Professional Documents
Culture Documents
W e continue to offer online streaming video in this eighth edition, including over 70 videos of content
demonstrating key concepts from the book, such as assessments, procedures, tips, stretches, and exer-
cises. You can access the online video by visiting www.HumanKinetics.com/AdvancedFitnessAssessment
AndExercisePrescription. If you purchased a new print book, follow the instructions on the orange-framed
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Once at the Advanced Fitness Assessment and Exercise Prescription website, select Online Video in the
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mation about the video. Select the link to open the online video web page. From the online video page, you
can select the chapter and then the desired video, numbered as they are in the text.
Following is a list of the clips in the online video.
viii
Video Contents • ix
Video 8.1 Guidelines for hydrostatic weighing Video C3.2 Shoulder pull
Video 8.2 Testing procedures for the Bod Pod Video C3.3 Triceps extension
Video 8.3 A-mode ultrasound Video D2.1 Measurement of the chest skinfold
Video 8.4 Whole-body BIA measures Video D2.2 Measurement of the subscapular
Video 8.5 Upper body BIA measures skinfold
Video 8.6 Lower body BIA measures Video D2.3 Measurement of the abdominal
Video 10.1 Shoulder flexion skinfold
Video 10.2 Knee flexion Video D2.4 Measurement of the thigh skinfold
Video 10.3 Ankle flexion Video D2.5 Measurement of the calf skinfold
Video 10.4 Inclinometer test procedures Video D4.1 Circumference measurement of the
Video 10.5 Modified sit-and-reach test waist
Video 10.6 Modified back-saver sit-and-reach test Video D4.2 Circumference measurement of the
Video 11.1 PNF stretching techniques hips
Video 12.1 Unipedal stance test Video D5.1 Bony breadth measurement of the
Video 12.2 BESS test hips
Video 12.3 Functional reach test Video D5.2 Bony breadth measurement of the
Video 12.4 Timed up-and-go test elbow
Video 12.5 Y-balance test Video F1.1 Hamstring stretch
Video C3.1 Chest push Video F1.2 Chest stretch
Preface
x
Preface • xi
eligibility requirements, inequalities exist among ited exercise certifications, established a registry of
the certifications available to exercise science pro- professionals in the United States certified by any
fessionals. Some certification programs are more of six organizations (www.usreps.org). This website
rigorous than others, having stringent eligibility is a convenient means for locating professionals by
requirements; others may or may not be accredited location, certification, or name. Registries are also
by a third-party accrediting agency like the NCCA. available for the United Kingdom (www.exercisereg-
To address the inequality among certification pro- ister.org), Europe (www.europeactive.eu/why-ereps),
grams, the NCCA formally reviews applications for and New Zealand (www.reps.org.nz).
the accreditation of certification programs. In 2004,
the International Health, Racquet, and Sportsclub
Association (IHRSA) recommended that all health
NATIONAL BOARDS
clubs belonging to their organization hire only per-
Some professional organizations in the fitness indus-
sonal fitness trainers certified by an NCCA-accred-
try believe there should be alternatives to accred-
ited organization or agency. Wagner (2014) reported
itation of certification programs by the NCCA or
results from a survey of 589 exercise physiologists
other third-party agencies. In the United States, one
and indicated that 69% of the respondents held one
such alternative was the establishment of National
certification while 28% held two or more. Neverthe-
Board examinations for fitness professionals.
less, not all exercise science and fitness certifications
Unlike the multitude of certification examinations
are equal. This leads to confusion for the consumer
developed by individual organizations and agencies,
in terms of knowing who is and who is not highly
National Boards are standardized tests to assess the
trained and qualified as an exercise professional.
knowledge, skill, and competence of professionals.
It also complicates selecting the most appropriate
Most medical and allied health professions utilize
certification for yourself. Some agencies sponsor
National Boards.
certification programs primarily for financial gain,
In 2003, the National Board of Fitness Examiners
while others certify professionals in order to promote
(NBFE) was founded as a nonprofit organization
exercise science as a profession.
with the twin purposes of defining scopes of practice
Table 1 lists some of the organizations that offer
for all fitness professionals and determining stan-
certifications accredited by the NCCA. Addition-
dards of practice for various fitness professionals,
ally, the Coalition for the Registration of Exercise
including floor instructors, group exercise instruc-
Professionals (CREP), a not-for-profit corporation
tors, personal fitness trainers, specialists in youth
composed of organizations that offer NCCA-accred-
and senior fitness, and medical exercise specialists.
Table 1 Selected Organizations Associated With National Commission for Certifying Agencies
(NCCA) and National Board of Fitness Examiners (NBFE)
NCCA affiliates NBFE affiliates
American Council on Exercise (ACE) Aerobics and Fitness Association of America (AFAA)
American College of Sports Medicine (ACSM) American Aerobic Association International/International
Sports Medicine Association (AAAI/ISMA)
Cooper Institute for Aerobics Research International Sports Sciences Association (ISSA)
National Exercise and Sports Trainers Association (NESTA) National Association for Fitness Certification (NAFC)
National Exercise Trainers Association (NETA) National Council for Certified Personal Trainers (NCCPT)
National Federation of Professional Trainers (NFPT) National Exercise and Sports Trainers Association (NESTA)
National Strength and Conditioning Association (NSCA) National Gym Association (NGA)
International Fitness Professionals Association (IFPA) National Personal Training Institute (NPTI)
National Council on Strength and Fitness (NCSF) National Strength Professionals Association (NSPA)
National Academy of Sports Medicine (NASM)
xii • Preface
The NBFE established national standards of excel- Nevada, Oregon, and the District of Columbia have
lence that certifying organizations and colleges or considered licensure for personal trainers (Eick-
universities may adopt. The written portion of the hoff-Shemek and Herbert 2008b; Herbert 2004;
National Boards for personal fitness trainers is now Thompson 2017).
offered through the NBFE (for additional informa- To promote exercise science and exercise phys-
tion, visit www.NBFE.org). The practical portion iology as a profession, the ASEP is working with
of this exam is still being developed and validated exercise professionals throughout the United States
under the supervision of the National Board of Med- to develop uniform state licensure requirements
ical Examiners (NBME). The NBME and the NBFE for exercise physiologists. Licensure would place
are engaged in preliminary discussions and planning exercise physiologists and personal trainers on a par
that will allow certification organizations to assist in with other allied health professionals (e.g., nurses,
the delivery of practical exams for personal trainers. nutritionists, physical therapists, and occupational
To be eligible to sit for the National Boards, per- therapists) who are required to have licenses to
sonal fitness trainers must successfully complete practice. Licensed fitness professionals may be more
a personal training certification program from an likely to obtain referrals from health care profession-
approved NBFE affiliate. Affiliate status is avail- als and to receive reimbursement for services from
able to qualified groups from the areas of medicine, third parties (e.g., insurance companies).
certification organizations, fitness professionals, Along with advantages, added responsibilities and
health clubs, and higher education. In the future, the disadvantages are associated with state licensure.
NBFE’s National Boards may be used by certifying Licensure may limit the scope of practice and ser-
organizations, colleges and universities, and U.S. vices that exercise professionals are currently able
state licensing programs to test the knowledge, skill, to provide to the public. For example, Louisiana
and competence of fitness professionals (American licensure law requires clinical exercise physiologists
Fitness Professionals and Associates 2004). Table to work under the direction of a licensed physician.
