions. •• Presentation package plus image bank. Includes more than 400 PowerPoint text slides that highlight material from the text that instructors can use for class discussion and demonstration. Plus, the image bank includes most of the figures, content photos, and tables from the text, sorted by chapter, that can be used to develop a customized presentation based on specific course requirements. •• Chapter quizzes. A 25-question quiz at the conclusion of each chapter helps instructors assess students’ comprehension of the most important concepts in the chapter. Chapter quizzes can be imported into learning management systems or used in RTF format by instructors who prefer to offer a written quiz. •• Online video. Includes over 60 video clips for more than 75 minutes of content, helping readers focus on the content of the text. The video demonstrates exercise assessments, procedures, and common errors and offers tips on interacting with clients. Instructors can use the video in the classroom to help students visualize the techniques. Students will have access to the video, which is cross-referenced to relevant content in the text with a

in the book’s margin.

•• Visit www.HumanKinetics.com/Advanced FitnessAssessmentAndExercisePrescription to find the video clips, which are separated by chapter and intuitively titled for easy cross referencing with the text.

Acknowledgments T

he first edition of this textbook was titled Designs for Fitness and was published by Burgess Publishing Co. in 1984. It was a softcover book having about 200 pages. Dr. Swede Schoeller took the photos for that edition and Eileen Fletcher, our department secretary, typed the manuscript on her Smith-Corona. The second edition was published by Human Kinetics Publishers in 1991. This edition was a hardcover book consisting of 350 pages. For this edition, Linda K. Gilkey took the photos. For the first time, the manuscript was typed using a DOS word processing system by the department secretary, Sandi Travis. In 1998, the third edition was published by HK. The book grew in size from a 7" × 9" format to an 8.5" × 11" format. Once again, Linda K. Gilkey took the photos, and the computer graphics were done by Dr. Robert Robergs, Dr. Brent Ruby, and Dr. Peter Egan. The fourth edition, published by HK in 2002, was 370 pages. Our colleagues, Dr. Christine Mermier, Dr. Virginia Wilmerding, Dr. Len Kravitz, and Dr. Donna Lockner, shared their excellent ideas and expertise. The developmental editors, Elaine

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Mustain and Maggie Schwarzentraub, meticulously edited this edition. In 2006, the fifth edition was released. For this edition, the total number of pages increased to 425, and HK updated all of the photos. Sarah Ritz did an excellent job organizing and taking these photos. Dr. Dale Wagner contributed the test question bank that accompanied this edition. The sixth edition was released in May 2010. For the first time, this book was also published as an e-book. The book expanded to 480 pages. Dr. Dale Wagner updated the test question bank, and Dr. Ann Gibson prepared the slides for the presentation package. The seventh edition is now coauthored with Dr. Ann Gibson. Her knowledge, expertise, and contributions have greatly improved the scope and content of this edition. In addition to being published as an e-book, the seventh edition will be supplemented with instructional videos. Many individuals have contributed to the continued success of Advanced Fitness Assessment and Exercise Prescription. We are indebted to each person who played a role in the metamorphosis of this book.

Accessing the Online Video New to this seventh edition is online streaming video, including over 65 videos of content demonstrating key

concepts from the book, such as assessments, procedures, tips, stretches, and exercises. You can access the online video by visiting www.HumanKinetics.com/AdvancedFitnessAssessmentAndExercisePrescription. If you purchased a new print book, follow the instructions on the orange-framed page at the front of your book. That page includes access steps and the unique key code that you’ll need the first time you visit the Advanced Fitness Assessment and Exercise Prescription website. If you purchased an e-book from HumanKinetics.com, follow the access instructions that were e-mailed to you after your purchase. If you have purchased a used book, you can purchase access to the online video separately by following the links at www.HumanKinetics. com/AdvancedFitnessAssessmentAndExercisePrescription. Once at the Advanced Fitness Assessment and Exercise Prescription website, select Online Video in the ancillary items box in the upper-left corner of the screen. You’ll then see an Online Video page with information about the video. Select the link to open the online video web page. On the online video page, you will see a set of buttons that correspond to the chapters in the text that have accompanying video. Select the button for the chapter’s videos you want to watch. Once you select a chapter, a player will appear. In the player, the clips for that chapter will appear vertically along the right side, numbered as they are in the text. Select the video you would like to watch and view it in the main player window. You can use the buttons at the bottom of the main player window to view the video full screen and to pause, fast-forward, or reverse. Following is a list of the clips in the online video. Video 2.1 Resting BP measurement Video 2.2 Sources of BP measurement error Video 2.3 Measuring exercise BP Video 2.4 Measuring resting HR by auscultation Video 2.5 Measuring resting HR by palpation— brachial artery Video 2.6 Measuring resting HR by palpation— carotid artery Video 2.7 Measuring resting HR by palpation— radial artery Video 2.8 Measuring resting HR by palpation— temporal artery Video 2.9 Measuring HR using a heart rate monitor Video 2.10 6-lead ECG electrode placement Video 2.11 12-lead ECG electrode placement Video 2.12 Exercise ECG Video 4.1 Calibrating treadmills

Video 4.2 Calibrating cycle ergometers Video 4.3 Treadmill maximal exercise test Video 4.4 Cycle ergometer maximal exercise test Video 4.5 Treadmill submaximal exercise test Video 4.6 Cycle ergometer submaximal exercise test Video 4.7 How to safely mount a treadmill Video 6.1 Isometric muscle contraction Video 6.2 Concentric muscle contraction Video 6.3 Eccentric muscle contraction Video 6.4 Grip strength testing procedures Video 6.5 Grip endurance testing procedures Video 6.6 V-sit test Video 6.7 Side bridge test Video 6.8 Spotting over-the-face exercises Video 6.9 Pull-up tests Video 6.10 Push-up tests

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xiv • Accessing the Online Video

Video 6.11 Trunk curl tests Video 7.1 Inclined bench press Video 7.2 Flat bench press Video 7.3 Declined bench press Video 7.4 Pronated arm curl Video 7.5 Supinated arm curl Video 7.6 Mid arm curl Video 7.7 Common errors in performing the squat Video 7.8 Common errors in performing the bench press Video 8.1 Guidelines for hydrostatic weighing Video 8.2 Testing procedures for the Bod Pod Video 8.3 Whole-body BIA measures Video 8.4 Upper body BIA measures Video 8.5 Lower body BIA measures Video 10.1 Shoulder flexion Video 10.2 Knee flexion Video 10.3 Ankle flexion Video 10.4 Inclinometer test procedures Video 10.5 Modified sit-and-reach test Video 10.6 Modified back-saver sit-and-reach test Video 11.1 PNF stretching techniques

Video 12.1 Unipedal stance test Video 12.2 Functional reach test Video 12.3 Timed up and go test Video 12.4 Star excursion balance test Video C4.1 Chest push Video C4.2 Shoulder pull Video C4.3 Triceps extension Video D2.1 Measurement of the chest skinfold Video D2.2 Measurement of the subscapular skinfold Video D2.3 Measurement of the midaxillary skinfold Video D2.4 Measurement of the suprailiac skinfold Video D2.5 Measurement of the abdominal skinfold Video D2.6 Measurement of the triceps skinfold Video D2.7 Measurement of the biceps skinfold Video D2.8 Measurement of the thigh skinfold Video D2.9 Measurement of the calf skinfold Video F1.1 Hamstring stretch Video F1.2 Chest stretch

chapter

1

Physical Activity, Health, and Chronic Disease Key Questions uu Are adults in the United States getting enough physical activity? uu What diseases are associated with a sedentary lifestyle, and what are the major risk factors for these diseases? uu What are the benefits of regular physical activity in terms of disease prevention and healthy aging?

