The Active Female: Health Issues Throughout the Lifespan 2008th Edition

20. Traditional and Nontraditional Empirically Based Exercise Programs for Active Females

Jacalyn J. Robert-McComb  and Anna M. Tacón1

(1)

Texas Tech University, Lubbock, TX, USA

Jacalyn J. Robert-McComb

Email: jacalyn.mccomb@ttu.edu

Abstract

Girls and women are generally less active than boys and men. In order to help promote exercise as a tool for health, major organizations have set exercise guidelines to help people exercise safely, efficiently, and effectively. In order for anyone to continue to exercise, it must be enjoyable. Girls and women need to find either a traditional or nontraditional exercise program that they enjoy and will pursue willingly. An exercise regimen should include cardiovascular endurance, muscular strengthening, and flexibility exercises. Recommendations for cardiovascular fitness include at least 5 days•week−1of moderate activity for at least 30 min each day, OR 3 or more days•week−1of vigorous activity for at least 20 min, OR a combination of the two. Individuals should perform muscular strengthening at least 2 days•week−1 and implement flexibility routines a minimum of 2–3 days•week−1. Alternative exercises such as yoga, breathing, and mindfulness while exercising are also discussed in this chapter. Physical activity is key to long-term good health regardless of gender and age; however, it is especially important for girls and women to be active throughout their life span.

Keywords

Exercise guidelinesPhysical activityYogaAerobic trainingResistance trainingMindfulness

20.1 Learning Objectives

After completing this chapter, you should have an understanding of:

1.

2.

3.

4.

5.

20.2 Introduction

A landmark report on the benefits of physical activity was released on July 11, 1996, by the United States Department of Health and Human Services. It was the first Surgeon General’s Report (SGR) on Physical Activity and Health [1]. The SGR indicated that although health benefits improve with moderate amounts of physical activity (15 min of running, 30 min of brisk walking, or 45 min of playing volleyball), greater amounts are obtained with greater amounts of physical activity [1]. Healthy People 2000: National Health Promotion and Disease Prevention Objectives followed this landmark report with physical activity objectives for all Americans. As understanding of the benefits of physical activity grew, recommendations followed suit; since, on average, physically active people outlive those who are inactive [2]. In November of 2000, the United States Department of Health and Human Services ([HHS] http://​www.​hhs.​gov) released Healthy People 2010 [3]. In this document it was stated that women are generally less active than men at all ages and by age 75, one in three men and one in two women engage in noregular physical activity. Ten years later, Healthy People 2020 [4] was released by HHS. Healthy People 2020 was based on the accomplishments of four previous Healthy People initiatives as mentioned previously. Even after all of this effort by governing agencies to increase the level of physical activity for all Americans, the stated statistics for the number of people who engage in regular physical activity actively from 2000 to 2010 were not any better. Healthy People 2020 [4] states (http://​www.​healthypeople.​gov/​2020/​):

More than 80 % of adults do not meet the guidelines for both aerobic and muscle-strengthening activities. Similarly, more than 80 % of adolescents do not do enough aerobic physical activity to meet the guidelines for youth. This has important public health implications.

Why aren’t more people being active? As an exercise physiologist, I meet women every day who tell me that they are going to begin exercising. They also state unrealistic goals, I am going to exercise vigorously every day for an hour a day. I tell them, do not overdo it or you will not continue exercising. They understand the importance of being active, but they just cannot motivate themselves to carry out the activity.

The initiatives by leading governing agencies to increase the level of physical activity in all Americans reflects the importance of being physically active for long-term good health for all ages and all genders, especially young girls and women. Healthy People 2020 [4] defines physical activity as “participation in moderate and vigorous physical activities and muscle-strengthening activities.” The American Heart Association and the American College of Sports Medicine (ACSM) recommended that all adults in the USA should accumulate at least 30 min a day of moderate activity minimally 5 days a week or 20 min of vigorous activity at least 3 days a week or a combination of the two. They also recommend at least 2 days a week of muscular strengthening activity [5]. This is a big window for types of activities that can be chosen to meet health objectives.

The National Institutes of Health have funded numerous studies which have assessed the health benefits of a different type of exercise called Mindfulness. Mindfulness incorporates yoga and meditation. The focus of Mindfulness is on awareness. In this chapter we will discuss the guidelines established by leading health organizations for physical activity and exercise. We will also introduce you to a more subtle type of exercise called Mindfulness. What is important is that young girls and women participate in activities that are enjoyable, maybe it is Zumba, maybe it is Pilates, maybe it is Salsa Dancing; regardless of the activity, the reward comes with dedication to practice. If you do not enjoy the type of activity that you commit yourself to practice, you will not continue in the practice. So it is extremely important to find activities that are fun and rewarding for you and your children.

20.3 Research Findings

Why is Physical Activity Important? According to extensive research employing well designed studies, we can now say with certainty this statement as found on the Healthy People 2020 Web site [4]: http://​www.​healthypeople.​gov/​2020/​topicsobjectives​2020/​overview.​aspx?​topicid=​33

Regular physical activity can improve the health and quality of life of Americans of all ages, regardless of the presence of a chronic disease or disability. Among adults and older adults, physical activity can lower the risk of: Early death; Coronary heart disease; Stroke; High blood pressure; Type 2 diabetes; Breast and colon cancer; Falls; and Depression. Perhaps, even more importantly, among children and adolescents, physical activity can:

·        improve bone health,

·        improve cardiorespiratory and muscular fitness,

·        decrease levels of body fat,

·        reduce symptoms of depression.

Just what are the physical activity objectives for Healthy People 2020? Table 20.1 highlights some of the objectives designed to improve health, fitness, and quality of life through daily physical activity. From this list, you can see the importance of being active in terms of long-term good health. Notice the emphasis on providing avenues for physical activity for all ages, even children in daycare.

Table 20.1

Selected healthy people 2020 physical activity objectives: a verbatim sample

Reduce the proportion of adults who engage in no leisure-time physical activity

Increase the proportion of adults who engage in aerobic physical activity of at least moderate intensity for at least 150 min•week−1, or 75 min•week−1 of vigorous intensity, or an equivalent combination

Increase the proportion of adults who engage in aerobic physical activity of at least moderate intensity for more than 300 min•week−1, or more than 150 min•week−1 of vigorous intensity, or an equivalent combination

Increase the proportion of adults who perform muscle-strengthening activities on 2 or more days of the week

Increase the proportion of adolescents who meet current Federal physical activity guidelines for aerobic physical activity and for muscle-strengthening activity (See http://​www.​health.​gov/​paguidelines/​guidelines/​chapter3.​aspx or Tables 20.520.620.9 and 20.10 for physical activity guidelines for children.)

Increase the proportion of children and adolescents who do not exceed recommended limits for screen time

Increase the proportion of the Nation’s public and private schools that require daily physical education for all students

Increase the number of States with licensing regulations for physical activity provided in child care

Increase the number of States with licensing regulations for physical activity in child care that require children to engage in vigorous or moderate physical activity

Increase the proportion of trips made by walking

Increase the proportion of trips made by bicycling

Increase the proportion of office visits made by patients with a diagnosis of cardiovascular disease, diabetes, or hyperlipidemia that include counseling or education related to exercise

Increase the proportion of physician visits made by all child and adult patients that include counseling about exercise

Increase the proportion of employed adults who have access to and participate in employer-based exercise facilities and exercise programs

Note: For a complete list of objectives see: http://​healthpeople.​gov/​2020/​topicsobjectives​2020list.​aspx?​topicid=​33

Another series of questions probably arise when you look at this table: what is moderate exercise, what is vigorous exercise, why is the term used physical activity rather than exercise? We will answer these questions in the next section of the chapter.

20.3.1 The Difference Between Moderate Physical Activity, Vigorous Physical Activity, Exercise and Physical Activity, Health-Related Physical Fitness, and Sports-Related Fitness

According to Ainsworth and colleagues moderate-intensity physical activity refers to any activity that burns 3.5–7 kcal/min [6] or 3.5–5 METS [7]. One MET is the oxygen cost of an individual at rest or MET = 1 kcal/kg/h. METS are used because it is an easy way to represent energy. If someone is working at a 5 MET level they are working five times above their resting state. The ACSM defines moderate exercise intensity as 40 % to <60 %of oxygen uptake reserve (VO2 R) or heart rate reserve (HHR) [8]. In the 1996 Surgeon General’s Report [1], moderate exercise was defined as some increase in breathing or heart rate or a “perceived exertion” of 11–14 on the Borg Rate of Perceived Exertion (RPE) scale. These levels are equal to the effort a healthy individual might burn while walking at a 3–4.5 mph pace on a level surface, playing golf, gardening and yard work, swimming for recreation, or bicycling. In Appendix 1, steps are outlined to determine a moderate training heart rate using the HRR method. The Borg RPE scale can be found in Appendix 2.

