|Exam Name||:||ACSM Registered Clinical Exercise Physiologist|
|Questions and Answers||:||370 Q & A|
|Updated On||:||February 19, 2019|
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Cardiorespiratory undertaking has historically been the emphasis of cardiac rehabilitation courses. however, resistance working towards (RT) has regularly turn into a vital part of cardiac rehabilitation on account of its gigantic health advantages and effective consequences on cardiac comorbidities (1). There are protection concerns that deserve to be considered when enforcing a RT application for the cardiac affected person. in consequence, selected RT guidelines have been dependent for cardiac rehabilitation (2,3). this article will address the benefits of RT in cardiac rehabilitation. furthermore, defense concerns and guidelines and how to enhance, enforce, and video display an RT software for sufferers in cardiac rehabilitation and after cardiac rehabilitation might be introduced.RT advantages FOR CARDIAC patients
The benefits of RT for humans with heart problems are numerous. essentially the most time-honored benefit of RT is extended muscular energy and endurance (1,four-10). ordinary muscle electricity improvements of 25% to 30% are customarily considered (four,eight-10). additionally, a forty six% improvement in muscle vigour has been observed in frail people who perform RT (four).
here is critical for cardiac patients as a result of many actions of every day living require extra muscular electricity and endurance than what's developed from cardiorespiratory pastime. in addition, the requisite force to comprehensive these activities can also exceed medically imposed lifting restrictions placed on this patient inhabitants (11). These actions encompass rising from a chair, carrying groceries, mountain climbing stairs, and protecting/carrying children and grandchildren. Many cardiac sufferers also lack the confidence to operate many projects of every day living (1,2). Resistance practicing can give them with each the muscular electricity and confidence to are living a extra lively and impartial lifestyle (1,four-6,10,eleven).
For cardiac patients returning to work after rehabilitation, RT should be of particular activity, specifically for those with bodily stressful occupations. Resistance practising reduces cardiac demands at given workloads via reducing the price-power product (RPP) (systolic blood force × coronary heart expense) (2,4,6-10,12) and might make initiatives corresponding to lifting heavy objects safer to perform. mixed cardiorespiratory undertaking and RT have been shown to increase aerobic health greater than cardiorespiratory practicing by myself (8,13), further enhancing useful skill and first-rate of life (1,four,10).
Resistance working towards helps manipulate and stop a few coronary risk components (5,6,12) and different persistent diseases (5,6,10,12). These include class 2 diabetes, hypertension, overweight/obesity, arthritis, frailty/sarcopenia, and osteoporosis. on the grounds that many cardiac rehabilitation patients are of expanded age, holding or bettering functional independence is a noteworthy advantage received from RT (1,4,5,11). See table 1 for a summary of RT advantages for cardiac patients.RT PRECAUTIONS AND safeguard issues FOR CARDIAC patients
Resistance working towards become once concept to be dangerous for the cardiac patient. Cardiac patients have been (and infrequently nonetheless are) instructed no longer to carry the rest heavier than 5 to 10 lbs for an indefinite time length after a cardiac adventure or process (eleven). This, if anything, will inspire much less actual undertaking (1,11). however, research has shown RT to be protected in chosen cardiac patients (6-8,11-18). Many reviews have shown that low-risk (e.g., purposeful ability, ≥7 metabolic equivalents [METs]) and average-possibility (e.g., gentle to reasonable silent ischemia throughout pastime checking out or restoration) cardiac sufferers can engage in RT with out excessive myocardial pressure (6-12). This comprises certain individuals with congestive coronary heart failure who've confirmed the capability to tolerate RT (14,19,20). youngsters, high-risk cardiac patients (e.g., presence of complicated ventricular dysrhythmias) may still now not perform RT. Circuit RT can result in decrease myocardial strain than an eighty five% effort on a treadmill check (10,21,22) or stationary bicycling at 70% of oxygen consumption at peak effort (7).
Many cardiac sufferers have other cardiac- (e.g., hypertension, diabetes, implantable cardiac defibrillators [ICDs], and pacemakers) and noncardiac-linked (e.g., osteoarthritis, osteoporosis, and shoulder impingement) situations that should be considered when establishing an RT application. Most cardiac patients take a couple of medicinal drugs for their coronary heart circumstance. The sidebar describes one of the most extra general drugs taken by means of cardiac sufferers.
it is prudent that the health knowledgeable is aware of the cardiac history of the affected person/client before initiating RT (1). desk 2 outlines the time course for initiating RT in low- to reasonable-possibility cardiac sufferers.
Resistance training is contraindicated and/or requires doctor clearance for certain better chance patients (2,3,10). Absolute and relative RT contraindications had been centered for cardiac sufferers (desk 3). special RT precautions should be curious about sufferers who've had myocardial infarction (MIs), coronary artery skip surgical procedure (CABG), implantable defibrillators (ICDs), pacemakers, diabetes, and hypertension (1-3,8-eleven). workouts involving gigantic shoulder girdle involvement and elevation are frequently limited for four and 6 weeks for patients having ICDs/pacemeakers and CABGs, respectively (2,three,eleven). Adams and colleagues (eleven) examined 13 typical RT workout routines for protection, efficacy, and typical usefulness for patients who had a history of MI, CABGs, and ICDs/pacemakers. They developed a list of appropriate exercises and a timeline for particular stream/endeavor restrictions. higher-body RT may still be limited except the sternum has healed sufficiently (e.g., frequently three months) in patients receiving CABGs and unless physicians clear recipients of ICDs and pacemakers (2,10,eleven). Repetitive movement actions akin to weight lifting can result in pacing lead fractures and dislodgement (2,10,11). Resting BP values should still be less than 160/one hundred mmHg (three), and an activity BP cutoff of 220/105 mmHg could be prudent (2). computer screen rate-pressure product in sufferers with hypertension (10) by means of taking and paying attention to both heart rate and systolic blood pressure (eleven). agree with using single-limb (in its place of double limb) upper-extremity practising in sufferers who have an exaggerated upward push in blood drive or RPP during RT (1). This also can be effective in these patients with congestive coronary heart failure (eight).