A

lthough physical activity plays an important role in the prevention of chronic diseases, an alarming percentage of adults in the United States report no physical activity during leisure time. One of the national health objectives for the year 2020 is to increase to 47.9% the proportion of people aged 18 yr and older who regularly (preferably daily) engage in moderate physical activity at least 30 min per day (U.S. Department of Health and Human Services 2010). According to a U.S. national survey, in 2010, a small percentage (20.7%) of adults over the age of 18 met the 2008 federal physical activity guidelines for adults in terms of both aerobic and muscle strengthening activities. Slightly more than half (50.5%) met either the aerobic activity or the muscle-strengthening guideline, but not both (CDC 2011a). Generally, women (54%) are less likely to meet the full aerobic and muscle-strengthening recommendations than men (43.8%), and older (≥65 yr) adults are less likely (64.6%) to meet it than younger (18–24 yr) adults (39.4%) (CDC 2011a). Physical inactivity is not just a problem in the United States; it is a global issue and the fourth leading cause of global mortality (World Health

uu How does physical activity improve health? uu How much physical activity is needed for improved health benefits? uu What kinds of physical activities are suitable for typical people, and how often should they exercise?

Organization 2010). Results from survey data collected from 122 countries indicated that 31% of the global adult (≥15 yr) population is physically inactive. The prevalence of physical inactivity ranges from approximately 43% in the American and eastern Mediterranean countries to a low of 17% in southeast Asia (Hallal et al. 2012). In 2008, only 39% of men and 29% of women in the United Kingdom met the government’s physical activity guidelines (British Heart Foundation 2012). Also, the Canadian Fitness and Lifestyle Research Institute (2009) reported that 52% of Canadians (≥20 yr) did not meet the recommended 30 minutes of moderate to vigorous activity in 2007–2008. Thus, as an exercise specialist, you face the challenge of educating and motivating your clients to incorporate physical activity as a regular part of their lifestyles. This chapter deals with physical activity trends, risk factors associated with chronic diseases, the role of regular physical activity in disease prevention and health, and physical activity guidelines and recommendations for improved health. For definitions of terminology used in this chapter, see the glossary.

1

2 • Advanced Fitness Assessment and Exercise Prescription

Physical Activity, Health, and Disease: An Overview Our increased reliance on technology has substantially lessened work-related physical activity, as well as the energy expenditure required for activities of daily living like cleaning the house, washing clothes and dishes, mowing the lawn, and traveling to work. What would have once required an hour of physical work now can be accomplished in just a few seconds by pushing a button or setting a dial. As a result, more time is available to pursue leisure activities. The unfortunate fact is, however, that many individuals do not engage in physical activity during their leisure time. Although the human body is designed for movement and strenuous physical activity, exercise is not a part of the average lifestyle. One cannot expect the human body to function optimally and to remain healthy for extended periods if it is abused or is not

Coronary heart disease

used as intended. Physical inactivity has led to a rise in chronic diseases. Some experts believe that physical inactivity is the most important public health problem in the 21st century (Blair 2009). Each year at least 1.9 million people die as a result of physical inactivity (Cavill, Kahlmeier, and Racioppi 2006). Data from the Aerobics Center Longitudinal Study (Blair 2009) indicated that low cardiorespiratory fitness accounts for substantially more deaths (16%) compared to other risk factors (i.e., obesity 2–3%; smoking 8–10%; high cholesterol 2–4%; diabetes 2–4%; and hypertension 8–16%). Individuals who do not exercise regularly are at a greater risk for developing chronic diseases such as coronary heart disease (CHD), hypertension, hypercholesterolemia, cancer, obesity, and musculoskeletal disorders (see figure 1.1). For years, exercise scientists and health and fitness professionals have maintained that regular physical activity is the best defense against the development of many diseases, disorders, and illnesses. The importance of regular physical activity

Congestive heart failure

Cardiovascular diseases

Cardiomyopathy Hypercholesterolemia

Obesity

Hypertension Atherosclerosis

Overweight

Low back pain

Metabolic disorders

Musculoskeletal disorders

Diabetes

Bone fractures and connective tissue tears

Physical Inactivity and Sedentary Lifestyle

Breast

Osteoporosis Depression

Colon

Psychological disorders

Cancer Prostate

Osteoarthritis

Lung

Anxiety Pulmonary diseases Asthma

Emphysema Chronic bronchitis

Figure 1.1  Role of physical activity and exercise in disease prevention and rehabilitation.

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Mood

Physical Activity, Health, and Chronic Disease • 3

physical activity are needed to promote health and reduce the risk of chronic disease in adults. Table 1.1 summarizes the ACSM and AHA physical activity recommendations for adults. The recommended amounts of physical activity are in addition to routine activities of daily living (ADLs) such as cooking, shopping, and walking around the home or from the parking lot. The intensity of exercise is expressed in metabolic equivalents (METs). A MET is the ratio of the person’s working (exercising) metabolic rate to the resting metabolic rate. One MET is defined as the energy cost of sitting quietly. Moderate-intensity aerobic activity (3.0–6.0 METs or 5 or 6 on a 10-point perceived exertion scale) is operationally defined as activity that noticeably increases heart rate and lasts more than 10 min (e.g., brisk walking for 15 min). Vigorous-intensity activity (>6.0 METs or 7 or 8 on a 10-point perceived exertion scale) causes rapid breathing and increases heart rate substantially (e.g., jogging). For adults (18–65 yr) and older adults (>65 yr), the ACSM recommends a minimum of 30 min of moderate-intensity aerobic activity 5 days per week or 20 min of vigorous-intensity aerobic exercise 3 days per week. They also recommend moderate- to

in preventing disease and premature death and in maintaining a high quality of life received recognition as a national health objective in the first U.S. surgeon general’s report on physical activity and health (U.S. Department of Health and Human Services 1996). This report identified physical inactivity as a serious nationwide health problem, provided clear-cut scientific evidence linking physical activity to numerous health benefits, presented demographic data describing physical activity patterns and trends in the U.S. population, and made physical activity recommendations for improved health. In 1995, the CDC and the American College of Sports Medicine (ACSM) recommended that every U.S. adult should accumulate 30 min or more of moderate-intensity physical activity on most, preferably all, days of the week (Pate et al. 1995). Since 1995, new scientific evidence has increased our understanding of the benefits of physical activity for improved health and quality of life. In light of these findings, the American Heart Association (AHA) and the ACSM updated physical activity recommendations for healthy adults and older adults (Haskell et al. 2007; Nelson et al. 2007). These recommendations address how much and what kind of

Table 1.1  ACSM/AHA Physical Activity Recommendations Aerobic activitya Population group

Durationb (min/day)

Healthy adults 18-65 yr

30

Older adults >65 yr

Muscle-strengthening activity Frequency (days/wk)

Sets

Moderate (3.0–6.0 METS)

Minimum 5

20

Vigorous (>6.0 METS)

Minimum 3

30

Moderate (5 or 6 on 10 pt. scale)

Minimum 5

20

Vigorous (7 or 8 on 10 pt. scale)

Minimum 3

Intensity

Flexibility/ balance activity

Intensity or # of exercises

Frequency (days/wk)

1

8- to 12-RM; 8–10 exercises for major muscle groups

≥2 nonconsecutive days

No specific recommendation

1

10- to 15-RM; 8–10 exercises for major muscle groups; Moderate intensity (5 or 6 on 10 pt. scale) Vigorous intensity (7 or 8 on 10 pt. scale)

2 nonconsecutive days

For flexibility at least 2 days per wk for at least 10 min each day; include balance exercises for those at risk for falls.

a Combinations of moderate- and vigorous-intensity may be performed to meet recommendation (e.g., jogging 20 min on 2 days and brisk walking on 2 other days). b

Multiple bouts of moderate-intensity activity, each lasting at least 10 min, can be accumulated to meet the minimum duration of 30 min.

