1. Introduction to the Fitness Spectrum
TALKING POINTS:
Welcome and introductions.
Introduction to the Fitness Spectrum

2. Today we will: Review the increase of heart disease in America
Recognize the health implications of inactivity
Describe the Dr. Dean Ornish Program for Reversing Heart Disease Exercise Prescription
Learn the benefits of the exercise guidelines
Learn how to make exercise safe
Discuss the integrated approach to success
TALKING POINTS:
The goals for this session and the exercise component of the Dr. Dean Ornish Program for Reversing Heart Disease are:
To recognize why inactivity and sedentary lifestyles are so harmful to our health
To learn what the exercise component of this Program is
To discover how individuals with heart disease or those at risk of developing heart disease can benefit from exercise.
To explore how to integrate exercise into our lifestyles and into the other components of the Program to be successful
To learn how to exercise safely

3. US Cardiovascular Disease Mortality 1979-2004
TALKING POINTS:
Heart Disease is still the number one killer for both men and women. Although deaths continue to decrease, the rate is surprisingly higher in women. (AHA 2007).
The numbers represented in this chart are for total cardiovascular disease mortality rates. This includes ALL cardiovascular diseases, including coronary artery disease (CAD).
Ask participants why death rates in women would be higher?
Women are smoking more.
Women are more active in the workforce today while their home responsibilities have not decreased.
Women have different symptoms than men. Women don’t typically get the severe chest pain that men experience.
Heart disease is still considered a “man’s disease.”
Our society is becoming more inactive, and new epidemics, such as obesity and diabetes, are contributing to heart disease.
More facts from the American Heart Association (2007 Heart Disease and Stroke Statistics):
More than 452,300 men and women die each year from CAD.
More than 157,600 die each year from heart attack.
Over 150,000 die of a stroke.
More than 150,100 die each year of hypertension alone.
72,800 die each year with diabetes as the leading cause of death.

4. Diabetes 20.8 million Americans have diabetes 30% are unaware
Diabetes has doubled over the last 30 years.
65% of people with diabetes will die of heart disease or stroke
TALKING POINTS:
Diabetes is an epidemic in the US.
However, our western civilization has influenced many cultures around the world causing an epidemic worldwide.
It is estimated (Diabetes Care 2004;27: ) the incidence of diabetes will increase from 171 million in 2000 to 366 million in 2030.
The medical field treats diabetes with the same urgency as those with diagnosed heart disease since people with diabetes are likely to die of heart disease or stroke if left uncontrolled. (CDC Diabetes Surveillance Report 1999)

5. (*BMI 30, or about 30 lbs. overweight for 5’4” person)
Obesity Trends* Among U.S. Adults BRFSS, 1990, 1999, 2008
(*BMI 30, or about 30 lbs. overweight for 5’4” person)
1990
1999
2008
TALKING POINTS:
This slide portrays the prevalence of obesity (defined as approximately 30 lbs overweight) amongst US adults from 1990, 1999 and 2008.
Review and explain the maps.
During the past 20 years there has been a dramatic increase in obesity in the United States. In 2008, only one state (Colorado) had a prevalence of obesity less than 20%. Thirty-two states had a prevalence equal to or greater than 25%; six of these states (Alabama, Mississippi, Oklahoma, South Carolina, Tennessee, and West Virginia ) had a prevalence of obesity equal to or greater than 30%.
Increased obesity is due to a combination of poor food choices and decreased physical activity.
This just drives home the point that even though Americans are spending billions of dollars to lose weight, our society continues to get more overweight and obese.
The obesity rate doubled from 1980 to 2006.
We have never had an epidemic like this that we have been able to track so thoroughly. These statistics and trends are likely conservative.
The problem is only getting worse. The rate of overweight and obesity in children and teens has tripled since 1980.
SUPPORTING MESSAGES/REFERENCES: Center for Disease Control and Prevention; National Center for Health Statistics; Marketdata Enterprises.
Maps retrieved July 22, 2009 from,
No Data <10% %–14% %–19% %–24% %–29% ≥30%

