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1/16ACSMS CERTIFIED NEWS OCTOBERDECEMBER 2010 VOLUME 20:4 1ACSMS CERTIFIED NEWS JANUARY-MARCH 2010 VOLUME 20:1 1

NEWS

Continuing Education Self-Tests

page 15

Assessment and Managementof Clients with Obesity page 3

Insulin Resistance Not justfor people with diabetes?

page 5

Womens Health:The BEST StrengthTraining Programfor OsteoporosisPrevention page 7

Health Benefits ofRegular ResistanceExercise page 10

The Rise of theClinical ExercisePhysiologist Here to Stay page 12

Health Care Reform and theCertified Exercise Professional

page 14

ACSMSCERTIFIED

SHUTTERSTOC

K

O C T O B E R D E C E M B E R , 2 0 1 0 V O L U M E 2 0 : I S S U E 4

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2 ACSMS CERTIFIED NEWS OCTOBERDECEMBER 2010 VOLUME 20:4

ACSMS CERTIFIED NEWSOctoberDecember 2010 VOLUME 20 ISSUE 4

In this IssueAssessment and Management of Clients

with Obesity............................................................ 3

Insulin Resistance Not just for people

with diabetes?.......................................................... 5

Womens Health: The BEST Strength Training

Program for Osteoporosis Prevention.............. 7

Coaching News........................................................... 9

Health Benefits of Regular Resistance Exercise.......10

The Rise of the Clinical Exercise

Physiologist Here to Stay...................................12

Health Care Reform and the

Certified Exercise Professional.............................14

Self-Tests........................................................................15

Co-EditorsJames R. Churilla, Ph.D., MPH.

Paul Sorace, M.S.

Committee on Certificationand Registry Boards Chair

Madeline Bayles, Ph.D., FACSM

CCRB Publications Subcommittee ChairPaul Sorace, M.S.

ACSM National Center Certified News StaffNational Director of Certification

and Registry Programs

Richard Cotton

Assistant Director of CertificationTraci Sue Rush

Professional Education Coordinator

Shaina Miller

Publications Manager

David Brewer

Editorial BoardChris Berger, Ph.D.

Clinton Brawner, M.S., FACSM

Brian Coyne, M.Ed.

Avery Faigenbaum, Ed.D., FACSM

Yuri Feito, Ph.D., MPH

Tom LaFontaine, Ph.D., FACSM

Peter Magyari, Ph.D.

Thomas Mahady, M.S.

Jacalyn McComb, Ph.D., FACSM

Peter Ronai, M.S.

Larry Verity, Ph.D., FACSM

Stella Volpe, Ph.D., FACSM

Jan Wallace, Ph.D., FACSM

For More Certification Resources Contact the

ACSM Certification Resource Center:

1-800-486-5643

Information for SubscribersCorrespondence Regarding Editorial Content

Should be Addressed to:

Certification & Registry Department

E-mail: [email protected]

Tel.: (317) 637-9200, ext. 115

For back issues and author guidelines visit:

www.acsm.org/certifiednews

Change of Address or Membership Inquiries:

Membership and Chapter Services

Tel.: (317) 637-9200, ext. 139 or ext. 136.

ACSMs Certified News (ISSN# 1056-9677) is published

quarterly by the American College of Sports Medicine

Committee on Certification and Registry Boards (CCRB). All

issues are published electronically and in print. The articles

published in ACSMs Certified News have been carefullyreviewed, but have not been submitted for consideration as, and

therefore are not, official pronouncements, policies,

statements, or opinions of ACSM. Information published in

ACSMs Certified News is not necessarily the position of the

American College of Sports Medicine or the Committee on

Certification and Registry Boards. The purpose of this

publication is to provide continuing education materials to the

certified exercise and health professional and to inform these

individuals about activities of ACSM and their profession.

Information presented here is not intended to be information

supplemental to the ACSMs Guidelines for Exercise Testing and

Prescription or the established positions of ACSM. ACSMs

Certified News is copyrighted by the American College of

Sports Medicine. No portion(s) of the work(s) may be

reproduced without written consent from the Publisher.

Permission to reproduce copies of articles for noncommercial

use may be obtained from the Rights and Permissions editor.

ACSM National Center

401 West Michigan St., Indianapolis, IN 46202-3233.

Tel.: (317) 637-9200 Fax: (317) 634-7817

2011 American College of Sports Medicine.

ISSN # 1056-9677

THE CHANGINGOF THE GUARD

By James R. Churilla,Ph.D., MPH, Co-Editor

The coming of a new year is

typically accompanied by change...

The coming of a new year is typically accompanied by change ACSMs

Certif ied News is making one BIG one. As co-editor of Certified Newsover

the past two and a half years, I have had the privilege of working with our other

co-editor Paul Sorace. Paul and I have worked diligently at maintaining and

improving the integrity of this publication, and the feedback we have received

has been extremely supportive and greatly appreciated. Paul has been writing

for ACSMs Certif ied Newsand ACSMs Health & Fitness Journal for over

10 years and his contributions to ACSM and the field of exercise science, fitness,

and health do not stop there, as he has served and continues to serve on sev-

eral ACSM committees. Paul, thank you from your co-editor and everyone at

ACSM for your service on Certif ied Newsand your contributions to the pro-

fession. We look forward to your continued commitment to excellence as you

take on yet another new role as the new Chair of the

ACSM Publications Subcommittee. Thank you Paul!

Now we must continue to move forward and con-

tinue to improve our publication. We at ACSM are

pleased to announce Peter Ronai as our new co-editor

for Certified News. Peter is a long-standing member of

the ACSM and a regular contributor to several ACSM

publications. Peter has extensive experience in the field

of exercise science and has recently accepted a position

in academia. Please help ACSM in welcoming Peter as

our new co-editor and wishing him all the best with

ACSM and in his new position as an academician.

Welcome, Peter!

Peter Ronai, M.S.,

RCEP, CSCS-D

SELF-TESTANSWERKEYFORPAGE15

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ACSMS CERTIFIED NEWS OCTOBERDECEMBER 2010 VOLUME 20:4 3

PERHAPS THE BIGGEST HEALTH

PROBLEMS WE ARE FACING TODAY AREFROM THE COMBINED EFFECT OF

OBESITY, DIABETES, ANDCARDIOVASCULAR DISEASE (CVD)

(HTTP://WWW.CARDIOMETABOLIC HEALTH.ORG).

Excess weight, in particular, abdominal obesity, causes or exacer-

bates other cardiovascular and metabolic risk factors, including hyper-

tension, dyslipidemia, insulin resistance, and type 2 diabetes,4 and

increases the risk of gallbladder disease, osteoarthritis, sleep apnea, res-

piratory conditions, and cancer.14

While the prevalence of some modifiable risk factors, such as smok-

ing, has decreased over the past two decades, the prevalence of obesi-

ty has risen. Certified health and fitness professionals (CHFP) deal with

the consequences of overweight/obesity in most, if not all of the popu-

lations that they work with. The optimal management of clients with or

at risk for CVD requires the assessment and treatment of modifiable

risk factors.4 All clients should be assessed regularly for the presence of

modifiable CVD risk factors, and when risks are present, efforts should

be made to encourage the client to make changes in lifestyle to reduce

the risk for CVD.14 Information gained from an assessment of body com-

position and body fat distribution during a pre-exercise fitness appraisal

or health screening can be used to (a) identify and stratify a clients risk

for cardiovascular, metabolic, or pulmonary diseases, (b) set appropriate

measureable and attainable goals, (c) track changes over time, and (d)

educate the client or patient. The purpose of this article is to present

information that will help the CHFP select and correctly interpret assess-

ments of obesity.

Measures and Definitions of Obesity

Obesity is one of the risk factors listed by the American College of

Sports Medicine (ACSM) for cardiovascular, pulmonary, and metabolic

diseases.2 There are various methods of assessing body composition that

estimate percent body fat (%BF), of which, the simplest model, partition

the body into lean mass and fat mass. Because it is not the intent of this

paper to discuss individual methods of assessment, readers who are inter-ested in learning about available methods are directed to other

sources.1012

Anthropometric measurements (the measurement of physical

dimensions of the body such as height, weight, and circumferences) are

used as indices of obesity.5 These include body mass index (BMI) as an

indicator of obesity and waist circumference and waist-to-hip ratio

(WHR) as measures of body fat distribution ( i.e., central adiposity).

These are indices of obesity because they do not actually estimate but

are correlated with body composition and its health consequences. The

medical community, and most, if not all health profession organizations

have adopted BMI as an indicator of obesity.

Standardized landmarks for the measurement of waist and hip cir-

cumferences are necessary to assure an accurate assessment. ACSM rec-

ommends that the circumference of the hip should be measured at the

widest portion of the buttocks and the circumference of the waist should

be measured at the narrowest part of the torso between the iliac crest

and the xiphoid process.2 If there is not a narrowest part of the waist

because of overweight or obesity, the circumference should be measured

on a horizontal plane around the abdomen at the level of the iliac crest.14

The advantage of using indices of obesity and body fat distribution is

that when measured correctly, these measures have little source of

error (compared to estimates of %BF). As such, they are useful for mon-

itoring changes that occur as a result of diet and physical activity, while

providing comparable results across research studies. The CHFP who

estimates a clients %BF also should measure BMI, waist and hip circum-

ferences, and WHR. These measures provide additional information

that can be used to educate clients and track their progress over time.