4 • Advanced Fitness Assessment and Exercise Prescription

high-intensity (8- to 12-repetition maximum [RM] for adults and 10- to 15-RM for older adults) resistance training for a minimum of 2 nonconsecutive days per week. Balance and flexibility exercises are also suggested for older adults. Table 1.2 summarizes the physical activity guidelines (U.S. Department of Health and Human Services 2008) for children and adolescents (6–17 yr), adults (18–64 yr), and older adults (≥65 yr). The key message in these guidelines is that for substantial health benefits, adults should engage in aerobic exercise at least 150 min per week at a moderate intensity or 75 min per week at a vigorous intensity. In addition, adults and older adults should do muscle-strengthening activities at least 2 days per week. Children should do at least 60 min of physical activity every day. Most of the 60 min per day should be either moderate or vigorous aerobic activity and should include vigorous aerobic activities at least 3 days per week. Part of the 60 min or more of daily physical activity should be musclestrengthening activities (at least 3 days a week) and bone-strengthening activities (at least 3 days a week). The term exercise deficit disorder (EDD) has been used to identify children who do not attain at least 60 min of moderate- to vigorous-intensity physical activity on a daily basis. Children having EDD may be susceptible to pathological processes associated with a physically inactive lifestyle (Faigenbaum and Myer 2011). Exercising 150 min/wk equates to expending approximately 1000 kcal·wk−1. Results from a recent meta-analysis (Sattelmair et al. 2011) indicated that individuals meeting the 2008 physical activity guidelines decrease their risk for coronary heart disease by 14% compared to those reporting no leisure-time physical activity. Participating in moderate-intensity physical activity on a daily basis also reduces the risk of hypertension, diabetes, and stroke, as well as colon and breast cancer (Kesäniemi et al. 2010; McTiernan et al. 2003; U.S. Department of Health and Human Services, 1996). Disease risk is further reduced when the moderate-intensity physical activity (150–180 min/wk) is performed throughout the week (i.e., 30 min/day on 5 days/wk) and in bouts lasting at least 10 min as opposed to in one single session (Kesäniemi et al. 2010). Sattelmair and colleagues (2011) reported that 300 min/wk of moderate-intensity physical activ-

ity results in a 20% reduction in the risk for CHD. Furthermore, a review of studies on asymptomatic adults (19–65 yr) revealed that 90 min of vigorousintensity physical activity accumulated throughout the week (90 min/wk) in increments of no fewer than 10 min reduces the risk of all-cause mortality by 30%, as well as the risk for cardiovascular disease (CVD), hypertension, stroke, type 2 diabetes, and breast and colon cancer (Kesäniemi et al. 2010). In 2009, an international consensus conference was convened to review Canada’s Physical Activity Guide to Healthy Active Living (Health Canada 2003). The consensus panel recommended that asymptomatic Canadian adults (19–65 yr) accumulate 150 min/wk of moderate-intensity or 90 min/wk of vigorous-intensity physical activity as a primary prevention against cardiovascular disease, stroke, hypertension, colon cancer, breast cancer, type 2 diabetes, and osteoporosis. They also recommended multiple exercise sessions in a week, with each session lasting a minimum of 10 min (Kesäniemi et al. 2010). In addition to the aerobic exercise, they recommended strength activities (2–4 days/ wk), and flexibility activities (4–7 days/wk). The duration of the activity depends on the intensity or effort: Perform light activities (e.g., walking, video gaming that promotes light effort, gardening, carrying small children, or hairstyling) for 60 min, moderate activities (e.g., brisk walking, swimming, vacuuming, moving furniture, or chopping wood) for 30 to 60 min, and vigorous activities (e.g., jogging, hockey, wheelchair basketball, felling large trees, or rollerblading) for 20 to 30 min. Improvements in health benefits depend on the volume (i.e., combination of frequency, intensity, and duration) of physical activity. This is known as the dose-response relationship (Bouchard 2001; Canadian Society for Exercise Physiology 2003; Kesaniemi et al. 2001). Because of the dose-response relationship between physical activity and health, the ACSM/CDC physical activity recommendation states that “persons who wish to improve their personal fitness, reduce their risk for chronic diseases and disabilities, or prevent unhealthy weight gain will likely benefit by exceeding the minimum recommended amount of physical activity” (Haskell et al. 2007, p. 1431). Figure 1.2 illustrates the general dose-response relationship between the volume of physical activity

5

a

150–300 min/wk

Active

Vigorous (RPE = 7 or 8)

Moderate (RPE = 5 or 6)

Light (RPE = 3 or 4) to moderate (RPE = 5 or 6) ≥3 days/wk

≥1

1

2 or 3

≥1

1

Sets

Moderate (RPE = 5 or 6) to high (RPE = 7 or 8) 8- to 12-RM

Light (RPE = 3 or 4) to moderate (RPE = 5 or 6)

Moderate to high

Moderate to high 8- to 12-RM

Light to moderate

Moderate to high

Intensitya

≥2 days/wk, nonconsecutive days

2 or 3 days/wk

≥2 days/wk

≥2 days/wk

1 day/wk

3 days/wk

Frequency

Muscle-strengthening activities

3 days/wk

Bonestrengthening activities

Intensity is expressed in METs and repetition maximums (RM) for adults; for older adults, intensity is expressed as a rating of perceived exertion (RPE; 0-10 scale) and RM.

75–150 min/wk

or

150 min/wk

Vigorous (≥6.0 METs)

>150 min/wk

Inactive

Older adults ≥65 yr

Moderate (3.0–5.9 METs)

>300 min/wk

Vigorous (≥6.0 METs)

Highly active

75–150 min/wk



Moderate (3.0–5.9 METs)

150–300 min/wk or

Active

5 days/wk

3 days/wk

Vigorous

Light (1.1–2.9 METs) to moderate (3.0–5.9 METs)

Daily

Frequency

Moderate

Intensitya

60–150 min/wk

≥60 min

Duration

Aerobic activities

Inactive

Adults 18-64 yr

Children and adolescents 6-17 yr

Population group

Table 1.2  2008 Physical Activity Guidelines for Americans

Older adults should stretch to maintain flexibility for regular PA and ADLs. ≥3 days/wk balance

All adults should stretch to maintain flexibility for regular physical activity (PA) and activities of daily living (ADLs)

Flexibility and balance activities

6 • Advanced Fitness Assessment and Exercise Prescription

Health Benefits of Physical Activity Lower risk of • dying prematurely, • coronary artery disease, • stroke, • type 2 diabetes and metabolic syndrome, • high blood pressure, • adverse blood lipid profile, • colon, breast, lung, and endometrial cancers, and • hip fractures.

Reduction of • abdominal obesity and • feelings of depression and anxiety. Helps in • weight loss, weight maintenance, and prevention of weight gain, • prevention of falls and improved functional health for older adults, • improved cognitive function, • increased bone density, and • improved quality of sleep.

Data from USDHHS 2008.

Percent of potential improvement achieved

100 Triglycerides (TG)

80

Blood pressure

60

Body composition

40

High-density lipoproteins (HDL)

20

0

0

500

1000 1500 2000 Volume of physical activity (kcal/wk)

2500

3000

Figure 1.2  Dose-response relationship for health benefits and volume of physical activity. Source: The Canadian Physical Activity, Fitness & Lifestyle Approach: CSEP-Health & Fitness Program’s Health-Related Appraisal and Counselling Strategy, 3rd Edition © 2003. Reprinted with permission of the Canadian Society for Exercise Physiology. Schematic developed by N. Gledhill and V. Jamnik of York University.

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participation and selected health benefits (e.g., muscular strength and aerobic fitness) that do not require a minimal threshold intensity for improvement. The volume of physical activity participation needed for the same degree of relative improvement (%) varies among health benefit indicators. For example, to improve triglycerides from 0% to 40% requires 250 kcal·wk−1 of physical activity compared to 1800 kcal·wk−1 for the same relative improvement

(0–40%) in high-density lipoprotein (HDL; see figure 1.2). Additionally, you should note that too much physical activity, defined as engaging in 5 hr of structured high-intensity activity per week, may be associated with negative health consequences or overuse injuries. For extensive reviews of literature dealing with the dose-response relationship between physical activity and health, see Medicine & Science in Sports & Exercise (June 2001, Supplement).

