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ACSM’S CERTIFIED
NEWS
OCTOBER–DECEMBER,
2010
•
VOLUME
20:
ISSUE
4
Assessment and Management
of Clients with Obesity page 3
Insulin Resistance — Not just
for people with diabetes?
page 5
Women’s Health:
The BEST Strength
Training Program
for Osteoporosis
Prevention page 7
Health Benefits of
Regular Resistance
Exercise page 10
The Rise of the
Clinical Exercise
Physiologist
— Here to Stay page 12
Health Care Reform and the
Certified Exercise Professional
SHUTTERSTOCK
page 14
Continuing Education Self-Tests
page 15
ACSM’S CERTIFIED NEWS •
•OCTOBER–DECEMBER
JANUARY-MARCH 20102010
• VOLUME
• VOLUME
20:120:4
1
11:10 AM
ACSM’S CERTIFIED NEWS
October–December 2010 • VOLUME 20, ISSUE 4
In this Issue
Assessment and Management of Clients
with Obesity ............................................................ 3
Insulin Resistance — Not just for people
with diabetes? .......................................................... 5
Women’s 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-Editors
James R. Churilla, Ph.D., MPH.
Paul Sorace, M.S.
Committee on Certification
and Registry Boards Chair
Madeline Bayles, Ph.D., FACSM
CCRB Publications Subcommittee Chair
Paul Sorace, M.S.
ACSM National Center Certified News Staff
National Director of Certification
and Registry Programs
Richard Cotton
Assistant Director of Certification
Traci Sue Rush
Professional Education Coordinator
Shaina Miller
Publications Manager
David Brewer
Editorial Board
Chris 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 Subscribers
Correspondence 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.
ACSM’s 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 ACSM’s Certified News have been carefully
reviewed, but have not been submitted for consideration as, and
therefore are not, official pronouncements, policies,
statements, or opinions of ACSM. Information published in
ACSM’s 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 ACSM’s Guidelines for Exercise Testing and
Prescription or the established positions of ACSM. ACSM’s
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
2
Page 2
THE CHANGING
OF 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 ACSM’s
Certif ied News is making one “BIG” one. As co-editor of Certif ied News over
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 ACSM’s Certif ied News and ACSM’s 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 several ACSM committees. Paul, thank you from your co-editor and everyone at
ACSM for your service on Certif ied News and your contributions to the profession. 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 continue to improve our publication. We at ACSM are
pleased to announce Peter Ronai as our new co-editor
for Certif ied 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 Peter Ronai, M.S.,
RCEP, CSCS-D
our new co-editor and wishing him all the best with
ACSM and in his new position as an academician.
Welcome, Peter!
SELF-TEST ANSWER KEY FOR PAGE 15
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HEALTH & FITNESS FEATURE
ASSESSMENT AND MANAGEMENT
OF CLIENTS WITH OBESITY
PERHAPS
THE BIGGEST HEALTH
PROBLEMS WE ARE FACING TODAY ARE
FROM THE COMBINED EFFECT OF
OBESITY, DIABETES, AND
CARDIOVASCULAR DISEASE (CVD)
(HTTP://WWW.CARDIOMETABOLIC HEALTH.ORG).
Excess weight, in particular, abdominal obesity, causes or exacerbates other cardiovascular and metabolic risk factors, including hypertension, dyslipidemia, insulin resistance, and type 2 diabetes,4 and
increases the risk of gallbladder disease, osteoarthritis, sleep apnea, respiratory conditions, and cancer.14
While the prevalence of some modifiable risk factors, such as smoking, has decreased over the past two decades, the prevalence of obesity has risen. Certified health and fitness professionals (CHFP) deal with
the consequences of overweight/obesity in most, if not all of the populations 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 composition and body fat distribution during a pre-exercise fitness appraisal
or health screening can be used to (a) identify and stratify a client’s 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 assessments 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 interested in learning about available methods are directed to other
sources.10–12
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-
BY PAT VEHRS, Ph.D.