Ainsworth et al. defined vigorous-intensity physical activity as any activity that burns more than 7 cal per min ([6] kcal/min) or equal to 6 METS [7]. The ACSM [8] refers to vigorous exercise as 60 % to <90 % of VO2 R or HHR. In the 1996 Surgeon General’s Report [1], vigorous exercise was defined as a large increase in breathing or heart rate (conversation is difficult or “broken”) or a “perceived exertion” of 15 or greater on the Borg RPE scale (see Appendix 2). These levels are equal to the effort a healthy individual might burn race walking or walking at a 5 mph pace, engaging in heavy yard work, participating in high-impact aerobic dancing, swimming continuous laps, scuba diving, or bicycling uphill.

Examples of general physical activities that meet the guidelines established by the Centers for Disease Control and Prevention(CDC) and the ACSM for moderate activity (3.5–5 METs or 3.5–7 kcal/min) and vigorous activity (more than 7 kcal/min or equal to or greater than 6.0 METs) can be found at the CDC Web site http://​www.​cdc.​gov/​nccdphp/​dnpa/​physical/​recommendations/​adults.​htm and at the Compendium of Physical Activities Web site https://​sites.​google.​com/​site/​compendiumofphys​icalactivities/​. Table 20.2 highlights the MET cost of general activities from the compendium of physical activities.

Table 20.2

Metabolic equivalents (MET) values for physical activity levels

Physical activity intensity

MET

Light intensity activities

<3

Sleeping

0.9

Watching television

1.0

Writing, desk work, typing

1.8

Walking, 1.7 mph (2.7 km/h), level ground, strolling, very slow

2.3

Walking, 2.5 mph (4 km/h)

2.9

Moderate intensity activities

3–6

Bicycling, stationary, 50 W, very light effort

3.0

Walking 3.0 mph (4.8 km/h)

3.3

Calisthenics, home exercise, light or moderate effort, general

3.5

Walking 3.4 mph (5.5 km/h)

3.6

Bicycling, <10 mph (16 km/h), leisure, to work or for pleasure

4.0

Bicycling, stationary, 100 W, light effort

5.5

Vigorous intensity activities

>6

Jogging, general

7.0

Calisthenics (e.g., push-ups, sit-ups, pull-ups, jumping jacks), heavy, vigorous effort

8.0

Running jogging, in place

8.0

Rope jumping

10.0

Note: 1 MET = 1 kcal kg−1 h−1 or 1 MET = 3.5 mL kg−1 min−1 of O2

From compendium of Physical Activity found at https://​sites.​google.​com/​site/​compendiumofphys​icalactivities/​

Project supported by University of Arizona and the National Cancer

What is the difference between physical activity and exercise? The United States Department of Health and Human Services refers to physical activity as, bodily movement that is produced by the contraction of skeletal muscle that substantially increases energy expenditure [1], whereas exercise is a type of physical activity that represents structured, planned activities, and repetitive bodily movement, designed to maintainor enhance overall physical fitness [8].

Both physical activity and exercise contribute to increases in physical fitness. Physical fitness is a multidimensional concept that has been defined as a set of attributes that people possess or achieve that relates to the ability to perform physical activity [8]. There are skill-related components of physical fitness (also known as sports-related forms of physical fitness) and health-related components of physical fitness. Skill-related components of physical fitness include balance, agility, coordination, speed, power and reaction time. These components are associated mostly with sport performance. Health-related components of physical fitness include cardiovascular endurance, muscular strength and endurance, flexibility, and body composition. The focus of this chapter is on the health-related components of physical fitness.

20.3.2 Physical Activity Recommendations for Health-Related Fitness from Leading Health Organizations

Before beginning any physical activity or exercise program, it is recommended that individuals complete a self-administered questionnaire to help identify risks that may warrant further medical clearance before embarking on an activity program. Individuals should consult their physician before beginning a new physical activity program if they have chronic diseases, such as cardiovascular disease and diabetes mellitus, or are at high risk for these diseases. Additionally, men over age 45, and women over age 55, should consult a physician before beginning a vigorous activity program [8].

Table 20.3 lists physical activity recommendations for cardiorespiratory (CR) health-related fitness from selected leading health organizations. Public health recommendations have evolved from emphasizing vigorous activity for CR health-related fitness to including the option of moderate levels of activity for numerous health benefits.

Table 20.3

Physical activity recommendations for health-related fitness from leading health organizations

Organization: Centers for Disease Control (CDC) and the 2008 Physical Activities Guidelines for Americans (see http://​www.​cdc.​gov/​)

Recommendation: All adults aged 18–65 years should accumulate a minimum of 30 min of moderate exercise 5 days•week−1 or 20 min of vigorous exercise 3 days•week−1 (or any combination of the two)

It is also acknowledged that for most people, greater health benefits can be obtained by engaging in physical activity of more vigorous intensity or of longer duration

Every adult should participate in activities at least twice a week that increase or maintain muscular strength and endurance

Purpose: Health promotion and prevention of chronic diseases

Organization: American Heart Association (see http://​www.​heart.​org)

Recommendation: Older adults and people with disabilities can gain significant health benefits with a moderate amount of physical activity, preferably daily. Physical activity doesn’t need to be strenuous to bring health benefits. What’s important is to include activity as part of a regular routine

Children and adolescents should participate in at least 60 min of moderate to vigorous physical activity every day

Purpose: Health promotion and prevention of chronic diseases

Organization: American College of Obstetrics and Gynecology (see http://​www.​acog.​org/​)

Recommendation: For the promotion of a healthy pregnancy and postpartum recovery, women should accumulate 30 min of exercise a day on most days of the week (American College of Obstetrics and Gynecology Committee on Obstetric Practice. Exercise during pregnancy and the postpartum period. Committee Opinion No. 267. Int J Gynaecol Obstet 2002;77:79–81)

Purpose: Promotion of a healthy pregnancy and postpartum recovery

20.3.3 The American College of Sports Medicine’s Exercise Recommendations for Cardiorespiratory Fitness

Aerobic fitness, or CR fitness refers “to the ability to perform large muscle, dynamic, moderate-to-high intensity exercise for prolonged periods” The terms CR fitness, VO2max, aerobic capacity, and aerobic fitness are used synonymously. CR fitness is defined as the ability of the body to engage in physical activity in which oxygen consumption is relied on as the primary energy source [8]. These terms refer to the maximal capacity to produce energy aerobically and are usually expressed in METs or mL O2•kg−1•min−1. One MET (metabolic equivalent unit) is equal to approximately 3.5 mL O2•kg−1•min−1. Improvements in the ability of the heart to deliver oxygen to the working muscles and in the muscle’s ability to generate energy aerobically results in increased CR fitness [8].

Exercise recommendations must take into account the fitness level of the individual. Individuals with low level of fitness generally demonstrate the greatest improvements in CR fitness, whereas modest increases occur in healthy individuals and in those with high initial fitness levels [10]. Exercise recommendations to improve CR fitness include three components, frequency, intensity, and duration, also known as the FIT principles. The format for an exercise session should include a warm-up period (approximately 5–10 min), a stimulus or conditioning phase (20–60 min), and a cool-down period (5–10 min). Table 20.4 lists the recommendations proposed by the ACSM to improve and maintain CR fitness for Adults. The recommendation range is broad because of the heterogeneity in a response to an exercise stimulus.

