1. 1 Nutrition and Exercise Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax: 4970847

2. identify the benefits of exercise and healthy nutrition explain the health pyramid describe the components of healthy diet counseling calculate calories spent in different physical activities explain the FITTP acronym in exercise prescription explain exercise rules for special groups such as pregnancy and ASCVD Objectives

3. Health Effects of Obesity Prevalence of Medical Conditions by Body Mass Index (BMI) for Men Medical Condition Body Mass Index 18.5 to 24.925 to 29.930 to 34.9> 40 Prevalence Ratio (%) Type 2 Diabetes2.034.9310.1010.65 Coronary Heart Disease8.849.6016.0113.97 High Blood Pressure23.4734.1648.9564.53 Osteoarthritis2.594.554.6610.04 American Obesity Association.AOA Fact Sheets. Health effects of obesity. http://obesity1.tempdomainname.com/subs/fastfacts/Health_Effects.shtml

4. 10kg Weight Loss in 100kg Patient With Obesity Related Co-morbidities Mortality 20-25% fall in total mortality 30-40% fall in diabetes related deaths 40-50% fall in obesity related cancer deaths Blood pressure fall of approximately 10mm/Hg in both systolic and diastolic values Reduces the risk of developing diabetes by >50% Fall of 30-50% F. glucose Fall of 15% HbAIC Lipids:Fall of 10% in total cholesterol Fall of 15% LDL Fall of 30% triglycerides Increase of 8% in HDL 1 Hubert HB et al. Circulation 1996; 93: 1372–9, 2 Colditz GA et al. Am J Epidemiol 1990; 132: 501–13, 3 Chan JM et al. Diabetes Care 1994; 17: 961–9, 4 Soloman CG, Manson JE. Am J Clin Nutr 1997; 66 (Suppl. 4): 1055S–50S, 5 Schapira DV et al. Cancer 1994; 74: 632–9

5. Treatment 25–26.927–29.930–34.935–39.9 40 Diet, physicalYes withYes withYesYesYes activity, comorbidities comorbidities behaviortherapy Pharmaco-Yes withYesYesYes therapy comorbidities Weight-loss Yes with Yes surgery comorbidities Obesity Treatment BMI Category *Yes alone indicates that the treatment is indicated regardless of the presence or absence of comorbidities. The solid arrow signifies the point at which therapy is initiated. NIH/NHLBI/NAASO; October 2000. NIH Publication No. 00-4084.

6. Healthy Diet Pyramid 6 Europrev healthy diet, 2005 (modified)

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8. Healthy diet counseling Organization –Arrange for an appointment –Patients confidence in the GP and nurses –Consult a dietician if needed –Try to make the healthy lifestyle popular –Arrange discussion meetings with groups 8

9. Healthy diet counseling Method –Persons capacity for understanding –Use appropriate words –Talk quietly. Do not judge or preach –Explore the persons knowledge –Explore eating behaviours –Do not set time limits –Answer questions and clarify –Reinforce positive behaviour 9

10. Healthy diet counseling Concepts –They are going to feel better –Try to convert persons concept –Healthy diet is a way to increase health and well-being. –Use the word food instead of diet –No inflexible ban on some foods –Voluntary and willingly –Encourage people to think about pros –In adolescents, do not convey the message: the thinner the better 10

11. Healthy diet counseling Techniques –Eat several meals a day –Dont skip meals –Eat slowly –Avoid lots of salt –Modify the total number of calories consumed 11

12. Healthy diet counseling The composition of meals –Increase the amount of fibre –Decrease the amount of refined foods –Eat traditional wholegrain bread and cereals –Eat fruit and vegetables more than twice a day –Reduce the consumption of red meat –Increase the consumption of fish –Eat few eggs a week –Consume skimmed milk and yoghurt –Drink a lot of liquids, especially water 12

13. Healthy diet counseling Cooking –Avoid pre-cooked food, fast food, salted meals, manufactured sweets and cakes. –Roast, boil or grill food instead of frying –Avoid cooking with a lot of salt. –Use olive oil 13