1 lists some of the organizations offering personal Also, the costs of licensure, continuing education
training certifications affiliated with the NBFE. for licensure, and professional liability insurance
may be more expensive compared with the cost
LICENSURE of certifications. Professionals moving from state
to state may be required to obtain another license
because each state could require different creden-
Although many practitioners in the fitness and exer-
tials for licensure (Eickhoff-Shemek and Herbert
cise science fields agree that certification ensures
2008a, 2008b).
professional competency, other professionals believe
that licensure is better suited for protecting consum-
ers and for enhancing the credibility and profession- STATUTORY
alism of exercise science and fitness professionals
(Eickhoff-Shemek and Herbert 2007). For the first
CERTIFICATION
time in the 12 yr history of the worldwide survey
Instead of licensure, some American states use
of fitness trends, licensure for fitness professionals
statutory certification for allied health profession-
broke into the top 20 trends (number 16 for 2018)
als. Statutory certification regulates what titles
(Thompson 2017). In the United States, licensure
professionals can use and the qualifications needed
is decided at the state level; therefore, requirements
to obtain these titles. Only certified professionals
may vary from state to state. Louisiana was the first
with the required credentials are allowed to use
state to pass a law requiring licensure of all clinical
the specific title (e.g., certified nutritionist). Other
exercise physiologists (Herbert 1995). Licensure of
professionals without the necessary credentials can
clinical exercise physiologists has also been consid-
still practice in the state but must use a different title.
ered in Maryland, Massachusetts, Michigan, North
This approach could be promoted by the fitness and
Carolina, Texas, and Utah (Clinical Exercise Phys-
exercise professions to prevent the use of titles, such
iology Association, 2013). Several states including
as personal trainer or exercise physiologist, by indi-
Georgia, Maryland, Massachusetts, New Jersey,
Preface • xiii
viduals having no formal education or professional certified health and fitness instructors. Certification
certifications. by reputable professional organizations upgrades the
All these approaches demonstrate the pressing quality of the typical person working in the field and
need to get a handle on certifications for exercise assures employers and their clientele that employees
professionals so we can gain control of who is have mastered the knowledge and skills needed to
practicing in our field. This will ensure the safety be competent exercise science professionals. Hence,
of exercise program participants and enable individ- the likelihood of lawsuits resulting from negligence
uals working in the fitness field to be recognized as or incompetence may be lessened. Also, certification
exercise science professionals. Until these issues are and licensure help validate exercise specialists as
resolved and a list of accredited certification agen- health professionals who are equally deserving of
cies and organizations is finalized, you should select the respect afforded to professionals in other allied
a professional certification that matches your level health professions. Individuals holding a Registered
of education and career goals. For more information Clinical Exercise Physiologist (RCEP) or Certified
about certification programs, visit the websites of Clinical Exercise Physiologist (CEP) certification
those professional certifying organizations. now have a National Provider Identifier code
Many advantages are associated with obtaining that may be used for service reimbursement from
either state licensure or certification with profes- insurance companies. For more information on this
sional organizations. You will have a better chance development, visit the website of the Clinical Exer-
of finding a job in the health and fitness field because cise Physiology Association (www.acsm-cepa.org).
many employers are now hiring only professionally
Acknowledgments
xiv
1
Chapter 1
CHAPTER
1
2 • Advanced Fitness Assessment and Exercise Prescription
2016 may be less reflective of changes in activity for improved health, and the importance of includ-
levels than in updated physical activity recommen- ing exercise and physical activity as one of the vital
dations (150 min of moderate-intensity activity or signs (i.e. heart rate, blood pressure, etc.) monitored
75 min of vigorous-intensity activity per week, or during annual visits to the doctor. For definitions of
combination thereof). The current recommendations terminology used in this chapter, see the glossary.
changed the frequency of exercise bouts from 5 days
per week (moderate-intensity) or 3 days per week
(vigorous-intensity) to weekly totals of minutes.
PHYSICAL ACTIVITY,
The prevalence of physical inactivity ranges from HEALTH, AND DISEASE:
approximately 38% in the eastern Mediterranean AN OVERVIEW
countries to a low of 14.8% in southeast Asia; by
World Bank income classification, the low- and low- Technological advances affecting nearly every facet
er-middle-income countries were more physically of life have substantially lessened work-related
active than their upper-middle- and high-income physical activity as well as the energy expenditure
counterparts (Sallis et al. 2016). In England and required for performing activities of daily living
Scotland, more than 65% of men and at least 50% like cleaning the house, washing clothes and dishes,
of women met the government’s physical activity mowing the lawn, and traveling to work. What
guidelines in 2012 (British Heart Foundation 2015a). would have once required an hour of physical work
However, only 18% of Canadian adults responding now can be accomplished in just a few seconds by
to the 2014-2015 Canadian Health Measures Survey pushing a button or setting a dial. Survey results
met the recommendation of 150 minutes of mod- from 23 low-income and 25 upper-middle-income
erate-to-vigorous intensity activity in bouts lasting countries suggest that access to modern technolog-
at least 10 minutes (Statistics Canada 2017). Thus, ical conveniences underlies an inverse relationship
as an exercise specialist, you face the challenge of between both education level and financial assets
educating and motivating your clients to incorporate with the prevalence of physical inactivity (Allen
physical activity as a regular part of their lifestyles et al. 2017). The unfortunate fact is, however, that
and to reduce the amount of time spent being seated many individuals do not engage in physical activity
(Benatti and Ried-Larsen 2015; Bergouignan et al. during their leisure time and sit too much at work
2016; Levine 2015; Same et al. 2016). and after hours.
This chapter deals with the physical activity Although the human body is designed for move-
trends, risk factors associated with chronic noncom- ment and strenuous physical activity, exercise is
municable diseases, the role of regular exercise and not part of the average person’s lifestyle. Industri-
physical activity in disease prevention and health, alization and urbanization have led to increased
physical activity guidelines and recommendations
Physical Activity, Health, and Chronic Disease • 3
sedentarism and sedentary behaviors (performing 2 diabetes, and breast and colon cancers are due to
activities of ≤1.5 METs while in a sitting or reclining physical inactivity (Lee et al. 2012). As a risk factor,
posture) (Benatti and Ried-Larsen 2015; Sedentary physical inactivity is basically equivalent to the
Behaviour Research Network 2012). One cannot combined risk of smoking and obesity. Sedentarism
expect the human body to function optimally and to has repeatedly been identified as an independent risk
remain healthy for extended periods if it is abused factor associated with an increased risk for all-cause
or is not used as intended. mortality and metabolic and heart disorders (Benatti
Physical inactivity is recognized as a major and Ried-Larsen 2015). Individuals who do not
contributor to the physical and economic burden of exercise regularly and sit too much are at greater risk
disease nationally and globally. The identification of for developing chronic noncommunicable diseases
physical inactivity as the fourth leading risk factor such as those in figure 1.1.
for mortality supports what experts noted nearly a For years, exercise scientists as well as health and
decade ago—physical inactivity may well be the fitness professionals have maintained that regular
most important public health problem in the 21st physical activity is the best defense against the devel-
century (Blair 2009). To highlight this, a global opment of many diseases, disorders, and illnesses.
action plan was developed to increase the number The importance of regular physical activity in
of people meeting the recommended weekly amount maintaining a high quality of life and in preventing
of physical activity by 10% (World Health Organi- disease and premature death received recognition as
zation 2013). The World Health Organization (2014) a national health objective in the first U.S. surgeon
reported that physical inactivity causes an estimated general’s report on physical activity and health
3.2 million deaths annually. Data from large cohort (U.S. Department of Health and Human Services
studies conducted around the world were pooled 1996). This report identified physical inactivity as a
and analyzed; resulting estimations revealed that serious nationwide health problem, provided clear-
between 6% and 10% of coronary heart disease, type cut scientific evidence linking physical activity to
Metabolic Musculoskeletal
Obesity
disorders disorders
Prostate
Lung Anxiety
Pulmonary
diseases
Emphysema Asthma
Chronic bronchitis
FIGURE 1.1 Role of physical activity and exercise in disease prevention and rehabilitation.
