Guidelines for Dietitians

FITT and Other Principles

Cardio-Respiratory Capacityo The body's ability to take in oxygen, deliver it to the cells, and use it at the

cellular level to create energy for physical activity aka endurance, aerobic capacity

Flexibility

o Amount of motion that a joint is capable of performing

Muscular Capacity - Three Aspects

o Muscular strength - or, the ability to generate force. o Muscular capability is muscular endurance - or, the ability of your muscles to

apply force over a longer period of time. o Muscular capability refers to muscular power, or the ability to generate

strength in an explosive way.

Underlying principles that inform advice provided to patients

Knowledge of principles enable RD to: oAnswer questionso Provide appropriate directiono Limit potential for harm

Frequency (how often) Intensity (how hard, how much weight) Time (how long) Type (type of exercise planned)

Advice on exercise should be modified based on individual needs and capabilities.

General advice about physical activity may not be appropriate or helpful for all of our patients.

For example, a very de-conditioned patient should not be encouraged to immediately meet Canada's physical activity recommendations.

Strengthening of tendons and ligaments and increased vascularity and recruitment of motor units will result in the ability to sustain subsequently greater stresses with greater resistance to injury.

Without structural tolerance, increasing workload can result in injury.

Improvement in an aspect of their performance or fitness, only occur if a patient trains specifically to achieve this.

Improvements in the three main aspects of fitness (cardiovascular function, strength and flexibility) require different types of training

Example - our patients should not expect improvements in cardiovascular fitness or strength by doing flexibility training.

In order to improve, clients must continually challenge their current fitness level.

The work performed must become progressively harder as the client adapts to the current workload.

When a workload or resistance is placed on a muscle, the muscle is stimulated over time to become larger and stronger.

A plateau or steady state will be reached where there is no more growth unless a greater stimulus is applied eg heavier weight, higher repetitions.

Recovery (usually rest) is necessary for a client to return to the next workout as fit as the previous.

Rest above and beyond the normal requirements for usual functioning is not terribly important in very light physical activity, more important as physical activity becomes more strenuous

Muscles that have been exposed to an overload should be rested at least 24 hours before training again. It is during this recovery period that the actual growth and repair ( hypertrophy) occurs.

People who are well developed in all aspects of fitness have a lower likely hood of becoming injured and have greater performance in physical activity and sport.

Once training ceases a client’s body will gradually return to the pre-training state

Once a level of fitness is achieved, it can be maintained with less work than was needed to reach it in the first place.

Work needed to achieve a specific fitness level is greater than the work needed to maintain it.

Adequate rest for worked muscle (preferably 48 hours) is necessary for growth….but other muscle groups may be exercised during the rest period

The key goal for new exercisers is to learn proper form and to develop structural tolerance. After this occurs goals such as metabolic management, hypertrophy etc can may be reached.

Clients will usually see significant gains in strength, changes in metabolic parameters at approximately 3- 4 weeks after initiating training.

Changes plateau as training continues so it is important that patients do not look for dramatic changes

• Sandra is a 45 year old female who is over weight (BMI of 29). She’s a mother of two and hasn’t put much effort into her health the last few years. She’s never followed a workout routine before. Sandra has watched her friend have a lot of success using a personal trainer 4x/week but she wants to try things on her own because of the cost. She plans to start a program of walking a few times a week plus attend aqua fit and yoga with her friend 1x/week for 60 minutes each at the local community center.

• What guidelines would you give Sandra?

How often should Sandra go walking to achieve the minimum recommendation?

Sandra wants to know how to tell if she is working hard enough at each of her activities. What would you tell her?

Any advice to give her for the first few weeks of her program?

• Sandra has now been following her program for about 3 months and at first was seeing great results. She now has a BMI of 27 but lately she’s not seeing any changes and she’s getting frustrated. She’s contemplating giving up.

• What could you tell Sandra to help her?• Which of the principles of fitness might

explain what is going on?

Risk and Readiness to Increase Activity

RISK

Evaluation

Known Disease Signs and Symptoms of Disease That is Yet

Dx Increased Cardiac Risk Age Risk

• Internal to Client– Health conditions or diseases– Physical abnormalities (eg/ weak muscles)– Psychological (Not focused or high stress)

• External– Inappropriate workout gear– Faulty equipment– Temperature and humidity– Spills or messes

• Internal to Instructor– Not being prepared– Ignoring duty to warn or not monitoring clients

condition

• Must be done before any activity of any kind occurs– Safety– Liability

• Common Pre-screening Tools– PAR Q– Health Screening Questionnaire– CHD Risk Factors– Lifestyle Assessment– Readiness for Change

Physical Activity Readiness Questionnaire For clients ages15-69 Developed by the Canadian Society for

Exercise Physiology and Health Canada Designed to identify people who require

medical clearance before participating in a new exercise program

Known Disease Signs and Symptoms of Disease That is Yet

Dx Increased Cardiac Risk Age Risk

• What forms of risk does the PAR Q cover?– Known disease– Signs and symptoms of disease

• If clients answer YES to one or more questions on the PAR Q they should seek medical advice before becoming more physically active

• Your legal responsibility to have a signed PAR Q before giving out physical activity advice

• Should be redone annually

• Supplements Information not captured on PAR-Q. Not a standardized form.