6. The Epidemic of Obesity
Number ONE modifiable risk factor for diseases such as:
Heart disease
Cancer
Diabetes
High blood pressure
High cholesterol
TALKING POINTS:
Because of these startling statistics, obesity has become the number one modifiable risk factor for heart disease. Smoking used to be number one.
How do we modify it… through exercise, along with a complete lifestyle change that includes managing stress, eating healthier and group support.
Other diseases that can be prevented:
Cancer
Diabetes
Hypertension
Hyperlipidemia

7. Heavy to Heavier TALKING POINTS:
Even though billions of dollars are spent annually ($117 BILLION) to fight obesity, we keep getting heavier. Over 66% of our population is overweight, > 32% is obese, and more than 4.8% are morbidly obese. (Source: AHA Heart Disease and Stroke Statistics 2007)
Other statistics related to obesity:
Loss of productivity = $3.9 billion annually (Source:
Physical inactivity is certainly a leading cause/contributing factor of obesity.

8. The Influence of Exercise
Only 30% of adults engage in regular physical activity.
70% of Americans perform less than recommended levels of physical activity. No
Exercise
Inconsistent Exercise
Regular
Exercise
TALKING POINTS:
Inactivity is causing us to become a society that is increasingly developing disease.
There is a direct correlation between physical inactivity and increased rates of CAD, diabetes and other chronic conditions
70% of Americans are NOT getting the recommended daily exercise.
Let’s identify the major reasons why physical activity can be such a challenge?
Open up discussion to the group on major barriers to physical activity.
More men engage in physical activity than women.
What is even more concerning is the trend for young Americans.
In 2005, 43.8% of male and 27.8% of female student engaged in the recommended levels of physical activity. This is when we are supposed to be the most physically active. Why do you think children are not getting enough exercise: reasons may include gym classes are being eliminated in schools, safety of children playing in neighborhoods, computer games, costs of team sports, etc.
66.5% of children do not engage in any after school physical activity programs.
21.1% of high school students play video games three hours or more/day
37.2% of students watch over three hours of television each day.
Source: NHIS 2004 and AHA Heart Disease and Stroke 2007

9. Health Implications of Inactivity
Coronary Artery Disease
Obesity
High Blood Pressure
High Cholesterol
Bone Loss
Peripheral Artery Disease
Asthma
Stroke
Cancer (colon, breast, prostate, lung)
Diabetes
Metabolic Syndrome
Depression
High Stress
TALKING POINTS:
An as an inactive society, we are experiencing more:
Heart disease
Obesity
Hypertension
Hyperlipidemia
Metabolic Syndrome
Peripheral Vascular Disease
Osteoporosis
Asthma
More depression and stress
For Type 1 diabetes, exercise can help reduce the risk of developing heart disease. For Type 2 diabetes, exercise is an adjunctive treatment for managing diabetes.
Stroke is more prevalent now.
Inactivity has been associated with some cancers such as colon, breast, prostate and lung.
Source: American College of Sports Medicine, 2000; AHA Statistics Heart Disease and Stroke 2007

10. The Risk of Inactivity
“The relative risk of heart disease associated with physical inactivity ranges from , an increase in risk comparable to that observed for high blood cholesterol, high blood pressure or cigarette smoking.”
Source: JAMA 1995;273:
TALKING POINTS:
According to an paper in the Journal of the American Medical Association, physical inactivity puts a person at a greater risk of CAD than other risk factors such as Hypertension, high cholesterol and smoking.
This may be attributed to the fact that a sedentary lifestyle is linked to Hypertension and high cholesterol.