Interpreting Results of Body Composition andBody Fat Distribution Assessments

BMI, waist circumferences, and WHR are used to define obesity and

central adiposity (Table) but they do not distinguish between body fat

and lean muscle mass.

Obesity also is defined as having a %BF greater than 25% in men and

greater than 32% is women but definitions may vary with age.11 The

interpretation of %BF values is somewhat obscure since there are inher-

ent errors in any estimate of body composition. The first step in assur-

ing that an assessment of body composition is as accurate as possible

and can be correctly interpreted is to eliminate or minimize sources of

error in the actual measurement.16 To better understand the limitations

to interpreting body composition results, a brief review of statistics is

necessary. A method of assessing body composition is valid if it can accu-

rately predict the estimate of %BF by an accepted crite-rion method. A

criterion method, (e.g., DEXA) is believed to give the best estimate of

the actual or true amount of body fat. The standard error of estimate

(SEE) is a statistic that defines the amount of variability, or error, in a

measurement, and is used to describe the validity of a method to esti-

mate %BF. Assuming a bell-shaped curve for normal distribution, 68%

HEALTH & FITNESS FEATURE

BY PAT VEHRS, Ph.D.

ASSESSMENT AND MANAGEMENTOF CLIENTS WITH OBESITY

Table. Indices of Obesity and Central Adiposity

Norm a l We igh t BMI = 18.5 24.9 kg/m2Overwe i gh t BMI = 25 29.9 kg/m2Obese BMI > 30 kg/m2WC >102 cm in menWC >88 cm in womenC en t r a l d i p o s i t y WHR > 0.90 (men)WHR > 0.85 (women)WC >102 cm in menWC >88 cm in women

BMI = body mass index. WC = waist circumference.

WHR = waist-to-hip ratio. See references 2, 3, 7, and 8.
http://http//WWW.CARDIOMETABOLICHEALTH.ORGhttp://http//WWW.CARDIOMETABOLICHEALTH.ORGhttp://http//WWW.CARDIOMETABOLICHEALTH.ORGhttp://http//WWW.CARDIOMETABOLICHEALTH.ORGhttp://http//WWW.CARDIOMETABOLICHEALTH.ORGhttp://http//WWW.CARDIOMETABOLICHEALTH.ORGhttp://http//WWW.CARDIOMETABOLICHEALTH.ORGhttp://http//WWW.CARDIOMETABOLICHEALTH.ORGhttp://http//WWW.CARDIOMETABOLICHEALTH.ORG

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and 95% of the values obtained from a criterion method will fall within

1 SEE and 2 SEE of the predicted value, respectively. Predictions of

%BF estimate the %BF value that would be obtained from a criterion

method. For example, if a clients %BF was predicted to be 20% using a

method whose SEE is 5 %BF, then the value obtained from a criterion

method could be as little as 10 %BF and as great as 30 %BF. An accept-

able SEE for body composition devices is 35 %BF. For obvious reasons,

national organizations have adopted anthropometric measures asindices of obesity.

Educating the Client.

What is the role of the CHFP in helping clients and patients manage

their obesity? The CHFP educates clients on the influence of obesity on

the risk for cardiovascular, metabolic, and other diseases or conditions

and defines, teaches, and reinforces good nutrition and appropriate

amounts and types of physical activity to help clients achieve a healthy

body weight and composition.

Because obesity is a modifiable risk factor, focusing on lifestyle

changes is a critical component of reducing the risk of cardiovascular and

metabolic diseases.7 Certified health and fitness professionals should

focus on the preventable nature of CVD since much of the decline in

quality of life and many of the cardiovascular events and fatalities associ-

ated with CVD are the result of risk factors that are modifiable.7 More

than any other risk factor, the successful treatment of obesity through

diet and exercise can positively affect risk of cardiovascular and metabol-

ic diseases.14 Losing 5% to 10% of body weight reduces the risk of CVD

disease4 and has a positive effect on other risk factors, such as hyperten-

sion, blood glucose levels, and blood lipids.14

Central adiposity as measured by waist circumference and the

WHRincreases the risk of cardiovascular (e.g., hypertension) and

metabolic diseases (e.g., diabetes, dyslipidemia).15 Central adiposity is a

key component of the cluster of risk factors known as the metabolic syn-

drome.3, 7, 8 Clients with the metabolic syndrome are at twice the risk

of developing CVD over the next 5 to 10 years as individuals without

the metabolic syndrome.1 Having the metabolic syndrome increases the

risk of type 2 diabetes five-fold.1

For those people with BMI, waist circumference, WHR, or predicted

%BF values above the recommended range, the CHFP should encourage

modest and gradual changes in diet and physical activity to achieve a

healthy body weight and composition. Moderate improvements in body

weight, body fat, and body fat distribution can delay or prevent the onset

of diabetes.7, 13 Because high BMI, waist circumference, and WHR values

increase the likelihood of other health maladies, the CHFP must screen

for other conditions that need to be considered when prescribing exer-

cise. Exercise recommendations should align with recent minimal physicalactivity guidelines9 and the ACSM guidelines for exercise prescription for

the management of body weight.6 When necessary, the exercise pre-

scription also should follow recommendations specific to dyslipidemia,

hypertension, metabolic syndrome, and diabetes.2

The CHFP is in a position to educate clients about the assessment

and management of obesity. Assessments of obesity allow the CHFP to

define, teach, and reinforce sound nutrition and exercise habits.

Through objective measures of obesity and body fat distribution, the

CHFP can (a) help the client make realistic, achievable, and measureable

goals, (b) devise a safe and effective exercise program that meets the

needs and objectives of the client, and (c) provide needed education and

encouragement.

About the AuthorPat Vehrs, Ph.d., ([email protected]) is an associate

professor in the Department of Exercise Sciences at

Brigham Young University, Provo, UT 84602 where

his research focuses on cardiovascular risk, body

composition, and cardiovascular fitness across the

lifespan. He is an ACSM certified Health Fitness

Specialist, Exercise Specialist, and Program

Director.

References1. Alberti, K.G.M.M., R.H. Eckel, S.M. Grundy, P.Z. Zimmet, J.I Cleemen,

et al. Har-monizing the metabolic syndrome: A joint interim statement

of the International Diabetes Federation Task Force on Epidemiology

and Prevention; National Heart, Lung, and Blood Institutie;

American Heart Association; World Heart Federation; International

Atherosclerosis Society; and International Association for the Study

of Obesity. Circulation. 120:1640-1645, 2009.

2. American College of Sports Medicine. ACSMs Guidelines for

Exercise Testing and Prescription(8th ed., pp 28, 65, chapter10).

Lippincott Williams & Wilkins: Philadel-phia. 2010.

3. American Heart Association. What is Metabolic Syndrome.

Available on line at

http://www.heart.org/idc/groups/heartpublic/@wcm/@hcm/documents/downloadable/ucm_300322.pdf. Accessed October 25, 2010.

4. Cannon, C.P. Cardiovascular disease and modifiable cardiometabolic

risk factors. Clinical Cornerstone. 8(3)11-28, 2007.

5. Christian, A.H. H. Mochari, and L.J. Mosca. Waist circumference,

body mass index, and their association with cardiometabolic and

global risk.Journal of Cardiometabolic Syndrome. 4:12-19, 2009.

6. Donnelly, J.E., S.N. Blair, J.M. Jakicic, et al. American College of

Sports Medicine Position Stand: Appropriate physical activity inter-

vention strategies for weight loss and prevention of weight regain

for adults. Medicine and Science in Sports and Ex-ercise,

41(2):459471, 2009.

7. Early. J. Comprehensive management of cardiometabolic risk factors.

Clinical Cornerstone. 8(3):69-80, 2007.

8. Grundy S.M., H.B., Brewer, J.I. Cleeman, S.C. Smith, D. Lenfant, et al.

Definition of metabolic syndrome: Report of the National, Heart,Lung, and Blood Insti-tute/American Heart Association conference

on scientific issues related to defini-tion. Circulation. 109:433-438,

2004.

9. Haskell, W.I., I.M. Lee, R.R. Pate, et al., Physical activity and public

health: Updated recommendations for adults from the American

College of Sports Medicine and the American Heart Association.

Medicine and Science in Sports and Exercise, 39(8):14231434,

2007.

10. Heymsfield, S. B., T. Lohman, Z. Wang, and S.B. Going. Human body

composition(2nd ed., chapters 1-8). Champaign, IL: Human Kinetics,

2005.

11. Heyward, V. H. Advanced fitness assessment & exercise prescription

(6th ed., chapter 8). Champaign, IL: Human Kinetics, 2010.

12. Kaminsky, L., and G. Dwyer. Body composition. In L. A. Kaminsky, K.

A. Bonzheim, C. E. Garber, S. C. Glass, L. F. Hamm, H. W. Kohl III,and A. M. Milesky (Eds.), ACSMs resource manual for guidelines

for exercise testing and prescription(5th ed., pp. 195-205). Baltimore:

Lippincott, Williams & Wilkins, 2006.