Table 20.4

American College of Sports Medicine’s training guidelines for cardiorespiratory fitness

Frequency

3–5 days•week−1

Intensity

Frequency

3–5 days•week−1

Intensity

Determining intensity using the HR max method

   Moderate intensity: 64–76 % of maximum heart rate (HRmax) for a 20 year old

  HRmax = 220 − age

  Target heart rate = HRmax (64–76 %)

  i.e., HRmax = 220 − 20

   HRmax = 200

   Target heart rate = 200 (64–76 %)

   Target heart rate may range from 128 to 152 beats min−1

  Vigorous intensity: 76–96 % of maximum heart rate (HRmax) for a 20 year old

  HRmax = 220 − age

  Target heart rate = HRmax (76–96 %)

  i.e., HRmax = 220 − 20

   HRmax = 200

   Target heart rate = 200 (76–96 %)

   Target heart rate may range from 152 to 192 beats min−1

Determining intensity using the HRR method

  Moderate intensity: 40–60 % of heart rate reserve (HRR) for a 40 year old with a resting HR of 60 beats min−1

  HRR = HRmax (i.e., 220 − age) − resting heart rate

  Target heart rate = [(HRR) (exercise intensity)] + resting heart rate

  i.e., Target heart rate

   = HRmax = 220 − 40 = 180

   = HRR = 180 − 60 = 120

   = [(HRR) (exercise intensity)] + resting heart rate

   = [(120) (40–60 %)] + 60

   = 108–132 beats min−1 is your training heart rate range

  Vigorous intensity: 60–90 % of heart rate reserve (HRR) for a 40 year old with a resting HR of 60 beats min−1

  HRR = HRmax (i.e., 220 − age) − resting heart rate

  Target heart rate = [(HRR) (exercise intensity)] + resting heart rate

  i.e., Target heart rate

   = HRmax = 220 − 40 = 180

   = HRR = 180 − 60 = 120

   = [(HRR) (exercise intensity)] + resting heart rate

   = [(120) (60–90 %)] + 60

   = 132–168 beats min−1 is your training heart rate range

Determining intensity using the VO 2 R method

  Moderate Intensity 40 % to <60 % of oxygen uptake reserve (VO2R)

  Vigorous Intensity 60 % to <85 % of oxygen uptake reserve (VO2R)

  VO2R = VO2max − VO2rest (VO2max mL•kg−1•min−1 − 3.5 mL•kg−1•min−1)

  Target VO2 mL•kg−1•min−1 = [(VO2R) (exercise intensity)] + VO2rest

  i.e., Target VO2 mL•kg−1•min−1 for a person with VO2 max of 40 mL•kg−1•min−1

   = [(40 mL•kg−1.min−1 − 3.5 mL•kg−1•min−1) (60 %)] + 3.5 mL•kg−1.min−1 (example)

   = [(36.5 mL•kg−1.min−1) (60 %)] + 3.5 mL•kg−1•min−1 (example)

   = 21.9 mL•kg−1•min−1 + 3.5 mL•kg−1•min−1 (example)

   = 25.4 mL•kg−1•min−1 (example)

Determining exercise intensity using the rate of perceived exertion (RPE) scale

  12–16 (in the range of “somewhat hard” to “hard”) on the original 6–20 Borg RPE Scale is the average range associated with physiologic adaptation. However, there is significant interindividual variability in the psychophysiologic relationship to % HRmax, % HRR or %VO2R and RPE. Therefore, RPE should only be used as a guideline in setting the exercise intensity

Duration

20–60 min of continuous aerobic activity. Duration is dependent on the intensity of the activity: thuslower intensity should be conducted over a longer period of time

Note: For individuals with VO2max below 40 mL O2•kg−1•min−1, a minimal intensity of 30 % VO2R or HRR can elicit improvements in VO2max. In contrast, individuals with greater cardiorespiratory (CR) fitness (>40 mL O2kg−1•min−1) require a minimal threshold of 45 % VO2R or HRR. For most individuals, intensities within the range of 60–80 % of VO2R or HRR or 70–90 % HRmax are sufficient to achieve improvements in CR fitness with the appropriate duration and frequency of training.

Sources: Adapted from American College of Sports Medicine. ACSM’s guidelines for exercise testing and prescription. 7th ed., Philadelphia: Lippincott Williams & Wilkins, 2006. Adapted from American College of Sports Medicine. ACSM’s guidelines for exercise testing and prescription. 9th ed., Philadelphia: Lippincott Williams & Wilkins, 2013

For children, the emphasis is on play rather than structured exercises. Tables 20.5 and 20.6 highlight recommendations from leading organizations for children and adolescents t increase aerobic fitness.

Table 20.5

National Association for Sport and Physical Education (NASPE) national guidelines for physical activity for children

Toddlers should engage in a total of at least 30 min of structured physical activity each day

Toddlers should engage in at least 60 min—and up to several hours—per day of unstructured physical activity and should not be sedentary for more than 60 min at a time, except when sleeping

Preschoolers should accumulate at least 60 min of structured physical activity each day

Preschoolers should engage in at least 60 min—and up to several hours—of unstructured physical activity each day, and should not be sedentary for more than 60 min at a time, except when sleeping

Children age 5–12 should accumulate at least 60 min, and up to several hours, of age-appropriate physical activity on all, or most days of the week. This daily accumulation should include moderate and vigorous physical activity with the majority of the time being spent in activity that is intermittent in nature

Children age 5–12 should participate each day in a variety of age-appropriate physical activities designed to achieve optimal health, wellness, fitness, and performance benefits

Children age 5–12 should participate each day in a variety of age-appropriate physical activities designed to achieve optimal health, wellness, fitness, and performance benefits

Sources: Adapted from NASPE National Guidelines for Physical Activity for Children http://​www.​aahperd.​org/​naspe/​standards/​nationalGuidelin​es/​PAguidelines.​cfm

Table 20.6

American College of Sports Medicine recommendations for children

Frequency

Daily

Intensity

Moderate intensity corresponds to noticeable increase in HR with breathing

 

Vigorous intensity corresponds to substantial increase in HR and breathing

 

Moderate to vigorous intensity aerobic exercise daily with vigorous intensity exercise 3 days•week−1

Time

≥60 min per day

Type

Enjoyable running, walking, swimming bicycling, dancing

Obesity

Obese children may need to start slowly and build to achieve their goal of daily moderate to vigorous intensity exercise. Rest and recovery periods need to be included between bouts of exercise

Sources: Adapted from American College of Sports Medicine. ACSM’s guidelines for exercise testing and prescription. 9th ed., Philadelphia: Lippincott Williams & Wilkins, 2013

20.3.4 The American College of Sports Medicine’s Exercise Recommendations for Muscular Fitness

Improving muscular functioning through a resistance-training program may provide physiological benefits for girls and women of all ages. Research has clearly indicated that strength can be effectively increased with training in girls before the age of puberty [9] For middle aged, older adult, and postmenopausal women, a reduction in the risk of osteoporosis, low-back pain, hypertension and diabetes have been associated with resistance training programs [1011]. Appendix 3 displays resistance training exercises that can be performed by the mature woman.

Unlike cardiovascular activity, intensity for resistance exercise is not easily determined. Miriam E. Nelson [12], author of Strong Women Stay Young, suggests that women beginning a resistance-training program should use a scale similar to the RPE scale (see Appendix 2) to determine the amount of weight that they should incorporate into their resistance-training program. In order for strength gains to continue to accrue there must be a gradual increase in the stress or load placed on the body throughout the resistance-training program. The overload principle refers to placing greater demands on the body than what it is accustomed to, and the principle of progressionrefers to the constant application of the overload principle throughout the resistance-training program. Hence, the term progressive overloadhas been coined. The RPE scale has become a popular method to assess progressive overload. Nelson suggests that during the first week, individuals should focus on form and that the effort involved in lifting, should be easy or moderate. When learning the exercises, an intensity of 9 (very light) to 11 (light) on the RPE scale would be appropriate. According to Nelson [12], the goal should be for the exercise set (eight repetitions) to become difficult after six or seven repetitions. The ACSM recommends an initial goal of 12–13 (somewhat hard) and a final goal of 15–16 (hard, heavy) on the RPE scale for submaximal training [1314]. A target of 19–20 (extremely hard, maximal exertion) on the RPE scale is synonymous with high-intensity strength stimuli for healthy populations [14]. However, for people with high cardiovascular risk or those with chronic disease, the exercise should be terminated if the lifting portion of the exercise becomes difficult corresponding to an RPE of 15–16 [13] or if there are any warning signs such as dizziness, unusual shortness of breath, anginal discomfort, or dysrhythmias [815]. Therefore, a more modest level of exertion should be chosen. Table 20.7 provides resistance guidelines as outlined by the American College of Sports Medicine for healthy adults [8].