cumferences are necessary to assure an accurate assessment. ACSM recommends 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 monitoring changes that occur as a result of diet and physical activity, while
providing comparable results across research studies. The CHFP who
estimates a client’s %BF also should measure BMI, waist and hip circumferences, 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 and
Body 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 inherent errors in any estimate of body composition. The first step in assuring 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 accurately 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 estimate %BF. Assuming a bell-shaped curve for normal distribution, 68%
Table. Indices of Obesity and Central Adiposity
No r m a l We ig h t
Ove r w e ig h t
Ob e s e
Ce n t r a l A d ip o s it y
ACSM’S CERTIFIED NEWS •OCTOBER–DECEMBER 2010 • VOLUME 20:4
BMI = 18.5 − 24.9 kg/m2
BMI = 25 – 29.9 kg/m2
BMI > 30 kg/m2
WC >102 cm in men
WC >88 cm in women
WHR > 0.90 (men)
WHR > 0.85 (women)
WC >102 cm in men
WC >88 cm in women
BMI = body mass index. WC = waist circumference.
WHR = waist-to-hip ratio. See references 2, 3, 7, and 8.
3
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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 client’s %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 acceptable SEE for body composition devices is 3−5 %BF. For obvious reasons,
national organizations have adopted anthropometric measures as
indices of obesity.
References
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 associated 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 metabolic 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 hypertension, blood glucose levels, and blood lipids.14
Central adiposity as measured by waist circumference and the
WHR−increases 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 syndrome.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 exercise. Exercise recommendations should align with recent minimal physical
activity guidelines9 and the ACSM guidelines for exercise prescription for
the management of body weight.6 When necessary, the exercise prescription 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.
4
About the Author
Pat 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.
1. 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. ACSM’s 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/docum
ents/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 intervention strategies for weight loss and prevention of weight regain
for adults. Medicine and Science in Sports and Ex-ercise,
41(2):459–471, 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):1423–1434,
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.), ACSM’s 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 cardiometabolic 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 composition as-sessments in physical education. Journal of Physical
Education, Recreation, and Dance. 77(7):46-51, 2006.
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WELLNESS ARTICLE
INSULIN RESISTANCE —
NOT JUST FOR PEOPLE WITH
DIABETES?
By Stella L. Volpe, Ph.D., R.D., L.D.N., FACSM
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 into
the 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 the
Metabolic Syndrome (2006)
Central obesity (defined as waist circumference# with ethnicity
specific values) AND any two of the following:
Raised triglycerides: > 150 mg/dL (1.7 mmol/L), or
specific 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 specific treatment for this lipid abnormality.
Raised blood pressure: systolic BP > 130 or diastolic BP
>85 mm Hg, or treatment of previously diagnosed
hypertension.
Raised fasting plasma glucose :(FPG)>100 mg/dL (5.6
mmol/L), or previously diagnosed type 2 diabetes. If
FPG >5.6 mmol/L or 100 mg/dL, OGTT Glucose tolerance test is strongly recommended but is not necessary to define presence of the Syndrome.
# If BMI is >30 kg/m², central obesity can be assumed
and waist circumference does not need to be
measured.
Taken from: http://www.idf.org/webdata/docs/IDF_Meta_def_final.pdf
(2006 publication)
Sedentary Behavior and
Insulin Resistance
In 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 evaluated 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 resistance
and diabetes. The authors concluded, “Lack of complete normalization 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-
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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 exercise 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 ways
to 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 significantly compared to baseline stair use. At the end of the intervention, 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 Exercise
Can 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 mentioned), 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 established that performing planned daily exercise is important for maintaining fitness. Although regular exercise is important, and individuals 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 Author
Stella Lucia Volpe, Ph.D., R.D., L.D.N., FACSM, is professor and Chair of the Department of Nutrition at
Drexel 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. Volpe’s 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 associate editor of ACSM’s Health & Fitness Journal®.
Helpful Web sites
American Diabetes Association: http://www.diabetes.org/
American Heart Association: http://www.heart.org/HEARTORG/
References
1. Alibegovic AC, Sonne MP, Højbjerre L, Bork-Jensen J, Jacobsen S,
Nilsson E, Færch 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 skeletal 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 adherence, 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 exercise 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 intervention. Eur J Cardiovasc Prev Rehabil. 2010 Mar 17. 2010;17(5):56975.
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.