11. Exercise and All-Cause Mortality Harvard Alumni Health Study
TALKING POINTS:
It is never too late to start an exercise program.
Individuals who started an exercise program later in life, independent of age, had similar risks for disease as those who have been exercising all along.
Individuals who stop their regular exercise program have similar disease risks as those who have never exercised.
Source: NEJM 1993;328:

12. Age-Related Changes in Aerobic Capacity
TALKING POINTS:
As we age the efficiency and effectiveness of our cardiovascular system decreases.
Being of normal body weight does not guarantee fitness.
Surprisingly the values for a normal weight inactive person is not much different than an overweight sedentary person.
This slide shows that a 75 year old athlete is more fit than an inactive normal weight 25 year old.

13. Exercise and Obesity
22,000 participants were followed for 8 years and evaluated for fitness (treadmill testing) and body fat percentage.
Lean men, who were fit, had 1/3 the incidence of cardiac related death as those who were lean and unfit.
Fit obese men had lower death rates than unfit lean men.
Source: Lee et al. Am J of Clin Nutrition 1999; 69: 373
TALKING POINTS:
There is good news! Some research suggests that being overweight, but fit is better than being thin and sedentary.
This study by Lee and colleagues suggests that lean men who were fit had 1/3 less risk of heart disease; however, obese men who were fit had lower death rates than thin unfit men.
Fitness was defined by the level achieved on a graded exercise treadmill test.
Source: Lee et al, Am J of Clin Nutrition 1999; 69:373

14. Benefits of Exercise Improves heart efficiency
Improves oxygen carrying capacity of blood
Lowers resting blood pressure
Lowers triglycerides
Increases HDL cholesterol
Lowers blood glucose (sugar)
Improves metabolism
Prevents bone loss
TALKING POINTS:
1. Review the slide and the benefits of exercise.

15. Benefits of Exercise, cont.
Decreases body fat
Improves muscle mass and density
Improves exercise capacity
Decreases mortality rate
Decreases stress level
Decreases hostility
Decreases depression
Improves overall well-being
TALKING POINTS:
1. Review the slide and the benefits of exercise.

16. Exercise Prescription (Rx)
TALKING POINTS:
Discuss how we will customize an Exercise Prescription.
Explain your role in designing the exercise program and how this will differ from literature in the media.
This exercise program is for “health” not sports conditioning or competitive fitness.
This program is not directly designed for weight loss, but for overall health and well-being.
Weight loss may be a positive side effect of adopting a healthy exercise program.
Exercise Prescription (Rx) 16

17. Exercise Guidelines Limit passive inactive pursuits.
Add more activity into everyday life.
Exercise aerobically for a minimum of 3 hours per week.
Perform strength training activities a minimum of 2 times per week.
TALKING POINTS:
We want to limit inactive (passive) sedentary activities: reading, sitting at the computer, TV, etc.
Increase physical activity by walking to the store, taking the stairs, gardening etc.
Exercise aerobically a minimum of 3 hours each week.
Perform strength training at least 2 non-consecutive days each week.

18.  Flexibility / Stretching  Aerobic / Cardiorespiratory
Exercise Components
 Flexibility / Stretching
 Aerobic / Cardiorespiratory
 Resistance / Strength Training
TALKING POINTS:
All three components are important and add to a person’s overall fitness and health.

19. Format for Exercise Sessions
Warm Up Phase (5-10 minutes):
Includes a low level cardiorespiratory component followed by flexibility exercises
Stimulus or Conditioning Phase (30-60 minutes):
Cardiorespiratory component within your training range
Resistance training
Cool Down Phase (5-10 minutes):
Same as warm-up period
TALKING POINTS:
Review and discuss the slide.

20. Warm Up and Cool Down
The warm up helps move the body from rest to exercise.
The low level cardio activity increases blood flow to muscles and warms them up before stretching.
Low intensity stretching before exercise may reduce the likelihood of musculoskeletal injuries.
TALKING POINTS:
Review and discuss the slide.