13.Lindstrom, J., A. Louheranta, M. Mannelin, M. Rastas, V. Salminen, J.

Eriksson, M. Uusitupa, and J. Tuomilehto. The Finnish Diabetes

Prevention Study (DPS): Life-style Intervention and 3-Year Results on

Diet and Physical Activity. Diabetes Care. 26(12): 3230-3236, 2003.

14. Nesto, R.W. Comprehensive clinical assessment of modifiable car-

diometabolic risk factors. Clinical Cornerstone. 9(Suppl 1):S9-S19,

2008.

15 Pi-Sunyer F. X. The Relation of Adipose Tissue to Cardiometabolic

Risk. Clinical Cornerstone. 8(Suppl 4):S14-S23, 2006.

16. Vehrs, P., and R. Hager. Assessment and interpretation of body com-

position as-sessments in physical education.Journal of Physical

Education, Recreation, and Dance. 77(7):46-51, 2006.
mailto:[email protected]://www.heart.org/idc/groups/heartpublic/@wcm/@hcm/documhttp://www.heart.org/idc/groups/heartpublic/@wcm/@hcm/docummailto:[email protected]

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Sedentary Behavior and

Insulin ResistanceIn the past few years, researchers have been evaluating the effect

of time spent in sedentary behavior during the day in individuals who

perform daily exercise. Alibegovic et al.1 assessed the effects of nine

days of bed rest on insulin sensitivity in 20 healthy, young men.

Following the extended bed rest, participants were then re-evaluated

after four weeks of re-training. These researchers reported that nine

days of bed rest resulted in insulin resistance in these otherwise

healthy, previously exercising young men. Bed rest also altered more

than 4,500 genes within the skeletal muscle. Even though they eval-

uated the participants after four weeks of re-training, the changes to

insulin sensitivity and gene expression were only partly normalized.

Bed rest changes the expression of genes involved in insulin resistanceand diabetes. The authors concluded, Lack of complete normaliza-

tion of changes after four weeks of exercise retraining underscores

the importance of maintaining a minimum of daily physical activity. 1

In a population-based study, Helmerhorst et al.2 evaluated 376

middle-aged adults (210 women and 166 men) for more than five

years. They measured physical activity and time spent in sedentary

behavior by heart rate monitoring. They found that time spent in

sedentary behavior was predictive of higher concentrations of fasting

insulin, regardless of the time spent in moderate and/or vigorous

activities. The authors stated, This highlights the importance of

reducing sedentary time in order to improve metabolic health, possi-

INSULIN RESISTANCE NOT JUST FOR PEOPLE WITH

DIABETES? By Stella L. Volpe, Ph.D., R.D., L.D.N., FACSM

WELLNESS ARTICLE

Insulin resistance is a condition where the

hormone, insulin, is not as effective at

lowering blood glucose (sugar) in the body.

Basically, it has to do with the fact that the

receptors in the muscle cells and fat cells for

insulin are no longer as sensitive to insulin,

leading to lower uptake of blood glucose intothe cells. This leads to hyperglycemia (high

blood glucose). This cascade of events can

lead to the metabolic syndrome or type 2

diabetes mellitus. The metabolic syndrome

has distinct criteria, which can be found in the

Table.

Table. The International Diabetes Federation

Consensus Worldwide Definition of theMetabolic Syndrome (2006)

Central obesity (defined as waist circumference# with ethnicityspecific values) AND any two of the following:

Raised triglycerides: > 150 mg/dL (1.7 mmol/L), orspecific treatment for this lipid abnormality.

Reduced HDL cholesterol: < 40 mg/dL (1.03 mmol/L)in males, < 50 mg/dL (1.29 mmol/L) in females, or spe-cific treatment for this lipid abnormality.

Raised blood pressure: systolic BP > 130 or diastolic BP>85 mm Hg, or treatment of previously diagnosedhypertension.

Raised fasting plasma glucose :(FPG)>100 mg/dL (5.6mmol/L), or previously diagnosed type 2 diabetes. IfFPG >5.6 mmol/L or 100 mg/dL, OGTT Glucose tol-erance test is strongly recommended but is not neces-sary to define presence of the Syndrome.

# If BMI is >30 kg/m, central obesity can be assumedand waist circumference does not need to bemeasured.

Taken from: http://www.idf.org/webdata/docs/IDF_Meta_def_final.pdf(2006 publication)
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bly in addition to the benefits associated with a physically active

lifestyle.2 Though the benefits of exercising daily far outweigh the

risks of not exercising; however, the point of this research is to

emphasize more activity during the day, outside of the planned exer-

cise activity, which is especially important for people with sedentary

jobs.

Therefore, taking the stairs, parking farther away from buildings,

sitting on a balance ball while on the computer are all important waysto increase activity throughout the day and may further protect

against chronic disease. Meyer et al.5 examined the effect of stair use

instead of elevator use in the work place. They conducted a 12-week

promotional campaign for stair use in a university hospital setting.

They reported that, during the intervention, stair use increased signif-

icantly compared to baseline stair use. At the end of the interven-

tion, maximal aerobic capacity also significantly increased by about

9%. Furthermore, they reported significant decreases in body

weight, fat mass, waist circumference, diastolic blood pressure, and

low-density lipoprotein cholesterol. Although these changes occurred

in individuals who were previously sedentary, the benefits of being

active throughout the day, even if a person exercises regularly, may

diminish the negative changes seen in insulin sensitivity reported by

others.5

Multiple Bouts of ExerciseCan Play a Key Role

There has been strong evidence that exercising in multiple bouts

throughout the day is equally as effective for both cardiorespiratory

fitness and weight loss.3, 4, 6 Although multiple bouts of planned activ-

ity throughout the day may be convenient for some individuals, they

may not work for others. Nonetheless, informal bouts of different

types of activity throughout the day (such as those previously men-

tioned), may help to further improve cardiorespiratory fitness in a fit

person, decrease risk of obesity and overweight, and prevent insulin

resistance.

Summary

It has been well established that regular exercise can prevent

chronic disease and improve the quality of life. It also has been estab-

lished that performing planned daily exercise is important for main-

taining fitness. Although regular exercise is important, and individu-

als who exercise regularly should be commended, those individuals

who exercise regularly and who have primarily sedentary jobs should

include unplanned physical activity throughout the day. Simply using

the stairs each day can further improve cardiovascular fitness and

decrease the risk of insulin resistance.

About the AuthorStella Lucia Volpe, Ph.D., R.D., L.D.N., FACSM, is pro-

fessor and Chair of the Department of Nutrition atDrexel University, Philadelphia, PA. She is a member of

the Gatorade Sports Science Institute Network. Her

degrees are in both Nutrition and Exercise

Physiology, and she also is ACSM Exercise Specialist

certified. Dr. Volpes research focuses on obesity and

diabetes prevention, using traditional interventions,

mineral supplementation, and more recently, by altering the environment, to

result in greater physical activity and healthy eating. Dr. Volpe is an associ-

ate editor of ACSMs Health & Fitness Journal.

Helpful Web sitesAmerican Diabetes Association: http://www.diabetes.org/

American Heart Association: http://www.heart.org/HEARTORG/

References1. Alibegovic AC, Sonne MP, Hjbjerre L, Bork-Jensen J, Jacobsen S,

Nilsson E, Frch K, Hiscock NJ, Mortensen B, Friedrichsen M,

Stallknecht B, Dela F, Vaag A. Insulin resistance induced by physical

inactivity is associated with multiple transcriptional changes in skele-

tal muscle in young men. Am J Physiol Endocrinol Metab.

2010;299(5):E752-63

2. Helmerhorst HJ, Wijndaele K, Brage S, Wareham NJ, Ekelund U.

Objectively measured sedentary time may predict insulin resistance

independent of moderate- and vigorous-intensity physical activity.

Diabetes. 2009;58(8):1776-1779.

3. Jakicic JM, Wing RR, Butler BA, Robertson RJ. Prescribing exercise in

multiple short bouts versus one continuous bout: effects on adher-

ence, cardiorespiratory fitness, and weight loss in overweight

women. Int J Obes Relat Metab Disord. 1995;19(12):893-901.4. Jakicic JM, Winters C, Lang W, Wing RR. Effects of intermittent exer-

cise and use of home exercise equipment on adherence, weight loss,

and fitness in overweight women: a randomized trial. JAMA.

1999;282(16):1554-1560.

5. Meyer P, Kayser B, Kossovsky MP, Sigaud P, Carballo D, Keller PF,

Martin XE, Farpour-Lambert N, Pichard C, Mach F. Stairs instead of

elevators at workplace: cardioprotective effects of a pragmatic inter-

vention. Eur J Cardiovasc Prev Rehabil. 2010 Mar 17. 2010;17(5):569-

75.

6. Schmidt WD, Biwer CJ, Kalscheuer LK. Effects of long versus short

bout exercise on fitness and weight loss in overweight females. J Am

Coll Nutr. 2001;20(5):494-501.
http://www.diabetes.org/http://www.heart.org/HEARTORG/http://www.heart.org/HEARTORG/http://www.diabetes.org/

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CLINICAL FEATURE

Osteoporosis is a significant health problem in the United States.