Physical Activity, Health, and Chronic Disease • 7

Although the physical activity guideline—a minimum of 150 min per week of moderate-intensity aerobic activity, preferably performed 30 min/ day—reduces disease risk, it may not be optimal for maintaining a healthy body weight (Kesäniemi et al. 2010). In 2002, the Institute of Medicine (IOM) recommended 60 min of daily moderate-intensity physical activity. In the IOM report, the expert panel stated that 30 min of daily physical activity is insufficient to maintain a healthy body weight and to fully reap its associated health benefits. The IOM recommendation addresses the amount of physical activity necessary to maintain a healthy body weight and to prevent unhealthful weight gain (Brooks et al. 2004). The IOM recommendation of 60 min of daily physical activity is consistent with recommendations for preventing weight gain made by other organizations (i.e., Health Canada, International Association for the Study of Obesity, and World Health Organization) (Brooks et al. 2004). The bottom line is that 150 min per week of moderateintensity physical activity provides substantial health benefits but may be insufficient to prevent weight gain for many individuals. It is a good initial goal

and a sufficient amount of activity to move individuals from a sedentary to low physical activity level (Brooks et al. 2004). As individuals adopt regular physical activity and improve their lifestyle and fitness, they should increase the duration of daily physical activity to a level (60 min) that prevents weight gain and provides additional health benefits. This goal is especially important for individuals who have difficulty controlling their body weight (Blair, LaMonte, and Nichaman 2004; Lohman, Going, and Metcalfe 2004), and it is sufficient to move individuals from a sedentary to active physical activity level (Brooks et al. 2004). The Exercise and Physical Activity Pyramid illustrates a balanced plan of physical activity and exercise to promote health and to improve physical fitness (see figure 1.3). You should encourage your clients to engage in physical activities around the home and workplace on a daily basis to establish a foundation (base of pyramid) for an active lifestyle. They should perform aerobic activities a minimum of 3 days/wk; they should do weight-resistance exercises and flexibility or balance exercises at least 2 days per week. Recreational sport activities

Examples of Moderate-Intensity and Vigorous-Intensity Aerobic Activities This list provides several examples of moderate- and vigorous-intensity aerobic activities. Some activities can be performed at varied intensities. This list is not all-inclusive; examples are provided to help people make choices. For a detailed list of energy expenditures (METs) for conditioning exercises, sports, and recreational activities, see appendix E.4. Generally, light activity is defined as 6.0 METs.

Moderate Intensity • Walking briskly (3.0 mph [4.8 km·hr-1] or faster, but not race walking) • Water aerobics • Bicycling slower than 10 mph (16 km·hr-1) • Tennis (doubles) • Ballroom dancing • General gardening

Data from USDHHS 2008.

Vigorous Intensity • Race walking, jogging, or running • Swimming laps • Tennis (singles) • Aerobic dancing • Bicycling 10 mph (16 km·hr-1) or faster • Jumping rope • Heavy gardening (continuous digging or hoeing with heart rate increases) • Hiking uphill or with a heavy backpack

8 • Advanced Fitness Assessment and Exercise Prescription

Sports and recreational activities • 2-3 days a week • Intersperse days of training with a variety of sport and recreational activities • Follow safety rules for each activity • Wear protective equipment

Balance activities • 3 or more days a week, for prevention of falls • Tai chi, yoga, Pilates, and dance improve balance

Flexibility exercise • 2 or more days a week, preferably daily • 10 min duration minimum • 3-4 repetitions • Hold each stretch 10-30 sec

Resistance exercise • 2 or more days a week • 8-12 repetitions • 8-10 exercises • Rest at least one day between workouts

Aerobic exercise • 30 min, moderate-intensity (3-6 METs), 5 days a week or • 20 min, vigorous-intensity (>6 METs), 3 days a week • Activity can be continuous or in multiple segments of at least 10 min

Activities of daily living

• Daily physical activity is the base for physical fitness • Try to be active for at least 30 min every day

Figure 1.3  The Exercise and Physical Activity Pyramid. Adapted, by permission, from “Exercise and Activity Pyramid” Metropolitan Life Insurance Company, 1995.

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(middle levels of pyramid) are recommended to add variety to the exercise plan. High-intensity training and competitive sport (top of pyramid) require a solid fitness base and proper preparation to prevent injury; most adults should engage in these activities sparingly.

Cardiovascular Disease Cardiovascular disease (CVD) caused 17.3 million deaths (30%) worldwide in 2008, and it is projected to cause more than 26 million deaths by 2030 (World Health Organization 2011b). More than 80% of those cardiovascular deaths occurred in low- and middle-income countries (World Health

Organization 2007a). CVD is the principal cause of premature death in Europe, accounting for more of all deaths before age 75 in women (42%) than men (38%) (Fifth Joint Task Force of the European Society of Cardiology 2012). CVD is also a leading cause of disease burden in developing low- and middle-income countries; deaths due to CVD range from a low of 10% in sub-Saharan Africa to 58% in Eastern Europe (Wagner and Brath 2012). In 2008, diseases of the heart and blood vessels claimed the lives of 811,940 people in the United States alone. CVD accounted for 33% of all deaths (one out of every three) in the United States. More than 82 million Americans have some form of CVD such as hypertension (76.4 million), coronary heart disease (CHD; 16.3 million), or stroke (7 million) (AHA 2012). Among American adults 20 years of age

Physical Activity, Health, and Chronic Disease • 9

or older, the estimated age-adjusted prevalence of coronary heart disease is higher for black men and women compared to Mexican-American and white men and women (AHA 2008b). One myth about CVD is that it is much more prevalent in men than in women. In 2008, the prevalence of CVD in women (35.0%) and men (37.4%) in the U.S. was similar (AHA 2012). Nearly 419,000 females died from CVD in 2008 in the United States. Another misconception about CVD is that it only afflicts the older population. Although it is true that older people are at greater risk, more than 50% of the people in the United States with CVD are younger than 65 yr, and CVD ranks as the second-leading cause of death for children under age 15 (AHA 2012). Globally, coronary heart disease (CHD) accounts for more deaths than any other disease, with more than 7.6 million people dying from it in 2005 (World Health Organization 2007a). CHD is caused by a lack of blood supply to the heart muscle (myocardial ischemia) resulting from a progressive, degenerative disorder known as atherosclerosis. Atherosclerosis is an inflammatory process involving a buildup of low-density lipoprotein (LDL) cholesterol, scavenger cells (monocytes), necrotic debris, smooth muscle cells, and fibrous tissue. This is how plaques form in the intima, or inner lining, of the medium- and large-sized arteries throughout the cardiovascular system. As more lipids and cells gather in the plaques, they bulge into the arterial lumen (World Health Organization 2011b). In the heart, these bulging plaques restrict blood flow to the myocardium and may produce angina pectoris, which is a temporary sensation of tightening and heavy pressure in the chest and shoulder region. A myocardial infarction, or heart attack, can occur if a blood clot (thrombus) or ruptured plaque obstructs the coronary blood flow. In this case, blood flow through the coronary arteries is usually reduced by more than 80%. The portion of the myocardium supplied by the obstructed artery may die and eventually be replaced with scar tissue.

