Physicians Increasingly Prescribe Exercise

Physicians and other healthcare professionals can be influential sources of health information. Specifically, exercise counseling by primary care physicians has been shown to increase patients’ participation in physical activity.

A 2012 report from the Centers for Disease Control and Prevention (CDC) suggests that over the past decade, the medical community has increased its efforts to recommend participation in exercise and other physical activity (Barnes & Schoenborn, 2012). The key findings of the report include:

1) In 2010, one in three adults who had seen a physician or other health professional had been advised to begin or continue to do exercise or physical activity.

2) Between 2000 and 2010, the percentage of adults receiving advice to exercise increased by about 10 percentage points.

3) Receiving advice to exercise occurred more frequently for adults with chronic diseases (e.g., hypertension, cardiovascular disease, cancer, and diabetes).

4) Adults who were overweight or obese had the largest percentage point increases over the decade 2000–2010 in being advised to exercise.

Unfortunately, the prevalence of receiving advice from physicians to become or continue to be physically active remains well below one-half of U.S. adults and varies substantially across population subgroups. If you are a fitness professional, I encourage you to seize the opportunity to connect with those healthcare providers that regularly recommend exercise to their patients. If you are not a fitness professional and are interested in making healthful changes that include regular exercise, consider having a conversation with your physician about the types of exercise that would be best for you.

Barnes, P.M. & Schoenborn, C.A. (2012). Trends in adults receiving a recommendation for exercise or other physical activity from a physician or other health professional. National Center for Health Statistics data brief, no 86. Hyattsville, MD: National Center for Health Statistics.

 

Obesity-Related Myths, Presumptions, and Facts

In a study funded by the National Institutes of Health, Casazza and colleagues (2013) set out to study numerous beliefs about obesity that persist in the absence of supporting scientific evidence (presumptions) as well as those that persist despite contradicting evidence (myths). The researchers used Internet searches of popular media and scientific literature to identify, review, and classify obesity-related myths and presumptions. What they found were seven obesity-related myths concerning the effects of small sustained increases in energy intake or expenditure, establishment of realistic goals for weight loss, rapid weight loss, weight-loss readiness, physical-education classes, breast-feeding, and energy expended during sexual activity. They also identified six presumptions about the purported effects of regularly eating breakfast, early childhood experiences, eating fruits and vegetables, weight cycling, snacking, and the built (i.e., human-made) environment. Lastly, the authors reported nine evidence-supported facts that are relevant for the formulation of sound public health, policy, or clinical recommendations.

 

The following myths of obesity were found to persist, even though there is contradictory data that does not support them:

  • Small, sustained changes in energy intake or expenditure results in significant, long-term weight changes.
  • Setting realistic weight-loss goals is important so that obese individuals do not become frustrated and therefore lose less weight.
  • Large, rapid weight loss results in poorer long-term weight outcomes than slow, gradual weight loss.
  • Assessing the stage of change or diet readiness is important in helping patients who seek weight-loss treatment.
  • The way physical-education classes are taught today play an important role in preventing or reducing childhood obesity.
  • Breast-feeding protects against obesity.
  • The calorie expenditure of one bout of sexual activity equates to 100 to 300 kcal for each person involved.

 

The following presumptions about obesity were reported, even though there is a lack of evidence to support them:

  • Regularly eating (rather than skipping) breakfast protects against obesity.
  • The exercise and eating patterns that we learn in early childhood become habits that influence our weight throughout life.
  • Eating more fruits and vegetables protects against obesity, regardless of whether any other intentional behavioral or environmental changes are made.
  • Weight cycling (i.e., yo-yo dieting) is associated with increased mortality.
  • Snacking contributes to weight gain and obesity.
  • The built environment (i.e., accessibility to sidewalks and parks) influences obesity.

 

Lastly, the list below presents obesity-related facts that are supported by sufficient evidence to consider them empirically proved:

  • Although genetic factors play a large role, genes do not fully dictate a person’s destiny.
  • Diets very effectively reduce weight, but they generally do not work well in the long-term.
  • Exercise increases health levels, regardless of body weight or weight loss.
  • Sufficient doses of physical activity or exercise aids in long-term weight maintenance.
  • Continuation of conditions that promote weight loss promotes maintenance of lower weight.
  • Greater weight loss or maintenance is achieved for overweight children with programs that involve the parents and the home setting.
  • Provision of meals and use of meal-replacement products promote greater weight loss.
  • The continued use of some pharmaceutical agents can help patients achieve clinically meaningful weight loss and maintain the reduction.
  • In appropriate patients, bariatric surgery results in long-term weight loss and reductions in the rate of incident diabetes and mortality.