More than 25 million people are affected, most of whom (80%) are

women. Women who are not receiving hormone replacement thera-

py, are not consuming adequate amounts of calcium, and are inactive

can lose 20% to 30% of their peak bone mass between 40 and 70

years of age. As a result, women have a 40% fracture risk through-

out their lifetime, with more than 1.5 million fractures per year attrib-

uted to osteoporosis.3 According to the U.S. National Womens

Health Resource Center, 59% of women over age 40 have not talked

with their physician about bone health or have had a bone mineral

density scan.

The BEST Strength Training Program

With this important public health issue, is it possible to develop an

exercise program for sedentary postmenopausal women that could

improve bone health and prevent osteoporosis? Would these same

women engage in a vigorous strength training program three times a

week for a year? Would this program make a significant difference

beyond bone health in their lives?

These were the fundamental questions that a research team at

the University of Arizona considered in the development of the

Bone, Estrogen, and Strength Training (BEST) study. The BEST study

began in 1995 to examine how strength-training exercise affects

changes in bone density in two groups of postmenopausal women:

those on hormone therapy and those who were not.

BEST Study objectives

Many of the recommendations to prevent bone loss encourage

weight bearing exercises such as walking, but the value of strength

training is often overlooked. Previous research focusing on strength

training with postmenopausal women found that bone mass can be sig-

nificantly increased by a regimen that uses high load, low repetition (6-

8 reps) versus low-load, high-repetition (20 reps) resistance exercises.4

The BEST exercise programs main objective was to explore a high-

load, low repetition approach in strength training. Considerations

underlying the development of the BEST exercise program were to:

promote exercise at an intensity sufficient to elicit an increase

in bone mineral density (BMD) in the hip and lumbar spine

select exercises specifically designed for function and mobility

counter the changes in the curvature of the spine and posture

of the body that occur with aging (i.e., lordosis)

develop the small muscle groups of the back that are used for

stability, spinal support and posture

exclude exercises that are counterproductive to maintaining a

healthy posture and that put participants at risk for fracture (for

example the chest press which pulls the shoulders forward).

During the f irst year, 266 Tucson, Arizona-area women ranging in

age from 45to 65, who were 3 to 10 years postmenopausal, were

recruited. The participants were, sedentary, non-smokers, with no

history of bone fractures or osteoporosis. All participants took

Citracal calcium citrate supplements twice daily to provide a total

800 mg of calcium. Women were randomized to either an exercise

group or a non-exercise control group. Of the 177 women random-

ized to exercise who underwent baseline measurements, 142 com-

pleted the one-year study period (80% retention).

Participants randomized to the exercise intervention were asked

to attend training sessions three days per week, on non-consecutive

days, in one of four community facilities under the supervision of study

on-site trainers. Sessions lasted 60 minutes and included stretching,

balance, weight-bearing activities (steps with weighted vests for warm-

up or treadmill walking using weighted vests), and weightlifting.

Exercise frequency, weightlifting loads, sets and repetitions, steps with

weighted vests, and minutes of aerobic activity were recorded in exer-

cise logs that were monitored regularly by on-site trainers.

The participant-to-trainer ratio was five-to-one in the first year.

Supervision was reduced during the second year; and in the third and

fourth years, trainers were available at each facility once per week.

After the fourth year participants were exercising on their own or in

small self-selected groups and trainer visits were scheduled bi-monthly.

Weightlifting was done using free weights and machines. Six core

exercises focused on major muscle groups with attachments on or

near BMD measurement sites. These exercises included the seatedleg press, lat (latissimus dorsi) pull down, seated row, back extension,

one-arm military press (right and left), and squats (wall squats initial-

ly, progressing to Smith or hack squats).

Core BEST strength exercises:

seated leg press one-arm military press

seated row wall squat, progressing

back extension to the Smith squat

lat pulldown

Women completed two sets of six to eight repetitions (four to six

repetitions for the military press to decrease injury to the shoulder) at

70% (two days per week) or 80% (one day per week) of the one-rep-

Women achieve peak bone mass in their 20s, and then

begin to lose bone with the process accelerating at the

onset of menopause. While most will not experience a

hip or vertebrae fracture, many may develop low bone

mineral density and be at risk for osteopenia or osteo-

porosis before the onset of menopause. Establishing an

exercise program for adult women that addresses

osteoporosis can slow down bone loss and reduce the

loss of muscle mass over time.

WOMENS HEALTH:THE BEST STRENGTH TRAINING PROGRAM

FOR OSTEOPOROSIS PREVENTION

BY LAUVE METCALFE, M.S., FAWHP

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etition maximum (1- RM), determined by monthly testing. Repetition

maximums were recomputed every six-weeks to adjust loads and

offer an opportunity to set goals for the next training period. A

detailed description of the exercise program can be found elsewhere.6

What BEST researchers found

After 12 months, strength training exercises combined with calci-

um supplementation, significantly improved bone mineral density atskeletal sites at risk for osteoporotic fractures in postmenopausal

women.3 Women taking hormone therapy were most successful at

maintaining or increasing BMD, although exercise without hormone

therapy also showed positive results.

Four-year data showed that women who supplemented with

800mg of calcium daily showed greater improvement than those who

consumed less calcium. Participants with higher attendance showed

greater improvement than less frequent exercisers, suggesting a dose-

response relationship. Those exercisers that attended more exercise

sessions and lifted more weight were those that increased their BMD

the most, from 1 to 2%.2

Muscle strength improved by 28% to 67% from baseline in

women who exercised and used hormone replacement therapy and

25% to 75% in women who exercised without using hormone

replacement therapy (see Table). Increases in muscle strength with

exercise were statistically significant for exercisers in both groups.

We also compared women who were lifting weights consistently

over four years with those who were less consistent. We divided the

BEST women into three groups based on their overall weight lifted

using the military press as a measure of exercise compliance (see

Figures 1 and 2). We found for both femur trochanter and lumbar

spine that those who lifted more weight over four years had signifi-

cantly greater change in bone mineral density.4

Six-year data supported the use of regular strength training as a

viable long-term method to prevent weight gain. In fact, an average

of training just one to two days per week for six years was enough

to maintain body weight in comparison to weight gain seen among

controls.1

Intervention Support Programs

The BEST intervention support program was based on social cogni-

tive/social ecological theory constructs and encompassed a variety of

interpersonal, intrapersonal, and environmental reinforcement strate-

gies to motivate participants and promote high levels of retention.

Goals of the support programs were to create a fun, social environ-

ment and to challenge participants to improve daily exercise perform-

ance. Participation was based on individual improvement rather than

competition among participants. Some examples of the intervention

support programs included: orientation workshops, monthly newslet-

ters, Personal Best testing every two months to monitor progress,

yearly evaluation results, goal setting logs, personal contracts, motiva-

tional meals scheduled every two months, and two major promotional

events each year held in January/February and over the summer

months at the exercise facilities or at community parks.

The investigators observed strong social benefits related to partic-

ipating in the exercise program over time. Anecdotal testimonies from

the BEST women conveyed the value of the program as a confidence

builder for life, not just related to their concern of osteoporosis. The

participants who have continued with the program and are well into

their tenth year of exercise, and are 70+ years of age state that they

are emotionally and mentally more resilient to handle whatever life cir-

cumstance comes their way. They also have created a remarkable

bond with one another and unanimously feel that their exercise pro-gram has enriched their lives and given them back their vitality.

Conclusions

BEST researchers concluded that the participants who maintained

bone density with greater effects were those who lifted weights two

or more times per week. Over the four years we found that calcium

intake, exercise, and hormone therapy all affected BMD change.

The BEST program was designed as an osteoporosis prevention pro-

gram, not a program for women with osteoporosis. It is recommended

to have the supervision of a trainer who is well versed in the principles

of safely exercising with high loads and low repetitions to introduce a

Womens Health (continued on page 11)

Table. Changes in Muscle Strength Assessedby 1-Rm in Exercise Groups

Figure 2: Tertiles of Weight Liftedin Military Press

Figure 1: Tertiles of Weight liftedin the Military Press

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Body intelligence is about how aware you

are of your body (body awareness), what

you know about your body (body knowl-

edge), and what you actually do for and with

your body (body engagement). This concept

may sound new, but it is central to the work

of fitness and wellness professionals, as well

as to your self-care.

Body Awareness

Awareness is about being tuned into your

body and its signals. It is about being awake

to how your body speaks to you and what

it is telling you, in a whisper or up to a yell.

We often have many physical sensations that

we ignore and hope will go away. Being con-

scious of the impacts that certain foods, phys-

ical practices, or internal and external stres-

sors have on your body allows you to learn

about what promotes health and vitality, and

to make adjustments in the moment.

The greater your body awareness, the

more you are in control of bodily outcomes.

Being attuned to the effects of that first cup

of coffee gives you a base for choosing orrefusing a second cup. Mindfulness, reflec-

tion, experimenting, and learning are impor-

tant paths forward to greater body aware-

ness. Body awareness questions include:

1. When does your body feel good? Not so

good? What do you attribute this to?

2. What are the best and worst you have

ever felt physically? How do you think this

came about?

3. How do you know something is wrong

with your body? What signals do you

interpret?