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4 • Advanced Fitness Assessment and Exercise Prescription
numerous health benefits, presented demographic The intensity of exercise is expressed as a metabolic
data describing physical activity patterns and trends equivalent of task (MET). An MET is the ratio of
in the U.S. population, and made physical activity the person’s working (exercising) metabolic rate to
recommendations for improved health. In 1995, the the resting metabolic rate, with 1 MET defined as
CDC and the American College of Sports Medicine the energy cost of sitting quietly. Moderate-intensity
(ACSM) recommended that every U.S. adult should aerobic activity (3.0-6.0 METs or 5 or 6 on a 10-point
accumulate 30 min or more of moderate-intensity perceived exertion scale) is operationally defined as
physical activity on most, preferably all, days of the activity that noticeably increases heart rate and lasts
week (Pate et al. 1995). This recommendation has more than 10 min (e.g., brisk walking at 3.0-4.0 mph
since been adopted by many international organi- [4.8-6.4 km·hr−1]). Vigorous-intensity activity (>6.0
zations. METs or 7 or 8 on a 10-point perceived exertion
Since 1995, new scientific evidence increased our scale) causes rapid breathing and increases heart
understanding of the benefits of physical activity rate substantially (e.g., jogging or running at 4.5
for improved health and quality of life. In light of mph [7.2 km·hr−1] or higher). For adults (18-65 yr)
these findings, the American Heart Association and older adults (>65 yr), the ACSM recommends a
(AHA) and the ACSM updated physical activity minimum of 150 min of moderate-intensity aerobic
recommendations for healthy adults and older adults activity per week or 75 min of vigorous-intensity
(Haskell et al. 2007; Nelson et al. 2007). These rec- aerobic exercise per week. It is also recommended
ommendations address how much and what type of that these totals be spread over the course of a week
physical activity are needed to promote health and to avoid injury). They also recommend moderate- to
reduce the risk of chronic disease in adults. Table 1.1 high-intensity (8- to 12-repetition maximum [RM]
summarizes the ACSM and AHA physical activity for adults and 10-RM to 15-RM for older adults)
recommendations for adults. resistance training for a minimum of 2 nonconsecu-
The recommended amounts of physical activity tive days per week. Balance and flexibility exercises
are in addition to routine activities of daily living are also suggested for older adults.
(ADLs) such as housework, cooking, shopping, and Table 1.2 summarizes the physical activity
walking around the home or from the parking lot. guidelines (U.S. Department of Health and Human
20 Vigorous Minimum 3
(>6.0
METS)
Older adults 30 Moderate Minimum 5 1 10-RM to 15-RM; 8-10 2 noncon- For flexibility at least 2
>65 yr (5 or 6 exercises for major secutive days/wk for at least 10
on 10 pt. muscle groups; days min each day; include
scale) Moderate intensity (5 balance exercises for
or 6 on 10 pt. scale) those at risk for falls
20 Vigorous Minimum 3 Vigorous intensity (7
(7 or 8 or 8 on 10 pt. scale)
on 10 pt.
scale)
a
Combinations of moderate and vigorous intensity may be performed to meet recommendation (e.g., jogging 20 min on 2 days and brisk walking
on 2 other days).
b
Multiple bouts of moderate-intensity activity, each lasting at least 10 min, can be accumulated to meet the minimum duration of 30 min.
Table 1.2 2008 Physical Activity Guidelines for Americans
BONE- FLEXIBILITY
STRENGTHENING AND BALANCE
AEROBIC ACTIVITIES MUSCLE-STRENGTHENING ACTIVITIES ACTIVITIES ACTIVITIES
*
Population group Duration Intensity Frequency Sets Intensity* Frequency
Children and adoles- ≥60 min Moderate Daily Moderate to high 3 days/wk 3 days/wk
cents 6-17 yr
Vigorous 3 days/wk
Adults 18-64 yr
Inactive 60-150 min/wk Light (1.1-2.9 METs) to 1 Light to moderate 1 day/wk All adults should
moderate (3.0-5.9 METs) stretch to main-
tain flexibility for
Active 150-300 min/wk Moderate (3.0-5.9 METs) ≥1 Moderate to high ≥2 days/wk
regular physical
or 8-RM to 12-RM activity (PA) and
75-150 min/wk Vigorous (≥6.0 METs) activities of daily
living (ADLs).
Highly active >300 min/wk Moderate (3.0-5.9 METs) 2 or 3 Moderate to high ≥2 days/wk
>150 min/wk Vigorous (≥6.0 METs)
Older adults ≥65 yr
Inactive 150 min/wk Light (RPE = 3 or 4) to 5 days/wk 1 Light (RPE = 3 or 4) to 2 or 3 days/ Older adults
moderate (RPE = 5 or 6) moderate (RPE = 5 or 6) wk should stretch to
maintain flexibil-
Active 150-300 min/wk Moderate (RPE = 5 or 6) ≥3 days/wk ≥1 Moderate (RPE = 5 or 6) ≥2 days/wk,
ity for regular PA
or to high (RPE = 7 or 8) nonconsec-
and ADLs.
8-RM to 12-RM utive days
≥3 days/wk
75-150 min/wk Vigorous (RPE = 7 or 8) balance
*
Intensity is expressed in METs and repetition maximums (RM) for adults; for older adults, intensity is expressed as a rating of perceived exertion (RPE; 0-10 scale) and RM.
5
6 • Advanced Fitness Assessment and Exercise Prescription
Services 2008) for children and adolescents (6-17 to become obese as young adults (Kwon et al. 2015).
yr), adults (18-64 yr), and older adults (≥65 yr). The Exercising 150 min/wk equates to expending
key message in these guidelines is that for substan- approximately 1,000 kcal·wk−1. Results from a
tial health benefits, adults should engage in aerobic meta-analysis (Sattelmair et al. 2011) indicated
exercise at least 150 min/wk at a moderate intensity that individuals meeting the 2008 physical activity
or 75 min/wk at a vigorous intensity or an equivalent guidelines decrease their risk for coronary heart
combination thereof. In addition, adults of all ages disease by 14% compared with those reporting no
should do muscle-strengthening activities at least 2 leisure-time physical activity (LTPA). Participating
days/wk. In addition to stretching to support physical in regular physical activity and exercise on a daily
activity and activities of daily living, those who are basis provides numerous preventative benefits for
at risk for falling should also perform balance exer- no fewer than 25 chronic medical conditions (War-
cises. Children should do at least 60 min of physical burton and Breden 2016) such as cardiovascular
activity every day. Most of the 60 min per day should disease, hypertension, diabetes, stroke, dementia,
be either moderate or vigorous aerobic activity and and several types of cancer. Disease risk is further
should include vigorous aerobic activities at least 3 reduced when moderate-intensity physical activity
days/wk. Part of the 60 min or more of daily physical (150-180 min/wk) is performed throughout the week
activity should be muscle-strengthening activities (at (i.e., 30 min/day on 5 days/wk) and in bouts lasting
least 3 days/wk) and bone-strengthening activities at least 10 min as opposed to in one single session
(at least 3 days/wk). (Kesäniemi et al. 2010).
The term exercise deficit disorder (EDD) has Sattelmair and colleagues (2011) reported that
been used to identify children who do not attain 300 min/wk of moderate-intensity physical activity
at least 60 min of moderate- to vigorous-intensity results in a 20% reduction in the risk for coronary
physical activity (MVPA) on a daily basis (Faigen- heart disease (CHD). Furthermore, a review of
baum and Myer 2011). Children with EDD are at studies on asymptomatic adults (19-65 yr) revealed
an increased risk for developing harmful health that 90 min of vigorous-intensity physical activity
effects in their adolescent and adult years due to accumulated throughout the week (90 min/wk) in
a physically inactive lifestyle (Stracciolini, Myer, increments of no fewer than 10 min reduces the risk
and Faigenbaum 2013). For example, results from of all-cause mortality by 30%, as well as the risk
a study that monitored children for 14 yr revealed for cardiovascular disease (CVD), hypertension,
that those who maintained their active childhood stroke, type 2 diabetes, and breast and colon cancer
MVPA levels through adolescence were less likely (Kesäniemi et al. 2010).