 

I encourage you to read the entire manuscript of this study as it sheds light on the numerous myths and presumptions about obesity that reflect unsupported beliefs held by many people, including academics and the general public. The authors of this study were careful to conclude that any of the aforementioned myths and presumptions might one day be justifiably proved correct with appropriate scientific research. They also note that the facts about obesity, of which we may be reasonably certain, are facts that are useful today.

Casazza, K. et al. (2013). Myths, presumptions, and facts about obesity. New England Journal of Medicine, 368, 446–454.

Part 3: How Low Can You Go? Performing Squats Correctly

In my last post, I suggested that you perform a self-experiment to discover which type of squatting pattern you perform on a daily basis (i.e., lumbar, quadriceps, or glute dominant). If you found that you are any type other than a glute-dominant squatter, you could be setting yourself up for future knee and/or low-back discomfort. In other words, if the hip-hinge (i.e., pushing the hips slightly backward) is not the first action that occurs as you start to squat, your knees or lumbar spine could be taking the brunt of the forces imposed during a squat. In my last post, I also promised to give you some tips on how to clean up your squatting pattern and move toward a more glute-dominant squat. The following tips are cues that I use with my clients to help them master a better squat.

4 Tips for Better Squatting Technique

1)    Feel the Heel

Before you begin to descend, focus equal amounts of body weight toward the back half of each foot, toward the heel. This does not mean shift backward so that you feel off balance, nor does it mean that the toes should lift off the floor. It means your direct attention to the back half of your foot so that your brain can connect with a base of support that includes your heels. Most likely, if you have mobility problems in the ankle joint, keeping your heels down throughout the descent and ascent of the squatting pattern will prove very challenging, especially in the depths of the squat.

2)    Hinge the Hip

After connecting with the weight in the heels, begin the descent by flexing the hips and moving them backward slightly. This sets the stage for placing the focus on the strong hip muscles (i.e., gluteals) and taking the stress off of the more vulnerable joints of the lower back and knees.

3)    Know the Knee

As you continue your descent, be sure that each kneecap points in line with the lesser toes. That is, avoid allowing the knees to cave inward and/or track on top of the big toe. The gluteal muscles play an important role in stabilizing the knees and keeping them tracking properly, so continuously squeezing the glutes on both the descent and ascent of the squat pattern can help the knees avoid veering inward toward the midline of the body. Knees collapsing inward could be an indication of inflexible ankles or weak gluteals, or both.

4)    Recognize the Ribs

Keeping the ribs in line with the hips (i.e., not allowing them to flare upward and/or shift forward of the pelvis) is a good indication that the abdominals and other core musculature are working properly to support the spine. If you have a tendency to move into an excessive back arch (i.e., back bend) as you get lower in the squat, chances are you suffer from weak core muscles. This exaggerated motion in the spine could lead to low-back pain and perhaps injury. Therefore, recognize where your ribs are in relation to your pelvis throughout the squatting pattern and keep the abdominals engaged to limit excessive spine movement. Think of keeping the bottom ribs on top of or in line with the top of the pelvis.

Are These Tips Achievable?

There are numerous reasons why—if performed incorrectly—the squat could potentially wreak havoc on the joints of the spine and lower extremity. Following these four tips could help you avoid a faulty squatting pattern. If performing any of these strategies is difficult, it is possible that you have muscle imbalances or neuromuscular issues that are preventing you from achieving proper form. If you have questions about these tips or issues you might be having with the squat exercise, be sure to leave a comment below.

Part 2: How Low Can You Go? Performing Squats Correctly

The gluteals and core musculature play an important role in the squat movement, during which people often exhibit “lumbar dominance,” “quadriceps dominance,” or “glute dominance.”

Lumbar Dominance
This implies a lack of core abdominal and gluteal muscle strength to counteract the force of the hip flexors and erector spinae as they pull the pelvis forward during a squat movement. In this scenario, the individual experiences excessive loads within the lumbar spine as it moves into extension during the squat. The muscles of the abdominal wall and gluteal complex do not contribute enough in this situation to spare the back and foster proper execution of the squat. Chronically tight hip flexors, such as those caused by sitting for prolonged periods throughout the day, may also contribute to this problem.