Coronary Heart Disease Risk Factors Epidemiological research indicates that many factors are associated with the risk of CHD. The greater

the number and severity of risk factors, the greater the probability of CHD. The positive risk factors for CHD are •• age, •• family history, •• hypercholesterolemia, •• hypertension, •• tobacco use, •• diabetes mellitus or prediabetes, •• overweight and obesity, and •• physical inactivity. An increased level (≥60 mg·dl–1) of high-density lipoprotein cholesterol, or HDL-cholesterol (HDLC), in the blood decreases CHD risk. If the HDL-C is high, you should subtract one risk factor from the sum of the positive factors when assessing your client’s CHD risk.

Physical Activity and Coronary Heart Disease Approximately 6% of CHD deaths worldwide can be attributed to a lack of physical activity (World Health Organization 2010). As an exercise scientist, you must educate your clients about the benefits of physical activity and regular exercise for preventing CHD. Physically active people have lower incidences of myocardial infarction and mortality from CHD and tend to develop CHD at a later age compared to their sedentary counterparts (Berlin and Colditz 1990). Individuals who exercise regularly reduce their relative risk of developing CHD by a factor of 1.5 to 2.4 (AHA 1999; Powell et al. 1987). Leading a physically active lifestyle may prevent 20% to 35% of cardiovascular diseases (Department of Health, Physical Activity, Health Improvement and Protection 2011). Physical activity exerts its effect independently of smoking, hypertension, hypercholesterolemia, obesity, diabetes, and family history of CHD (Bouchard, Shephard, and Stephens 1994). Also, in a meta-analysis of studies dealing with the dose-response effects of physical activity and cardiorespiratory fitness on CVD and CHD risk, Williams (2001) reported that cardiorespiratory fitness and physical activity have significantly

10 • Advanced Fitness Assessment and Exercise Prescription

different relationships to CVD and CHD risk. Although physical fitness and physical activity each lower the risk of developing CVD and CHD, the reduction in relative risk was almost twice as great for cardiorespiratory fitness as for physical activity. These findings suggest that in addition to physical activity level, cardiorespiratory fitness level should be considered a potential risk factor for CHD (U.S. Department of Health and Human Services 2008).

Hypertension Hypertension, or high blood pressure, is a chronic, persistent elevation of blood pressure that is clinically defined as a systolic pressure ≥140 mmHg or a diastolic pressure ≥90 mmHg. Individuals taking antihypertensive medicine also have this diagnosis. Prehypertension is a term used to describe individuals with a systolic pressure of 120 to 139 mmHg, a diastolic pressure of 80 to 89 mmHg, or both (Chobanian et al. 2003). A clear link exists between hypertension and CVD. The World Health Organization (2011b) identified hypertension as the leading cardiovascular risk factor, attributing 13% of deaths worldwide to high blood pressure. Hypertension is also the primary risk factor for all types of stroke (Dubow and Fink 2011). In the United States, 7.3% of all adult deaths occurring in 2008 were attributable to hypertension (Roger et al. 2012). About 15% to 40% of the global adult population has hypertension. Generally, the average blood pressure of adults from European countries (England, Finland, Germany, Italy, and Spain) is higher than that of American and Canadian adults (Wolf-Maier et al. 2003). In the United States, 25% to 33.5% of adults were told on at least two separate occasions that they have hypertension (AHA 2012; U.S. Department of Health and Human Service 2012b). Additionally, nearly one out of every three adults is prehypertensive (AHA 2012). In England, approximately 35% of adult men and 28% of adult women are hypertensive (British Heart Foundation 2008). In comparison, the prevalence of hypertension is estimated to be 10% to 17% for adults in the eastern Mediterranean region, 4% to 12% for adults in India, 8% for people 15 yr and older in China, and 5% to 12% for adults in Africa (AHA 2001).

Up to age 45 yr, the percentage of American men with hypertension (11–23%) is greater than that of women (6–18%). Between ages 45 and 54 yr, the prevalence of hypertension (37%) is similar for men and women. After age 65, the percentage of women (58%) with high blood pressure is somewhat higher than that of men (53%). Women with hypertension have a 3.5 times greater risk of developing CHD than do women who have normal blood pressure (normotensive). Also, the prevalence of high blood pressure for blacks in the United States (44%) is among the highest in the world and is substantially greater than that of American Indians or Alaskan Natives, Asians or Pacific Islanders, Mexican Americans, and whites in the United States (AHA 2012). Table 1.3 summarizes the risk factors associated with developing hypertension. Epidemiological studies indicate an inverse relationship between the resting blood pressure and the level of physical activity in women and men (Fagard 1999). Regular physical activity prevents hypertension and lowers blood pressure in younger and older adults who are normotensive, prehypertensive, or hypertensive. Compared to normotensive individuals, training-induced changes in resting systolic and diastolic blood pressures (5–7 mmHg) are greater for hypertensive individuals who participate in endurance exercise. However, even modest reductions in blood pressure (2–3 mmHg) by endurance or resistance exercise training decrease CHD risk by 5% to 9%, stroke risk by 8% to14%, and all-cause mortality by 4% in the general population (Pescatello et al. 2004). In a position paper on exercise and hypertension (Pescatello et al. 2004), the ACSM endorsed the following exercise prescription to lower blood pressure in adults with hypertension (see “Exercise Prescription for Individuals With Hypertension”).

Hypercholesterolemia and Dyslipidemia Hypercholesterolemia, an elevation of total cholesterol (TC) in the blood, is associated with increased risk for CVD. Hypercholesterolemia is also referred to as hyperlipidemia, which is an

Physical Activity, Health, and Chronic Disease • 11

Exercise Prescription for Individuals with Hypertension (ACSM 2013; Pescatello et al. 2004) Mode: Primarily endurance activities supplemented by resistance exercises Intensity: Moderate-intensity endurance (40– · 60% VO2R)* and resistance training (60–80% 1-RM) Duration: 30–60 min or more of continuous or

accumulated aerobic physical activity per day, and a minimum of one set (8–12 reps) of resistance training exercises for each major muscle group. Frequency: Most, preferably all, days of the week for aerobic exercise; 2 or 3 days/wk for resistance raining.

. . * VO2R is the difference between the maximum and the resting rate of oxygen consumption. See the “ VO2 Reserve (MET) Method” section in chapter 5 for more information.

increase in blood lipid levels; dyslipidemia refers to an abnormal blood lipid profile. Approximately 18% of strokes and 56% of heart attacks are caused by high blood cholesterol (World Health Organization 2002a). Over 98.8 million Americans age 20 yr and older have total blood cholesterol levels of 200 mg·dl-1 or higher. Based on data from 2008, 33.6 million American adults ≥20 yr have TC levels that are classified as high risk (>240 mg·dl-1); more women (19 million) than men (14.6 million) have TC levels equaling or exceeding 240 mg·dl-1 (Roger et al. 2012). Compared to those in Western countries, the average TC levels for adults in China, Japan, and Indonesia are uniformly lower (190–207 mg·dl-1) (AHA 2001). Risk factors for hypercholesterolemia are identified in table 1.3.

LDLs, HDLs, and TC Cholesterol is a waxy, fatlike substance found in all animal products (meats, dairy products, and eggs). The body can make cholesterol in the liver and absorb it from the diet. Cholesterol is essential to the body, and it is used to build cell membranes, to produce sex hormones, and to form bile acids necessary for fat digestion. Lipoproteins are an essential part of the complex transport system that exchanges lipids among the liver, intestine, and peripheral tissues. Lipoproteins are classified by the thickness of the protein shell that surrounds the cholesterol. The four main classes of lipoproteins are chylomicron, derived from the intestinal absorption of triglycerides (TG); very low-density lipoprotein (VLDL),

made in the liver for the transport of triglycerides; low-density lipoprotein (LDL), a product of VLDL metabolism that serves as the primary transporter of cholesterol; and high-density lipoprotein (HDL), involved in the reverse transport of cholesterol to the liver. The molecules of LDL are larger than those of HDL and therefore precipitate in the plasma and are actively transported into the vascular walls. Excess LDL-cholesterol (LDL-C) stimulates the formation of plaque on the intima of the coronary arteries. Plaque formation reduces the cross-sectional area and obstructs blood flow in these arteries, eventually producing a myocardial infarction. Therefore, LDL-C values less than 100 mg·dl-1 are considered optimal for reducing CVD and CHD risk (National Cholesterol Education Program 2001). The prevalence of borderline high levels (≥130 mg·dl-1 to A

F>M

↑

Osteoporosis

↑

↓

↓

↑

↓

↓

↑

↑

↑

A,W > AI, B, H

F > Mb

↑

Cancer

↑

↓

↑

↑

↑

↑

↑

↑

CHD = coronary heart disease; CHO = carbohydrate; A = Asian; AI = American Indian; B = Black; H = Hispanic; W = White; Na = sodium; Ca = calcium; SES = socioeconomic status (reflects income and education levels).

b

Males (M) at higher risk than females (F) up to age 55 yr.