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CLINICAL FEATURE
WOMEN’S HEALTH:
THE BEST STRENGTH TRAINING PROGRAM
FOR OSTEOPOROSIS PREVENTION
BY LAUVE METCALFE, M.S., FAWHP
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 osteoporosis 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.
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 therapy, 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 throughout their lifetime, with more than 1.5 million fractures per year attributed to osteoporosis.3 According to the U.S. National Women’s
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 significantly increased by a regimen that uses high load, low repetition (68 reps) versus low-load, high-repetition (20 reps) resistance exercises.4
The BEST exercise program’s main objective was to explore a highload, 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 first 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 randomized to exercise who underwent baseline measurements, 142 completed 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 warmup 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 exercise 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 seated
leg press, lat (latissimus dorsi) pull down, seated row, back extension,
one-arm military press (right and left), and squats (wall squats initially, 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-
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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
Figure 1: Tertiles of Weight lifted
in the Military Press
What BEST researchers found
After 12 months, strength training exercises combined with calcium supplementation, significantly improved bone mineral density at
skeletal 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 doseresponse 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.
Table. Changes in Muscle Strength Assessed
by 1-Rm in Exercise 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 significantly 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 cognitive/social ecological theory constructs and encompassed a variety of
interpersonal, intrapersonal, and environmental reinforcement strategies to motivate participants and promote high levels of retention.
Figure 2: Tertiles of Weight Lifted
in Military Press
Goals of the support programs were to create a fun, social environment and to challenge participants to improve daily exercise performance. Participation was based on individual improvement rather than
competition among participants. Some examples of the intervention
support programs included: orientation workshops, monthly newsletters, Personal Best testing every two months to monitor progress,
yearly evaluation results, goal setting logs, personal contracts, motivational 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 participating 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 circumstance comes their way. They also have created a remarkable
bond with one another and unanimously feel that their exercise program 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 program, 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
Women’s Health (continued on page 11)
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COACHING NEWS:
WHAT IS YOUR BQ?
By Margaret Moore (Coach Meg), MBA
YOU MAY BE FAMILIAR WITH THE CONCEPTS OF EMOTIONAL INTELLIGENCE, HOW WELL ONE
HANDLES ONE’S 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
ONE’S BODY IS ALSO AN IMPORTANT FORM OF INTELLIGENCE, ONE THAT IS NEGLECTED BY THE
FIELD OF PSYCHOLOGY AND BY MANY PEOPLE IN THEIR EVERYDAY LIVES.
Body intelligence is about how aware you
are of your body (body awareness), what
you know about your body (body knowledge), 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.
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 feeling (good or bad) and reflecting on possible
influences.
Body Awareness
Body Knowledge
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 conscious of the impacts that certain foods, physical practices, or internal and external stressors 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 or
refusing a second cup. Mindfulness, reflection, experimenting, and learning are important paths forward to greater body awareness. 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
Body knowledge is akin to what scientists
call “health literacy.”1 How much do you
know about accepted evidence-based standards and guidelines for healthy bodily functioning? Knowing scientific facts is an important part of health literacy, along with an
understanding of the actions needed to diagnose 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 exercise, 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 addictive 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 commitment 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 developed. Change that lasts requires a solid foundation 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 in
healthy 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
approach to setting goals and
experimenting?
Coaching News (continued on page 13)
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HEALTH & FITNESS COLUMN
HEALTH BENEFITS OF EXERCISE
REGULAR RESISTANCE EXERCISE
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.”
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) maintain/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 discomfort; (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 healthrelated reasons for performing resistance exercise, the strength training benefit of reduced resting blood pressure is undoubtedly the most
misunderstood. Many people, including some fitness 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 welldesigned strength training program, may be mistakenly advised to
avoid this important physical activity. It would therefore seem welladvised to further examine the effects of resistance training on exercise blood pressure and resting blood pressure.
First, it is true that strength training elevates systolic blood pressure during the exercise set. A 1982 study by Westcott and Howes15
revealed that systolic blood pressure increases progressively (repetition by repetition) during an exercise set to fatigue using the 10 repetition 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 average, 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 20minute bout of stationary cycling at approximately 75% of their maximum 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 subjects’ systolic blood pressure increased 50% (127 mmHg to 190
10
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 resistance exercise should be performed with moderate loads, proper technique and continuous breathing.