Table 20.7

American College of Sports Medicine’s resistance training guidelines for healthy adults

Frequency

 Each major muscle group should be trained 2–3 days•week−1

Intensity

 60–70 % 1-RM (moderate-to-vigorous intensity) for strength improvement in novice and intermediate trainers

 80 % or less 1-RM (vigorous-to-very vigorous) for strength improvement in experienced trainers

 40–50 % 1-RM (very light-to-light) for older individuals and sedentary individuals whom are just beginning a program

 <50 % 1-RM to improve muscular endurance

Type

 Multijoint exercises affecting more than one muscle group are recommended

Repetitions

 8–12 repetitions is recommended for strength and power improvements

 10–15 repetitions is effectives in middle-aged and older individuals beginning exercise to improve strength

 15–20 repetitions are recommended to improve muscular endurance

Sets

 2–4 sets are recommended to improve strength and power

 2 or more sets are effective for muscular endurance improvements

Pattern

 2–3 min rest intervals between each set are effective

 Rest at least 48 h between sessions for any single muscle group

Progression

 Gradual progression of greater resistance, and/or more repetitions or sets, and/or more frequency is recommended

Sources: Adapted from American College of Sports Medicine. ACSM’s guidelines for exercise testing and prescription. 9th ed., Philadelphia: Lippincott Williams & Wilkins, 2013

Table 20.8 outlines the ACSM Position Stand on Progression Models in Resistance Training for Healthy Adults [16]. Although it is common to estimate intensity on repetition maximum (RM), this should only be used as a general guideline since RM differs between muscle groups [17]. These guidelines are appropriate for healthy adult women who desire goal-oriented guidelines for athletic performance enhancement, rather than simply health benefits. In order to more fully understand the guidelines as outlined in Table 20.8, the following terms are defined [1819].

Table 20.8

Overview of American College of Sports Medicine’s position stand on progression models in resistance training for healthy adults

Concentric, eccentric and Isometric actions must all be included for all training levels

Unilateral and bilateral and multiple-joint exercises should be included

Sequence of exercise should be: multiple-joint before single-joint, higher-intensity exercises before lower-intensity, rotation of upper and lower body or opposing exercises

Novice individuals should train the entire body 2–3 days•week−1

Intermediate individuals should train 3 days•week−1 total body or 4 days with a lower/upper body split

Advanced lifters should train 4–6 days•week−1

Strength training

1–3 sets of 8–12 repetitions using an intensity of ~60–70 % 1RM is recommended for novice and intermediate individuals

Cycling loads of ~80–100 % 1RM is recommended for advanced individuals

Rest period of at least 3 min for core exercises

Muscle hypertrophy

For novice and beginning individuals, an intensity range of 70–85 % 1RM should be used for 1–3 sets of 8–12 repetitions with 1–2 min rest between sets

For advanced individuals, working at an intensity of 70–100 % 1RM for 1–12 repetitions in 3–6 sets with a 2–3 min rest time in core exercises

Local muscular endurance

Novice and intermediate training should include a relatively light load with a moderate to high volume (10–15 repetitions with about 1 min rest)

Advanced training should use various loading with high repetitions (15–25 repetitions or more with a min or less rest)

When circuit training, rest intervals should be the time it takes to get from one exercise to the next

Older adults

Use a slow-to-moderate lifting velocity for 1–3 sets of 8–12 repetitions using 60–80 % 1RM with 1–3 min rest

Should train 2–3 days•week−1

Source: American College of Sports Medicine position stand: progression models in resistance training in healthy adults. Med Sci Sports Exerc 2009;41:687–708

·               Concentric (shortening): Concentric muscle actions occur when the total tension developed in all the cross-bridges of a muscle is sufficient to overcome any resistance to shortening.

·               Eccentric (lengthening): Eccentric muscle actions occur when the tension developed in the cross-bridge is less than the external resistance, and the muscle lengthens despite contact between the myosin cross-bridge heads and the actin filament.

·               Hypertrophy: The muscular enlargement that results from resistance is called hypertrophy and is primarily a result of an increase in the cross-sectional area of the existing fibers.

·               Multi-Joint exercise: multi-joint exercises involve two or more primary joints (i.e., front or back squat, bench press, shoulder press).

·               Periodization: Effective program design involves the use of periodization, which is the varying or cycling of training specificity, intensity, and volume to achieve peak levels of conditioning.

·               Power: Power is precisely defined as the “time rate of doing work” [20] where work is the product of the force exerted on an object and the distance the object moves in the direction in which the force is exerted (power = work/time).

·               Repetitions: Repeating an identical movement for a specific number of times. To improve strength, you must do enough repetitions of each exercise to fatigue your muscles. The number of repetitions needed to cause fatigue depends on the amount of resistance. In general, a heavy weight and a low number of repetitions (1–5) build strength, a lightweight and high number of repetitions (15–20) build endurance, for general fitness purposes, 8–12 repetitions are usually recommended.

·               Repetition maximum: The maximum amount of resistance a person can move a specific number of times is referred to as a repetition maximum (RM). The RM indicates that the muscle has reached a point of fatigue in which the force generating capacity falls below the required force to shorten the muscle against the imposed resistance [7]. One RM is the maximum amount of resistance that can be lifted one time, 5 RM is the maximum amount of weight that can be lifted five times.

·               Set: A set refers to a group of repetitions of an exercise followed by a rest period.

·               Single joint exercise: Single joint exercise involves only one primary joint (i.e., bicep curl).

Even though guidelines for children and adolescents are similar to those for adults, there are specific guidelines for children and adolescents. Guidelines for children and adolescents can be found in Tables 20.9 and 20.10.

Table 20.9

American College of Sports Medicine guidelines for resistance training with children

American College of Sports Medicine guidelines for resistance exercise in children and adolescent populations

Children should be supervised by a qualified instructor when performing exercises

High intensity exercises such as 1RM should be avoided and progressive loading should be utilized instead

Equipment should be appropriate for the size and skill level of the child

The goals of the resistance program should work to increase motor skill and fitness level

The child should perform each exercise between 8 and 15 repetitions and weight should only be increased when they can perform this number of repetitions with correct form. If 8 repetitions cannot be performed then the resistance weight needs to be lowered so the child can perform the 8 repetitions with correct form

Young children should not perform below 8 repetitions. A training load of 8 or below should be utilized only for older adolescents

The focus should be on developing correct form rather than maximizing weight

Source: Adapted from American College of Sports Medicine. ACSM’s guidelines for exercise testing and prescription. 7th ed., Philadelphia: Lippincott Williams & Wilkins, 2006

Table 20.10

Kraemer’s age specific exercise guidelines for resistance training

Resistance training exercise for children

Guidelines by age group

7 years or younger

Use little or no weight

Focus on technique

Volume should stay low

8–10 years of age

Can increase number of exercises as well as resistance and volume

Important to monitor progression and tolerance of increases

11–13 years of age

Continue slow progression of resistance and volume

Begin to introduce advanced exercises using little or no weight

Add sport specific exercises

14–15 years of age

Continue resistance progression

Advance sport specific components

16 years and older

After demonstrating mastery of proper technique the child should be progressed to entry-level adult programs

Source: Adapted from Kraemer WJ and Fleck SJ. Strength training for young athletes, 2nd ed. Champaign: Human Kinetics, 2005

For more specific information on developing effective resistance training programs for specific goals, it is recommended that you access on-line resources at http://​www.​nsca-lift.​org/​Home/​ (National Strength and Conditioning Association), http://​www.​acsm.​org/​ (American College of Sports Medicine), or http://​www.​exrx.​net/​index.​html (Exercise Prescription on the Net). These resources will also provide recommendations for texts and videos. In addition workout templates and live video clips of the proper form for performing resistance exercise can be found at Exercise Prescription on the Net.

20.3.5 The American College of Sports Medicine’s Exercise Recommendations for Healthy Body Composition

Although national standards have been developed and accepted for body mass index and waist circumference, there are no national standards for body fat percentage. Lohman et al. [20] proposed a set of standards for women using data from the National Health and Nutrition Examination Survey. Table 20.11 lists Lohman’s et al. [20] body fat percentage recommendations for women.

Table 20.11

Recommendations for body fat percentages for women

Category

Recommended percentage

Essential

 8–12 %

Minimal

10–12 %

Athletic

12–22 %

Recommended body fat percentage levels for adults and children

Age (years)

NR

Low

Mid

High

Obese

6–17

<12

12–15

16–30

31–36

>36

18–34

<20

20

28

35

>35

18–34 PA

 

16

23

28

 

35–55

<25

25

32

38

>38

35–55 PA

 

20

27

33

 

55+

<25

25

30

35

>35

55+ PA

 

20

27

33

 

NR not recommended, PA physically active

Source: Lohman TG, Houtkooper LB, Going SB. Body fat measurement goes high-tech: not all are created equal. ACSM Health Fitness J 1997; 7:30–35

Exercise programs to optimize lean body mass should include both cardiovascular and muscular fitness exercise components. In accordance with the United States Department of Health and Human Services, the ACSM recommends a target of 1,000 kcal (or range of 5,400–7,900 steps each day) of physical activity and/or exercise a week for energy expenditure [8]. Reports indicate that at the very least >150 min a week may be necessary for weight loss [21]. Greater amounts of physical activity (>250 min•week−1) may be needed to promote long-term weight control [8]. Physical activity and/or exercise expenditure in excess of 2,000 kcal•week−1 (8,000–12,000 steps per day) have been successful for both short- and long-term weight control [822]. Energy expenditure equivalents for activity can be found on the Fitness Partner’s Activity Calorie Calculator (see http://​www.​primusweb.​com/​fitnesspartner).