Quadriceps Dominance
This implies reliance on loading the quadriceps group during a squat movement. The first 10 to 15 degrees of the downward phase are initiated by driving the lower leg forward, creating shearing forces across the knee as the femur slides over the tibia. In this lowered position, the gluteus maximus does not eccentrically load and cannot generate much force during the upward phase. Quadriceps‐dominant squatting transfers more pressure into the knees, placing greater loads on the anterior cruciate ligament (ACL).

Glute Dominant
This implies reliance on eccentrically loading the gluteus maximus during a squat movement. The first 10 to 15 degrees of the downward phase are initiated by pushing the hips backward, creating a hip‐hinge movement. In the lowered position, this maximizes the eccentric loading on the gluteus maximus to generate significant force during the upward, concentric phase. The glute‐dominant squat pattern is the preferred method of squatting, as it spares the lumbar spine and relieves undue stress on the knees.

Which Type of Squatter Are You?
Take a personal inventory of where you feel squats the most (i.e., lower back, quadriceps, or glutes), whether you’re getting up out of a chair or performing a workout that includes squats. In my next post, I’ll give you some tips on how to clean up your squat pattern and move toward a more glute-dominant squat.

Part 1: How Low Can You Go? Squatting in Privacy

How low do you squat? I can reliably predict that most of you squat at least 14 inches from the floor, several times everyday. The standard toilet-seat height in the U.S. is between 14 and 15 inches, so if you’re using the restroom on a regular basis, you’re squatting on a regular basis. If you “do your business” in many other countries around the world, you might squat even lower (like over a hole in the ground), but that’s a topic for a different blog. What I’ve just described is an important reason why the squat is such a fundamental, functional exercise.

Unfortunately, most of us do not squat properly, which means that we place unnecessary stress on the joints of the spine and lower body. For example, if you can’t perform a deep squat (all the way down with your butt close to your ankles) without losing balance, or if your knees cave in or heels lift up whenever you squat down, you have mobility and/or stability problems plaguing your muscles and joints.

In my next blog, I will discuss some quick fixes to help you improve your squatting function. These tips can be applied even if you don’t workout or do squats on a regular basis. In fact, everyone can start my first tip today… the next time you squat down to the toilet, pay attention to where you feel most of your body weight balanced in the feet. If most of your weight is toward the ball of your foot, slightly shift your weight back toward your heels. Practice shifting your body weight toward your heels when doing your “potty squats” for the next several days. I’ll write about why that’s important in my next blog. Until then, happy squatting!

Should your child be lifting weights?

Since the early 1960s, there has been concern in the physical education community that participation in a strength-training program could have an adverse effect on a young person’s growth and stature. The fear was that lifting weights could damage a child’s growth plates, which are cartilaginous structures covering the ends of the long bones where growth occurs. This concern seems to have come from a 1964 report indicating that children in remote areas of Japan who performed heavy labor where short in stature. The report, however, failed to control for etiologic factors such as poor nutrition and hours-long heavy labor. Current data show no evidence of a decrease in stature in children who perform a well-designed strength-training program. Additionally, growth-plate fractures have never been reported in any prospective youth strength-training study published to date. Indeed, research conducted over the past 20 years offers credible evidence that strength training can be a safe and effective method of conditioning for children, as long as appropriate guidelines are followed.

Developing a strong and fit musculoskeletal system is the cornerstone of a healthy exercise-conditioning program. Children as young as six have shown gains in muscular strength of approximately 30 to 50% following short-term strength-training programs. Additionally, childhood and adolescence may be the period during which the bone-building process responds most favorably to the mechanical loading of physical activities such as strength training. It seems that maximizing bone mineral density (BMD) during youth with exercise and proper nutrition may help to prevent the condition of osteoporosis seen in older adults.

A regular strength-training program has been shown to help youth involved in athletic activities reduce their risk of muscle imbalance and overuse injuries. Children should have good overall strength before engaging in competitive sports that can place excessive stress on an unconditioned musculoskeletal system. Focusing only on sport-specific skills typically provides too little stimulus for many major muscle groups and too much stimulus on others, with the result being injury to the child. For this reason, it is crucial that children develop fundamental fitness before specializing in the specific-skill training required for sport.