Physical Activity, Health, and Chronic Disease • 7
In 2009, an international consensus conference MVPA each week is better than none; doses less
was convened to review Canada’s Physical Activity than one-half of the recommended guidelines may
Guide to Healthy Active Living (Health Canada lead to notable health benefits for those with elevated
2003). The consensus panel recommended that risks for chronic conditions and premature mortality
asymptomatic Canadian adults (19-65 yr) accu- (Warburton and Breden 2016). Exceeding the min-
mulate 150 min/wk of moderate-intensity physical imum recommended MVPA dose by a factor of 5
activity or 90 min/wk of vigorous-intensity activity (i.e., 750 min/wk or ≥10,000 MVPA MET-min/mo)
as a primary prevention against cardiovascular may confer the greatest reduction in all-cause mor-
disease, stroke, hypertension, colon cancer, breast tality risk; no additional mortality-related benefit is
cancer, type 2 diabetes, and osteoporosis. They also associated with a dose 10 times higher than recom-
recommended multiple exercise sessions in a week, mended (Arem et al. 2015; Loprinzi 2015). MVPA
with each session lasting a minimum of 10 min MET-min/mo is easily computed by multiplying
(Kesäniemi et al. 2010). In addition to the aerobic the respective MET level for the specific activities
exercise, they recommended strength activities (2-4 (see appendix E.3) by the number of minutes one
days/wk) and flexibility activities (4-7 days/wk). The engages in those MVPA activities within a month.
duration of the activity depends on the intensity or Figure 1.2 illustrates the general dose-response
effort: Perform light activities (e.g., walking, video relationship between the volume of physical activity
gaming that promotes light effort, gardening, car- participation and selected health benefits (e.g., mus-
rying small children, or hairstyling) for 60 min, cular strength and aerobic fitness) that do not require
moderate activities (e.g., brisk walking, swimming, a minimal threshold intensity for improvement. The
vacuuming, moving furniture, or chopping wood) for volume of physical activity participation needed for
30 to 60 min, and vigorous activities (e.g., jogging, the same degree of relative improvement (%) varies
hockey, wheelchair basketball, felling large trees, among health benefit indicators. For example, to
or rollerblading) for 20 to 30 min. improve triglycerides from 0% to 40% requires 250
Improvements in health benefits depend on the kcal·wk−1 of physical activity compared with 1,800
volume (i.e., combination of frequency, intensity, kcal·wk−1 for the same relative improvement (0%-
and duration) of physical activity. This is known as 40%) in high-density lipoprotein (HDL; see figure
the dose-response relationship (Loprinzi 2015). 1.2). It appears that aerobic-style activities that can
Because of the dose-response relationship between be maintained for longer periods (e.g., bicycling,
physical activity and health, even a low level of dancing, jogging) are positively related to beneficial
100
Percent of potential improvement achieved
Triglycerides (TG)
80
Blood pressure
60
Body composition
40
High-density
20 lipoproteins (HDL)
0
0 500 1000 1500 2000 2500 3000
Volume of physical activity (kcal/wk)
FIGURE 1.2 Dose-response relationship for health benefits and volume of physical activity.
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Courtesy of N. Gledhill and V. Jamnik of York University School of Kinesiology and Health Science.
8 • Advanced Fitness Assessment and Exercise Prescription
changes in HDL (Loprinzi 2015). Jogging at a slow aerobic activity weekly, preferably performed on a
or average pace ≤3 days/wk for a total of 60 to 150 daily basis—reduces disease risk, additional physical
min/wk confers a favorable increase in heart func- activity is needed to mitigate weight gain over time
tion and a similar decrease in mortality, whereas (Moholdt et al. 2014). Levine (2015) describes how
decades-long strenuous endurance training routines standing and walking double the energy expended as
(≥12 METs) in preparation for extreme endurance compared with sitting; he also illustrates how office
competitions may actually damage the cardiovas- workers can expend approximately 1,000 kcal·day−1
cular system (Schnohr et al. 2015). Therefore, too and increase time spent being active by incorporat-
much physical activity, defined as engaging in 5 hr ing walking meetings and short activity breaks in
of structured high-intensity activity per week, may the typical business day. In 2002, the Institute of
be associated with negative health consequences or Medicine (IOM) recommended 60 min of daily mod-
overuse injuries. erate-intensity physical activity. In the IOM report,
Although no specific dose of sedentary behavior the expert panel stated that 30 min of daily physical
has been found, a direct linear relationship between activity is insufficient to maintain a healthy body
total daily time in sedentary behavior and negative weight and to fully reap its associated health benefits.
health indicators associated with metabolic syn- The IOM recommendation addresses the amount of
drome (high triglycerides, high fasting blood glu- physical activity necessary to maintain a healthy
cose, and low HDL-C) has been reported (Gennuso body weight and to prevent unhealthful weight gain
et al. 2015). Each 60 min increase in daily time spent (Brooks et al. 2004). The IOM recommendation of
being sedentary is associated with a 9% increase 60 min of daily physical activity is consistent with
in the odds of satisfying the criteria for metabolic recommendations for preventing weight gain made
syndrome (Gennuso et al. 2015). by other organizations (i.e., Health Canada, Inter-
Although the physical activity guideline—a min- national Association for the Study of Obesity, and
imum of 150 min of moderate- to vigorous-intensity World Health Organization) (Brooks et al. 2004).
The bottom line is that 150 min/wk of moder- on exercise type (aerobic vs. resistance) or intensity
ate-intensity physical activity provides substantial (lower vs. higher), the reduced time requirement
health benefits but may be insufficient to prevent for equivalent energy expenditure of high-intensity
weight gain for many individuals. It is a good initial exercise as compared with low-intensity exercise
goal and a sufficient amount of activity to move may increase exercise adherence and, hence, weight
individuals from a sedentary to low physical activ- maintenance (Bray et al. 2016).
ity level (Brooks et al. 2004). As individuals adopt The Exercise and Physical Activity Pyramid
regular physical activity and improve their lifestyle illustrates a balanced plan of physical activity and
and fitness, they should increase the duration of exercise to promote health and to improve physical
daily physical activity to a level (60 min) that pre- fitness (see figure 1.3). Encourage your clients to
vents short-term weight gain and provides additional engage in physical activities around the home and
health benefits. Progression to daily engagement in workplace on a daily basis to establish a foundation
physical activity, inclusive of resistance training, (base of pyramid) for an active lifestyle. Strategies
for 60 to 90 min is important for long-term weight for increasing energy expenditure in the workplace
maintenance after weight loss (Bray et al. 2016; are built on encouraging active breaks from sitting
Ryan and Heaner 2014). Although there appears to in order to move around (e.g., step in place, walk
be little overall effect on long-term weight loss based laps around the office, perform light calisthenics,
Activities of
daily living
walk down the hall to a colleague’s office instead as hypertension (~86 million), CHD (27.6 million),
of calling or e-mailing to deliver a message, climb or stroke (7.2 million) (American Heart Association
a flight of stairs to get a drink of water or use the 2017). Among American adults 20 yr of age or older,
restroom). Your clients should perform aerobic the estimated age-adjusted prevalence of coronary
activities a minimum of 3 days/wk; they should do heart disease is higher for black men and women
weight-resistance exercises and flexibility or balance compared with Hispanic and white men and women
exercises at least 2 days/wk. Recreational sport activ- (American Heart Association 2017).
ities (middle levels of pyramid) are recommended One myth about CVD is that it is much more
to add variety to the exercise plan. High-intensity prevalent in men than in women. Between 2011 and
training and competitive sport (top of pyramid) 2014, the prevalence of CVD in adult women (35.9%)
require a solid fitness base and proper preparation and men (37.7%) in the United States was similar
to prevent injury; most adults should engage in these (American Heart Association 2017). Nearly 399,000
activities sparingly. females died from CVD in 2014 in the United States.
Another misconception about CVD is that it afflicts
only the older population. Although it is true that
CARDIOVASCULAR older people are at greater risk, more than 50%
DISEASE of the people in the United States with CVD are
younger than 60 yr (American Heart Association
2017), and CVD ranks as the second-leading cause
Cardiovascular disease (CVD) is projected to
of death for children under age 15 (American Heart
cause more than 26 million deaths by 2030 (World
Association 2012).