21. Warm Up and Cool Down, cont.
The cool down provides a recovery period to return the body (and heart rate and blood pressure) to the resting state.
Helps maintain adequate venous return (reduces “pooling” of blood in lower extremities) and reduces the potential for hypotension (low blood pressure) and dizziness.
Stretching after exercise helps to maintain flexibility.
TALKING POINTS:
Review and discuss the slide.

22. F.I.T.T. Principle F = Frequency How often I = Intensity How hard
T = Time
How long
T = Type
What type
TALKING POINTS:
We will review the Dr. Dean Ornish Program for Reversing Heart Disease exercise guidelines in detail, and we’ll use the F.I.T.T. Principle to discuss our recommendations. We’ll discuss F.I.T.T. Principle in detail in a few moments.
F.I.T.T. stands for:
Frequency- How often?
Intensity- How hard?
Time- How long?
Type- What type?

23. Flexibility TALKING POINTS:
Performing stretching exercises on a regular basis can aid in improving and maintaining range of motion in joints.
Stretching can also reduce the tension in muscle groups and reduce the likelihood of injury.
Flexibility 23

24. Guidelines for Flexibility Training
3 to 7 days per week I
To a mild tension, without discomfort T
Hold each stretch for seconds
Repeat 2 to 4 times each stretch
Static stretches that involve the major muscle tendon units.
May use yoga poses.
TALKING POINTS:
Review the slide.
There aren’t “specific” Dr. Dean Ornish Program for Reversing Heart Disease guidelines. These are generally accepted guidelines recommended by ACSM.
Flexibility is variable from individual to individual. Do not compare yourself with others.
Many experts recommend daily stretching, since flexibility is believed to be temporary.
Holding each stretch for second is optimal, with the greatest change in flexibility occurring in the first 15 seconds, with no real improvements after 30 seconds.
2-4 stretches per muscle group is recommended, since additional improvements are not seen with more.
As you will see, yoga poses can be used as a flexibility exercise and is a great example of the overlap of the components.
Warm up before stretching.
Do not bounce when stretching.

25. Aerobic/Cardiorespiratory
TALKING POINTS:
Of course, aerobic/cardiorespiratory exercise is an important part of our exercise prescription.
Aerobic/Cardiorespiratory 25

26. Activity vs. Exercise Activity Stop and go activities
< 45% or > 80% of maximal capacity
Doesn’t condition the cardiopulmonary system
Exercise
Continuous activity involving large muscle groups
45-80% of maximal intensity
Conditions the cardiopulmonary system
TALKING POINTS:
What is the difference between physical activity and exercise?
Although both are very important for heart health and general well-being, it is important to be able to distinguish between activity and exercise.
Activity = (1) stop and go activities, (2) activities that are less than 45% or greater than 80% of maximal capacity (like a sprint), and (3) doesn’t result in conditioning the cardiopulmonary system
Exercise = (1) continuous activity involving large muscle groups, (2) 45-80% of maximal intensity, and (3) conditions the cardiopulmonary system

27. Activity or Exercise? TALKING POINTS:
How many people think this is exercise?
How many people think this is an activity?
For most individuals basketball is an activity. It is stop and go and doesn't maintain a heart rate that evokes a training response.

28. Activity or Exercise? TALKING POINTS:
How many people think this is exercise?
How many people think this is an activity?
Swimming is usually a continuous activity that promotes cardiovascular conditioning; therefore, we would consider water aerobics and swimming a wonderful aerobic exercise.

29. Activity or Exercise? TALKING POINTS: What about golf?
Does anyone feel it is exercise?
Because of the stop and go nature of golf, even if you walk the course, it is considered an activity.
Golf is a wonderful activity that usually is done with a group of friends.
Connection is very important in our lives, and golf is a great activity to connect with those you love.

30. Activity Versus Exercise
Gardening
Golf
Household Chores
Shopping
Cooking
Doubles Tennis
Basketball
Dancing
Exercise
Hiking
Aerobic dance
Jogging
Rowing
Rollerblading
TALKING POINTS:
Here are examples of different types of physical activities and aerobic exercises.
What activities or exercises have I left out?