↓ = Indirect relationship; as factor increases, risk decreases.

↑ = Direct relationship; as factor increases, risk increases.

a

↑

↓

↓

↑

↓

↑

↓

↓

↑

↓

F=M

↑

Low back pain



Exercise amenorrhea

↑

↑

↑

↑

↑ ↑

↓

↑

↓

↑

B, H, W > A, AI

F > Mb

↑

Hypercholesterolemia

Flexibility



Physical activity

CHO intake



intake/vitamin D

Fat/cholesterol intake

Ca



++

Na+ intake

Nutrition

Smoking

↑

↑

↑

Family history

↑

AI, B, H > A, W

B, H > A, AI, W

Race

Alcohol use

F > Mb

F>M

M > Fa

Gender B > A, AI, H, W

↑

↑

↑

Age

Hypertension

Type 2 diabetes

CHD

Factor

Table 1.3  Summary of Factors Associated With Disease Risk

Physical Activity, Health, and Chronic Disease • 13

risk regardless of their TC level. This fact emphasizes the importance of screening for both TC and HDL-C in adults.

Physical Activity and Lipid Profiles Regular physical activity, especially habitual aerobic exercise, positively affects lipid metabolism and lipid profiles (Durstine et al. 2002). Cross-sectional comparisons of lipid profiles in physically active and sedentary women and men suggest that physical fitness is inversely related to TC and the TC/HDL-C ratio (Despres and Lamarche 1994; Shoenhair and Wells 1995). Data from 49 randomized controlled trials were pooled to examine the effects of aerobic exercise on lipids and lipoproteins in adult men. Results showed that aerobic exercise reduces TC (−2%), LDL-C (−3%), and TG (−9%) and increases HDL-C (2%) in men 18 yr and older (Kelley and Kelley 2006). A 1% reduction in TC has been shown to reduce the risk for CHD by 2%; likewise, a 1% reduction in HDL-C increases CHD risk by 2% to 3% (Gordon et al. 1989). However, for individuals with hyperlipidemia, lifestyle (e.g., healthy diet) or pharmacologic (e.g., statins) interventions, in addition to aerobic exercise, may be necessary for optimizing lipid and lipoprotein profiles (Durstine et al. 2002; Kelley and Kelley 2006). Increases in HDL-C in response to aerobic exercise appear to be related to the training dose (interaction of the intensity, frequency, and duration of each exercise session and the length of the training period), and they are less dramatic in women than in men. An analysis of longitudinal and cross-sectional exercise studies concluded that 15 to 20 mi·wk-1 (24–32 km·wk-1) of brisk walking or jogging (equivalent to 1200–2200 kcal of energy expenditure) decreases blood triglyceride levels by 5 to 38 mg·dl-1 and increases HDL-C by 2 to 8 mg·dl-1 (Durstine et al. 2002). In comparison, resistance training has no effect on blood triglyceride levels, and TC and LDL-C are lowered only when the training increases lean body mass and decreases relative body fat (Durstine et al. 2002). The research on the effect of resistance training on cholesterol levels continues to remain incon-

clusive. Thirty-two weeks of resistance training produced no significant improvements in HDL-C in sedentary adults (18–70 yr) with abnormal lipid profiles (Bateman et al. 2011). Conversely, Ho and associates (2012) reported improvements in HDL-C for three groups (aerobic, resistance, combination) of overweight and obese adults (predominantly female) exercising for 30 minutes at a moderate intensity 5 days/wk. Compared to the other groups, the resistance training group had the largest increase in HDL-C at the end of the 12 wk study (Ho et al. 2012). Furthermore, moderate-intensity resistance training performed twice weekly for 14 wk produced significant increases in fasting HDL-C but not LDL-C or TC in a group of middle-aged adults (Geisler et al. 2011).

Tobacco The World Health Organization (2011b) estimates that there are approximately 1 billion smokers in the global population. In Great Britain, 25% of men and 23% of women aged 16 yr and older smoke cigarettes (British Heart Foundation 2008). Likewise, in Italy, approximately 24% of men and 20% of women smoke cigarettes (Gallus et al. 2011). In the United States, the prevalence of adults (18 yr and older) who smoke has declined to 19.3% as of 2010 (Roger et al. 2012). Approximately 17.5% of American women, 21.2% of American men, and 21.5% Canadian adults are smokers (AHA 2009; Centers for Disease Control and Prevention 2007; Klein-Geltink, Choi, and Fry 2006; Roger et al. 2012). Globally, the ageadjusted prevalence of daily tobacco smoking is highest (39–74%) for men in Russia, China, Asia, and Eastern European countries. For women, the prevalence is highest in Chile, Argentina, Russia, and throughout Europe (World Health Organization 2011b). About 40% of men from Malaysia and 70% of men from Indonesia smoke tobacco daily (CDC 2012a). While the prevalence of smoking is falling in well-developed countries, tobacco consumption is rising in developing countries by 3.4% per year (World Health Organization 2002b). Worldwide, one in five teenagers (13–15 yr) is a smoker. Also, the risk of death from CHD increases by 30% in those exposed to environmental tobacco smoke at home or at work (AHA 2004).

14 • Advanced Fitness Assessment and Exercise Prescription

Smoking is the largest preventable cause of disease and premature death. Cigarette smoking is linked to CHD, stroke, and chronic lung disease. It causes cancer of the lungs, larynx, esophagus, mouth, and bladder, and is also associated with cancer of the cervix, pancreas, and kidneys (World Health Organization 2002b). Compared to nonsmokers, smokers have more than twice the risk of heart attack. Cigarette smoking remains a major cause of stroke in the United States; there is a causal relationship between smoking and subclinical atherosclerosis (AHA 2008c). When individuals stop smoking, their risk of CHD declines rapidly, regardless of how long or how much they have smoked. One year after quitting, the risk of CHD decreases by 50%, and within 15 yr, the relative risk of dying from CHD almost matches that of a longtime nonsmoker (AHA 2004). Also the risk of stroke decreases steadily after smoking cessation; former smokers have the same risk as nonsmokers after 5 to 15 yr (AHA 2008c).