20.3.6 The American College of Sports Medicine’s Exercise Recommendations for Flexibility

Since flexibility is believed to be transient, it is recommended that flexibility exercises should be performed a minimum of 2–3 days a week [8]. The greatest change in flexibility has been shown to be in the first 15 s of the stretch with no significant improvements after 30 s [23]. Therefore ACSM recommends that each stretch be held for 15–30 s. The optimal number of stretches per muscle group is two to four since no significant improvement in muscle elongation is seen in repeated stretching of five to ten repetitions [24]. Table 20.12 lists general exercise guidelines for achieving and maintaining flexibility [825].

Table 20.12

General exercise prescription for achieving and maintaining flexibility

Precede stretching with light aerobic activity or by external methods (ex: hot bath, moist heat packs) to warm up body

Perform a minimum of 2–3 days•week−1, 7 days•week−1 is most effective

Stretch to the end of the range of motion to a point of tightness or slight discomfort

Hold each stretch for 10–30 s

For older adults, holding each stretch for 30–60 s may show more benefits

For proprioceptive neuromuscular facilitation (PNF) stretching, a 3–6 s light-to-moderate contraction followed by a 10–30 s assisted stretch is desirable

Perform 60 s of total stretching time for each exercise

Source: American College of Sport Medicine. ACSM’s guidelines for exercise testing and prescription. 9th ed., Lippincott Williams & Wilkins: Philadelphia, 2013

Table 20.13 lists some common high-risk stretches and safe alternative exercises. The high-risk exercises could be appropriate for certain groups of athletes, for example, ballet dancers would perform stretches using the barre’, whereas the alternative stretch would be more suitable for the average female. There are many Web sources to find appropriate flexibility exercises as well as research articles about the effectiveness of flexibility training [2526]. The American Academy of Orthopaedic Surgeons provides examples of flexibility exercises for the young athlete as well as for older individuals (see http://​orthoinfo.​aaos.​org/​main.​cfm).

Table 20.13

High-risk flexibility exercises with alternative stretches

High-risk stretch

Alternative stretch

Standing toe touch

Seated toe touch or modified hurdler’s stretch

Barre’ stretch

Seated toe touch or modified hurdler’s stretch

Hurdler’s stretch

Modified hurdler’s stretch (bend the knee so that the tibia moves towards the torso rather than away from the torso as in the traditional hurdler’s stretch)

Neck circles

Non-twisting directional stretch

Knee hyperflexion

Kneeling hip and thigh stretch

Yoga plow

Seated toe touch

Source: American College of Sport Medicine. ACSM’s guidelines for exercise testing and prescription. 7th ed., Lippincott Williams & Wilkins: Philadelphia, 2006

20.4 Contemporary Understanding of the Issues

20.4.1 Alternate Physical Activity and Programs

As noted above, the majority of healthy children, adolescents, and adult women are not engaged in physical activity consistent with public health recommendations. The issue of physical activity becomes even more crucial for “unhealthy” female populations, for example, women with cardiovascular disease, cancer, or eating disorders. In such cases, physical ability may be limited to due to a patient’s condition. In such cases, other types of physical activity, namely, yoga, may be recommended due to its proliferation and popularity; specifically, 15 million people practice various forms of yoga in the USA and profess advantages that extend well beyond traditional benefits of exercise [27]. Yoga is an ancient tradition designed to bring balance and health to the physical, mental, emotional, and spiritual domains of an individual [2829]. This ancient discipline is often represented metaphorically as a tree consisting of eight “limbs” or aspects: yama (universal ethics), niyama (self-discipline), asana (physical postures), pranayama (breath control), pratyahara (control of the senses), dharana (concentration), dyana (meditation), and samadhi (bliss or transcendent meditative awareness) [2829].

In contrast to other branches of yoga, the type known as Hatha focuses on the body and fitness [27]. Indeed, what most people refer to as simply “yoga” is hatha yoga, the most popular type practiced in the West [2729], which emphasizes the exercise or asana component as exemplified by the ACSM’s view of yoga as an “alternate type” of exercise [30]. Yoga, however, is inherently holistic or biopsychosocial in nature [29]. The purpose here is to discuss the following: the beneficial health effects of Western yoga (exercise focus) compared to exercise, as well as the benefits from integrated yoga; mindful awareness, mindfulness or mindfulness meditation; and lastly, the role of mindfulness-based interventions in eating disorders.

20.4.2 Health Benefits of Westernized Yoga

A growing body of literature indicates that yoga may be another option for improving and maintaining physical and emotional health. A growing body of literature indicates that yoga may be another option. The most commonly practiced hatha yoga in the West emphasizes the exercise component of physical postures or asanas that stretch and strengthen the body’s musculature [27]. Numerous research studies and reviews attest to the structural-physiological benefits of yoga, including findings contrary to the belief that static yoga asanas are only equivalent to light intensity exercise; that is, intensive asanas or sequences have been associated with sufficiently elevated metabolic and heart rate responses to improve cardiorespiratory fitness [31]. In addition to structural–physiological benefits, musculoskeletal–cardiopulmonary and endocrine and autonomic nervous system benefits of yoga are documented [282932].

A growing literature supports the notion that certain yoga techniques may improve physical and mental health in regard to stress through down-regulation of the hypothalamic–pituitary–adrenal (HPA) axis and the sympathetic nervous system (SNS) [28]. The HPA axis and SNS are triggered responses to a physical and/or psychological demand (stressor) that leads to a cascade of physiological, psychological, and behavioral effects primarily due to the release of cortisol and catecholamines. Over time, constant hypervigilence from repeated firing of the HPA axis and the SNS can lead to system dysregulation and conditions such as obesity, diabetes, autoimmune disorders, depression, substance abuse, and cardiovascular disease [3334]. While these studies suggest that yoga has an immediate quieting effect on the SNS/HPA axis responses to stress, the precise mechanism of action has not been determined. It has been hypothesized, however, that some yoga exercises, or asanas, cause a shift toward parasympathetic nervous system dominance, possibly via direct vagal stimulation [35].

Yoga is associated with rapid stress reduction and anxiolysis, significant decreases in heart rate, systolic and diastolic blood pressure [3639], as well as increases heart rate variability (HRV) [35]; this is of import because an increase in HRV is associated with healthy functioning and a reduced risk of heart disease [29]. Likewise, Shapiro and colleagues found significant reductions in low-frequency heart rate variability (HRV)—a sign of sympathetic nervous system activation—in depressed patients following an 8-week yoga intervention [40]. Data also show that yoga decreases levels of salivary cortisol [3641], blood glucose [4243] as well as plasma renin levels, and 24-h urine norepinephrine and epinephrine levels [37]. Furthermore, research suggests that yoga reverses the negative impact of stress on the immune system by increasing levels of immunoglobulin A and natural killer cells [4445]. Yoga decreases markers of inflammation such as high sensitivity C-reactive protein and inflammatory cytokines such as interleukin-6 and lymphocyte-1B [4647].

In terms of specific disease processes, several literature reviews have been conducted that examine the impact and benefits of yoga on physical and mental conditions including cardiovascular disease [32], metabolic syndrome [48], cancer [49], pain [50], depression [51], and anxiety [52]. Galantino and colleagues [53] published a systematic review of the effects of yoga on children, which is not surprising, given a recent complementary and alternative medicine (CAM) study investigating CAM preferences among children at a tertiary pain clinic where yoga was ranked among the three most popular pain treatments [54]. These reviews have contributed to an ever growing literature supporting the positive health benefits of yoga, especially in the context of chronic illness; that is, from a basic physical activity perspective, yoga may be particularly suited for individuals who have a chronic health disease or condition [29].