31. Exercise Monitoring: Heart Rate
Target Heart Rates
Based on the maximum heart rate achieved during an exercise test
Pulse taking
Wrist
Neck
TALKING POINTS:
As we go through the discussion on exercise prescription one of the components is the intensity of exercise.
It is important to understand how you will monitor your exercise intensity. We use 2 methods - heart rate and perceived exertion.
It is important for you to know how hard you are working when you exercise. You want to be working hard enough to bring about the positive health benefits, but you don’t want to be overdoing it. Exercising above your training range can put you at risk for injuries and burn out.
We determine your exercise heart rate range using your last stress test.
Let’s practice taking your pulse.
Show the cohort how to take radial/carotid pulses and explain the reason why we prefer radial pulses over carotid.

32. Exercise Monitoring: RPE
RATING
DESCRIPTION 6
No Exertion 7
Extremely Light 8 9
Very Light 10
Light 11 12 13
Somewhat Hard 14 15
Hard / Heavy 16 17
Very Hard 18 19
Extremely Hard 20
Maxim
BORG’S RATE OF PERCEIVED EXERTION (RPE) SCALE
TALKING POINTS:
In addition to taking your pulse, we want you to rate your RPE or your “Rate of Perceived Exertion.”
Based on scientific testing, these numbers have been developed to correspond how hard you feel you are exerting yourself. For instance, laying on the couch and resting would be similar to a RPE of 6. An RPE of 20 would be similar to how you feel during a maximal stress test, when you feel as though you cannot exercise anymore.
Another way to look at it is, if you can sing during exercise you are in the 6-10 range and need to kick it up a notch.
If you are gasping for air and cannot talk at all, you are in the range and need to back off.
If you are breathing heavily, but are still able to talk to someone you are in the range and are exercising in an appropriate range.
Borg RPE scale © Gunnar Borg, 1970, 1985, 1994, 1998

33. Program Guidelines: Aerobic ExerciseF
3 to 6 days per week I
45-80% of maximal capacity T
30 to 60 minutes/session
Accumulate at least 3 to 5 hours of exercise weekly
Activities using large muscles that are continuous and rhythmical in nature
TALKING POINTS:
Explain the components of the FITT Principle.
Based on volumes of research, we recommend that you perform aerobic exercise a minimum of 3 times per week and up to 6 times per week for minutes each session at a moderate intensity.
Exercising aerobically less than 3 times per week will not condition the heart/cardiovascular system.
If exercising for 30 minutes each session is too much, it is OK to start off exercising in three 10-minute intervals until you increase your duration to 30 plus minutes.
Exercising beyond 60 minutes will burn extra calories, however it will not give you increased cardiovascular conditioning.
Each one of you will be receiving an individualized exercise prescription at the start of the Program, at 12 weeks and again at one year. We will calculate your target heart rate ranges from your maximal exercise tests that you will have at these time points.

34. Program Guidelines for Diabetes
Aerobic Exercise F
Daily preferred I
45-80 % of maximal capacity
Or RPE 11 to 14 T
20 to 60 minutes/session
Accumulate at least 3 to 5 hours of exercise weekly
Activities using large muscles that are continuous and rhythmical in nature
TALKING POINTS:
Due to the insulin like response that exercise has on the body, people with diabetes should try to exercise at the same time every day in order to establish a routine, determine the impact of exercise on their diabetes control and prevent hypoglycemia.
Exercise is like ‘medicine’ for the person with diabetes. You take medication every day, you eat every day, and therefore, you should exercise every day. Exercising every day helps keep your blood sugar levels even and consistent.
The same intensity, time and type of exercise is used for people with diabetes as with any other participant.
Work closely with the nurse and your doctor, since you may have to adjust insulin (or other diabetes medication) or eat a snack prior to exercise to avoid hypoglycemia.
It is very important that you check pre- and post-glucose levels when starting a new exercise program. You may need to consume grams of carbohydrate for each 30 minutes of exercise. Our Registered Dietitians will help you choose healthy, Ornish friendly carbohydrate snacks.
Exercise is not recommended if your blood glucose > 250 mg/dl with urinary ketones (for Type 1 diabetes) or >300 mg/dl with no ketones.
Source: ACSM, 2000