Health Organization 2011b). CVD caused 17.9
The prevalence of American adults with CHD
million deaths (46% of the deaths attributed to all
was 45.1% in 2014 (American Heart Association
noncommunicable diseases) worldwide in 2015. Of
2017). In Europe, CHD accounts for more than 1.7
the deaths due to CVD in 2015, the combination
million deaths, with nearly 19% of those occurring
of stroke and ischemic heart disease accounted for
in adults below the age of 65 (Townsend et al. 2016).
the great majority (85%) (GBD 2015 Mortality and
Coronary heart disease (CHD) is caused by a lack
Causes of Death Collaborators 2016). More than
of blood supply to the heart muscle (myocardial
75% of cardiovascular deaths occurred in low- and
ischemia) resulting from a progressive degenerative
middle-income countries (World Health Organiza-
disorder known as atherosclerosis. Atherosclerosis
tion 2016a). CVD is the principal cause of premature
is an inflammatory process involving a buildup of
death in Europe, accounting for a nearly equal per-
low-density lipoprotein (LDL) cholesterol, scav-
centage of all deaths before age 75 in women (36%)
enger cells (monocytes), necrotic debris, smooth
and men (35%). Interestingly, however, CVD was
muscle cells, and fibrous tissue. This is how plaques
surpassed by cancer as the leading cause of death
form in the intima, or inner lining, of the medium-
in several Western European countries (Townsend
and large-sized arteries throughout the cardiovas-
et al. 2016). CVD is also a leading cause of disease
cular system. As more lipids and cells gather in the
burden in developing low- and middle-income coun-
plaques, they bulge into the arterial lumen (Barquera
tries; deaths due to CVD range from a low of 10%
et al. 2015). In the heart, these bulging plaques
in sub-Saharan Africa to 58% in Eastern Europe
restrict blood flow to the myocardium and may
(Wagner and Brath 2012).
produce angina pectoris, which is a temporary sen-
In a 2015 report by the CDC identifying the
sation of tightening and heavy pressure in the chest
underlying causes of death in the United States
and shoulder region. A myocardial infarction, or
between 1999 and 2003, diseases of the heart and
heart attack, can occur if a blood clot (thrombus) or
blood vessels claimed the lives of about 610,000
ruptured plaque obstructs the coronary blood flow.
people (Centers for Disease Control and Prevention
In this case, blood flow through the coronary arteries
2015a). CVD accounted for 25% of all deaths (one
is usually reduced by more than 80%. The portion
out of every four) in the United States. Extrapolating
of the myocardium supplied by the obstructed artery
to 2014 levels, the CDC estimated that more than 92
may die and eventually be replaced with scar tissue.
million Americans have some form of CVD such
Physical Activity, Health, and Chronic Disease • 11
attacks, heart and kidney failure, dementia, and have a 3.5 times greater risk of developing CHD
blindness (World Health Organization 2014). In the than do women who have normal blood pressure
United States, hypertension attributes to about 40% (normotensive). Also, the prevalence of high blood
of all adult deaths from CVD (Yang et al. 2012). pressure for blacks in the United States (45.5%) is
In 2014, about 22% of the global adult population among the highest in the world and is substantially
(≥18 yr of age) had hypertension (World Health greater than that of American Indians or Alaskan
Organization 2014). As of 2015, hypertension is Natives, Asians or Pacific Islanders, Hispanics, and
more prevalent in low-income countries in sub-Saha- whites in the United States (American Heart Asso-
ran Africa and south Asia than in high-income coun- ciation 2017). Table 1.3 summarizes the risk factors
tries; however, elevated blood pressure continues to associated with developing hypertension.
be problematic in Eastern and Central Europe (NCD For individuals with elevated blood pressure
Risk Factor Collaboration 2017). With an estimated values, healthy lifestyle changes and periodic BP
1.4 billion adult diagnoses worldwide, hypertension reassessments are recommended as part of the
is touted as being the leading preventable cause treatment plan. For people whose blood pressure is
of death before age 70. Its prevalence is lower in in the stage 1 range, their risk for stroke and CVD
high-income countries (28.5%) as compared with within the next 10 yr should be assessed using the
low- and middle-income countries (31.5%), which atherosclerotic cardiovascular disease risk calculator
reflects differences in awareness levels as well as (http://static.heart.org/riskcalc/app/index.html#!/
treatment and control of the condition (Mills et baseline-risk) (Whelton et al. 2017). Sharman, La
al. 2016). Nearly one out of every three adults has Gerche, and Coombes (2015) combined data from
blood pressure values in the elevated rage (Centers studies investigating the effect of exercise on blood
for Disease Control and Prevention 2016). In the pressure values in people diagnosed with hyper-
United Kingdom, approximately 14% of adults are tension. They indicate that while both aerobic and
hypertensive, with Northern Ireland having a lower resistance training can reduce blood pressure, aer-
prevalence compared with England and Scotland obic training is the preferred method. Their study
(British Heart Foundation 2015b). In comparison, also reports on the combination of exercise and
the prevalence of hypertension is estimated to be antihypertensive medications, with a cautionary
higher for adults in Latin America and the Caribbean note about monitoring postexercise blood pres-
(~39%) than for the Pacific and East Asian region sure responses. Regular physical activity prevents
(~36%), Europe and Central Asia (~32%), South Asia hypertension and lowers blood pressure in younger
(~29%), and Africa (~27%) (Sarki et al. 2015). and older adults who have normal, elevated, stage
In the United States, more men than women are 1, or stage 2 values. Compared with normotensive
hypertensive prior to age 65; after that the percentage individuals, training-induced changes in resting
of hypertensive women surpasses that of their male systolic and diastolic blood pressures (5-7 mmHg)
counterparts (American Heart Association 2017). are greater for hypertensive individuals who partic-
Up to age 45 yr, the percentage of American men ipate in endurance exercise. However, even modest
with hypertension (11%-23%) is slightly higher than reductions in blood pressure (2-3 mmHg) by endur-
that of women (8%-23%). Between ages 45 and 54 ance or resistance exercise training decrease CHD
yr, the prevalence of hypertension is similar for men risk by 5% to 9%, stroke risk by 8% to 14%, and
(36.1%) and women (33.2%). Likewise, for those all-cause mortality by 4% in the general population
between 55 and 64 yr, men have a slightly higher (Pescatello et al. 2004). See Exercise Prescription
(57.6%) prevalence of hypertension than do women for Individuals with Hypertension for an exercise
(~55.5%). After age 65, the percentage of women prescription that the ACSM endorses to lower blood
(65.8%) with high blood pressure is somewhat higher pressure in adults with hypertension.
than that of men (63.6%). Women with hypertension
Table 1.3 Summary of Factors Associated With Disease Risk
Factor CHD Type 2 diabetes Hypertension Hypercholesterolemia Low back pain Obesity Osteoporosis Cancer
Age ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑
a b b b
Gender M>F F>M F>M F>M F=M F>M F>M
Race B > W > AA, AI, AN, B, H > B > A, AI, H, W B, H, W > A, AI AI, B, H, W A,W > AI, B, H
AN > H A, W >A
Family history ↑ ↑ ↑ ↑ ↑ ↑ ↑
SES ↓ ↓ ↓ ↓ ↓ ↓ ↑
Alcohol use ↑ ↑ ↑ ↑
Smoking ↑ ↑ ↑ ↑ ↑ ↑
Nutrition
Na+ intake ↑
++
Ca intake/vitamin D ↓
Fat/cholesterol intake ↑ ↑ ↑ ↑ ↑
CHO intake ↑
Intake > expenditure ↑
Physical activity ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓
Exercise amenorrhea ↑
Flexibility ↓
Muscular strength ↓ ↓
Skeletal frame size ↓
Other diseases
Anorexia nervosa ↑
Diabetes ↑
Hypertension ↑
Hypercholesterolemia ↑
Obesity and overweight ↑ ↑ ↑ ↑ ↑ ↑
↑ = Direct relationship; as factor increases, risk increases.
↓ = Indirect relationship; as factor increases, risk decreases.
CHD = coronary heart disease; CHO = carbohydrate; A = Asian; AI = American Indian; AN = Alaska Native; B = Black; H = Hispanic; W = White; Na = sodium; Ca = calcium; SES = socioeconomic status
(reflects income and education levels).
a
Males (M) at higher risk than females (F) up to age 55 yr.
b
Menopausal females at higher risk than males.