Ways to improve body awareness include

body scans throughout our days. Journaling

and meditation are wonderful aids as are

stop-and-notice practices. Cause-effect

reflections involve noticing how you are feel-

ing (good or bad) and reflecting on possible

influences.

Body Knowledge

Body knowledge is akin to what scientists

call health literacy.1 How much do you

know about accepted evidence-based stan-

dards and guidelines for healthy bodily func-

tioning? Knowing scientific facts is an impor-

tant part of health literacy, along with an

understanding of the actions needed to diag-

nose and treat physical concerns.

But that is not enough, it is important to

know our markers for health such as weight,

blood pressure, cholesterol, and blood levels

of vitamin D and B12. We also need to know

about what our bodies need to make us

healthy and increase vitality, what supports

our bodies to thrive, including habits of exer-cise, cooking, and eating, relaxation and

recharge, sleep, and stress management.

Body knowledge questions include:

1. What do you think you have to know

about your body to take good care of it?

2. What is your pattern of checking in with

health professionals for checkups, issues,

or concerns?

3. What do you know about healthy

lifestyles and what is your formula? What

should you eat and when? How should

you exercise? How should you sleep,

recharge, and de-stress?

4. What is your relationship to alcohol,

drugs, cigarettes, caffeine, and other addic-

tive substances, and what would you like it

to be?

Body Engagement

Even with high levels of body awareness

and knowledge, engagement does not come

easily. Engagement is about doing the best

thing repeatedly until you need to switch to

the next best thing. Engagement is commit-

ment to intelligent action based on what you

need at this point in your life. How can you

configure your life so that your body fully

supports your work in the world?

Habits are hard to break and build and

that is why the industry of professional

health and wellness coaching is being devel-

oped. Change that lasts requires a solid foun-

dation of self-motivation and self-efficacy to

support our stretching beyond our comfort

zones and experimenting with new habits.

New habits are not just about engaging inhealthy behaviors, but engaging in regular

activities to bring body awareness to top of

mind. Body engagement questions include:

1. What habits do you engage in consistently

that make your body feel better?

2. How do you experiment when you are

developing a new habit?

3. What works best for you when you are

developing a new habit, for example your

a p p r o a c h t o s e t t i n g go a l s a nd

experimenting?

COACHING NEWS:WHAT IS YOUR BQ?

Coaching News (continued on page 13)

By Margaret Moore (Coach Meg), MBA

YOU MAY BE FAMILIAR WITH THE CONCEPTS OF EMOTIONAL INTELLIGENCE, HOW WELL ONE

HANDLES ONES EMOTIONS, OR SOCIAL INTELLIGENCE, HOW WELL ONE HANDLES SOCIAL

INTERACTIONS. I WOULD LIKE TO PROPOSE A NEW FORM OF INTELLIGENCE BODY

INTELLIGENCE OR BQ. I COLLABORATED WITH PSYCHOLOGIST JAMES GAVIN AT CONCORDIA

UNIVERSITY IN MONTREAL ON THIS CONCEPT. WE WANT TO CONVEY THAT HOW ONE MANAGES

ONES BODY IS ALSO AN IMPORTANT FORM OF INTELLIGENCE, ONE THAT IS NEGLECTED BY THE

FIELD OF PSYCHOLOGY AND BY MANY PEOPLE I N THEIR EVERYDAY LIVES.

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Numerous studies support the authors stance, and the available

information indicates a strong relationship between strength training

and general health. Baechle and Westcott2 have identified a dozen

research-based reasons why adults and older adults should perform

regular resistance exercise from a health perspective. These are to:

(1) maintain/increase muscle mass; (2) reduce fat weight; (3) main-

tain/increase resting metabolic rate; (4) enhance insulin sensitivity and

glucose utilization; (5) increase gastrointestinal transit speed; (6)

reduce resting systolic and diastolic blood pressure; (7) improve blood

lipid profiles; (8) increase bone density; (9) decrease lower back dis-

comfort; (10) reduce arthritic pain; (11) enhance self-confidence and

relieve depression; and (12) improve post-coronary performance.

Although research studies clearly confirm all of these health-

related reasons for performing resistance exercise, the strength train-

ing benefit of reduced resting blood pressure is undoubtedly the most

misunderstood. Many people, including some f itness professionals and

medical professionals, have a misconception that resistance exercise

elevates resting blood pressure. Consequently, men and women with

modest blood pressure concerns, who have much to gain from a well-

designed strength training program, may be mistakenly advised to

avoid this important physical activity. It would therefore seem well-

advised to further examine the effects of resistance training on exer-

cise blood pressure and resting blood pressure.

First, it is true that strength training elevates systolic blood pres-

sure during the exercise set. A 1982 study by Westcott and Howes15

revealed that systolic blood pressure increases progressively (repeti-tion by repetition) during an exercise set to fatigue using the 10 repe-

tition maximum weight load (10 RM). However, the highest systolic

blood pressure readings, recorded during the final repetition of each

set, were similar to those attained during an aerobic activity. On aver-

age, the subjects systolic blood pressure increased 34% (123 mmHg

to 165 mmHg) during a 10 RM set of dumbbell curls, which was the

same percent elevation that they attained and maintained during a 20-

minute bout of stationary cycling at approximately 75% of their maxi-

mum heart rate. In a follow-up study,14 performing 10RM leg presses

resulted in higher systolic blood pressure responses, most likely due to

the greater muscle mass involved in this exercise. On average the sub-

jects systolic blood pressure increased 50% (127 mmHg to 190

mmHg) during the exercise set. In both resistance exercises, the mean

peak systolic blood pressure was below the 250 mmHg ceiling level

for exercise-related systolic blood pressure recommended by the

ACSM.1 Because intense strength training with heavy weights has been

shown to raise blood pressure above 250 mmHg,10 standard resist-

ance exercise should be performed with moderate loads, proper tech-

nique and continuous breathing.

Although resistance exercise temporarily elevates blood pressure

during an exercise set, it does not result in higher resting blood pres-

sure levels following a properly designed program of strength training.5

In fact, a meta-analysis of research on resistance exercise and blood

pressure indicated an average 3% reduction in systolic pressure and a

4% reduction in diastolic pressure after several weeks of strength

training.8 Strength training appears to be as effective as endurance

exercise for reducing resting blood pressure,13 and a combination of

strength and endurance exercise has demonstrated significant decreas-

es in resting systolic and diastolic readings.16 In a 10-week study, more

than 1,600 participants who performed 20 minutes of strength train-

ing and 20 minutes of endurance exercise, two or three days a week,

experienced a 4 mmHg reduction in resting systolic blood pressure

and a 2 mmHg reduction in resting diastolic blood pressure.16

Contrary to the incorrect assumption that resistance exercise

increases resting blood pressure, properly performed strength train-

ing actually decreases resting blood pressure. Adults and older adults

who understand this fact are less likely to avoid this productive phys-

ical activity which provides many more health benefits.In addition to attaining lower blood pressure readings, strength

training participants may experience other physiological adaptations

that enhance cardiovascular health. These may include improved

blood lipid profiles and lower risk of metabolic syndrome.4, 7, 9, 17

According to Braith and Stewart, when taken together these benefi-

cial responses to strength training may provide significant risk reduc-

tion for cardiovascular disease.3

One of the more remarkable resistance exercise research findings

is the positive effect of circuit strength training on muscle mitochon-

drial content and oxidative capacity.11 Mitochondria serve as the pow-

erhouse of each muscle cell, but aging is associated with genetic

changes that impair mitochondrial function with respect to energy

BY WAYNE L. WESTCOTT, Ph.D.

A new article published in a journal of the American College of Sports Medicine (ACSM) advocates for

a public health mandate for resistance exercise.12 The authors of this well-researched article state that

Compared to aerobic training, resistance training has received far less attention as a prescription for

general health. However, resistance training is as effective as aerobic training in lowering risk for

cardiovascular disease, diabetes, and other diseases. There is a clear ability of resistance training, in contrast

to aerobic training, to promote gains, maintenance or slow the loss of skeletal muscle mass and strength.

Thus, as an antisarcopenic exercise treatment, resistance training is of greater benefit than aerobic training;

given the aging of our population, this is of primary importance.

REGULAR RESISTANCE EXERCISE

HEALTH BENEFITS OF EXERCISE

HEALTH & FITNESS COLUMN

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production and muscle performance. In the study by Melov and asso-

ciates, older adults (mean age 70 years) who performed six months

of resistance exercise (10 exercises, progressing from 1 to 3 sets of

10 repetitions each, 2 x wk) experienced reversal of gene expression

in 179 genes related to age and exercise, resulting in mitochondrial

characteristics closer to those of moderately active young adults

(mean age 21 years). This demonstration of strength training actually

reversing mitochondrial dysfunction would seem to be a compellingreason for older adults to perform resistance exercise.

Finally, with an essentially out of control obesity epidemic a recently

published research study that reveals muscular strength is inversely

related to prevalence and incidence of obesity in adult men may be

especially relevant.6 After evaluating a sample of more than 3,200

mean (mean age 42 years) the study authors concluded that, evidence

suggests muscular strength may provide protection from excessive

body fat and excessive abdominal fat and their related co-morbidities.