35. Strength Training TALKING POINTS:
Another component of our exercise prescription and overall fitness is strength training.
Strength Training 35

36. Benefits of Strength Training
 fat mass
Improves cholesterol
 blood pressure
 symptoms of depression
Improves glucose utilization
Improves self-confidence
Improves bone density
 arthritis pain
 metabolism
Can help break through a weight loss plateau
TALKING POINTS:
Because strength training has been shown to decrease cardiac demand when performing ADL’s (activities of daily living) and all of the other benefits listed here, we have included it in our Exercise Prescription.
Source: J Appl Physiol 1993;74: ), (Med Sci Sports Exerc 1980;12: ), (ACSM, 2000)

37. Program Guidelines: Strength TrainingF
2 to 3 days per week I
RPE of 10 to 15 T
10-15 repetitions of 8 to 10 different exercises
Weights, resistance bands, body weight, household items, water resistance
TALKING POINTS:
Benefits of strength training can be obtained with just 2 non-consecutive days of lifting. If possible, a third day will only add to the benefit.
We recommend using a weight that is somewhat challenging or a on the RPE scale.
Completing one set of repetitions of 8-10 different exercises, working the large muscles groups (chest, back, abdomen, quadriceps, hamstrings, biceps, and triceps) using resistance bands, free weights, machines, household items, is recommended.
We’ll learn a strength training routine around week 6 in the Program.
Source: Circulation, 2000;101:

38. Exercising Safely TALKING POINTS:
You can achieve all the benefits of exercise while monitoring yourself to be sure that you are safe.
Lecturer Note: It is important that you present this material in a relaxed, non-anxious way. Be clear about the information, confident that they can take on this responsibility and relaxed in your tone to help participants develop and maintain the positive attitude toward exercise that has been building throughout the lecture.

39. General Exercise Guidelines
Monitor your exercise response.
Pace yourself.
Have a regular exercise routine.
Relax with stress management.
Stay hydrated.
TALKING POINTS:
It is very important for us to exercise on a regular basis, stay hydrated and to monitor ourselves.
Also, take a well-deserved rest after exercise.
Your body deserves it. Practicing stress management after exercise is a great complement to your exercise routine.

40. Exercise Guidelines for Diabetes
Monitor glucose levels before, during and after exercise sessions.
Do not exercise if blood glucose > 250 with urinary ketones or >300 if no ketones.
Eat carbohydrate if blood glucose is < 100 mg/dL.
Exercising at night may cause nocturnal hypoglycemia.
TALKING POINTS:
Exercise for diabetes is extremely beneficial in helping to control the disease, however some precautions must be taken.
When starting an exercise program, people with diabetes should monitor their glucose levels before, during and after the exercise session.
If glucose levels exceed 250 mg/dl and ketones are present in your urine (Type 1 diabetes), you should not participate in the exercise session. If your blood glucose is high before you exercise, physical activity can make it go even higher, so be cautious about doing something active.
Even if ketones are not present, you should not exercise if your blood sugar is >300mg/dl.
If the glucose levels measure <100 mg/dl you should consider ingesting grams of carbohydrates.
Learn your blood glucose response to exercise. Everyone’s blood glucose response to exercise is different. Checking your blood glucose before and after exercise can show you the benefits of activity. You also can use the results of your blood glucose checks to prevent low blood glucose or high blood glucose.
Keep in mind that low blood glucose can occur during or long after physical activity. Low blood glucose is most likely if you: (1) Take insulin or diabetes pill, (2) skip a meal, (3) exercise a long time or (4) exercise strenuously.
If low blood glucose is interfering with your exercise routine, eating a snack before you exercise or adjusting your medication may help. Talk to your health care team about what is right for you. 
During activity, check your blood glucose if you notice symptoms such as hunger, nervousness, shakiness or sweating.