extra RT safeguard precautions and information for selected conditions encompass right here:Hypertension
continual respiration right through RT is in particular important for cardiac patients, to evade the Valsalva maneuver. Exhaling all through the exertion (lifting) part is informed. fending off tight gripping and sustained static (isometric) contractions additionally will support steer clear of excessive raises in blood power throughout RT (1-three,8,10,11). activity gurus may still stop RT classes automatically if any of here hostile responses turn up including:
no longer all fitness facilities can have electrocardiogram or blood force device to monitor these essential signals. despite the fact, many ACSM licensed authorities (i.e., endeavor specialist, registered clinical pastime physiologist, and software administrators) have the knowledge to display screen blood drive, take a pulse, and calculate RPP. it's prudent that fitness gurus working with this inhabitants possess or acquire these ability sets.RT PROGRAMMING FOR CARDIAC patients
as soon as a patient has been medically cleared to begin RT, a personalized software should still be developed. it is essential to consider other fitness situations that might also alter the RT program design. A cardiac patient with osteoporosis should perform all workouts with an upright posture and keep away from spinal flexion (ahead and lateral) and spinal rotation (twisting) (2,23). A affected person with a shoulder impingement should preserve actions under 90 degrees of shoulder abduction and flexion and hold arms just a little in entrance of the body in the scapular aircraft. Emphasis should still be placed on scapular retraction and melancholy and on shoulder inside and exterior rotation. Rows are an acceptable choice for patients with a shoulder impingement (24).
There may still be a balance amongst fundamental muscle agencies knowledgeable (5,6,10,12,25,26). this may keep away from electricity imbalances between opposing muscle groups, which might outcomes in musculoskeletal injury. both lower- and higher-body muscle corporations should be informed on the identical day to preserve time (5,10,26). on account of their efficiency and practical results, multijoint workouts may still be emphasised and use single-joint exercises to praise the RT program (1,2,5,10,26). no longer all cardiac rehabilitation classes have the time, house, and device to increase wide RT programs. This amplifies the significance of performing multijoint workout routines. When lots of RT gadget is purchasable, opt for modes that might be most comfy for the patient (1).
despite the fact there are informed 1RM percentages for lower- and upper-physique workout routines for cardiac sufferers (desk 4), 1RM testing commonly is not performed on account of protection considerations and a lack of RT event that is normal in cardiac patients. An RPE of 11 to 13 (fairly easy to a bit of challenging) on the Borg Scale is an acceptable components for identifying preliminary hundreds for RT workouts (2,3). A gradual boost in resistance (5%) should still turn up once the patient can finished 12 to 15 repetitions easily (3). a number of working towards tips encompass here:
The RT application design for the affected person after cardiac rehabilitation will rely upon the place the affected person plans on exercising upon completion of their allotted cardiac rehabilitation sessions and what RT gadget (e.g., variable dynamic resistance machines, free weights, and variable resistance [or color] bands/tubing) an individual can have access to. In a great condition, upon completion of the monitored section of cardiac rehabilitation (frequently called part II), an individual could be offered the possibility to proceed exercising within the identical facility as a member of their upkeep program (frequently called phases III to IV). ultimate in a familiar atmosphere will enhance each an individual's consolation and confidence level in moving forward with their activity application, specially RT. despite the fact, as is frequently the case, many sufferers need to locate a brand new vicinity to recreation with distinct equipment and, simply as critical, a brand new workforce.
With the a variety of modes of RT and recreation machine obtainable to the health and fitness skilled, every cardiac affected person have to be evaluated on a person foundation. figuring out the brand new client's clinical historical past (e.g., MI, CABG, and angioplasty) is elementary. In a part IV atmosphere, the fitness and fitness knowledgeable along with the clinical software director can be charged with constructing the customer's undertaking prescription. although, in a nonclinical atmosphere (e.g., native fitness club or gymnasium), the fitness skilled need to contact and work with the customer's health professional or healthcare professional in designing the client's pastime prescription (table four). for example, a cardiac affected person who had open-coronary heart surgery and participated in barely four weeks of supervised cardiac rehabilitation (part II) would no longer be able to function the same RT exercises that an individual who had an angioplasty with stent placement four weeks prior can be able to perform. during this certain case, each the open-heart surgery affected person and the fitness and health skilled must be cognizant of sternal precautions (curative constantly takes 12 weeks), which might essentially consist of limiting upper-body RT workout routines (table 2).
health and fitness gurus working in the medical ambiance additionally have to be comfortable with making ready cardiac sufferers for exercising in their buildings. As is the case with many cardiac patients, they do not transition into one other formal surroundings, as a consequence they ought to be prepared to proceed their power-practicing software at domestic. Many cardiac rehabilitation courses will include using colored tubing or resistance bands (distinctive colours point out a unique level of resistance) into their RT courses. in addition to being a safe and useful kind of energy working towards, using this type of RT machine is easy for the patient to gain knowledge of. furthermore, cardiac rehabilitation programs can continually accommodate distributing these resistance bands and colored tubing for use by means of their customer's at home upon completion of their software.