Two more research reviews regarding the benefits of yoga have recently been reported [2728]. Results from a recent review of studies comparing health benefits of yoga as an alternate exercise regimen to traditional exercise concluded that in both healthy and diseased populations, yoga may be as effective—or better than exercise—at improving a variety of health-related outcomes. In particular, yoga was deemed to be equal or superior to exercise in relieving certain symptoms associated with diabetes, multiple sclerosis, menopause, kidney disease and schizophrenia [28]. Recall that the westernized exercise-focused yoga previously discussed stands in contrast to the more holistic or integrated hatha yoga discipline of which exercise is one among several components involved (breath control, meditation, spiritual, and ethical components) [27]. Smith and colleagues wanted to compare the physical and psychological benefits of an exercise-based yoga practice to that of a more holistic or integrated yoga practice. Eight-one undergraduate students were recruited for one of three conditions over a period of 7 weeks with 2 sessions each week: yoga as exercise; integrated yoga including exercise, breath work, meditation, and spiritual/ethical teaching components; and a control group that only met to fill out questionnaires. Participants were assessed on measures of depression and anxiety, hope, stress, flexibility and salivary cortisol. Results showed that both groups’ scores decreased significantly on depression and stress as well as increased flexibility and hopefulness compared to the control group. However, only the integrated yoga group demonstrated significant decreases in anxiety symptoms and levels of salivary cortisol; thus, the participants in the holistic yoga intervention experienced benefits above and beyond yoga-as-exercise [27].

Evans and colleagues, in applying the biopsychosocial model to understand the health benefits of yoga, propose that yoga not only shares many of the physical and psychological benefits of exercise—but additionally also provides effects beyond regular exercise in that yoga appears to produce homeostasis across multiple domains of individual functioning and physiological pathways [29].

20.5 Future Directions

20.5.1 Mindful Awareness and Eating Disorders Premise

Yoga is associated with mindful awareness [29], an openness or receptivity to being aware of, as well as being in…the present moment…and the combination of both yoga and mindfulness is exemplified in the well-known mindfulness-based stress reduction (MBSR) program. Indeed, this psychosocial intervention is a structured therapeutic intervention that combines mindfulness meditation with Hatha yoga [55]. Awareness that a problem, such as an eating disorder, exists is the first key toward change. This leads to the next crucial step in the process of change, that of acceptance, which is an aspect of mindfulness meditation. Mindfulness involves non-judging awareness of each present moment with acceptance of reality as it is—including a lack of denial as to our own personal problems and issues. Thirdly, the basic level or component to any process of change is that of behavior, such as replacing a negative behavior with a positive or healthy one. The MBSR exemplifies all three aspects in its psychosocial program by the sheer fact that the heart of mindfulness is self-regulation, that is, holistic self-regulation of emotions, cognitions, and behaviors.

Eating disorders are associated with serious health problems and consequences if individuals do not receive effective treatment. This coincides with the fact that this type of disorder is a multidimensional, complex, and biopsychosocial condition that is viewed as involving major deficits in self-regulation, affect, behavior, and cognitive patterns (distortion) surrounding the focus on and intake of food [5658]. Thus, mindfulness-based interventions with self-regulation as its core appears clinically appropriate as a treatment for those with disordered eating. Eating disorders can be a major challenge to treatment; for example, in a 5-year study of 2,881 women with bulimia, a high relapse rate of 45 % resulted. Such findings provoke the notion of eating disorders being likened to a chronic disease with periodic remissions [59].

The chaotic absence of self-structural competence (i.e., dysregulation) in eating disorders may connect to a desperate sense of insecurity in the face of threat or challenge; understandably, this leads to extreme [eating-related] behaviors to calm the storm and reduce distress. Of course, the calm does not last for long.

To be fully present with that which distresses one to the core, a genuine trusting of something is needed. Meditation provides the structure and the process for that trust. Mindful, single-pointed attention to the present moment anchors and centers self to a regulating structure and process that merits trust; and, equally as important, it strips away the layers of biased meaning and subjective value judgments to which one is attached that causes distress and suffering in the first place. From this vantage point of stripped and raw experience, things are seen simply as they are, in a neutral and dispassionate process of objective witnessing. Thus, one comes to trust self as a calm and safe container of objective reality—a reality that is experienced one bite of food one moment at a time, which helps to reduce feelings of being overwhelmed.

In sum, a substantial body of literature over the last several decades indicates that the basic deficits in eating disorder populations may be due to ineffective self-regulation in multiple domains [6062]. Eating disordered groups have problems with affect or emotional regulation, that is, they have difficulty in identifying or being aware of emotional states as well as managing emotions or skillfully modulating feelings so as to be adaptive. As previously mentioned, mindfulness is a self-regulatory process, and mindlessness may be viewed as a component in some eating disorders, for example, binge eating and obesity, and likely plays some role in unsuccessful long-term weight loss programs.

20.5.2 MBSR Foundations, Basic Strategies and Structure

Meditation is a unique kind of attention. Meditation can be described as the self-regulation of attention and awareness that immerses the individual into the fullness of psycho-physiological experience. Basically, meditation is the disciplined practice of paying attention to the present moment with uncritical or non-judging acceptance. This alert, yet calm attentiveness is practiced in two basic forms: exclusive/concentrative meditation or inclusive/mindfulness meditation Exclusive or concentrative meditation, exemplified by transcendental meditation or TM, emphasizes concentration where the individual focuses on an internal or external object (such as a mantra) while minimizing distractions of other stimuli.

Mindfulness, as taught by Kabat-Zinn, is an example of inclusive meditation that involves including rather than excluding stimuli from the field of consciousness [63]. This type of meditation is more reality-based with daily life because we are constantly challenged to pay attention while being bombarded with multiple, competing and distracting stimuli. Mindfulness encourages detached non-judging observation or witnessing of thoughts, perceptions, sensations, and emotions. This provides a means of self-monitoring and self-regulating one’s arousal with detached awareness. Where the brain is an animate object that can be measured and touched, the mind is formless and without boundaries [5564]. Mindfulness meditation redirects the mind to a level of higher awareness. Individuals are taught to keenly observe their thoughts and emotions and then to let them pass without judging them or becoming immersed in them [63].

A simple analogy is watching the sky on a clear day. Clouds and birds will move across the sky, but they will not stay. Similarly, negative thoughts will enter the mind but mindfulness reorients the individual to the present and broadens self-awareness allowing negative thoughts to pass like the clouds through the sky [65]. Added benefits of the MBSR come from mindfulness meditation being used in conjunction with hatha yoga [55]. An underlying concept of Hatha yoga is that the mind is focused on the asana so it cannot be occupied with distracting thoughts [66]. Additionally, yoga provides the added benefit of giving people with physical illnesses some degree of control over their bodies [66].

The clinically driven MBSR, rooted in Theravada Buddhism and westernized by Kabat-Zinn, was developed originally as the Stress Reduction and Relaxation Program (SRRP) in the Stress Reduction Clinic, at University of Massachusetts Medical Center in 1979 [63]. From modest beginnings at one clinic, this therapeutic intervention has been completed by more than 15,000 patients at the original site alone, not including participants in over 250 MBSR programs around the world at last count in 2004 [67].

The traditional MBSR involves participants meeting once per week for a period of 8 weeks for approximately 2 h. Mindfulness-based interventions include didactic, inductive, and experiential modes of learning about stress responses and mindfulness skill development training. The participants received training in three basic mindfulness practices: the body scan, sitting meditation and hatha yoga. The body scan is a guided and experiential journey through the physical geography of the body from feet to head, while paying attention to whatever feelings and sensations—or lack of sensations—that arise in regions of the body. Mindfulness includes an observational, non-judging attitude with acceptance of ourselves as we are, without harsh criticism; thus, this technique encourages one to get acquainted or reacquainted with his/her body just as it is in the present moment.

Sitting meditation involves mindful attention of the breath, which serves as a focal anchor, with a heightened state of observational yet non-judging awareness of cognitions and the stream of thoughts and distractions that constantly flow through the mind. Hatha yoga, meditation-in-motion, involves stretches and postures (asanas) designed to strengthen and relax the musculoskeletal system and develop mindful movement of the body with essential harmonic regulation of breathing. Participants are given tapes or CDs to facilitate daily homework practice of the techniques learned from the weekly sessions [63].

20.5.3 Mindfulness General Research Findings

For over 30 years, abundant research documents the significant benefits of mindfulness interventions across a wide range of populations with various physical and psychological conditions. For example, results of recent mindfulness-based intervention studies continue to find improved levels of various forms of psychological distress such as anxiety, depression, prenatal stress, worry, and rumination [6872]. Mindfulness-based skills also have been found to be beneficial in conjunction with more serious underlying mental conditions such as anxiety in schizophrenic patients, acute psychotic symptoms, and bipolar and borderline personality disorders [7376]. Also, empirical evidence from a mindfulness-based relapse prevention program (MBRP), developed by Marlatt’s group at the Addictive Behaviors Research Center at the University of Washington, shows promising benefits for addiction populations [77].