13
14 • Advanced Fitness Assessment and Exercise Prescription
and CHD risk (National Cholesterol Education likewise, a 1% reduction in HDL-C increases CHD
Program 2001). The prevalence of borderline high risk by 2% to 3% (Gordon et al. 1989). However, for
levels (≥130 mg·dl−1 to <160 mg·dl−1) of LDL-C is individuals with hyperlipidemia, lifestyle changes
nearly identical for adult women (31%) and adult (e.g., healthy diet) or pharmacologic interventions
men (32.5%) in the United States (Roger et al. 2012). (e.g., statins), in addition to aerobic exercise, may
The smaller HDL molecules are suspended in the be necessary for optimizing lipid and lipoprotein
plasma and protect the body by picking up excess profiles (Kelley and Kelley 2006).
cholesterol from the arterial walls and delivering it to Increases in HDL-C in response to aerobic exer-
the liver, where it is metabolized. HDL-cholesterol cise appear to be related to the training dose (inter-
(HDL-C) values less than 40 mg·dl−1 are associated action of the intensity, frequency, and duration of
with a higher risk of CHD. Based on data collected each exercise session and the length of the training
between 2011 and 2014, 19% of men and women period), and they are less dramatic in women than in
in the United States who are older than 20 yr have men. Across adult age ranges, those who met (17.7%)
low (<40 mg·dl−1) HDL-C levels (Zwald et al. 2017). the physical activity guidelines (≥150 min of MVPA
Individuals with low HDL-C or high TC levels per week) had higher HDL-C levels than did those
(dyslipidemia) have a greater risk of heart attack. American adults (21.0%) who did not meet the meet
Those with lower HDL-C (<37 mg·dl−1) are at higher the guidelines. Interestingly, the prevalence of low
risk regardless of their TC level. This emphasizes the HDL-C values decreased with increasing age for
importance of screening for both TC and HDL-C adults meeting the physical activity guidelines; for
in adults. those ≥60 yr old, only 12.6% of the active seniors
had low HDL-C values compared with approxi-
PHYSICAL ACTIVITY AND mately 19% for the younger age groups (Zwald et
al. 2017). Based on results from a longitudinal study
LIPID PROFILES of biracial adults, a high level of aerobic fitness
Regular physical activity, especially habitual MVPA as a young adult in combination with a continued
aerobic exercise, positively affects lipid metabo- physically active lifestyle confers favorable results
lism and lipid profiles (Lin, Zhang, et al. 2015). for blood lipid levels in the middle-age adult years
Cross-sectional comparisons of lipid profiles in (Sarzynski et al. 2015).
physically active and sedentary women and men sug- The research on the effect of resistance training on
gest that physical fitness is inversely related to TC cholesterol levels continues to remain inconclusive.
and the TC/HDL-C ratio (Despres and Lamarche Ribeiro and associates (2016) reported improve-
1994; Shoenhair and Wells 1995). ments in HDL-C for the older, physically indepen-
Data from 160 randomized controlled trials were dent women (67.6 ± 5.1 yr) randomly assigned to 8
pooled to examine the effects of aerobic exercise wk of traditional (three sets of 8-RM to 12-RM) or
on cardiometabolic biomarkers such as lipids and 8 wk of pyramid (12-RM/10-RM/8-RM) styles of
lipoproteins in a large number of adults. Results resistance training. After a 12 wk washout period,
show that compared with control groups, adults in the women switched training styles. There were
moderate-intensity and vigorous-intensity aerobic numerous favorable responses, including increases
exercise interventions, respectively, reduce TC (4.3 in HDL-C, by the end of each 8 wk period; however,
and 3.87 mg·dl−1), LDL-C (3.09 and 4.64 mg·dl−1), there were no differences between training styles.
VLDL-C (1.93 and 7.35 mg·dl−1), and TG (5.31 and Similarly, 12 wk of a nonlinear resistance training
5.31 mg·dl−1) and increase HDL-C (1.16 and 2.71 program designed to increase strength significantly
mg·dl−1) (Lin, Zhang, et al. 2015). However, Lin improved HDL-C and other variables compared
and colleagues found no differences across exer- with the normally active controls in a sample of
cise-intensity subgroups, which lends support to adults (18-60 yr) living with HIV and taking pre-
the premise that moderate- and vigorous-intensity scribed highly active antiretroviral medications
exercise training confer similar favorable results (Zanetti et al. 2016). Conversely, 16 wk of combined
for cardiometabolic health. A 1% reduction in TC aerobic (30 min) and resistance (27 min) training
has been shown to reduce the risk for CHD by 2%; produced no significant improvements in HDL-C
16 • Advanced Fitness Assessment and Exercise Prescription
in postmenopausal women as compared with those from smoking tobacco, the risk of death from CHD
in the aerobic training (52 min) group (Rossi et al. increases by 30% in those exposed to environmental
2016). It is possible that the resistance training por- tobacco smoke at home or at work (American Heart
tion of their combined group (three or four sets of Association 2004).
12-RM to 15-RM) may not have provided the exer- Smoking is one of the largest preventable causes
cise intensity needed to invoke significant changes of disease and premature death. Nearly 33% of
in HDL-C in their postmenopausal sample. CHD deaths are due to first- and secondhand expo-
sure to smoke (American Heart Association 2017).
TOBACCO Cigarette smoking is linked to CHD, stroke, and
chronic obstructive pulmonary disease. It causes
cancer of the lungs, larynx, esophagus, mouth, and
Although tobacco usage (e.g., cigarettes and cigars)
bladder and is also associated with no fewer than
is declining in the United States and other countries,
eleven cancers (Carter et al. 2015). Compared with
there continues to be a steep increase worldwide
nonsmokers, smokers have more than twice the
(American Heart Association 2017). Ng and col-
risk of heart attack and die, on average, at least 10
leagues (2014) attribute the increase in the number
yr earlier (American Heart Association 2017). As
of smokers to the world’s population growth. The
mentioned previously, cigarette smoking is a major
World Health Organization (2011) estimates there
cause of stroke. It also multiplies the effect of CHD
are approximately 1 billion smokers in the global
risk factors such as elevated blood lipid levels, dia-
population. According to age-standardized results
betes mellitus, and untreated hypertension. Some
for smoking prevalence (Ng et al. 2014), between
researchers who study adults ≥55 yr of age are
16.5% and 19.7% of men in the United States,
encouraging further investigations of the possible
Canada, Brazil, and Australia smoke, while 34.7%
associations between smoking and deaths resulting
to 61.1% of men in Russia, China, Eastern Europe,
from infections, respiratory diseases, prostate and
Egypt, and Turkey smoke. The lowest prevalence
breast cancer, intestinal ischemia, kidney failure,
(0.5%-2.6%) of female smokers is found in Africa,
and hypertensive heart disease. The relative risk of
China, and the Persian Gulf, whereas the prevalence
dying from these conditions drops with each year
exceeds 25% in Austria, Chile, France, and Hun-
subsequent to quitting (Carter et al. 2015). Addi-
gary. Of the 187 countries included in the study, the
tionally, although not well studied at this time, the
age-adjusted prevalence of men who smoke daily
inhaled vapors from electronic cigarettes deliver
exceeds that of their female counterparts in all but
nicotine and other substances for which the health
one country: Sweden. Although the prevalence
risks are not yet known.
of tobacco usage is lower for women than men
When individuals stop smoking, their risk of
across the majority of the predominant race and
CHD declines rapidly, regardless of how long or
ethnic groups in the United States, the prevalence
how much they have smoked. Although health
is slightly higher for Native American and Alaskan
benefits associated with smoking cessation happen
Indian women and nearly equal for non-Hispanic
within weeks or months, the relative risk of a former
white women compared with their respective male
smoker dying from CHD approximates that of a
counterparts (American Heart Association 2017).
nonsmoker within 10 yr of quitting (American Heart
Approximately 13.7% of American women and
Association 2017).