The number of cardiac sufferers isn't going to decrease in the years forward, for that reason the cardiac rehabilitation programs and fitness facilities are charged with here: facilities ought to have the essential device (e.g., treadmills, higher-physique ergometers, variable dynamic resistance machines, free weights, and coloured tubing/bands) to elicit expected consequences; and group of workers should be appropriately knowledgeable/proficient (e.g., degreed, certified) to work no longer most effective with cardiac patients however also with the increasing numbers of various particular populations.summary
Resistance practising is protected for chosen cardiac rehabilitation sufferers and offers a few fitness and fitness merits. it is essential for each cardiac affected person to follow the correct time direction for initiating RT and adhere to specific RT programming and safeguard guidelines. Cardiac patients should still have their RT software tailored to their particular wants and capabilities. this can permit them to achieve the advantages of RT, whereas minimizing the possibility of opposed pursuits or harm. Resistance training, like cardiorespiratory exercise, should still be endured after the completion of a cardiac rehabilitation application to retain or extra increase muscular fitness.CONDENSED version AND final analysis
proof now naturally demonstrates that cardiac rehabilitation patients should still be performing RT. The merits received from RT will compliment the cardiorespiratory component of cardiac rehabilitation. once a cardiac patient has been deemed safe and ready to provoke RT, selected safeguard and programming guidelines may still be adopted to maximize RT defense and efficacy. besides keeping their cardiorespiratory working towards after cardiac rehabilitation, cardiac sufferers should still proceed to engage in RT to increase their best of life.References 1. Spencer, J.L. Resistance working towards in outpatient cardiac rehabilitation. strength and Conditioning Journal 29(1):18-23, 2007. 2. ACSM's instructions for activity testing and Prescription. seventh ed. Whaley, M.H., P.H. Brubaker, and R.M. Otto (Editors). Baltimore: Lippincott Williams & Wilkins, 2005:176-177, 189-191, 199-200, 223-225. 3. American affiliation of Cardiovascular and Pulmonary Rehabilitation. guidelines for Cardiac Rehabilitation and Secondary Prevention programs. 4th ed. Human Kinetics, 2004:36, 119, 182. four. Ades, P.A., P.D. Savage, M.E. Cress, et al. Resistance practising on actual efficiency in disabled older feminine cardiac sufferers. medication & Science in activities & undertaking® 35(eight):1265-1270, 2003. 5. American school of activities medication and the American heart association. physical activity and public health in older adults: strategies from the American faculty of sports medication and the American heart association. drugs & Science in activities & pastime® 39(eight):1435-1445, 2007. 6. Pollock, M.L., B.A. Franklin, G.J. Balady, et al. Resistance pastime in individuals with and with out cardiovascular disease: advantages, motive, security, and prescription. An advisory from the Committee on exercise, Rehabilitation, and Prevention, Council on medical Cardiology, American heart affiliation. Circulation one hundred and one:828-833, 2000. 7. Meyer, k. Resistance pastime in continual coronary heart failure: landmark experiences and implications for follow. medical and Investigative drugs. 29(3):166-169, 2006. 8. Volaklis, k.A., and S.P. Tokmakidis. Resistance activity practicing in sufferers with heart failure. activities drugs 35(12):1085-1103, 2005. 9. Volaklis, k.A., H.T. Douda, P.F. Kokkinos, et al. Physiologic ameliorations to detraining following prolonged combined electricity and aerobic practising in cardiac sufferers. European Journal of Cardiovascular Prevention and Rehabilitation 13:375-380, 2006. 10. Williams, M.A., W.L. Haskell, P.A. Ades, et al. Resistance training in individuals with and without cardiovascular disease: 2007 replace. A scientific update from the American heart affiliation Council on scientific Cardiology and Council on food, physical endeavor, and Metabolism. Circulation 116:572-584, 2007. eleven. Adams, J., M.J. Cline, M. Hubbard, et al. a new paradigm for submit-cardiac experience resistance exercise instructions. American Journal of Cardiology 97:281-286, 2006. 12. Franklin, B.A., D.P. Swain, and R.J. Shephard. New insights within the prescription of activity for coronary patients. Journal of Cardiovascular Nursing 18(2):116-123, 2003. 13. Stewart, k., L.D. McFarland, J.J. Weinhoffer, et al. protection and efficacy of weight training quickly after acute myocardial infarction. Journal of Cardiopulmonary Rehabilitation 18:37-44, 1998. 14. Weber-Zion, G., E. Goldhammer, E. Shaar, et al. Left ventricular function all through electricity trying out and resistance recreation in patients with left ventricular dysfunction. Journal of Cardiopulmonary Rehabilitation 24(2):one hundred-109, 2004. 15. Maiorana, A.J., T.G. Briffa, and J. Hung. A managed trial of circuit weight working towards on aerobic ability and myocardial oxygen demand in men after coronary artery pass surgical procedure. Journal of Cardiopulmonary Rehabilitation 17(4):239-247, 1997. 16. Vanbiervliet, W., J. Pélissier, B. Lédermann, et al. power practising with elastic bands: measure of its consequences in cardiac rehabilitation after coronary diseases. Annales de réadaptation et de médecine physique. 46(8):545-552, 2003. 17. DeJong, A.T., C.J. Womack, J.A. Perrine, et al. Hemostatic responses to resistance working towards in sufferers with coronary artery disorder. Journal of Cardiopulmonary Rehabilitation 26(2):80-83, 2006. 18. Beniamini, Y., J.J. Rubenstein, and A.D. Faigenbaum. high-intensity energy practising of patients enrolled in an outpatient cardiac rehabilitation program. Journal of Cardiopulmonary Rehabilitation 19:eight-17, 1998. 19. King, M.L., k.A. Dracup, G.C. Fonarow, et al. The hemodynamic outcomes of isotonic pastime using hand-held weights in patients with heart failure. Journal of coronary heart Lung Transplant 19:1209-1218, 2000. 20. Karlsdottir, A.E., C. Foster, J.P. Porcari, et al. Hemodynamic responses all the way through cardio and resistance exercise. Journal of Cardiopulmonary Rehabilitation 22:one hundred seventy-177, 2004. 21. DeGroot, D., T. Quinn, R. Kertzer, et al. Circuit weight practicing in cardiac sufferers: opting for ideal workloads for safety and energy expenditure. Journal of Cardiopulmonary Rehabilitation 18(2):145-152, 1998. 22. Ebben, W.P., and D.H. Leigh. The results of resistance practicing on cardiovascular patients. strength and Conditioning Journal 28(2):fifty two-fifty eight, 2006. 23. national electricity and Conditioning association. NSCA's necessities of non-public practicing. Earle, R., and T. Baechle (Editors). Champaign, IL: Human Kinetics, 2004:468. 24. Ronai, P. activity modifications and techniques to increase shoulder feature. strength and Conditioning Journal 27(4):36-45, 2005. 25. country wide strength and Conditioning association. necessities of electricity working towards and Conditioning. 2nd ed. Baechle, T., and R. Earle (Editors). Champaign, IL: Human Kinetics, 2000:four hundred-401. 26. Sorace, P., and T. LaFontaine. Resistance training muscle energy: design classes that work. ACSM's fitness & health Journal® 9(2):6-12, 2005.