• Should include: – Client details– Current medical conditions–Medications and allergies– Current or past injuries– Treatment from healthcare professionals– Family history– Past & present exercise history– Past and present nutritional information– Past and present work history

No

No

No

No

Yes

Yes

Yes

Yes

Med

ical R

efe

rral

Med

ical R

efe

rral

Vigorous ActivityVigorous Activity

Moderate ActivityModerate Activity

Cleared for Low-Moderate Physical

Activity

Cleared for Low-Moderate Physical

Activity

Physiotherapist Kinesiology Podiatrist Doctor

You cannot continue with client until they are cleared by medical doctor

ParMedX should be reviewed by doctor Should have a written note for clearance

from doctor

PARmed-X is a 4-page physical activity-specific checklist to be used by a physician with patients who have had positive responses to the (PAR-Q)

There is a separate one for pregnancy Important: If a patient is at risk and doesn’t

pass the PARQ and you train them without clearance from their physician you are liable!

Refer! Most of us are only qualified to work with

beginner clients

Risk and Readiness to Increase Activity

Stage of change (pre-contemplation, contemplation, preparation, action, maintenance relapse)

Readiness, Importance Rating

Tools: Physical Activity and You* Motivational Interviewing* In the Physical Activity Counselling Toolkit (PACT)

Ask about current physical activity Many people significantly over-report frequency, time

and intensity of physical activity…ask for details

Tools: Rapid Assessment of Physical Activity* Brief Physical Activity Assessment* Physical Activity and You*

* In the Physical Activity Counselling Toolkit (PACT)

Ask permission to discuss benefits of PA and risks of inactivity to all

Match advice to current motivational and physical readiness to engage in more physical activity

Tools: Promoting Physical Activity* Brief Contact to Increase Physical Activity* Matching Counseling To Stages of Change* Physical Activity Counselling Tools* Physical Activity and Exercise (CDA)

* In the Physical Activity Counselling Toolkit (PACT)

Use FITT to prescribe physical activity, including resistance training:

• Frequency: how often • Intensity: how hard • Time: duration• Type: what kind of exercise

• For each FITT element…start with where the patient is based on assessment of risk, readiness and current physical activity, then help patient move to CDA physical activity targets

• Balance principles of progressive resistance (it gets harder) and structural tolerance (need to build a base) and recovery

Exercise Counselling and PrescriptionTools: Diabetes and Physical Activity Your Exercise

Prescription (CDA) Prescription for an Active You* Canada’s Physical Activity Guide* Exercise Prescription for Special Populations*

* In the Physical Activity Counselling Toolkit (PACT)

For Clients and Professionals

ProfessionalsWorkshops/Courses CDA Physical Activity and Exercise workshop CANFIT PRO coursesPrint Diabetes Physical Activity and Exercise

Toolkit (2nd ed) Exercise is Medicine -

http://exerciseismedicine.org/

ProfessionalsOnline American College of Sports Medicine -

http://www.acsm.org/ Canadian Society for Exercise Physiology -

www.csep.ca/ Canadian Diabetes Association Physical Activity Counselling Toolkit

Available on Hamilton Family Health Team intranet - http://www.hamiltonfht.ca/files/PACT2011_final.pdf

Patients and ProfessionalsResistance Exercise Demonstration

Websites: ExRx.net GymProfessor.com Critical Bench.com

PatientsPrint Resistance Exercise for Diabetes Pamphlet Exercise to Do At Home Strengthening for Older Adults (Theraband)

PatientsVideo Sweet Success Exercise DVD * Diabetes and Physical Activity Toolkit DVD

PatientsApps Lose It – allows for tracking of physical activity and food,

and has an interactive forum (ipad/iphone) iPump – provides large exercise data base and exercise

videos showing proper execution (i pad, i phone) Nike Training Club App – wide variety of exercises for

different levels (iOS smartphones; Nike Boom (similar) for Android)

Workout Trainer – step by step video instruction to address a range of goals(iOS smartphone or Android)

*** large number of physical activity apps available

Mapping of the Issues for RDs

Scope of PracticeAs a Registered Dietitian, what is within your

expertise and scope of practice regarding physical activity counseling and advice?

General advice? Specific advice? Physical Activity Prescription? Specific Exercises? Specific Exercises with performance, repetition and

resistance instructions? Demonstration of Specific Exercises Leading patient through execution of specific

exercises

Scope of Practice There are risks attached to physical activity

counseling training: Injury related to improper technique, load or

repetitions Equipment Malfunction- falling plates, band

breakage Pre-existing physical limitations/risks

As an RD what can you do: Make general physical activity

recommendations Talk about Canada’s Physical Activity

Guidelines Talk about physical activity principles and

benefits Help clients develop a FITT prescription Suggest types of exercise that may meet

client needs

As an RD what you cannot do: Lay out a specific, individualized exercise

plan that includes specifics of exercise type, resistance, repetitions

Demonstrate specific exercises Help clients execute specific exercises 

 

Know your personal scope of practice: What is your personal experience with pa? What are your beliefs What additional training, education and

certification have you had? What is your comfort level? What is your physical activity counseling experience?

Note that liability insurance carried by RD’s is for activities carried out within our scope of practice. Those engaged in providing specific exercise programs to clients would require a different separate

type of liability insurance

 

What can you do to further integrate physical activity counselling into your practice?

 

Enhance your scope of practice – additional reading, training, observation, mentorship, practice

Be familiar with physical activity recommendations and terminology Talk to other health professionals in your practice about physical

activity When completing a patient assessment, assess adequacy of current

physical activity. Are Canada’s recommendations being met? Make use of professionally developed tools to augment current skill set

– patient hand-outs, videos, web sites Refer to community programs, specialty programs, and exercise

professionals as necessary Know that you don’t have to be the physical activity expert to start the

discussion and help increase the motivation

 

Refer to Your Handouts