Although resistance exercise temporarily elevates blood pressure
during an exercise set, it does not result in higher resting blood pressure 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 decreases in resting systolic and diastolic readings.16 In a 10-week study, more
than 1,600 participants who performed 20 minutes of strength training 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 training actually decreases resting blood pressure. Adults and older adults
who understand this fact are less likely to avoid this productive physical 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 beneficial responses to strength training may provide significant risk reduction for cardiovascular disease.3
One of the more remarkable resistance exercise research findings
is the positive effect of circuit strength training on muscle mitochondrial content and oxidative capacity.11 Mitochondria serve as the powerhouse of each muscle cell, but aging is associated with genetic
changes that impair mitochondrial function with respect to energy
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production and muscle performance. In the study by Melov and associates, 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 compelling
reason 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 physiological adaptations that, in addition to increasing muscle strength,
endurance and mass, may have a positive impact on a variety of fitness 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 participation in this essential exercise activity.
About the Author
Wayne L. Westcott, Ph.D., teaches exercise science
and conducts fitness research at Quincy College
in Quincy, MA.
References
1. American College of Sports Medicine. ACSM’s
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 Professional’s Guide to
Strength 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, cardiovascular, 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 controlled 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 training 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 Association
Journal, 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 frequencies. 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.
Women’s Health continued from page 8
participant to the program. It is critical that the exerciser maintain correct 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 programs similar to BEST. Such a program is realistic and may be successful in reducing the impact of osteoporosis on public health. The
best treatment is prevention, and women of all ages should be concerned 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 organizational health consultant and on the faculty of the
University of Arizona College of Medicine. Lauve
was a co-investigator and directed the exercise
intervention for the BEST program.
([email protected])
References
1. Bea, J, Cussler, E, Going, S, Blew, R, Metcalfe, L, Lohman, T,
Resistance training predicts six-year body composition change in postmenopausal 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 continuing education module The BEST Exercise Program for Osteoporosis
Prevention by contacting www.dswfitness.com
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CLINICAL COLUMN
THE RISE OF THE CLINICAL EXERCISE PHYSIOLOGIST
HERE TO STAY
BY JONATHAN K. EHRMAN, Ph.D., CES, FACSM
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 “doctorallevel research scientist,” thus paying respect to
the term “physiologist” as one who aspires to
become an independent researcher.
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 provide exercise testing and training expertise for individuals, who understands the acute and chronic response to exercise, and who has the ability 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 diseases including obesity, hypertension, lipid disorders, and glucose intolerance. During this period the exercise physiologist was becoming a true
clinical practitioner.
Leading the way, ACSM developed a definition of a “Clinical Exercise
Physiologist” in the 1990s. This definition built upon the ACSM Clinical
Exercise Specialist (CES) certification, which was initiated in the mid1970s, and was developed in response to the growth of cardiac rehabilitation as a treatment option for patients with heart disease. As these
professionals expanded to begin to work with the pulmonary and metabolic 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) necessary to perform required job duties of someone working in the CEP
field. By the late 1990’s the Registry of Clinical Exercise Physiologist was
developed by the ACSM. The goal of this registry was to develop a credential 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-
12
forms regular reassessments of the profession to ensure adequate certification 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 defined 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., licensure). 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 master’s degree in exercise science, exercise physiology,
or kinesiology. And beginning in 2011 the CES certification will limit
examinees to those with a bachelor’s degree in one of the stated exercise 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 multiple 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 important steps in the profession. These attempts must be made on a stateby-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 physiologists 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 development
of 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 standards 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 representative portion of certified CEPs. Data from the job task analysis is used
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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 professional 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 independent of other allied health professions. Today, this body includes plenty 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 life’s work to get rich,
recent data (currently unpublished) compiled by CEPA is encouraging. 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 reported 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 master’s degree over a bachelor’s was $5,000 to $6,000
in 1996. Today this difference has increased to about $7,000 to
$15,000.
Salary Ranges Among Respondents Who Are
Exercise Physiologists with a Bachelors or
Masters Degree (n= 744).
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 profession. Don’t be left watching from the outside!
About the Author
Jonathan 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 hospital’s Clinical
Weight Management Program. He served on
ACSM’s 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 ACSM’s
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.