41. More Guidelines for Diabetes
Exercise with caution in extreme hot/cold weather.
Insulin, diabetes pills or other non-insulin injectables may have to be adjusted.
Maintain good foot care and wear proper footwear for your activity.
Exercise has an insulin-like response in the body. Exercise daily at the same time to prevent low blood sugar (hypoglycemia).
Hypoglycemia can occur up to 6 hours after exercise.
TALKING POINTS:
Because exercise has an insulin like response in the body, you may have to adjust insulin and oral hypoglycemic medications.
Drastic peaks and valleys in glucose levels can be managed by exercising around the same time each day.
Maintain close contact with your diabetes physician to ensure you maintain good diabetes control and are properly medicated.

42. Special Exercise Considerations
Eating
Alcohol
Hot weather
Cold weather
Altitude
Medications
Illness
Overexertion
Carbon monoxide (smoking, smog)
TALKING POINTS:
We talked about how exercise makes your heart healthier and improves your health and happiness.
To ensure safety, avoid common-sense pitfalls as they relate to exercise:
Exercise one or more hours after a meal.
Alcohol makes the heart work harder and can cause irregular heart beats.
Be careful of extreme weather changes. Dress appropriately or exercise indoors.
Consult your physician and/or exercise professional before exercising at high altitudes.
When starting this program you may experience the need to change medications. Please inform us when medication changes occur because this may effect your exercise program.
Before adjusting medications, speak with your physician. If changes have been made, please let the Ornish team know.
On days when you feel overly tired or ill, it is important to exercise at a very low level or not at all. (Do not exercise when you have a fever or when the symptoms of a cold are below the neck.)
Carbon monoxide transports through the body 40 times greater than oxygen. Avoid exercising in the smog or around cigarette smoke because your body will not have sufficient oxygen to the muscles and to the heart.

43. Warning Signs Chest pressure/pain Severe breathlessness
Excessive fatigue
Poor recovery
Irregular heart rate (palpitations)
Sweating with cold, clammy skin
Dizziness
Nausea
Fainting
Confusion
New or increased chest, jaw, back or arm pain that does not go away with rest or nitroglycerin
TALKING POINTS:
If you follow the safety guidelines, it is unlikely that you’ll experience any of these symptoms.
But if you do, stop exercising and call your physician. Or if you are onsite, notify the staff immediately.
If you have anginal symptoms that do not go away with rest and/or Nitroglycerin, call 911 immediately.

44. If You Have Chest Pain With Exercise…
When you are exercising at Program sessions:
STOP exercise and let a staff member know.
If you are exercising on your own:
STOP exercising, and follow your doctor’s instructions regarding calling 911, seeking immediate medical attention, taking nitroglycerin or other recommendations from your doctor.
ALWAYS let your physician and Program staff know if you have had any angina symptoms when you have been exercising on your own—especially if your symptoms are changing in intensity or frequency.
TALKING POINTS:
As a staff member, use your department protocol for resuming exercise after resolution of angina.
If a participant has recommendations from their physician that they can resume exercise if the angina is relieved with rest or nitroglycerin, review this with them.
Review nitroglycerin protocol and when to call 911

45. Musculoskeletal Injury
R Rest
I Ice the area for 20 minutes at a time
C Compression (use an ACE bandage to hold the ice on the injured area)
E Elevate the injured area
TALKING POINTS:
We discussed how stress management can complement your exercise program. By practicing stress management daily and stretching regularly before your exercise program, you will help prevent against musculoskeletal injuries.
If you do have an injury (sometimes from over-exercising), make sure you:
Rest
Ice the area if appropriate
Compress the area using an ACE bandage if appropriate
Elevate the area if possible. This will reduce swelling.