Current research also documents the efficacy of mindfulness-based skills training in reducing stress-related symptoms and emotions in those suffering with chronic conditions.

Studies among different cancer groups have documented improved coping, quality of life as well as rapid immune function recovery with lower cortisol levels post-intervention [7879].

Additional findings provide evidence as to medical benefits of mindfulness interventions in symptoms associated with the following conditions: attention-deficit hyperactivity disorder (ADHD), chronic fatigue syndrome, chronic heart failure and myocardial ischemia, chronic pain fibromyalgia, HIV, insomnia, rheumatoid arthritis, and Type 2 Diabetes Mellitus [5568708084].

20.5.4 Mindfulness: Related Programs for Eating Disorders

A growing body of research suggests that mindfulness (i.e., non-judgmental, present-moment awareness) and its related constructs are relevant to understanding the development and maintenance of eating disorders [85]. Anorexia nervosa and bulimia nervosa are both characterized by experiential avoidance and a strong desire to maintain control over eating-related behaviors, urges, thoughts, and feelings [8688]. Eating disorder behaviors may be reinforced in part because they allow individuals to temporarily avoid other distressing internal experiences by focusing instead on one’s weight or eating behavior [8990]. Many individuals with eating disorders also have deficits in emotion recognition and emotional awareness [9192]. Recognition and awareness of internal experience may be a precondition to cognitive defusion, which is the ability to have distance and perspective from the literal meaning of cognitive activity [87]. More specifically, a small number of case studies and pilot studies suggest that mindfulness and acceptance might be effective foci of treatment for eating disorders [9397].

Mindfulness is recognized as a vital component of the several third generation behavioral therapies, including Dialectical Behavior Therapy (DBT), Acceptance and Commitment Therapy (ACT), Mindfulness-based Cognitive Therapy (MBCT), and Mindfulness-Based Eating Awareness Training (MB-EAT) [98]. Since these interventions draw heavily from clinical mindfulness-based conceptualization, they will now be briefly reviewed.

According to Wolever and Best [99], Dialectical Behavior Therapy (DBT) has the distinction of being the most extensively studied mindfulness approach within eating disorder populations. DBT originally was implemented to improve dysregulation deficits in those with borderline personality disorder in the early 1990s [100], and since then has been expanded by Telch and colleagues into an 18-session treatment program for those with BED [101102]. The underpinning for DBT here involves an affect dysregulation perspective where binges are viewed as serving the maladaptive function of attempts at reducing distressing emotional states with poor strategies. Mindfulness-based skills of awareness of the present moment with uncritical or nonjudgmental acceptance—being with what is happening rather than reacting and trying to change things—is the bedrock for teaching affect regulation and distress tolerance building strategies. The mindful, uncritical acceptance of fearful thoughts or images as being just that helps clients be aware of their emotions without the reactive behavioral automaticity of a binge eating event.

Both uncontrolled and randomized controlled trials (RCT) have shown significant and positive results. In the uncontrolled trial, 82 % of the sample were binge-free at post-intervention with follow-ups at 3-months (80 %) and 6-months (70 %). The RCT results at post-intervention revealed 89 % abstinence for the treatment group compared to 12.5 % of the control group; at 6-month follow-up, however, modest sustained abstinence was found for the treatment group (56 %) [101102].

Another mindfulness-based intervention is that of Acceptance and Commitment Therapy (ACT), based on an avoidance model, which asserts that some types of disorganized behavior are associated with efforts to escape distressing internal-external experiences, feelings, urges, etc. [103104]. This therapeutic approach holds promise in that it exposes individuals to the exact stimuli from which they chaotically attempt to avoid, which helps fuel the inflexible and vicious cycle of extreme behavior; however, the confrontation is done from a mindful accepting mindset. The ACT program has been applied notably to anorexia nervosa with publication of a self-help workbook [105]. ACT emphasizes uncritical acceptance of thoughts and feelings while working toward behavior change [103] and incorporates several mindfulness and acceptance strategies such as the thought parade. This mindfulness technique involves an individual imagining self’s thoughts as being written on cards or plackards carried by people in a parade, for example, “I’m as big as a whale” or “I look like Shamu.” The task is to be a witness to one’s thoughts in an uncritical and accepting mindset rather than automatically—and mindlessly—engage in an unregulated maladaptive eating reaction to counter distressing thoughts.

Theoretically and therapeutically, ACT therapy for eating disorders is an up and coming approach. Future empirical studies and clinical trials in this line of therapy will be a promising source of clinically scientific literature for this population.

The first mindfulness-based program developed specifically to treat an eating disorder, specifically, that of binge eating, is Kristeller’s Mindfulness-Based Eating Awareness Training (MB-EAT), which has evolved into a 12-week program [96106108]. This intervention’s approach is based on the view of eating disorders as related to pervasive underlying dysregulation patterns of affect, cognition, behavior, and physiology. MB-EAT combines mindfulness with cognitive therapy and imagery. A scientific approach fosters intake regulation, that is, biological cues of hunger and satiety, and appetite awareness training. The MB-EAT applies strategies from Kabat-Zinn’s [63] original program and mindfulness is integrated daily with regard to food craving and eating. Participants experience several guided eating meditations that involve nonjudgmental awareness of thoughts, emotions, and sensations relating to hunger-satiety cues as well as binge triggers. Gradually, the intervention guides participants in the process of mindfulness-based healthy food selection, and culminates with later weeks shifting towards deeper levels of cultivating forgiveness and inner wisdom.

20.5.5 Recent Mindfulness and Eating Disorder Research

Mindfulness-based approaches are being used increasingly to treat eating disorders. Indeed, mindfulness is appropriate for eating disorder populations because many patients, as touched upon earlier, have difficulties with regulation—regulating emotional, cognitive, and physical experiences [109]. Lavander, Jardin, and Anderson [110] found that non-eating disordered individuals who exhibited higher levels of dispositional mindfulness were less likely to engage in disordered eating behaviors. Other findings indicate that mindfulness-based skills offered to young women early in their psychosocial development may aid in preventing eating disorders [111]. Mindfulness-based interventions, in combination with the development of emotion regulation and distress tolerance skills, appear to be effective in managing the urge to binge eat when it arises [112]. Additionally, there is growing interest in developing mindfulness treatments for the specific types of eating disorders, i.e., anorexia nervosa [113], bulimia nervosa [114], and binge eating [107].

According to Butryn and colleagues [85], very little data have been collected to examine whether improvements in mindfulness and it related constructs such as awareness, acceptance, and cognitive defusion, are related to symptom severity and improvement in eating disorder symptoms. Thus, Butryn [85] investigated mindfulness and its relationship to eating disorders symptomatology in 88 women with multiple eating disorder diagnoses in residential treatment. Multiple measures of eating disorder symptomatology, as well as a mindfulness scale, were administered to the participants upon admission and again at discharge. Baseline eating disorder (ED) symptomatology was associated with lower awareness, acceptance, and cognitive defusion, and higher emotional avoidance. Improvements in these variables were related to improvement in ED symptomatology. It was concluded that interventions targeting mindfulness are beneficial to improving eating disorder symptomatology [85]. This generally coincides with findings from a systematic review of eight studies of mindfulness-based interventions in eating disordered participants [98]. Supporting evidence was found for the effectiveness of mindfulness-based interventions for the treatment of eating disorders; however, it was noted that trial quality of the studies was variable with small sample sizes; thus, more and larger trials were recommended. It was concluded that the application of mindfulness-based interventions to eating disorders is a promising approach worthy of further research [98].

The burgeoning literature indicating the efficacy of mindfulness-based interventions for clinical populations has lead to interest in mindfulness skills as a potential adjunct to long-term treatment for eating disorders. Specifically, most mindfulness-based research studies have examined brief group interventions independent of continued or long-term treatment [115].

Consequently, Hepworth [115] conducted an exploratory study to investigate the potential benefits of a “mindful eating group” for individuals with various types of eating disorders in conjunction with long-term treatment at a treatment facility specializing in eating disorders.