Do you see undertaking as an important element in the prevention and medicine of disease, and need to encourage individuals to follow healthy behaviors? ACSM licensed activity Physiologists® take practicing to an advanced degree by using conducting and interpreting actual fitness assessments and setting up pastime prescriptions for people who're match or have medically controlled illnesses.
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Q&A: ACSM’S materials FOR scientific endeavor PHYSIOLOGY
ACSM is recognized globally for outlining science-based mostly framework for professionals who conduct fitness-connected activity evaluation, particular person actual endeavor plans, and activity programs for adults. Now, a brand new edition of ACSM’s substances for clinical exercise Physiology: Musculoskeletal, Neuromuscular, Neoplastic, Immunological, and Hematological situations is assisting scientists and clinicians convert research into practice. The pastime-based mostly innovations contained within the guide intently relate to the concepts of undertaking is medication™. study the Q&A with Jon Myers, Ph.D., FACSM, senior editor of the booklet.
Myers and David Nieman, Ph.D., FACSM, have been the senior editors of the publication, and coordinated the writing with a host of contributing consultants. Myers is a clinical professor of cardiology at the Veterans Administration Palo Alto health Care equipment and Stanford institution. He chaired the publications subcommittee of ACSM’s committee on Certification and Registry Boards (CCRB) from 2001-07, and contributed content for several essential ACSM publications, together with diverse versions of ACSM’s instructions for exercise testing and Prescription.
Q: What’s entertaining about this new medical undertaking physiology resource manual?A: here's one of three books in a sequence that ACSM publishes and updates periodically with Lippincott Williams and Wilkins. The content of this publication, ACSM’s materials for medical undertaking Physiology: Musculoskeletal, Neuromuscular, Neoplastic, Immunological, and Hematological conditions (CEP Res-2) is complementary to ACSM’s instructions for exercise checking out and Prescription and ACSM’s resource guide for exercise checking out and Prescription. For the first time, all three new versions of those books are being released on a synchronized schedule, with all copyright dates indicated as 2010, but obtainable now. The standard theme within the collection is to translate the latest in science and authoritative clinical experience into apply guidelines and continuing schooling substances to be used by means of undertaking specialists and physicians global. while all of those texts are directed to the application of activity assessment and remedy for patients with cardiovascular and pulmonary ailment, CEP Res-2 is interesting in offering information for working with patients who've chronic circumstances and disabilities, no longer addressed through the other two books – particularly, orthopedic, neurological, metabolic, musculoskeletal, neoplastic, and immunodeficiency circumstances. These medical populations are often mostly underserved. fitness gurus gained’t be capable of finding such up-to-date substances beneath one cover in different places that specifically handle recreation remedy for circumstances equivalent to cancer, traumatic brain harm, or immune problems.
Q: How is the booklet involving ACSM’s credentialing and certifications? A: The concerns addressed within the textual content are essential to the existing or advantage ACSM Registered clinical activity Physiologist� (RCEP), on account that the expected knowledge, capabilities and abilities covered address clinical and pathological instances where activity has been proven to supply therapeutic or practical benefit. accordingly, CEP Res-2, in conjunction with ACSM’s instructions for recreation trying out and Prescription and ACSM’s useful resource guide for undertaking testing and Prescription deliver the complete scope of diseases and problems upon which the RCEP credential is based mostly.
Q: What’s distinct during this second version? A: All chapters from the first version have been up to date. terrific advances were made in analysis and medical event on the grounds that the first version become published eight years in the past; a scan of chapter bibliographies affirms the extent of those advancements and the way present the chapter contents basically are. CEP Res-2 comprises an entirely new area on “medical practice concerns.” as the ACSM RCEP has turn into greater established over the remaining decade, this new section is specifically timely and important seeing that it helps supply the RCEP and different health care authorities with a more robust knowing of their role and how they can have an important and indispensable vicinity in nowadays’s health care ambiance. This new section contains chapters on the evolution of the clinical undertaking physiologist, tactics to demonstrating purposeful results for fitness and health classes, criminal and moral concerns, and client referral and consulting relations with allied professions.
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Exercise can help people prevent or manage heart problems.