16.7% of American men currently smoke (Amer-
ican Heart Association 2017). Smoking cessation
strategies in Canada, Iceland, Mexico, and Norway DIABETES MELLITUS
have cut smoking rates in half since 1980 (Ng et
al. 2014) and may provide invaluable assistance Diabetes is a global epidemic with rising prevalence
for curbing tobacco use in other countries. In a rates, especially in the low- and middle-income
study of school-aged adolescents (average age 15 countries. Consequently, there is a commitment by
yr) representing 50 schools in six European cities world leaders to reduce, by one-third, the rates of
(Lorant et al. 2015), 17.4% of the 11,000 participants premature mortality from diabetes and the other
self-reported being a smoker. Even if people abstain priority NCDs by 2030 (World Health Organiza-
Physical Activity, Health, and Chronic Disease • 17
tion 2016b). As of 2014, an estimated 422 million (24.1%) that is four times that of Alaska Natives
adults (8.5%) worldwide have the disease (World (Centers for Disease Control and Prevention 2014).
Health Organization 2016b). Factors linked to this Prediabetes, in addition to being a positive risk
epidemic include urbanization, aging, physical factor for CVD, is a medical condition identified
inactivity, unhealthy diet, and obesity (Wagner and by fasting blood glucose or glycated hemoglobin
Brath 2012). At least 43% of the deaths attributable (HbA1c) levels that are above normal values but
to elevated blood glucose levels occur in people lower than the threshold for a diagnosis of diabetes.
younger than 70 yr of age (World Health Organiza- HbA1c is an indicator of the average blood glucose
tion 2016b). Diabetes is a major contributor toward over the past 2 to 3 mo (Centers for Disease Control
the development of CHD, stroke, specific cancers, and Prevention 2014). Fortunately for the 86 million
kidney failure, and cognitive disability (World American adults (Centers for Disease Control and
Health Organization 2016b). This increased risk Prevention 2014) and others worldwide, prediabetes
of CHD and stroke is higher for women than men appears to respond favorably to weight loss, dietary
with diabetes for a variety of reasons: higher-level changes, and increases in physical activity. The
CVD risk factors and obesity at time of diagnosis, age-adjusted percentage of prediabetes in U.S. adults
longer exposure to an elevated risk profile when in during the period 2009 to 2012 was nearly identi-
the prediabetic stage, and relative undertreatment cal for non-Hispanic whites, non-Hispanic blacks,
following diagnosis (Peters, Huxley, and Woodward and Hispanics (35%, 39%, and 38%, respectively)
2014). In the United States, diabetes was the seventh (Centers for Disease Control and Prevention 2014).
leading cause of death in 2010 (American Diabetes Type 1 diabetes, formerly referred to as insu-
Association 2017). lin-dependent diabetes mellitus (IDDM), usually
In 2012, 29 million adults in the United States occurs in children and adolescents but can develop
had type 2 diabetes, while 86 million ≥20 yr of age at any age. Type 2 diabetes, previously known as
were identified as having prediabetes (American non-insulin-dependent diabetes mellitus (NIDDM),
Diabetes Association 2017). In China and India, is more common and no longer occurs primarily
there are 138 million people with diabetes (Danaei in middle-aged and elderly adults; 90% to 95% of
et al. 2011). Danaei and colleagues (2011) also esti- individuals diagnosed with diabetes mellitus have
mated that approximately 42 million people with type 2 diabetes (Centers for Disease Control and Pre-
diabetes are from Brazil, Indonesia, Japan, Mexico, vention 2014). Risk factors for developing diabetes
and Pakistan. Furthermore, in 2008, they reported are presented in table 1.3. Type 1 diabetes may be
the highest prevalence of diabetes was found in caused by autoimmune, genetic, or environmental
countries located in Oceania, northern Africa, the factors, but the specific cause is unknown. Unfortu-
Middle East, and the Caribbean. Conversely, the nately, although clinical trials are under way, there
lowest prevalence of diabetes was in southeast Asia, is currently no known way to prevent type 1 dia-
east Africa, and Andean Latin America (Danaei et betes (World Health Organization 2016b). Healthy
al. 2011). nutrition and increased physical activity, however,
The prevalence of diabetes for adults (≥20 yr) can reduce the risk of type 2 diabetes by as much
in the United States was 12.3%; 1.7 million people as 67% in high-risk individuals (Sanz, Gautier, and
in this age group were diagnosed with diabetes for Hanaire 2010). Regular physical activity, as part of
the first time in 2012 (Centers for Disease Control a modest weight loss intervention, has reduced the
and Prevention 2014). Compared with white adults risk of developing type 2 diabetes by a maximum
in the United States, the prevalence of diabetes and of 58% for those in the high-risk category (Colberg
impaired blood glucose levels for blacks (13.2%), et al. 2010). Too much body fat is recognized as the
Hispanics (12.8%), and American Indians/Alaska dominant risk factor for type 2 diabetes. Elevated
Natives (15.9%) is higher (Centers for Disease Con- waist circumferences and BMI values also increase
trol and Prevention 2014). The age-adjusted preva- the risk, but the associated risk varies by geographic
lence of diabetes for American Indians and Alaska region (World Health Organization 2016b).
Native adults is region dependent; American Indians The effect of exercise alone as an intervention for
in southern Arizona have a prevalence of diabetes people with type 2 diabetes is not well known beyond
18 • Advanced Fitness Assessment and Exercise Prescription
its ability to improve glucose control (Handelsman between 25 and 29.9 kg/m2 are classified as over-
et al. 2015). However, a minimum of 150 min/wk weight; those with a BMI of 30 kg/m2 or more are
of MVPA is recommended and should include classified as obese (Smith and Smith 2016). As the
flexibility and strength training (Handelsman et al. result of research on people from various population
2015). Of note, though, for continued benefits, the subgroups, more conservative BMI cut-points for
exercise program needs to be performed regularly identifying overweight (23-24.9 kg/m2) and obesity
and include both strength and aerobic training to (≥25 kg/m2) have been identified for Asians and
help those with type 2 diabetes achieve optimal South Asians (Seidell and Halberstadt 2015). Conse-
health. Decreasing the time spent being sedentary, quently, as noted by Seidell and Halberstadt (2015),
in addition to increasing daily physical activity, is a the prevalence of obesity in the world may be under-
viable means of decreasing the risk for developing stated because many Asians would be erroneously
type 2 diabetes. As reported in a review of five stud- classified based on BMI. Although BMI has utility
ies, the pooled hazard of developing type 2 diabetes as a simple index of obesity, it cannot account for
is nearly double for those reporting high amounts of relative fatness, and including some additional deter-
sedentary time (Biswas et al. 2015). Although few mination or estimation of abdominal fat distribution
adverse effects or diabetic complications resulting is recommended for understanding actual health risk
from exercise have been reported, being watchful (Seidell and Halberstadt 2015). The World Health
for acute postexercise hypoglycemia and transient Organization (2012b) defines overweight and obesity
hyperglycemia is prudent (Colberg et al. 2010). as having abnormal or excessive fat accumulation
Research that associates physical activity with that may impair health. Regardless, overweight
weight loss, fat loss, and glycemic control suggests and obesity ranks as the fifth leading risk factor for
that regular physical activity in accordance with death worldwide.
the recommended guidelines reduces one’s risk of More than 2.1 billion people worldwide are
developing type 2 diabetes (Colberg et al. 2010). In classified as being overweight or obese (Smith
a small sample of overweight and obese participants, and Smith 2016). Globally, more than 1 in 3 adults
an intensive 6 mo nonrandomized lifestyle interven- (≥18 yr) is overweight, and more than 1 in every 10
tion consisting of exercise and behavioral weight adults is obese (World Health Organization 2016b).