References
1. 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.
Coaching News continued from page 9
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 Author
As the profession of CEP continues to develop at a seemingly exponential rate, there are several items that prospective and current professionals 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 emerging 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 certification
quest and ongoing renewal.
Margaret Moore/Coach Meg, MBA, is the
founder & CEO of Wellcoaches Corporation, a
strategic 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])
Reference
1. Hasnain-Wynia, R., & Wolf, M.S. 2010. Promoting health care equity:
Is health literacy a missing link? Health Services Research, 45 (4),
897–903.
ACSM’S CERTIFIED NEWS •OCTOBER–DECEMBER 2010 • VOLUME 20:4
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WELLNESS ARTICLE
HEALTH CARE REFORM AND THE
CERTIFIED EXERCISE PROFESSIONAL
BY Tom Spring, M.S., CES
Much political, policy, and philosophical discussion in the United States over the past several
years has focused on how to fix our health care
system. Ongoing debate exists with some advocating for a complete overhaul of the system,
while others argue for modest changes and focus
on specific aspects of health care delivery and
reimbursement. This article explores potential
impacts and opportunity health care reform will
have on exercise professionals, particularly related to worksite health promotion and disease prevention programs.
As ACSM certified exercise professionals, we are in a unique position 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 client’s history and goals for their exercise 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 improving 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 administration, 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 benefits, 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 individuals to get involved. Prevention of chronic diseases (e.g., diabetes,
coronary disease, obesity, etc.) is a major focus and incentives are available 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
14
Workplace Wellness Grants ” authorizes the development of a grant
program that will assist businesses in establishing certified wellness
programs.1 Programs will be able to apply for grants to help fund wellness in the workplace in an attempt to influence 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 wellness2 providing direct opportunity to ACSM certified* 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 professionals (CPT, HFS).
3. Community wellness initiatives strengthened with promotion of
activity-friendly community design and programming: physical activity, 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 evidenced 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 hospital services and internal referrals. According to the Medical Fitness
Association, nearly 1,100 such centers exist today with over 3.5 million 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 certifications like the HFS, CES, and RCEP.
Several government agencies are being formed and convened to
examine prevention and health promotion efforts with annual appropriation of funds at $500 million in 2010, with significant additional
funding allocated for years beyond.1 Issues related to tobacco dependence, obesity, diabetes, and reducing preventable and expensive disease treatments are on the forefront of health care reform.
Health Care Reform continued on page 16
ACSM’S CERTIFIED NEWS • OCTOBER–DECEMBER 2010 • VOLUME 20:4
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October–December 2010 Continuing Education Self-Tests
Credits provided by the American College of Sports Medicine • CEC Offering Expires December 31, 2011
SELF-TEST #1 (1 CEC):The following questions are
from “Assessment and Management of Clients with
Obesity” published on page 3.
1. Which of the following have most health profession
organizations adopted as an overall measure or
indicator of obesity?
a. Percent body fat.
b. Waist circumference.
c. Waist-to-hip ratio.
d. BMI.
SELF-TEST #2 (1 CEC): The following questions
are taken from “Insulin Resistance – Not just for
people with diabetes?” published on page 5.
1. Insulin resistance means ________.
a. high blood glucose levels
b. high blood insulin levels
c. inability for insulin to bring glucose into the cells
d. all of the above
2. The optimal management of clients or patients at risk
of cardiovascular and metabolic disease requires the
assessment of _____.
a. modifiable risk factors
b. unmodifiable risk factors
c. genetic markers for the disease
d. the metabolic syndrome
e. all of the above
2. The metabolic syndrome is not solely characterized
by central obesity.
True
False
3. Bed rest was shown to change the genes involved in
______ and _____
a. insulin resistance and diabetes
b. insulin resistance and cardiovascular disease
c. diabetes and cancer
d. none of the above
3. The exercise prescription for a client or patient with
increased BMI, waist circumference, and waist-to-hip
ratio values should or may _____.