It would appear that resistance exercise provides many physiolog-

ical adaptations that, in addition to increasing muscle strength,

endurance and mass, may have a positive impact on a variety of fit-

ness and health factors. With a better understanding of the wide

range of physical benefits associated with standard strength training,

fitness professionals may be more successful in encouraging participa-

tion in this essential exercise activity.

About the AuthorWayne L. Westcott, Ph.D., teaches exercise science

and conducts fitness research at Quincy College

in Quincy, MA.

References1. American College of Sports Medicine. ACSMs

Guidelines for Exercise Testing and Prescription (8th Ed.)

Philadelphia: Lippincott, Williams and Wilkins. 2010. p.140.

2. Bachle, T.R. and W.L .Westcott. Fitness Professionals Guide toStrength Training Older Adults (2nd Ed.) Champaign, Ill: Human

Kinetics. 2010. p. 1-14.

3. Braith, R. and K. Stewart. Resistance exercise training: Its role in the

prevention of cardiovascular disease. Circulation, 113:2642-2650,

2006.

4. Hagerman, F., S. Walsh, R. Staron, et al. Effects of high-intensity

resistance training on untrained older men. I. Strength, cardiovas-

cular, and metabolic responses.Journals of Gerontology. Series A,

Biological Sciences and Medical Sciences, 55A(7): B336-346,

2000.

5. Hurley, B. Does strength training improve health status?Journal of

Strength and Conditioning, 16: 7-13, 1994.

6. Jackson, A., DC. Lee, X. Sui, et al. Muscular strength is inversely

related to prevalence and incidence of obesity in adult men. Obesity,

18: 1988-1995, 2010.

7. Joseph, L., S. Davey, W. Evans, and W. Campbell. Differential effects

of resistance training on body composition and lipoprotein- lipid

profile in older men and women. Metabolism, 48(11): 1474-1480,

1999.

8. Kelley, G. Dynamic resistance exercise and resting blood pressure in

healthy adults: A meta-analysis.Journal of Applied Physiology, 82:

1559-1565, 1997.

9. Kelley, G. and K. Kelley. Impact of progressive resistance training on

lipids and lipoproteins in adults: a meta-analysis of randomized con-

trolled trials. Preventive Medicine, 48: 9-19, 2009.

10. MacDougall, J., D. tuxen, D. Sale, J. Moroz, and J. Sutton. Arterial

bloos pressure response to heavy resistance exercise.Journal of

Aplied Physiology, 58(3): 785-790, 1985.

11. Melov, S., M. Tarnopolsky, K. Beckman, K. Felkey, and A. Hubbard.

Resistance exercise reverses aging in human skeletal muscle. PLoS

One. 2007 May 23: 2(5): e465.

12. Phillips, S. and R. Winett. Uncomplicated resistance training and

health-related outcomes: Evidence for a public health mandate.

Current Sports Medicine Reports, 9(4): 208-213, 2010.

13. Smutok, M., C. Reece, P. Kokkinos, et al. Aerobic vs. strength train-

ing for risk factor intervention in middle-aged men at high risk for

coronary heart disease. Metabolism, 42: 177-184, 1993.

14. Westcott, W. Strength training and blood pressure. American

Fitness Quarterly, 5(3): 38-39, 1986.

15. Westcott, W. and B. Howes. Blood pressure response during weight

training exercise. National Strength and Conditioning AssociationJournal, 5: 67-71, 1983.

16. Westcott, W., R. Winett, J. Annesi, J. Wojak, E. Anderson, and P.

Madden. Prescribing physical activity: Applying the ACSM protocols

for exercise type, intensity, and duration across 3 training frequen-

cies. The Physician and Sportsmedicine, 37(2): 51-58, 2009.

17. Wijndaele, K.N. Duvigneaud, L. Matton, et al. Muscular strength,

aerobic fitness, and metabolic syndrome risk in Flemish adults.

Medicine and Science in Sports and Exercise, 39: 233-240, 2007.

Womens Health continued from page 8participant to the program. It is critical that the exerciser maintain cor-

rect form and alignment. Progression and alignment are the safe ways

to lift heavier loads with minimal injury for this population.

Given the social and medical impact of osteoporosis, program

directors may want to consider development of intervention pro-

grams similar to BEST. Such a program is realistic and may be suc-

cessful in reducing the impact of osteoporosis on public health. The

best treatment is prevention, and women of all ages should be con-

cerned about their bone health and take action to stay active and

improve their nutrition and bone strength.

The BEST study was initially funded by a grant from the National

Institute for Arthritis and Musculoskeletal and Skin Diseases of the

National Institutes of Health.

About the Author

Lauve Metcalfe, M.S., FAWHP is an organiza-tional health consultant and on the faculty of the

University of Arizona College of Medicine. Lauve

was a co-investigator and directed the exercise

i n t e r v e n t i o n f o r t h e B E S T p r o g r a m .

([email protected])

References1. Bea, J, Cussler, E, Going, S, Blew, R, Metcalfe, L, Lohman, T,

Resistance training predicts six-year body composition change in post-

menopausal women. Medicine & Science in Sports & Exercise, 42(7);

1285-1295, July 2010

2. Cussler, E, Going, S, Houtkooper, L., et al, Exercise attendance and

weight lifted predict four-year bone changes in postmenopausal

women. Osteoporosis International, 16(12), 2129-2141. 2005

3. Going, S., Lohman, T., Houtkooper, L., et al, Effects of exercise on

bone mineral density in calcium-replete postmenopausal women with

and without hormone replacement therapy. Osteoporosis

International, 14:637. 2003

4. Kerr, D., I. Morton, R. Dick, Prince exercise effects on bone mass in

postmenopausal women are site-specific and load-dependent. Journal

of Bone and Mineral Research, 11(2):218-225. 1996

5. Lohman, T., S. Going, L. Metcalfe, The BEST Exercise Program for

Osteoporosis Prevention, DSWFitness, 2004

6. Metcalfe, L., T. Lohman, S. Going, et al. Postmenopausal women and

exercise for prevention of osteoporosis. ACSM Health Fitness

Journal, 5:6-14, 2001.

Health, fitness, and medical professionals can obtain the complete con-

tinuing education module The BEST Exercise Program for Osteoporosis

Prevention by contacting www.dswfitness.com
mailto:[email protected]://www.dswfitness.com/http://www.dswfitness.com/mailto:[email protected]

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Early pioneers of exercise physiology trained physical educators to

use information from the exercise physiology curriculum to assist

patients with heart disease to achieve improved functional capacity.2

Foster also stated that it was the initial ACSM Guidelines for Graded

Exercise Testing and Prescription, published in 1975, that launched the

profession of clinical exercise physiology (CEP).2 Since those early days

the definition has evolved. Today an exercise physiologist is typically

defined as a person who has an academic degree in exercise physiology

or a related title (e.g., exercise science, kinesiology), who is able to pro-

vide exercise testing and training expertise for individuals, who under-

stands the acute and chronic response to exercise, and who has the abil-

ity to assess both adaptation and maladaptation to an exercise stimulus.

In the early days of the profession the primary focus was to assist

patients with cardiac disease resume normal daily function. Through the

1980s and 1990s the scope of practice widened to include patients with

pulmonary diseases and those with a variety of metabolic disordered dis-

eases including obesity, hypertension, lipid disorders, and glucose intoler-

ance. During this period the exercise physiologist was becoming a true

clinical practitioner.

Leading the way, ACSM developed a def inition of a Clinical Exercise

Physiologist in the 1990s. This definition built upon the ACSM Clinical

Exercise Specialist (CES) certification, which was initiated in the mid-

1970s, and was developed in response to the growth of cardiac rehabil-

itation as a treatment option for patients with heart disease. As theseprofessionals expanded to begin to work with the pulmonary and meta-

bolic diseased populations, the field of CEP began to emerge as an

accepted allied health profession. What followed was the development

of a scope of practice that included the knowledge and skills (KSs) nec-

essary to perform required job duties of someone working in the CEP

field. By the late 1990s the Registry of Clinical Exercise Physiologist was

developed by the ACSM. The goal of this registry was to develop a cre-

dential to ensure that minimally competent individuals are available to

provide exercise management for patients with a broad spectrum of

chronic diseases or disabilities. Since 1999, over 750 individuals have

been certified as a Registered Clinical Exercise Physiologist (RCEP). The

RCEP credentialing committee oversees certification renewals and per-

forms regular reassessments of the profession to ensure adequate certi-

fication examinations.

In the past there has been criticism of the CEP vocation, stating that

CEP is not an allied health profession.1 These arguments include: 1) CEP

does not have a def ined academic program similar to physical therapy or

nursing, 2) CEP does not limit who can sit for certification and registry

exams, and 3) CEPs are not sanctioned by law to practice (i.e., licen-

sure). The past 10 years have brought developments that have

addressed these issues. Academic programs have been refined and

many universities have developed specific curriculums for clinical exercise

physiology. The ACSM RCEP examination limits those sitting for the

exam to have a masters degree in exercise science, exercise physiology,

or kinesiology. And beginning in 2011 the CES certification will limit

examinees to those with a bachelors degree in one of the stated exer-

cise curricula. Finally, there is ongoing action in many states to work

toward state licensure of clinical exercise professionals.