Diabetes Mellitus Diabetes is a global epidemic. More than 346 million people worldwide have the disease (World Health Organization 2011a). Factors linked to this epidemic include urbanization, aging, physical inactivity, unhealthy diet, and obesity (Wagner and Brath 2012). At least 65% of people with diabetes mellitus die from some form of heart or blood vessel disease (AHA 2008a). Diabetes is a major contributor toward the development of CHD and stroke. In the United States, diabetes was the seventh leading cause of death in 2007 (CDC 2011b). Also, diabetes is among the leading causes of kidney failure; 10% to 20% of people with diabetes die of kidney failure (World Health Organization 2008a). Nearly 18 million adults in the United States have type 2 diabetes (Roger et al. 2012). However, in China and India, there are 138 million people with diabetes (Danaei et al. 2011). Danaei and colleagues (2011) also estimated that approximately 42 million people with diabetes are from Brazil, Indonesia, Japan, Mexico, and Pakistan. Furthermore, in 2008, they reported the highest prevalence of diabetes was found in countries located in Oceania, northern Africa, the Middle East, and the Caribbean. Conversely, the lowest prevalence of diabetes was

in southeast Asia, east Africa, and Andean Latin America (Danaei et al. 2011). The prevalence of diabetes for adults (≥20 yr) in the United States was 25.6%; slightly more than 1 million people in this age group were diagnosed with diabetes for the first time in 2010 (CDC 2011b). Compared to white adults in the United States, the prevalence of diabetes and impaired blood glucose levels for blacks (12.6%), Hispanics (11.8%), and American Indians (16.1%) is higher (CDC 2011b). In fact, the prevalence of diabetes for American Indians and Alaska Native adults is one of the highest in the world (CDC 2011b). Diabetes rates for Alaskan Natives are lower (5.5%) than those for the American Indians living in southern Arizona (33.5%) (National Diabetes Information Clearinghouse 2012). Prediabetes, in addition to being a positive risk factor for CVD, is a medical condition identified by fasting blood glucose or glycated hemoglobin (HbA1c) levels that are above normal values but lower than the threshold for a diagnosis of diabetes (CDC 2011b). HbA1c is an indicator of the average blood glucose over the past 2 to 3 months (World Health Organization 2011c). Fortunately, prediabetes appears to respond favorably to weight loss and increases in physical activity. The age-adjusted percentage of prediabetes in U.S. adults during the period 2005 to 2008 was nearly identical for nonHispanic whites, non-Hispanic blacks, and Mexican Americans (35%, 35%, and 36%, respectively) (CDC 2011b). Type 1, formerly referred to as insulin-dependent diabetes mellitus (IDDM), usually occurs before age 30 but can develop at any age. Type 2, previously known as non-insulin-dependent diabetes mellitus (NIDDM), is more common; 90% of individuals diagnosed with diabetes mellitus worldwide have type 2 diabetes (World Health Organization 2011a). Risk factors for developing diabetes are presented in table 1.3. Type 1 diabetes may be caused by autoimmune, genetic, or environmental factors, but the specific cause is unknown. Unfortunately, there is no known way to prevent type 1 diabetes (CDC 2011b). Healthy nutrition and increased physical activity, however, can reduce the risk of type 2 diabetes by as much as 67% in high-risk individuals (Sanz, Gautier, and Hanaire 2010). Nearly 90% of cases of type 2 diabetes worldwide may be related to obesity (Wagner and Brath 2012).

Physical Activity, Health, and Chronic Disease • 15

The effect of exercise alone as an intervention for people with type 2 diabetes is not well researched (Sanz et al. 2010). However, exercise (30–120 min, 3 days/wk for 8 wk) produced clinically significant improvements in HbA1c and reduced visceral and subcutaneous adipose tissue stores in people with type 2 diabetes (Thomas, Elliott, and Naughton 2006). Additionally, no adverse effects or diabetic complications resulting from exercise were reported (Thomas et al. 2006). Research that associates physical activity with weight loss, fat loss, and glycemic control suggests that regular physical activity reduces one’s risk of developing type 2 diabetes (Sanz et al. 2010). Both resistance and aerobic exercise alone or in combination improve HbA1c values in people with type 2 diabetes. The frequency of exercise is crucial for those with diabetes. If daily exercise is not possible, it should not be skipped 2 days in a row. Specific guidelines for prescribing exercise programs for people who have type 1 and type 2 diabetes are available elsewhere (American College of Sports Medicine 2010c, 2014).

Obesity and Overweight In clinical guidelines established by the Obesity Education Initiative Task Force of the National Institutes of Health and National Heart, Lung, and Blood Institute (1998), adult overweight and obesity are classified using the body mass index (BMI) (BMI = weight [kg] / height squared [m2]). Individuals with a BMI between 25 and 29.9 kg/m2 are classified as overweight; those with a BMI of 30 kg/m2 or more are classified as obese. While the World Health Organization (2012c) acknowledges the utility of BMI as a simple index of obesity, they also caution that it cannot account for the relative fatness of different individuals having the same BMI. Actually, they define overweight and obesity as having abnormal or excessive fat accumulation that may impair health. Regardless, overweight and obesity ranks as the fifth leading risk factor for death worldwide (World Health Organization 2012c). Based on 2008 estimates, more than 1.4 billion adults (≥20 yr) worldwide are overweight and at least 500 million of overweight individuals (200 million men, 300 million women) are obese. Glob-

ally, more than 1 in every 10 adults is obese (World Health Organization 2012d). Originally overweight and obesity were considered to be problems of high-income countries; now, these conditions are on the rise in the low- and middle-income countries (World Health Organization 2012d). In England, equal percentages (26%) of men and women were categorized as obese based on BMI in 2010 (NHS Information Centre 2012); 23% of Canadian adults had a BMI ≥30 kg/m2 (World Health Organization 2012c). In sub-Saharan Africa, the prevalence of obesity ranges from less than 1% in rural Tanzania to 34% for black South African women (Dalal et al. 2011). The prevalence of obesity for men and women from five cities in China was 3.27% (BMI ≥ 30 kg/ m2). When the Asian BMI classification for obesity (≥27.5 kg/m2) was used, that estimate of obesity increased to 9.42% (Wang et al. 2012). In 2010, two out of every three adults in the United States were overweight or obese (BMI > 25 kg/m2), and one out of every three adults was obese (BMI > 30 kg/m2). Regardless of ethnicity, the ageadjusted prevalence of obesity for American men is approximately 35%; the exception is an obesity prevalence of approximately 50% for black men. For American women, the age-adjusted prevalence of obesity based on BMI is 33%, 41%, and 58%, respectively, for white, Hispanic, and black women. When all race and ethnicity groups are combined, the American women had an age-adjusted prevalence of obesity of 36% (Flegal et al. 2012). Asian adults in the United States have a much lower (8.1%) prevalence of obesity (Barnes et al. 2008) compared to American Indian and Alaskan Native adults (31.2%) (Jernigan et al. 2010). Childhood obesity (≥95th percentile for sex and age) is also a global problem (see chapter 9). Overweight adolescents have a 70% chance of becoming overweight adults; this increases to 80% if one or both parents are overweight or obese (AHA 2012). In England, 33% of boys and 35% of girls, ages 2 to 15 yr, were either overweight or obese (British Heart Foundation 2006). Similarly, in the United States, the prevalence of overweight and obesity in children and adolescents, ages 2 to 19 yr, was approximately 33% in 2009 (AHA 2012). The prevalence of obesity in children (6–11 yr) increased from 4% in 1974 to 17.4% in 2006. During this same time span, the prevalence of obesity in adolescents