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Clinical exercise specialists work in heart health clinics, cardiovascular rehabilitation facilities, fitness centers and doctor's offices to help people avoid or recover from heart health or metabolic problems through exercise. Exercise specialists design individualized exercise programs to help their clients change established patterns of behavior, improve their health and enhance their lives.
Do you see exercise as an important element in the prevention and treatment of disease, and want to motivate people to practice healthy behaviors? ACSM Certified Exercise Physiologists® take training to an advanced level by conducting and interpreting physical fitness assessments and developing exercise prescriptions for people who are healthy or have medically controlled diseases.
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Abnormal blood lipids, known as dyslipidemia, are an increasing health problem in the United States and the world. Approximately 107 million American adults have borderline or high total cholesterol (1) (see Table 1 for cholesterol guidelines). Dyslipidemia is one of the major risk factors for heart disease (1-4). Excess cholesterol builds up in the walls of the arteries. Over time, this buildup contributes to atherosclerosis, a disease process in which arteries become narrowed and blood flow is impaired. If the blood supply to a portion of the heart is completely cut off by a blockage, the result is a heart attack.
There are a number of different forms of dyslipidemia. Hypercholesterolemia indicates elevated blood cholesterol levels (2). Hypertriglyceridemia implies elevated triglycerides (TGs). Hyperlipidemia indicates elevated cholesterol and TGs. Hyperlipoproteinemia is defined as elevated lipoproteins (2). Hypoalphalipoprotein syndrome denotes low high-density lipoprotein (HDL) cholesterol (2). Postprandial lipemia (PPL), discussed in greater detail later, is characterized by a postprandial rise in TG-rich lipoproteins after eating.
One of the first steps in atherogenesis is the infiltration and entrapment of low-density lipoproteins (LDLs) in the blood vessel wall. This leads to a series of events (e.g., oxidation of LDLs, monocyte migration, macrophage uptake of modified LDLs, foam cells, fatty streaks, etc.) that result in the development of fibrous plaques within the walls of the intima.
Dyslipidemia is caused by genetic and environmental factors that lead to problems with enzyme deficiencies, apolipoproteins, or lipoprotein particles. There are a number of factors that contribute to dyslipidemia (see Table 2 for a partial listing).
Dyslipidemia also is a characteristic of the recently defined metabolic syndrome. The metabolic syndrome consists of a group of coronary heart disease (CHD) risk factors which includes glucose intolerance (fasting plasma glucose of 100-125 mg/dL), atherogenic dyslipidemia (TGs ≥150mg/dL and HDL cholesterol <40 mg/dL in men and <50 mg/dL in women), increased blood pressure (≥130/85 mm Hg), abdominal obesity (waist circumference of 102 cm or greater in men and 88 cm or greater in women), a prothrombotic state, and a proinflammatory state (5). A prothrombotic state is a condition that predisposes to venous or arterial thrombosis. A proinflammatory state is the presence of low-grade generalized inflammation within the body that increases cardiac risk.
Lipoproteins are the carriers of lipids (primarily cholesterol and TGs) in the blood. Because fat and water do not mix, the body combines protein plus lipid so that the lipid substance can be transported in plasma. There are several lipoproteins in the body, with different functions (see Table 3). Some contribute to cardiovascular disease (e.g., LDLs) and some help prevent it (e.g., HDLs). In summary, dyslipidemia refers to an abnormality of lipoproteins, covering a variety of disorders relating to abnormal levels of total cholesterol, LDL cholesterol, HDL cholesterol, and/or TGs.
Postprandial lipemia (PPL) refers to the rise in TG-rich lipoproteins (e.g., very low density lipoproteins [VLDLs]) after a meal. It is a dynamic condition in which humans spend the majority of their time (7). PPL reflects a combined measure of an individual's capacity to metabolize TGs. Elevated/prolonged PPL, defined as a delayed clearance of TGs after a high-fat meal, is a significant risk factor for the development of atherosclerosis (7, 8). The exchange of core lipids between postprandial lipoproteins and LDLs/HDLs increases during prolonged PPL in susceptible persons, resulting in elevated TGs; the production of small, dense LDL particles; and reduced HDLs (7). Smaller, denser LDLs are more atherogenic than the larger, less dense LDLs. Other atherogenic factors including clotting factors, platelet reactivity, and monocyte and cytokine expression, all of which contribute to endothelial dysfunction, may increase during PPL (7).
Testing for PPL involves a 12-hour fast and initial blood collection. Subjects then ingest a high-fat beverage, and blood samples are collected every 2 hours for 8 hours. Triglyceride concentrations are measured by colorimetry (quantitative chemical analysis by color), and values are plotted over time. PPL is assessed using total area under the curve (AUC). A large value for TG area AUC indicates that the TGs were maintained in the blood longer than expected.Exercise Effects on Lipid Metabolism
The lowering of TGs is the most consistent effect exercise has on lipoproteins. HDLs often are increased with sustained aerobic exercise that results in an expenditure of >1,200 calories/week, but this effect is less consistent and may be genetically predetermined (9). The greater the exercise volume (and caloric expenditure), the more likely an exerciser will achieve a significant increase in HDL cholesterol. Lower TGs are typically observed with both acute exercise and sustained aerobic exercise training (3). TGs are used as energy by skeletal muscles during endurance exercise. The enzyme lipoprotein lipase (LPL) splits TGs from VLDLs, making them available for uptake by skeletal muscles. Chronic exercise training also increases hepatic HDL production and the conversion of HDL3 to HDL2 in the blood, both of which protect against heart disease (3).
The evidence for exercise alone reducing LDLs and total cholesterol is less conclusive. It appears that weight loss/fat loss is required for significant reductions in LDLs and total cholesterol (3, 10). Regular aerobic exercise does, however, produce favorable changes in LDL subfractions, which will reduce the risk of CHD. For example, aerobic exercise has been shown to convert smaller LDLs to larger LDLs, reducing cardiac risk (3, 11).