Leading organizations, including the American College of Sports Medicine (ACSM) and the National Strength and Conditioning Association (NSCA) all support strength training for children and adolescents as long as the appropriate guidelines are followed. Although there is no minimum age requirement for engaging in a strength training program, all children considering participation should have the emotional maturity to accept and follow directions and should understand the benefits and risks associated with resistance training. Young children (six years of age) have participated in and benefited from a strength-training program. However, there have been reports that children younger than age six are more likely than older children to be injured with weight-training equipment.

Youth strength training is relatively safe when compared with other sports and activities in which children and adolescents regularly participate. One retrospective evaluation of strength training injures incurred by 13 to 16 year olds revealed that strength training was remarkably safer than other sports such as soccer, basketball, and football. Currently, there are no justifiable safety reasons to prohibit children and adolescents from participating in well-designed strength programs.

Should you add Olympic lifts to your training routine?

In Olympic lifting, athletes attempt to quickly lift as much weight as possible using movements that test their explosive muscular power (speed and strength), such as the clean and jerk and the snatch. In the snatch, a barbell is lifted from the ground to over the head in one smooth movement. In the clean and jerk, a barbell is lifted from the floor to the shoulders and then over the head. These movements involve the whole body and require the muscles and joints to provide functional strength throughout maximum ranges of motion. This type of lifting is an essential training method for athletes in various sports.

Olympic lifts are not recommended for the average fitness enthusiast. Observing a highly conditioned athlete perform an Olympic lift might lead you to believe that the movement is a simple matter of quickly thrusting the barbell from one location to another. However, Olympic lifts are highly technical whole-body movements that call upon an exerciser’s strength, flexibility, power, speed, coordination, agility, and balance. Needless to say, this type of training is highly taxing and most fitness enthusiasts do not have the requisite skills needed to perform the lifts correctly.

That said, there has been an emerging interest among the general fitness population in this type of exercise due to organizations such as CrossFit promoting Olympic lifts as part of their structured workout regimen. Although a person new to exercise should not attempt to perform Olympic lifts, those who have proper instruction, supervised practice time, and a reasonable level of conditioning can pursue these complex lifting techniques. The key is to find a fitness trainer or coach who is experienced in teaching Olympic lifting who can set you up on a program to gradually progress your conditioning level and skills to the point where you can safely perform the lifts. In addition, programming for these techniques requires specific periodization to reduce the risk of overtraining and overuse injuries. You can find excellent technique and coaching resources related to Olympic lifting at the Team USA Olympic Website http://www.teamusa.org/USA-Weightlifting.aspx. You can also search for a personal trainer or coach in your area who specializes in sports conditioning and Olympic lifting.

People who safely and effectively perform Olympic lifting as part of their workout programs enjoy tremendous performance benefits. While these techniques are not for everyone, those who do train with these lifts experience myriad benefits, especially if increased sports or athletic performance is a primary goal.

How do you gain weight and muscle (while avoiding body fat)?

In order to gain body weight that consists of healthy lean tissue (muscle mass), three contributing factors must be present: sufficient caloric intake with appropriate protein levels, a program of regular resistance training, and adequate rest and recovery between exercise sessions. Protein plays an important role resistance-training exercise. Regular strength training stimulates muscle protein synthesis, which is further enhanced by consumption of protein around the time of exercise. An acceptable range of protein intake appears to be between 10 and 35% of total daily caloric intake. The table below lists the number of protein grams for different levels of caloric intake.

 

Protein Intake (grams) at Various Levels of Energy (Calorie) Intake

Energy intake (cal/day) Low-protein diet (<10% cal) Average diet (˜15% cal) High-protein diet (≥20% cal) Very-high protein diet (≥30% cal)

1200

30

45

60

90

2000

50

75

100

150

3000

75

112

150

225

 

To promote muscle mass increases, heavy resistance exercise [i.e., 85 to 95% of one-repetition maximum (1 RM)], or moderate- to high-volume training with multiple sets and/or exercises with less than one-minute rest intervals, along with training larger muscle groups is required. This type of training leads to an increase in testosterone release (more so in men than in women), which helps to develop and maintain protein in muscle.

Lastly, allowing adequate time off from exercise for recovery between resistance training workouts is an important, but often overlooked, component of gaining muscle. Strenuous exercise breaks down the body’s muscle, which triggers a process of healing and tissue bonding that results in increased strength. This recovery can only happen if the muscle is not overstressed and has adequate recovery time (between 48 to 72 hours minimum) between training sessions. If the muscle is not given enough time to heal and rebuild, the exerciser can actually lose weight and suffer from overtraining.