16 • Advanced Fitness Assessment and Exercise Prescription

(12–19 yr) increased from 6% to 18% (AHA 2012). In 2004, nearly 14% of preschool children (2–5 yr) were overweight (Ogden et al. 2006). In addition, from 2007 to 2008, 19.6% and 18.1% of children aged 6 to 11 yr and 12 to 19 yr, respectively, were considered at risk of being overweight (Roger et al. 2012). The World Health Organization (2012d) reported that nearly 35 million children living in developing countries are overweight (85th percentile ≤ BMI < 95th percentile for age and sex). In developed countries, approximately 8 million children are overweight. Table 1.3 summarizes factors associated with increased risk of obesity. Excess body weight and fatness pose a threat to both the quality and duration of one’s life. Obese individuals have a shorter life expectancy and greater risks of CHD, stroke, dyslipidemia, hypertension, diabetes mellitus, certain cancers, osteoarthritis, sleep apnea, abnormal menses, and infertility (National Heart, Lung, and Blood Institute 2012). Although obesity is strongly associated with CHD risk factors such as hypertension, glucose intolerance, and hyperlipidemia, the contribution of obesity to CHD appears to be independent of the influence of obesity on these risk factors. For a comprehensive report and roundtable discussion of the role of physical activity in the prevention and treatment of obesity and its comorbidities, see the November 1999 supplement to Medicine & Science in Sports & Exercise. Obesity may be caused by genetic and environmental factors. Although studies suggest that genetic factors contribute to some of the variation in body fatness, there has been no substantial change in

the genotype of the American population since the 1960s (Hill and Melanson 1999). Thus, the major cause of obesity in the United States may be linked to our environment. Consequently, we have been exposed to an environment that strongly promotes not only the consumption of high-fat, energy-dense foods (increased energy intake), but also reliance on technology that discourages physical activity and reduces the amount of physical activity (decreased energy expenditure) needed for daily living (e.g., use of energy-saving devices and prepared foods) (Hill and Melanson 1999). As an exercise specialist, you play an important role in combating this major health problem by encouraging a physically active lifestyle and by planning exercise programs and scientifically sound diets for your clients, in consultation with trained nutrition professionals. Restricting caloric intake and increasing caloric expenditure through physical activity and exercise are effective ways of reducing body weight and fatness while normalizing blood pressure and blood lipid profiles.

Metabolic Syndrome Metabolic syndrome refers to a combination of CVD risk factors associated with hypertension, dyslipidemia, insulin resistance, and abdominal obesity. According to clinical criteria adopted by the National Cholesterol Education Program (2001), individuals with three or more CVD risk factors are classified as having metabolic syndrome (see table 1.4). These criteria vary among different

Table 1.4  Risk Factors for Metabolic Syndrome* Risk factor

Risk criteria

Waist circumference

>102 cm (>40 in.) for men >88 cm (>35 in.) for women

Blood pressure (BP)

≥130 mmHg (systolic BP) or ≥85 mmHg (diastolic BP) or both

Fasting blood glucose

≥100 mg·dl−1 or ≥6.1 mmol·L−1

Triglycerides

≥150 mg·dl−1 or ≥1.6 mmol·L−1

HDL-C

110 mmHg or resting systolic blood pressure > 200 mmHg or both 5. Tachydysrhythmias or bradydysrhythmias 6. Hypertrophic cardiomyopathy and other forms of outflow tract obstruction 7. High-degree atrioventricular block 8. Ventricular aneurysm 9. Chronic infectious disease (e.g., mononucleosis, acquired immune deficiency syndrome [AIDS], hepatitis) 10. Uncontrolled metabolic disease (e.g., diabetes, thyrotoxicosis, or myxedema) 11. Mental or physical impairment leading to inability to exercise adequately a

For definitions of specific medical terms, refer to the glossary.

Reprinted, by permission, from R.J. Gibbons et al. 2002, ACC/AHA 2002 guideline update for exercise testing. A report of the American College of Cardiology/American Heart Association Task Force on practice guideline (Committee on Exercise Testing) (Baltimore, PA: Lippincott, Williams, and Wilkins), 5.

absolute contraindications unless their physician orders an exercise test. Individuals with relative contraindications may be tested if the potential benefit from exercise testing outweighs the relative risk of testing. In some cases, individuals who are asymptomatic at rest can be tested using low-level endpoints. It is also important to note the types of medication being used by the client. Drugs such as digitalis, beta-blockers, bronchodilators, vasodilators, diuretics, and insulin may alter the individual’s heart rate, blood pressure, ECG, and exercise capacity. If your client reports a medical condition or drug that is unfamiliar to you, be certain to consult medical references or a physician to obtain more information before conducting any exercise tests or allowing the client to participate in an exercise program.

Signs and Symptoms of Disease and Medical Clearance As part of the pretest health screening, you should ask your clients if they have any of the conditions or symptoms listed in appendix A.3, “Checklist for Signs and Symptoms of Disease.” Feel free to reproduce and use this checklist. Clients with any of the signs or symptoms on the checklist should be referred to their physician to obtain a signed medical clearance prior to any exercise testing or participation. The Physical Activity Readiness Medical Examination (PARmed-X) was designed for this purpose. The PARmed-X is a physical activity–specific checklist (see appendix A.4) that is used by the physician to assess and convey medical clearance for physical activity participation or to make a referral to a medically supervised exercise program for individuals who answered yes to one of the questions in the Physical Activity Readiness Questionnaire (PAR-Q). For definitions of specific medical terms used, refer to the glossary. The PARmed-X is also available electronically at www.csep.ca/cmfiles/publications/ parq/parmed-x.pdf.

Preliminary Health Screening and Risk Classification • 27

Coronary Risk Factor Analysis To assess your client’s coronary risk profile, evaluate each item in table 2.2 carefully. If your client will not or cannot provide the information you need to include or exclude a positive risk factor, then you should include it in your total count. The exception is the prediabetes risk factor. In this instance, if your client is either ≥45 yr and has a body mass index (BMI) ≥25 kg/m2 or is younger than 45 yr, has a BMI ≥25 kg/m2, and at least one other positive cardiovascular disease (CVD) risk factor for prediabetes, then count it. Otherwise, do not count your client’s inability to disclose the blood glucose information as a positive risk factor (American College of Sports Medicine 2014). Guidelines for classification of blood pressure and blood cholesterol levels in adults are presented in tables 2.3 and 2.4, respectively. If your client’s high-density lipoprotein cholesterol (HDL-C) equals or exceeds 60 mg·dl−1, subtract 1

from the total number of positive risk factors. This information is especially helpful in classifying the individual for exercise testing and in designing safe exercise programs.

Disease Risk Classification On the basis of the results from the coronary risk factor analysis, you should classify individuals as low, moderate, or high risk. According to the American College of Sports Medicine (ACSM 2014), the low CHD risk category comprises individuals who are asymptomatic with no more than one major risk factor (see table 2.2). Asymptomatic individuals having two or more risk factors are classified as moderate CHD risk. The high CHD risk category includes individuals who have one or more signs or symptoms of cardiovascular, pulmonary, renal, or metabolic disease or individuals with known cardiovascular, pulmonary, renal, or metabolic disease (see appendix A.3).

Table 2.2  Coronary Heart Disease Risk Factors Positive risk factors*

Criteria

1. Age

Men ≥ 45 yr, women ≥ 55 yr

2. Family history

Myocardial infarction, coronary revascularization, or sudden death before 55 yr of age in father or other first-degree male relative (brother or son) or before 65 yr of age in mother or other first-degree female relative (sister or daughter)

3. Cigarette smoking

Current cigarette smoking, exposure to environmental smoke, or smoking cessation within previous 6 mo

4. Hypertension

Systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg measured on two separate occasions; individual is taking antihypertensive medication.

5. Dyslipidemia

HDL-C < 40 mg·dl−1 or LDL-C ≥ 130 mg·dl−1; on lipid-lowering medication; use TC ≥ 200 mg·dl−1 if no cholesterol subfractions are available.

6. Prediabetes

Fasting plasma glucose ≥ 100 mg·dl−1 (impaired fasting glucose, IFG) or 2 hr oral glucose tolerance test values ≥ 140 mg·dl−1 and ≤ 199 mg·dl−1 (impaired glucose tolerance, IGT) measured on two separate occasions

7. Obesity

Body mass index (BMI) ≥ 30 kg/m2 or waist circumference is >102 cm (40 in.) for men and >88 cm (35 in.) for women

8. Sedentary lifestyle

Not meeting recommendations for 30 min moderate-intensity physical activity on at least 3 days/wk for at least 3 mo

Negative risk factor** High HDL-C

Serum HDL-C ≥ 60 mg·dl−1

If client cannot or will not provide a risk factor value, count it as a positive risk factor except for prediabetes. For prediabetes, only count a missing or unknown IFG or IGT value for adults ≥45 yr with a BMI ≥25 kg/m2 or for adults