Exercise training also favorably alters lipid enzyme activity, resulting in improved lipid profiles. Table 4 lists and defines the major enzymes involved in lipid metabolism. LPL and lecithin-cholesterol acyltransferase are increased with aerobic exercise, whereas hepatic lipase is usually decreased (3). The effects of exercise training on cholesterol ester transport protein are inconclusive at this time (3). Genetic deficiencies can alter the exercise response for some individuals. For example, LPL activity will not be increased in those who have a LPL deficiency (2). It was recently demonstrated in 35 pairs of monozygotic twins (active twins ran a mean of 63 km/week vs. a mean of 7 km/week in the inactive twins) that low HDL cholesterol may be largely determined by genetic factors and is less effectively treated with vigorous exercise (12).
Table 4Lifestyle Effects on Dyslipidemia
National Cholesterol Education Program III recommends nutritional intervention, increased exercise/physical activity, and weight loss for many individuals with dyslipidemia (5). There is substantial evidence to support the profound beneficial effects of lifestyle changes on dyslipidemia (3, 4, 10, 11). Although there are a number of medications (e.g., statins) that are effective for treating dyslipidemia, lifestyle changes alone can often normalize lipid profiles. Lipid lowering typically results in modest plaque regression and stabilization, reducing the risk of a cardiac event (3).
Regular aerobic exercise is an essential lifestyle component for improving/controlling blood lipids. The total amount of physical activity seems to be more important than the intensity to induce beneficial effects on lipoproteins (10, 11). Significant daily and weekly energy expenditures are recommended to produce notable changes in individuals with dyslipidemia (3, 4, 10). Cross-sectional studies have shown that lipids continue to improve across weekly running distances from <10 to >40 miles in a direct dose-response relationship (13).
The effect of exercise on PPL also is significant. Individuals who regularly perform aerobic exercise typically display low levels of PPL (14). Vigorous aerobic exercise has been shown to reduce PPL in men with elevated TGs, even when performed 12 hours before a high-fat meal (15). In a recent study, intermittent exercise in young, normolipidemic men and women was shown to improve PPL significantly more than continuous exercise (16). The breakdown of blood TGs (and some TG-rich lipoproteins) is increased during exercise and continues well into the recovery phase. Exercise that stimulates fat use as a substrate during and after the activity helps clear TG from the blood. In addition, exercise stimulates the enzyme LPL and this enzyme may remain active for several hours. Thus, moderate intensity exercise attenuates PPL (17, 18). It is important to note that the favorable effects (e.g., TG lowering) of endurance exercise on PPL seem to be a result of acute metabolic changes as opposed to chronic exercise effects (14, 15). This encourages daily or near daily aerobic exercise to treat elevated PPL. Possible mechanisms for the exercise-induced TG reductions include increased muscle LPL activity and reduced hepatic TG secretion (14, 17).
There only have been a couple of studies on resistance training and PPL, and the results were inconsistent (19, 20). Thus, there are no specific guidelines to recommend at the present time.
Weight loss is another lifestyle factor that significantly improves dyslipidemia. Obesity typically elevates VLDL and LDL fractions, increases TG levels, lowers HDL cholesterol, increases blood pressure, and promotes insulin resistance. Weight loss typically lowers LDLs, TGs, and total cholesterol (2, 3). HDLs may increase, decrease, or remain the same (2, 3). If weight loss is combined with aerobic exercise, HDLs are more likely to be sustained or increase following training. Weight loss also lowers blood pressure, improves glycemic control, and reduces inflammation linked to metabolic and cardiac diseases (3, 5, 21, 22).
Exercise training can improve lipid profiles either directly (without weight loss) by increased lipid enzymatic activity or indirectly (reduced body weight) (2). When weight loss occurs in conjunction with exercise, LDL and total cholesterol are usually lowered (2, 3). Weight loss also has beneficial effects on lowering PPL, as obesity increases PPL. When weight loss is indicated, a loss of 5% to 10% body weight from baseline is a starting goal (4). This amount of weight loss can significantly improve blood lipids. However, even when there is minimal or no weight loss, an improved lipid profile can still be achieved with adequate exercise (11).Exercise/Physical Activity Guidelines
It is prudent that the fitness professional check with the individual's physician if he or she is taking lipid-lowering medications or other medications for any coexisting diseases (e.g., obesity, hypertension, type 2 diabetes) that may require medical clearance. Statins, for example, can cause muscle damage (myopathy) and this should be considered (4). Table 5 summarizes general exercise guidelines for dyslipidemia. The emphasis should be on aerobic exercise and total weekly caloric expenditure. A good initial goal is to perform aerobic exercise three to five times per week for 20 to 60 minutes, expending ≥1,200 calories/week. Ideally, aerobic exercise for dyslipidemia should gradually progress, as tolerated, to five to seven times per week for 40 to 60 minutes, creating an energy expenditure of >2,000 calories/week (4). A gradual increase in aerobic exercise intensity should also occur. Exercise programs with higher volumes and intensities have been shown to be most effective for increasing HDL cholesterol (11). These guidelines may also need adjusting based on coexisting diseases, current fitness level, and time constraints that may be present. The aerobic training may need to be performed intermittently throughout the day. It is important to remember that lifestyle physical activity (e.g., climbing stairs, lunchtime walks, housework) contributes to the total weekly energy expenditure. Also, for a well-rounded exercise program, resistance and flexibility training should be incorporated (see Table 5 for guidelines).Nutritional Guidelines
Dietary modification is a powerful nonpharmacological strategy for improving blood lipids. Diets that are high in saturated and trans-fat and cholesterol increase TGs, LDL, and total blood cholesterol. Polyunsaturated fats (e.g., corn oil) seem to have a neutral effect on blood cholesterol, whereas monounsaturated fats (e.g., olive oil) seem to sustain HDLs and lower LDLs and TGs. Reducing saturated and trans-fats and cholesterol intake will usually improve blood lipids. Even though there is variability in individual responses to dietary changes, reducing total calories consumed, particularly saturated fat calories, which results in weight loss, typically lowers total and LDL cholesterol. HDL cholesterol is sometimes lowered as well, but when dieting is coupled with exercise, HDL cholesterol can be maintained (2, 3, 23, 24).