46. Pathways to Success Buddies Clubs Classes Events Feelings Fun
Time management
Confidence
Commitment
TALKING POINTS:
Regardless of your attitude toward exercise right now, you can get more of an edge toward success if you plan ways to increases your motivation.
Exercising and participating in activities with a friend or significant other can help you adhere to the exercise component of the Program as well as utilize your group support (connection and support) tools.

47. Integrated Approach Love & Support Stress Management Fitness Nutrition
TALKING POINTS:
As you know by now, the Reversal Program is comprised of 4 components: Group Support, Stress Management, Nutrition and Exercise.
Can anyone tell me “What the most important component of the Program” is?
Answer: All of the components together are the most important. If you think of the Program in 4 SEPARATE components, you may become frustrated. But if you try and connect each component with the other ones, you will be VERY successful.

48. Lifestyle Heart Trial Results
Exercise adherence in combination with the other modalities is associated with:
Heart disease reversal
Improved blood lipids
Weight loss
Improved mood
More satisfaction and pleasure from life
TALKING POINTS:
In the results of the Lifestyle Heart Trial, the research that this Program is based upon, exercising in combination with the other modalities was associated with:
Heart disease regression
Improved blood lipids
Weight loss
Improved mood
More satisfaction and pleasure from life
In fact, in the Lifestyle Heart Trial, it was found that people who had a positive attitude toward exercise, could see the benefits, believed they could exercise and intended to follow through with exercise were the most successful in adhering to the Exercise Guidelines.
Source: Lancet 1990;336: ), (JAMA 1998;280: ), (JAMA 1995;274: )

49. Exercise and Stress Management
Improved flexibility
Increased awareness and ability to focus
Improved breathing techniques
Improved balance
TALKING POINTS:
Stress Management and exercise work beautifully together.
Exercise will assist in the efficiency and effectiveness of the poses and improve our ability to focus.
The breathing techniques you learn in stress management will help with exercise.
Stress Management and exercise also help improve balance, therefore reducing the risk of falling.
Provide an example of how stress management and exercise work together for you or one of your previous participants.

50. Exercise and Group Support
Decreased hostility
Improved mood
Increased satisfaction and pleasure from life
Exercising with a partner or in a group can improve interpersonal relationships.
TALKING POINTS:
Exercise and group support are wonderful complements to each other.
Exercise has been shown to be very effective in decreasing hostility, improving one’s mood, improving connectedness and overall satisfaction from life improves.
Exercising in a group setting can help improve exercise adherence.
Provide an example of how group support and exercise work together for you or one of your previous participants.

51. Exercise, Nutrition and Your Eating Plan
Aids in weight loss and maintenance of weight loss
Moderates appetite
Helps curb binge eating
TALKING POINTS:
Nutrition and exercise have always gone hand in hand. We know if you are trying to lose weight, a good exercise program is imperative to succeed.
Exercise helps moderate appetite and increase metabolism.
Provide an example of how nutrition and exercise work together for you or one of your previous participants.

52. Upcoming Exercise Support and Training
We’ll exercise twice weekly for the next 12 weeks.
We’ll add strength training around week 6.
Toward the completion of Stage I, you will have another stress test, and we will update your exercise prescription to reflect the new test.
TALKING POINTS:
The entire Ornish team will be supporting you 2 days a week for the next 12 weeks.
Around week 6 of the Program we will add a strength training program based on your personal goals and objectives.
We will also update your total exercise prescription at week 12 after you have your follow-up stress test.
All of the this information from today’s session can be found in your participant manual. We’ll refer back to the information throughout the upcoming weeks.
Encourage participants that you look forward to spending time with them and seeing the wonderful changes they are about to experience. Open the floor up to questions.

53. TALKING POINTS:
1. Allow time for Q&A.
Questions 53