14. Physical activity counseling 14

15. Is your patient ready? 15

16. Prescribing physical activity Caloric threshold –The optimal caloric threshold for a healthy adult is 2000 kcal/week. Calories spent in physical activity: 16 American College of Sport Medicine

17. Prescribing physical activity 17

18. Prescribing physical activity F - frequency (how many days per week) I - intensity (mild, moderate, intense) T - time (quantity of physical activity/day) T - type of activity (aerobic, anaerobic, for strength, stretching…) P - progression 18 EUROPREV Guide on Promoting Health through Physical Activity A Guide to Physical Activity Counselling in Daily Practice, 2007

19. Prescribing physical activity F- Frequency –It is advisable that the patients are active every day, no matter what type of activity they choose. –Physical activity gives beneficial effects when done regularly, –the minimum being 30 minutes for 3-5 days per week 19

20. Prescribing physical activity I – Intensity –Mild: strolling, walking slowly, doing moderate housekeeping, The heart rate (pulse) in mild exercise is less than 50% of the maximal pulse –Moderate: walking briskly, mowing the lawn... heart rate is 50-70% of the maximal pulse. –Intensive: jogging, engaging in heavy yard work... heart rate is more than 70% of the maximal pulse. 20

21. Prescribing physical activity Intensity assessment –One can count his/her heart beats or observe his/her reaction to exercise. 21

22. Prescribing physical activity 22

23. Subjective evaluation of intensity 23

24. Prescribing physical activity T- Type –Anaerobic Without air ie energy exchange in living tissue independent of oxygen brief, strength-based activities such as sprinting or bodybuilding, weight lifting, sprinting, jumping... 24

25. Prescribing physical activity T- Type –Aerobic Aerobic meaning requiring air/oxygen Aerobic exercise is generally activity performed over a long period of time, typically 20 min. Or more Continuous activities that involve using the large muscles in the arsm or legs are called indurance or aeorbic exercise endurance activities such as marathon running or long- distance cycling, swimming, dancing, walking, running, climbing stairs... 25

26. Typical Aerobic Exercise session ACSM (2006) p.137

27. Prescribing physical activity Balanced physical activity 27

28. Prescribing physical activity Start the exercise session with a gradual warm-up –During this time (about 5 to 10 minutes), one should slowly stretch muscles first, and then gradually increase the level of activity. –For example, one should begin walking slowly and then pick up the pace. When the exercise is finished, cool down for about 5 to 10 minutes, stretch the muscles and let the heart rate slow down gradually. 28

29. Prescribing physical activity T- Time 29

30. Prescribing physical activity P- Progression 30

31. Exercise advice and tips 1.Start by talking with your doctor 2.Start out slowly 3.Choose the activity you like to do 4.Get a partner 5.Vary your routine 6.Choose a comfortable time of day 7.Don't get discouraged 31

32. Exercise advice and tips 8.Forget "no pain, no gain 9.Make exercise fun 10.Use appropriate clothes and footwear. 11.Drink plenty of fluids. 12.Warm up before starting 13.Do not forget to cool down 14.Self-monitoring –Record food intake daily –Check body weight 1 x/wk 32

33. Special Considerations Pregnancy – target HR < 140 –(60-70% MaxHR) –Duration 30-45 minutes Breastfeeding – reports of failure of milk production in strenuously exercising women

34. ASCVD Risk categories for exercise Class A Individuals who are apparently healthy and in whom there is no clinical evidence of increased cardiovascular risk with exercise. Class B Individuals with established CHD that is clinically stable. These individuals are at low risk of cardiovascular complications of vigorous exercise. Class C Individuals who are at moderate or high risk of cardiovascular complications during exercise. Examples of people who would be in this category are those who have had several heart attacks and those who have chest pain at a relatively low level of exercise. Patients with certain positive findings on an exercise test may also be in this group. Class D Individuals with unstable disease who should not participate in an exercise program.

35. ASCVD Class A – No prescreening recommended Class B – ECG monitored for the first 6 sessions Class C – Monitored exercise until 8-12 weeks. Class D – not able to exercise * Warm up and cool down periods should be monitored for B & C.