High-carbohydrate diets can increase TG levels and decrease HDL cholesterol, but again, this effect is negated with aerobic exercise (2, 3, 23, 24). Dietary fiber, particularly soluble fiber, helps to lower blood cholesterol levels. Omega-3 fatty acids lower blood TG levels (3). Plant sterols also have been shown to favorably alter lipid profiles, particularly when combined with aerobic exercise (25). Moderate alcohol consumption (no more than one drink per day in women and lighter persons and no more than two drinks per day in most men) (4) may raise HDL cholesterol levels. It may also increase TGs, but its effect on LDL cholesterol appears to be minimal.
Table 6 summarizes the key components of a diet to help lower blood lipids. The emphasis should be on restricting fat, particularly saturated fats, and cholesterol intake while increasing intake of soluble fiber and other foods such as soy, almonds, walnuts, plant sterols and stanols, cold water fish (e.g., salmon), etc., which have been shown to have a beneficial effect on blood lipids. Here are some nutrition tips that favorably help impact blood lipids:
In December of 2003, a 75-year-old man was referred for lifestyle management to lose body weight and manage cardiovascular risk factors. On medical history and physical fitness, he was found to have had a recent surgical repair of a left quadriceps muscle rupture and had gained 45 lbs over six to eight months of recovery and rehabilitation. He had a history of dyslipidemia and overweight but was not diabetic nor hypertensive. He was a nonsmoker, and his mother and father died of cardiovascular disease at age 78 and 84, respectively. He has been an avid golfer since retirement in 1995, walking nine holes, three days/week. He also has been very active in his daily life but had not been following a regular exercise program. His dyslipidemia was being treated only with Altaprev, 20 mg/day, started in April of 2001. He had had no advice in regard to weight loss, exercise, or other therapeutic lifestyle changes. He was enrolled in the INTERXVENTUSA Cardiovascular Risk Reduction Program (www.interventusa.com). After one year, he had lost 43 lbs (from 244 to 201 lbs). He was eating a low-fat, high-fiber diet (22% fat calories and 45 g of fiber per day by seven day food recall) and exercising 260 minutes/week on average (walking 200 minutes and Airdyne bicycle ergometer 60 minutes). Lipid changes with indicated therapy from 04/01 through 01/05 are summarized below:Summary
Dyslipidemia is a condition that promotes the genesis and progression of atherosclerosis. Dyslipidemia and PPL can often be prevented or treated with lifestyle management of exercise/physical activity, proper nutrition, and weight loss (if needed). Having a sound knowledge of lipid disorders, their associated risks, guidelines for treatment, and understanding how lifestyle management can prevent/improve dyslipidemia will better enable the fitness professional to coach individuals to live healthier lives.Condensed Version and Bottom Line
A large body of evidence suggests that dyslipidemia is directly related to the progression of coronary artery disease. Lifestyle changes, which include increased exercise/physical activity, dietary modifications, and weight loss (if needed) have profound effects on improving dyslipidemia and other lipid disorders such as PPL. This will result in a lower rate of coronary artery disease.Recommended Readings Durstine, J. Larry, Ph.D. ACSM Action Plan for High Cholesterol. Human Kinetics, 2006. ACSM Fitness Book. 3rd ed. Human Kinetics, 2003. Cooper, Kenneth H., M.D., MPH. Controlling Cholesterol the Natural Way: Eat Your Way to Better Health With New Breakthrough Food Discoveries. Bantam, 1999. References 2. Durstine, J.L., and G.E. Moore. ACSM's Exercise Management for Persons with Chronic Diseases and Disabilities. 2nd ed. Human Kinetics, 2003, pp. 142-148. 3. Roitman J.L. (Senior Editor). ACSM's Resource Manual for the Guidelines for Exercise Testing and Prescription. 4th ed. Baltimore: Lippincott Williams & Wilkins, 2001, pp. 263-276, 308-318. 4. Whaley, M.H., P.H. Brubaker, and R.M. Otto (Editors). ACSM's Guidelines for Exercise Testing and Prescription. 7th ed. Baltimore: Lippincott Williams & Wilkins, 2005, pp. 211-212, 217. 5. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). The Journal of the American Medical Association 285(19):2486-2497, May 16, 2001. 6. Grundy S.M., J.I. Cleeman, C.N.B. Merz, et al., for the Coordinating Committee of the National Cholesterol Education Program, Endorsed by the National Heart, Lung, and Blood Institute, American College of Cardiology Foundation, and American Heart Association. Implications of Recent Clinical Trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines. Circulation 110:227-239, 2004. 7. Hyson D.C., J.C. Rutledge, and L. Berglund. Postprandial Lipemia and Cardiovascular Disease. Current Atherosclerosis Reports 5:437-444, 2003. 8. Parks E.J. Recent findings in the study of postprandial lipemia. Current Atherosclerosis Reports 3(6):462-470, November 2001. 