As the profession progresses it is important to consider several items

that are central to both the profession and the professional.

1. First the issue of licensure for the CEP continues to be pressed in mul-

tiple states. To date only Louisiana has passed a CEP licensure bill, but

recently states such as Massachusetts, North Carolina, and Utah have

either begun discussion toward licensure or have developed bills that

have been or will be presented to state legislatures. These are impor-

tant steps in the profession. These attempts must be made on a state-

by-state basis and not all states have solid groups willing to move the

process forward. Depending upon the level of support or opposition

by other allied health groups within a state the road to licensure can

be long and difficult. And not all states or clinical exercise physiolo-

gists agree that licensure is the best way to go. What licensure will not

do is guarantee that the CEP will become an accepted allied health

professional and able to bill for his/her services; nor will it directly

affect salaries. However, it may help to develop the profession

beyond its current restraints and open the door to allow the public

to be under the guidance of qualified CEPs.

2. Next, a professional organization is vital to the ongoing developmentof a profession. In 2008 the Clinical Exercise Physiology Association

(CEPA) was organized. The goal of CEPA is to assist the profession of

CEPs with respect to the development of professional education stan-

dards and opportunities, to develop a code of ethics with respect to

knowledge and conduct, and to advocate for the CEP at the local,

state and national levels.

3. The KSs that a CEP must possess are important to both the CEP and

the general public. On a four-year cycle, ACSM performs a job task

analysis and role delineation study conducted by the Committee on

Certification and Registry Boards (CCRB). This committee is charged

with the task of developing the survey and sending it to a representa-

tive portion of certified CEPs. Data from the job task analysis is used

The term Exercise Physiologist did not exist

before the 1970s with respect to the job title of a

health care worker. The early pioneers of exercise

physiology sought to define the exercise

physiologist as someone who was a doctoral-

level research scientist, thus paying respect to

the term physiologist as one who aspires to

become an independent researcher.

HERE TO STAYBY JONATHAN K. EHRMAN, Ph.D., CES, FACSM

THE RISE OF THE CLINICAL EXERCISE PHYSIOLOGIST

CLINICAL COLUMN

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by a working group to reshape the current professional certification

examination. Additionally, a role delineation assessment is performed

to develop expert opinion on best practices of the practicing CEP.

These assessments are used to guide the development of profession-

al certifications and for continuing education opportunities for those

wishing to remain certified. The most recent KSs are set to be

released by ACSM in 2011.4. The research body of CEP is becoming more robust and independ-

ent of other allied health professions. Today, this body includes plen-

ty of independent studies published in a number of clinical and applied

exercise physiology journals, position statements, clinical textbooks,

and resource texts that have been directly developed by CEPs.

5. Finally, the pay of any professional is important to those working in a

given field. Although few choose CEP as their lifes work to get rich,

recent data (currently unpublished) compiled by CEPA is encourag-

ing. The Table provides information about salary ranges based on

several points including experience, degree, and certification. There

are a couple of important items to consider. In 1996 it was report-

ed that ACSM certification advanced salaries by $2,000 to $3,000

over those not certified (3). As noted in the Table, the CEPA data

shows that certified individuals make $7,000 to $8,000 more than

those without certification. And the annual salary advantage for

those with a masters degree over a bachelors was $5,000 to $6,000

in 1996. Today this difference has increased to about $7,000 to

$15,000.

As the profession of CEP continues to develop at a seemingly expo-

nential rate, there are several items that prospective and current profes-sionals should be cognizant of in order to stay abreast of the field to

help shape its ongoing development, as well as to stay on top of emerg-

ing information:

1. Be aware of any development of the licensure process in your state.

And you may wish to become involved in this type of effort as the

opportunity presents.

2. Join national and regional professional organizations that advocate for

the clinical exercise profession and professional.

3. Obtain updates to the KS statements and role delineation results as

developed and released by the ACSMto help guide their certif ication

quest and ongoing renewal.

Joining a group such as CEPA (www.acsm-cepa.org) and ACSM

(www.acsm.org) is currently the best way to easily obtain this important

information in real-time. This is an exciting time to be in the CEP profes-

sion. Dont be left watching from the outside!

About the AuthorJonathan K. Ehrman, Ph.D., CES, FACSM, is the

associate program director of Preventive

Cardiology at Henry Ford Hospital, Detroit, MI. He

is also the Director of the hospitals Clinical

Weight Management Program. He served on

ACSMs Committee of Certification and Registry

Board from 2000 to 2010 and was chair of the

Clinical Exercise Specialist Committee. He also is

the senior editor of the 6th edition of ACSMs

Resource Manual for Guidelines for Exercise Testing and Prescription

and is the umbrella Editor for the next editions (2013 release date) of the

ACSM certification texts.

References1. Brown, SP. Profession or discipline: the role of exercise physiology in

allied health. Clin Exerc Physiol 2000;2:168.

2. Foster C. ACSM and the emergence of the profession of exercise

physiologist. Med Sci Sports Exerc 2003;35(8):1247.

3. Porcari JP. Exercise physiologists salary survey results. AACVPR News &

Views 1996;10(1):5-7.

Salary Ranges Among Respondents Who AreExercise Physiologists with a Bachelors orMasters Degree (n= 744).

4. What life factors help you engage more consistently in a healthy

lifestyle?

5. What new habits do you want to develop as your next step?

Conclusion

It is time to consider body intelligence as an important domain for

your personal development as a fitness and wellness professional,

allowing you to thrive and serve as an inspiring role model for your

clients and other important people in your life. What is your body

IQ score?

About the AuthorMargaret Moore/Coach Meg, MBA, is the

founder & CEO of Wellcoaches Corporation, astrategic partner of ACSM, widely recognized as

setting a gold standard for professional coaches

in health care. She is co-director, Institute of

Coaching, at McLean Hospital/ Harvard Medical

School. She co-authored the ACSM-endorsed

Lippincott, Williams & Wilkins Coaching

Psychology Manual, the first coaching textbook in health care.

(www.wellcoaches.com www.instituteofcoaching.org

www.coachmeg.com [email protected])

Reference1. Hasnain-Wynia, R., & Wolf, M.S. 2010. Promoting health care equity:

Is health literacy a missing link? Health Services Research, 45 (4),

897903.

Coaching News continued from page 9
http://www.acsm-cepa.org/http://www.acsm.org/http://www.wellcoaches.com%E2%80%A2www.instituteofcoaching.org%E2%80%A2www.coachmeg.com%E2%80%[email protected]/http://www.wellcoaches.com%E2%80%A2www.instituteofcoaching.org%E2%80%A2www.coachmeg.com%E2%80%[email protected]/http://www.wellcoaches.com%E2%80%A2www.instituteofcoaching.org%E2%80%A2www.coachmeg.com%E2%80%[email protected]/http://www.wellcoaches.com%E2%80%A2www.instituteofcoaching.org%E2%80%A2www.coachmeg.com%E2%80%[email protected]/http://www.acsm.org/http://www.acsm-cepa.org/

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Much political, policy, and philosophical discus-sion in the United States over the past severalyears has focused on how to fix our health caresystem. Ongoing debate exists with some advo-cating for a complete overhaul of the system,while others argue for modest changes and focuson specific aspects of health care delivery andreimbursement. This article explores potentialimpacts and opportunity health care reform willhave on exercise professionals, particularly relat-ed to worksite health promotion and disease pre-vention programs.

As ACSM certified exercise professionals, we are in a unique posi-

tion to make a distinct difference in the lives and health of our clients

and those we serve. Beginning with the initial contact, the potential to

minimize preventable disease and manage existing conditions is great.

Learning and understanding a clients history and goals for their exer-

cise program are part of our training and applying sound principles of

exercise science and behavior change allows for clear and succinct

advice related to exercise and health maintenance. Whether working

with an older adult and chronic health issues, or an athlete and improv-

ing performance, the ACSM certified professional is positioned to

make profound individual differences.

Disease prevention, health maintenance and promotion have never

been more important than in our current situation. Nationally, health

care costs have risen to over 17% of the Gross Domestic Product

(GDP) without a reduction in sight.3 Annually, health plans across the

country are absorbing 5% to 15% increases in health coverage admin-

istration, with consumers being asked to pay out of pocket at much

higher rates. Health care reform, as presented by our government,

attempts to radically change several aspects of reimbursement,

universal coverage and payment, pharmaceutical coverage and bene-

fits, and hospital administration overhead expenses. Ultimately for

health care reform to be successful, personal health responsibility will

become a major focus and underlying requirement, thus underscoring

the importance of ACSM and their body of certified professionals.Behavior modification to include exercise, nutritional habits, and

healthy weight management are at the crux of this issue and it is

reflected in the Affordable Care Act of 2010. 4

Funding for wellness programming is built into the Act in several

places, creating opportunities for businesses, communities, and individ-

uals to get involved. Prevention of chronic diseases (e.g., diabetes,

coronary disease, obesity, etc.) is a major focus and incentives are avail-

able for businesses and communities to make efforts to this effect.