loss counseling reduced baseline HbA1C values The countries in the World Health Organization’s
(6.8 ± 0.2% to 6.2 ± 0.3%), consequently precluding Region of the Americas have the highest prevalence
the need for medications to reduce blood glucose of obesity, while those countries categorized into the
levels. Numerous other aspects (e.g., insulin levels, South-East Asian Region have the lowest (World
insulin resistance, blood pressure, body mass, body Health Organization 2016b). In England, fairly equal
composition) were also favorably affected (Ades et percentages of men (24%) and women (27%) were
al. 2015). The frequency of exercise is crucial for categorized as obese based on BMI in 2014 (NHS
those with diabetes. If daily exercise is not possible, Digital 2014). Self-reported heights and weights for
it should not be skipped 2 days in a row. Specific the 48,000 Canadian adults responding to the Cana-
guidelines for prescribing exercise programs for dian Community Health Survey in 2012 were used
people who have type 1 and type 2 diabetes are to calculate BMI for the younger (age 30-59 yr) and
available elsewhere (American College of Sports older (age 60-80+ yr) age groups. Nearly 55% of the
Medicine 2018). younger and 60% of the older group were overweight
or obese (Cohen, Baker, and Ardern 2016). In 2014,
OBESITY AND China surpassed all other countries for adult obe-
sity, with their obese men and women representing
OVERWEIGHT 16.3% and 12.4% of the world’s sex-specific obesity
prevalence; the United States ranked second for
Adult overweight and obesity are classified using both sexes (men: 15.7%; women: 12.3%) (NCD Risk
the body mass index (BMI) (BMI = weight [kg] Factor Collaboration 2017). For a detailed report
/ height squared [m 2]). According to traditional of changes in global BMI levels between 1975 and
BMI values, individuals ≥20 yr of age with a BMI 2014 based on data from about 99% of the world’s
Physical Activity, Health, and Chronic Disease • 19
population, see the work of the NCD Risk Factor men to document changes in BMI and cardiometa-
Collaboration group (2017). bolic outcomes (Xian et al. 2017). BMI trajectories
In the United States, approximately 35% of were modeled based on assessments at ages 20, 40,
adults are classified as obese, and one of every three 56, and 62 yr. Compared with the men who were
children and adolescents falls into the overweight normal weight in their 20s but attained an over-
or obese categories (Smith and Smith 2016). The weight BMI at age 62, those having normal-weight
age-adjusted prevalence of obesity for American BMIs at baseline and ending with BMIs in the obese
men is approximately 35% for whites and 12.6% range (normal-obese) had significantly greater risks
for Asians, respectively; the obesity prevalence is of hypertension, diabetes, dyslipidemia, and inflam-
approximately 38% for non-Hispanic black and His- mation; the same is true for the men having baseline
panic men. For American women, the age-adjusted BMI values in the overweight range and entering the
prevalence of obesity based on BMI is 40.4%, 46.9%, obesity level by age 40 and attaining the highest level
57.2%, and 12.4%, respectively, for white, Hispanic, of obesity (≥40 kg/m2) at age 62 (overweight-obese
black, and Asian women. For those having a BMI in level 3). However, the overweight-obese level 3 group
the class 3 obesity range (≥40 kg/m2), the prevalence had more than three times the risk of hypertension,
for both men and women across the four racial and double the risk of inflammation, and a 60% higher
ethnic groups ranged between 5.5% and 9.9%, with risk of diabetes compared with the normal-obese
the exception being 16.8% for black women (Flegal group. Interestingly, there were no differences in the
et al. 2016). Asian adults in the United States con- three groups for ischemic heart disease.
tinue to have a much lower prevalence of obesity Although obesity is strongly associated with
compared with whites, blacks, and Hispanics (Flegal CHD risk factors such as hypertension, glucose
et al. 2016). intolerance, and hyperlipidemia, the contribution
Childhood obesity (≥95th percentile for sex and of obesity to CHD appears to be independent
age) is also a global problem (see chapter 9). Over- of the influence of obesity on these risk factors.
weight adolescents have a 70% chance of becoming Interestingly, an obesity paradox has been iden-
overweight adults; this increases to 80% if one or tified; paradoxically and counterintuitively, when
both parents are overweight or obese (American investigating the short- and long-term prognosis for
Heart Association 2012). In England, 33% of boys cardiovascular diseases, such as hypertension, atrial
and 35% of girls, ages 2 to 15 yr, were either over- fibrillation, and heart failure, prognosis is improved
weight or obese (British Heart Foundation 2006). for those who are overweight or mildly obese as
Similarly, in the United States, the prevalence of compared with leaner clients (Lavie et al. 2014). For
overweight and obesity in children and adolescents, a comprehensive review of the effects of obesity on
ages 2 to 19 yr, was approximately 33% in 2014, cardiac performance, cardiac remodeling, aerobic
with 17.2% being classified as obese (American fitness level, and the obesity paradox, see the work
Heart Association 2017). That year’s prevalence of of Lavie and colleagues (2014).
obesity in children increased with each age group Obesity, the fifth leading cause of death, may
and ranged from 9.4% (preschool children 2-5 yr) be caused by genetic and environmental factors as
to 20.6% for adolescents (12-19 yr); the prevalence well as gut biome. Although studies suggest that
was 17.4% for grade school–aged children (Amer- genetic factors contribute to some of the variation in
ican Heart Association 2017). The World Health body fatness, there has been no substantial change
Organization (2018b) reported that approximately in the genotype of the American population since
41 million children (0 to 5 yr) globally are either the 1960s (Hill and Melanson 1999). Nevertheless,
overweight or obese, and nearly 340 million chil- in terms of prevalence, obesity varies across ethnic
dren (5 – 19 yr) are overweight or obese). Table 1.3 groups. Obesity clusters within families have been
summarizes factors associated with increased risk reported, as have hereditability estimates. Genome-
of obesity. wide association studies (GWASs) are now under
Excess body weight and fatness pose a threat to way, and upwards of 90 possible areas of genetic
both the quality and duration of one’s life. A rare variation associated with obesity and BMI have been
longitudinal study spanning 40 yr tracked over 900 identified (Chen et al. 2017). Without any doubt, our
20 • Advanced Fitness Assessment and Exercise Prescription
environment and culture are additional key contribu- criteria vary among different organizations such as
tors to the increases being seen in the rates of obesity. the International Diabetes Federation (IDF), World
In addition to the countless calorically dense food Health Organization (WHO), European Group for
options we have and technological advancements the Study of Insulin Resistance (EGIR), American
that reduce energy expenditure through physical Association of Clinical Endocrinology (AACE), and
activity and manual labor, we are exposed daily to American Heart Association/National Heart, Lung,
innumerable chemical compounds (e.g., pesticides, and Blood Institute (AHA/NHLBI). A side-by-side
personal and home care products, food additives, comparison of similarities and differences in criteria
industrial waste) that promote obesity through their is available in the article by O’Neill and O’Driscoll
interference with the endocrine system and meta- (2015). Body mass index is an acceptable criterion
bolic pathway functions (Regnier and Sargis 2014). according to the World Health Organization; how-
As an exercise specialist, you play an important ever, all of the other organizations use waist cir-
role in combating the obesity-related health epidemic cumference as the reference for abdominal obesity.
by encouraging a physically active lifestyle, planning Sex- and ethnic-specific references for the waist
scientifically sound exercise programs, and consult- circumference criteria are also now defined (O’Neill
ing with your clients and trained nutrition profes- and O’Driscoll 2015). Alberti and colleagues (2009)
sionals to formulate appropriate diets. Restricting present extensive information regarding the history
caloric intake and increasing caloric expenditure of metabolic syndrome and the ongoing efforts of
through physical activity and exercise are effective major organizations to reach a consensus on a single
ways of reducing body weight and fatness while set of criteria. Likewise, Steinberger and associates
normalizing blood pressure and blood lipid profiles. (2009) highlight similar issues for determining
metabolic syndrome in children and adolescents.
METABOLIC Data reviewed by O’Neill and O’Driscoll (2015)
indicate that approximately 34% of the men and 35%
SYNDROME of the women (≥20 yr) in the United States met the
National Cholesterol Education Program’s Adult
Metabolic syndrome (MetS) refers to a combina- Treatment Panel III (NCEP-ATPIII) criteria for
tion of CVD risk factors associated with hyperten- metabolic syndrome, as did 17% of the men and 19%
sion, dyslipidemia, insulin resistance, and abdominal of the women of similar age living in India. O’Neill
obesity. According to clinical criteria adopted by and O’Driscoll also present results from numerous
the National Cholesterol Education Program (2001), studies of adults from Australia, China, Denmark,
individuals with three or more CVD risk factors Ireland, and South Korea. By far, the prevalence
are classified as having metabolic syndrome (see of metabolic syndrome in adults is higher in adults
table 1.4). Although there is some overlap, these from the United States, but disparate age ranges
I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.