4. Multiple bouts of physical activity led to ______ and
a. at least meet the guidelines for minimal amounts of
______.
physical activity
a. increased body weight and healthier eating
b. adhere to the exercise guidelines for weight loss
b. weight loss and cardiorespiratory fitness
c. adhere to the exercise guidelines for the metabolic
c. weight loss and muscle hypertrophy
syndrome
d. none of the above
d. adhere to the exercise guidelines for hypertension
5. Incorporated unplanned exercise within a day, even
and diabetes
when a person has completed planned exercise, is
e. all of the above
important for overall health.
4. Which of the following are used as measures of
True
False
central adiposity?
a. Waist circumference and waist-to-hip ratio.
SELF-TEST #3 (1 CEC): The following questions are
b. Waist circumference, waist-to-hip ratio,
taken from “Women’s Health: The BEST Strength
and BMI.
Training Program for Osteoporosis Prevention”
c. BMI.
published on page 7.
d. BMI and %BF.
1. One of the primary objectives of the BEST exercises
5. You estimate the percent body fat of a client or
was to promote exercise at an intensity sufficient to
patient to be 21% using a method that has a SEE of 4
elicit an increase in bone mineral density (BMD) in the
%BF. What would you expect (with 95% confidence)
hip and lumbar spine.
the %BF from a criterion method to be?
True
False
a. 21 %BF
2. The six core BEST exercises are:
b. Between 19 – 23 %BF
a. leg press, chest press, squat, seated row, lat
c. Between 17 – 25 %BF
pulldown, leg extension
d. Between 13 – 29 %BF
b. lat pull down, lunges, seated row, one arm military
press, crunches, chest press
c. seated row, one arm military press, squat, lat pull
down, leg extensions, leg curls
d. leg press, lat pull down, squat, one arm military
press, seated row, back extension
ACSM’S
CERTIFIED
NEWS®
3. A major principle of the BEST exercise program was
that bone mass can be significantly increased by a
regimen that uses low-load, high-repetition (20 reps)
resistance versus high load, low repetition (six-eight
reps).
True
False
4. Some examples of the intervention support program
include:
a. monthly newsletters, goal setting logs, motivational
meals, yearly evaluation results
b. two major promotional events, personal contracts,
Personal Best testing, orientation workshops
c. competition among participants, all you can eat
buffets, personal contracts, paying cash for
exercising
d. a and b
5. The participants who maintained bone density with
greater effects were those who lifted weights two or
more times per week.
True
False
SELF-TEST #4 (1 CEC): The following questions
were 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 is
spent on health care?
a. 12%
b. 50%
c. 17%
d. 6%
2. The health care reform bill is called the:
a. Affordable Care Act
b. Health Reform of 2010
c. Accountable Care Act
d. Health Management Plan
3. How many medical fitness centers exist today?
a. 2,100
b. 1,100
c. 100
d. 3,100
4. Government agencies being formed to examine
prevention programs have been appropriated funds
to support efforts at this level:
a. $500
b. $500 thousand
c. $200 million
d. $500 million
5. The following ACSM certified individuals will benefit
from a governmental focus on worksite wellness and
disease prevention:
a. CPT
b. HFS
c. CES & RCEP
d. PAPHS
e. All of these
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)
ACSM USE:
666922
PLEASE PRINT OR TYPE REQUESTED INFORMATION
NAME
ADDRESS
CITY
STATE
BUSINESS TELEPHONE
E-MAIL
ZIP
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.
ACSM’S CERTIFIED NEWS •OCTOBER–DECEMBER 2010 • VOLUME 20:4
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NONPROFIT ORG
U.S. POSTAGE
PAID
Indianapolis, IN
Permit No. 6580
ACSM’s Certified News
ISSN # 1056-9677
P.O. Box 1440
Indianapolis, IN 46206-1440 USA
Health Care Reform continued from page 14
The ACSM certified professional is extremely well positioned to
become involved in health promotion, disease prevention, and advocacy 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.
References
1. Koh H. and Sebelius K. Promoting Prevention through the
Affordable Care Act. NEJM 363(14):1296-1299, 2010.
2. Medical Fitness Association, Benchmarks for Success 8th Edition,
2010. Available at www.medicalfitness.org
3. Truffer C., Keehan S., Smith S., et al. Health Spending Projections
Through 2019: The Recession’s Impact Continues. Health Affairs
29(3):522-529, 2010
4. http://healthyamericans.org/assets/files/Promoting%20
Prevention.pdf