Wellness initiatives are often organized and managed by individuals

with degrees in exercise science, health promotion, kinesiology, health

science, and worksite wellness. Section 10408 of the bill titled

Grants for Small Businesses to Provide Comprehensive

Workplace Wellnes s Grants authorizes the development of a grantprogram that will assist businesses in establishing certified wellness

programs.1 Programs will be able to apply for grants to help fund well-

ness in the workplace in an attempt to inf luence the health of the U.S.

workforce, and ultimately lower health care costs and exposure.

Specifically health care reform will have four direct impacts on well-

ness2 providing direct opportunity to ACSM certif ied* professionals:

1. Improved access to preventive services and screenings: although

somewhat undefined, increased awareness of health and benefits of

exercise and lifestyle change will increase use of exercise testing and

training (CES, RCEP).

2. Wellness in the workplace grants: employers are being empowered

to decreased health care costs by providing effective, best-practice

wellness programs often staffed and managed by exercise profes-

sionals (CPT, HFS).

3. Community wellness initiatives strengthened with promotion of

activity-friendly community design and programming: physical activ-

ity, school wellness programs, and exercise-related programs are

well served by health science and promotion professionals with

advanced exercise certifications (HFS, CES, PAPHS).

4. Disease prevention and health promotion as a national priority evi-

denced by initiatives such as the National Physical Activity Plan

and Exercise is Medicine: exercise, physical activity, and behavior

change on national, regional, and local levels are major initiatives

impacting how certified professionals will get involved in prevention

programs across the nation (CPT, HFS, CES, RCEP, PAPHS).

*CPT = Certified Personal Trainer; HFS = Health Fitness Specialist; CES =

Clinical Exercise Specialist; RCEP = Registered Clinical Exercise

Physiologist; PAPHS = Physical Activity in Public Health Specialist

In addition, hospitals are seeking ways to streamline expenses and

drive revenue to improve positioning among communities and prepare

for the economic impacts of reform. Although lowering costs are a

key intervention, programming to increase referral and down-stream

revenue are being examined and expanded dramatically. One such

resource is developing a medical fitness center, which incorporates

exercise, nutrition, stress reduction, and wellness practices into hospi-tal services and internal referrals. According to the Medical Fitness

Association, nearly 1,100 such centers exist today with over 3.5 mil-

lion members, expected to grow to over 4 million by 2015.2 Medical

fitness centers employ high level staff including exercise physiologist,

kinesiology majors, and allied health professionals with qualifying certi-

fications like the HFS, CES, and RCEP.

Several government agencies are being formed and convened to

examine prevention and health promotion efforts with annual appro-

priation of funds at $500 million in 2010, with significant additional

funding allocated for years beyond.1 Issues related to tobacco depend-

ence, obesity, diabetes, and reducing preventable and expensive dis-

ease treatments are on the forefront of health care reform.

WELLNESS ARTICLE

CERTIFIED EXERCISE PROFESSIONALBY Tom Spring, M.S., CES

HEALTH CARE REFORM AND THE

Health Care Reform continued on page 1614 ACSMS CERTIFIED NEWS OCTOBERDECEMBER 2010 VOLUME 20:4

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SELF-TEST 1 (1 CEC):The following questions arefrom Assessment and Management of Clients withObesity published on page 3.

1. Which of the following have most health professionorganizations adopted as an overall measure or

indicator of obesity?a. Percent body fat. b. Waist circumference.c. Waist-to-hip ratio. d. BMI.

2. The optimal management of clients or patients at riskof cardiovascular and metabolic disease requires theassessment of _____.a. modifiable risk factorsb. unmodifiable risk factorsc. genetic markers for the diseased. the metabolic syndromee. all of the above

3. The exercise prescription for a client or patient withincreased BMI, waist circumference, and waist-to-hipratio values should or may _____.a. at least meet the guidelines for minimal amounts of

physical activity

b. adhere to the exercise guidelines for weight lossc. adhere to the exercise guidelines for the metabolic

syndromed. adhere to the exercise guidelines for hypertension

and diabetese. all of the above

4. Which of the following are used as measures ofcentral adiposity?a. Waist circumference and waist-to-hip ratio.b. Waist circumference, waist-to-hip ratio,

and BMI.c. BMI.d. BMI and %BF.

5. You estimate the percent body fat of a client orpatient to be 21% using a method that has a SEE of 4%BF. What would you expect (with 95% confidence)the %BF from a criterion method to be?a. 21 %BFb. Between 19 23 %BFc. Between 17 25 %BFd. Between 13 29 %BF

SELF-TEST 2 (1 CEC): The following questionsare taken from Insulin Resistance Not just for

people with diabetes? published on page 5.

1. Insulin resistance means ________.

a. high blood glucose levelsb. high blood insulin levelsc. inability for insulin to bring glucose into the cellsd. all of the above

2. The metabolic syndrome is not solely characterizedby central obesity.True False

3. Bed rest was shown to change the genes involved in______ and _____a. insulin resistance and diabetesb. insulin resistance and cardiovascular diseasec. diabetes and cancerd. none of the above

4. Multiple bouts of physical activity led to ______ and______.a. increased body weight and healthier eatingb. weight loss and cardiorespiratory fitnessc. weight loss and muscle hypertrophyd. none of the above

5. Incorporated unplanned exercise within a day, evenwhen a person has completed planned exercise, isimportant for overall health.

True False

SELF-TEST 3 (1 CEC): The following questions aretaken from Womens Health: The BEST StrengthTraining Program for Osteoporosis Preventionpublished on page 7.

1. One of the primary objectives of the BEST exerciseswas to promote exercise at an intensity sufficient toelicit an increase in bone mineral density (BMD) in thehip and lumbar spine.True False

2. The six core BEST exercises are:a. leg press, chest press, squat, seated row, lat

pulldown, leg extensionb. lat pull down, lunges, seated row, one arm military

press, crunches, chest pressc. seated row, one arm military press, squat, lat pull

down, leg extensions, leg curlsd. leg press, lat pull down, squat, one arm military

press, seated row, back extension

3. A major principle of the BEST exercise program wasthat bone mass can be significantly increased by aregimen that uses low-load, high-repetition (20 reps)resistance versus high load, low repetition (six-eightreps).

True False4. Some examples of the intervention support program

include:a. monthly newsletters, goal setting logs, motivational

meals, yearly evaluation resultsb. two major promotional events, personal contracts,

Personal Best testing, orientation workshopsc. competition among participants, all you can eat

buffets, personal contracts, paying cash forexercising

d. a and b

5. The participants who maintained bone density withgreater effects were those who lifted weights two ormore times per week.True False

SELF-TEST 4 (1 CEC): The following questionswere taken from Health Care Reform and the

Certified Exercise Professional published in this issue

on page 14.

1. What percentage of the Gross Domestic Product isspent on health care?a. 12% b. 50%c. 17% d. 6%

2. The health care reform bill is called the:a. Affordable Care Actb. Health Reform of 2010c. Accountable Care Actd. Health Management Plan

3. How many medical fitness centers exist today?a. 2,100 b. 1,100c. 100 d. 3,100

4. Government agencies being formed to examineprevention programs have been appropriated fundsto support efforts at this level:a. $500 b. $500 thousandc. $200 million d. $500 million

5. The following ACSM certified individuals will benefitfrom a governmental focus on worksite wellness anddisease prevention:a. CPT b. HFSc. CES & RCEP d. PAPHSe. All of these

OctoberDecember 2010 Continuing Education Self-TestsCredits provided by the American College of Sports Medicine CEC Offering Expires December 31, 2011

To receive credit, circle the best answer for each question, check your answers against the answer key on page 2,and mail this entire page with check or money order payable in U.S. dollars to: American College of Sports Medicine,Dept 6022, Carol Stream, IL 60122-6022

ACSM Member (PLEASE MARK BELOW) Please Allow 4-6 weeks for processing of CECs

[ ] Yes-$15 TOTAL $_________________

[ ] No- $20 ($25 fee for returned checks)

ID # __________________ (Please provide your ACSM ID number)PLEASE PRINT OR T YPE REQUESTED INFORMATION

NAME

ADDRESS

CITY STATE ZIP

BUSINESS TELEPHONE E-MAIL

October December 2010 Issue EXPIRATION DATE: 12/31/11 SELF-TESTS SUBMITTED AFTER THE EXPIRATION DATE WILL NOT BE ACCEPTED Federal Tax ID number 23-6390952

Tip: Frequent self-test participants can find their ACSM ID number located on any ACSM CEC verification letter.

ACSMS

CERTIFIEDNEWS

ACSM USE:

666922

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ACSMs Certified NewsISSN # 1056-9677P.O. Box 1440Indianapolis, IN 46206-1440 USA

NONPROFIT ORGU.S. POSTAGE

PAIDIndianapolis, IN

Permit No. 6580

The ACSM certified professional is extremely well positioned to

become involved in health promotion, disease prevention, and advoca-

cy for healthier communities and a more fiscally stable nation.

ABOUT THE AUTHOR

Tom Spring, M.S., CES is the current Program

Manager for Health Promotion and Community

Health Education Outreach at William Beaumont

Hospital in metropolitan Detroit. He is an ACSM

Certified Personal Trainer and Clinical Exercise

Specialist and has extensive experience in diagnostic

exercise testing, cardiac rehabilitation, personal fitness training, and health

promotion program management and development.

References1. Koh H. and Sebelius K. Promoting Prevent

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