9. Williams P.T., P.J. Blanche, R. Rawlings, et al. Concordant lipoprotein and weight responses to dietary fat change in identical twins with divergent exercise levels 1. American Journal of Clinical Nutrition 82(1):181-187, 2005. 10. Durstine J.L., P.W. Grandjean, C.A. Cox, et al. Lipids, lipoproteins, and exercise. Journal of Cardiopulmonary Rehabilitation 22(6):385-398, 2002. 11. Kraus W.E., J.A. Houmard, B.D. Duscha, et al. Effects of the amount and intensity of exercise on plasma lipoproteins. The New England Journal of Medicine 347(19):1483-1492, 2002. 12. William P.T., P.J. Blanche, and R.M. Krauss. Behavioral versus genetic correlates of lipoproteins and adiposity in identical twins discordant for exercise. Circulation 112(3):350-356, 2005. 13. Williams P.T. High density lipoprotein cholesterol and other risk factors for coronary heart disease in female runners. The New England Journal of Medicine 334:1298-1303, 1996. 14. Gill J.M., and A.E Hardman. Exercise and postprandial lipid metabolism: an update on potential mechanisms and interactions with high-carbohydrate diets (review). The Journal of Nutritional Biochemistry 14(3):122-32, 2003. 15. Zhang J.Q., L.L. Ji, G. Nunez, et al. Effect of exercise timing on postprandial lipemia in hypertriglyceridemic men. Canadian Journal of Applied Physiology 29(5):590-603, 2004. 16. Altena T.S., J.L. Michaelson, S.D. Ball, et al. Single sessions of intermittent and continuous exercise and postprandial lipemia. Medicine & Science in Sports & Exercise ® 36(8):1364-71, 2004. 17. Herd S.L., B. Kiens, L.H. Boobis, et al. Moderate exercise, postprandial lipemia, and skeletal muscle lipoprotein lipase activity. Metabolism 50(7):756-762, 2001. 18. Zhang J.Q., T.R. Thomas, and S.D. Ball. Effect of exercise timing on postprandial lipemia and HDL cholesterol subfractions. Journal of Applied Physiology 85:1516-1522, 1998. 19. Petitt D.S., S.A. Arngrimsson, and K.J. Cureton. Effect of resistance exercise on postprandial lipemia. Journal of Applied Physiology 94(2):694-700, 2003. 20. Shannon K.A., R.M. Shannon, J.N. Clore, et al. Resistance exercise and postprandial lipemia: the dose effect of differing volumes of acute resistance exercise bouts. Metabolism 54(6):756-63, 2005. 21. Ryan A.S., and B.J. Nicklas. Reductions in plasma cytokine levels with weight loss improve insulin sensitivity in overweight and obese postmenopausal women. Diabetes Care 27:1699-1705, 2004. 22. Esposito K., A. Pontillo, C. DiPalo, et al. Effect of weight loss and lifestyle changes on vascular inflammatory markers in obese women: a randomized trial. The Journal of the American Medical Association 289:1799-1804, 2003. 23. Koutsari C., F. Karpe, S.M. Humphreys, et al. Exercise prevents the accumulation of triglyceride-rich lipoproteins and their remnants seen when changing to a high-carbohydrate diet. Arteriosclerosis, Thrombosis, and Vascular Biology 21(9):1520-1525, 2001. 24. Koutsari C., and A.E. Hardman. Exercise prevents the augmentation of postprandial lipaemia attributable to a low-fat high-carbohydrate diet. British Journal of Nutrition 86(2):197-205, 2001. 25. Varady K.A., N. Ebine, C.A. Vanstone, et al. Plant sterols and endurance training combine to favorably alter plasma lipid profiles in previously sedentary hypercholesterolemic adults after 8 wk. The American Journal of Clinical Nutrition 80(5):1159-66, 2004. Keywords:
Cholesterol; Dyslipidemia; Postprandial Lipemia; Exercise; Physical Fitness© 2006 American College of Sports Medicine Source
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Real-Estate [1 Certification Exam(s) ]
RedHat [8 Certification Exam(s) ]
RES [5 Certification Exam(s) ]
Riverbed [8 Certification Exam(s) ]
RSA [15 Certification Exam(s) ]
Sair [8 Certification Exam(s) ]
Salesforce [5 Certification Exam(s) ]
SANS [1 Certification Exam(s) ]
SAP [98 Certification Exam(s) ]
SASInstitute [15 Certification Exam(s) ]
SAT [1 Certification Exam(s) ]
SCO [10 Certification Exam(s) ]
SCP [6 Certification Exam(s) ]
SDI [3 Certification Exam(s) ]
See-Beyond [1 Certification Exam(s) ]
Siemens [1 Certification Exam(s) ]
Snia [7 Certification Exam(s) ]
SOA [15 Certification Exam(s) ]
Social-Work-Board [4 Certification Exam(s) ]
SpringSource [1 Certification Exam(s) ]
SUN [63 Certification Exam(s) ]
SUSE [1 Certification Exam(s) ]
Sybase [17 Certification Exam(s) ]
Symantec [134 Certification Exam(s) ]
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The-Open-Group [8 Certification Exam(s) ]
TIA [3 Certification Exam(s) ]
Tibco [18 Certification Exam(s) ]
Trainers [3 Certification Exam(s) ]
Trend [1 Certification Exam(s) ]
TruSecure [1 Certification Exam(s) ]
USMLE [1 Certification Exam(s) ]
VCE [6 Certification Exam(s) ]
Veeam [2 Certification Exam(s) ]
Veritas [33 Certification Exam(s) ]
Vmware [58 Certification Exam(s) ]
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Worldatwork [2 Certification Exam(s) ]
XML-Master [3 Certification Exam(s) ]
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