Participants were selected based on the following: their level of progress in treatment; a BMI ≥ 17; self-reported improvement in mood; and binging/purging purging behaviors of less than once per day—that is, once every couple of days. Potential participants were excluded if they had a current BMI < 17 (since low weight affects cognitive abilities), and if they were diagnosed with major depression as assessed by their psychologist. The concluding sample for this 10-week pilot study ended up being 33 females (mean age of 21.42 years), representing a variety of eating disorders. A trained psychologist and dietitian facilitated the ten mindful eating intervention sessions, that is, one session each week. Disordered eating symptoms were measured by the Eating Attitudes Test-26 (EAT-26) pre-and-post the 10-week program [115].

Results showed significant reductions on all scales of the EAT-26, along with large effect sizes; also, no significant differences were found between eating disorder diagnoses. Results from this pilot suggest potential benefits from an adjunct mindfulness-based intervention for those con-currently undergoing long-term individual treatment [115].

As mentioned previously, the first mindfulness-based program developed in 1999 specifically to treat an eating disorder—binge eating disorder or BED—was Kristeller’s Mindfulness-Based Eating Awareness Training (MB-EAT) [106]. This persistent and consistently expanding intervention has evolved into a 12-week program [96106108].

MB-EAT incorporates the clinical value and research of mindfulness, food intake regulation literature, and emotional dysfunction in binge eating and other disordered eating populations [63116117]. More specifically, traditional mindfulness meditation as well as guided meditation practices are included to address eating-related self-regulatory processes including emotional versus physical hunger triggers, gastric and sensory-specific satiety or fullness (SSS), food choice, and emotional regulation pertinent to self-concept and stress management [108].

Emergent wisdom and self-acceptance are core components of the program; that is, individuals are encouraged to recognize their own internal strengths and be open to their own understanding and salutations to challenging situations rather than reacting judgmentally to self-perceived variances from internalized norms [107].

Research continues to demonstrate the effectiveness of this program in treating BED [96106108]. For example, this year, Kristeller and colleagues [108] conducted a randomized trial to explore the efficacy of a 12 session MB-EAT, in comparison to a psychoeducational–cognitive–behavioral intervention (PECB) and a wait list control. The two-site study randomized 150 participants. Compared to the wait list control, MB-EAT and PECB showed generally comparable improvement after 1 and 4 months post-intervention on binge days per month, the Binge Eating Scale, and depression. At 4 months post-intervention, 95 % of those individuals with BED in MB-EAT no longer met the BED criteria versus 76 % receiving PECB; furthermore, binges that occurred were likely to be significantly smaller. Also, the amount of mindfulness practice predicted improvement on a range of variables, including weight loss. In conclusion, results indicate that MB-EAT decreased binge eating and related symptoms at a clinically meaningful level, with improvement related to the degree of mindfulness practice [108].

Recently, ongoing research suggests expanding the MB-EAT so that it can be adapted to also address weight loss—without losing its effectiveness for treating associated symptoms of binge eating. Indeed, a recently completed MB-EAT clinical NIH trial broadened its recruitment to include those with a BMI of at least 35. Preliminary data analyses indicate that BED participants showed comparable improvement to those without BED—including a weight loss of 7 lbs. at immediate post [107]. Recently, elements of the MB-EAT program have been successfully adapted for use with restaurant meals, showing weight loss and improved dietary patterns in perimenopausal women [118]. In sum, one aspect of this programs’ continuing and evolving effectiveness may well be its adaptability among different disorders. More information regarding the MB-EAT program can be found at its Web site, The Center for Mindful Eating, at http://​www.​tcme.​org/​.

20.6 Concluding Remarks

Despite the documented benefits of regular physical activity, the majority of children, adolescents, and adult women are not engaged in physical activity consistent with public health recommendations. At one end of the continuum, we have young girls and female athletes who are not taking in enough calories to meet their energy needs associated with exercise, and at the other end of the continuum, we have the vast majority of children, adolescents, and adult women who do not get enough physical activity.

Empirical literature about yoga and mindfulness has been presented. Additionally, the benefits of yoga and mindfulness-based programs have been reviewed as well as research regarding mindfulness incorporated programs specifically in the area of eating disorders. Future research, no doubt, will continue to inform and expand scientific knowledge as to the clinical utility of mindfulness-based interventions in eating disordered populations as well as in other health populations.

There are many resources on the Web to assist with activity and exercise recommendations to achieve optimum health and fitness. The Department of Health and Human Resources Centers for Disease Control and Prevention offers a Web site that provides information to assist in healthy physical activity program planning and evaluation as well as ideas for healthy physical activity promotion (see http://​www.​cdc.​gov/​physicalactivity​/​index.​html).

20.7 Appendix 1. Determining Moderate and Vigorous Exercise Intensity Using the Heart Rate Reserve Method (HRR)

STEP 1

Take your resting heart rate. In order for this to be the most accurate, it is suggested that you count the number of beats per minute three mornings in a row before arising and average the three readings.

Reading 1______bpm Reading 2______bpm Reading 3______bpm Average bpm_____

Resting heart rate = ______(i.e., resting heart rate =72)

STEP 2

Determine your maximum heart rate (MHR) 220 − age =______(i.e., 220 − 35 = 185)

Moderate Exercise Intensity

STEP 3

Target Heart Rate = [(MHR-resting heart rate) (40–59 %)] + resting heart rate

i.e., [(185 − 72) (40–59 %)] + 72 = 117–138 bpm

Vigorous Exercise Intensity

STEP 3

Target Heart Rate = [(MHR-resting heart rate) (≥60 %)] + resting heart rate

i.e., [(185 − 72) (≥60 %)] + 72 = 139 bpm or greater

Note: The intensity range to increase and maintain cardiorespiratory fitness (CR) is broad. For individuals with low levels of CR fitness, the lower range will result in improvements in CR fitness. For individuals who are already fit, exercise intensities at the high end of the continuum (60 % to <90 % HRR) may be needed to improve and maintain CR fitness.

20.8 Appendix 2. Determining Moderate and Vigorous Exercise Intensity Using the Borg Rating of Perceived Exertion (RPE) Scale

__________

13 Somewhat hard

6 No exertion at all

14

7

15 Hard (heavy)

Extremely light (7.5)

 

8

16

9 Very light

17 Very hard

10

18

11 Light

19 Extremely hard

12

20 Maximal exertion

Instructions: While doing physical activity, rate your perception of exertion. This feeling should reflect how heavy and strenuous the exercise feels to you, combining all sensations and feelings of physical stress, effort, and fatigue. Do not concern yourself with any one factor such as leg pain or shortness of breath, but try to focus on your total feeling of exertion. Choose the number that best describes your level of exertion. This will give you a good idea of the intensity level of your activity. Moderate exercise is defined as a “perceived exertion” of 1114Vigorous exercise is defined as a “perceived exertion” of 15 or greater. The average RPE range associated with physiologic adaptation is 1216. However, there is significant interindividual variability.

Note:

9 corresponds to “very light” exercise, for a healthy person, it is like walking slowly at his or her own pace

13 on the scale is “somewhat hard” exercise, but it still feels OK to continue.

17 “very hard” is very strenuous, a healthy really has to push himself or herself and you will probably feel very tired

19 on the scale is an extremely strenuous exercise level, for most people, this is the most strenuous exercise they have ever experienced

Borg RPE scale © Gunnar Borg, 1970, 1985, 1994, 1998, Division of Nutrition and Physical Activity, National Center for Chronic Disease Prevention and Health Promotion http://​www.​cdc.​gov/​nccdphp/​dnpa/​physical/​measuring/​perceived_​exertion.​htm

20.9 Appendix 3. Sample Exercise Resistance Program for Postmenopausal Women: 4, 6, 8, and 12-Week Programs

A safe and effective training load for postmenopausal women is from 50 % to 80 % of a 1 RM. This level is enough to allow for the development of strength but light enough to reduce the risk of injury. Progress gradually by starting off with 50 % 1 RM using 2 sets of 6 repetitions for the first 2 weeks. During weeks 3 and 4 increase the lower body intensity by 10 % and the upper body intensity by 5 % as well as increasing the reps to 2 sets of 7 repetitions. When reaching weeks 5 and 6 make similar increases in upper and lower body intensity by increasing intensity by 5 % and 10 % respectively as well as increasing the repetitions in each set to 8. Weeks 7 and 8 have increasing intensity but the repetitions are not increased. Finally, for those who have completed the 8th week, the following weeks have an increased the intensity to 70–80 % of the 1RM for all exercises as well as an additional set of repetitions. The 4-week program is intended for as an introduction to resistance training that can then progress to the 6, 8, and 12 week programs for beginners, intermediates, and advanced exercisers respectively. All programs are performed 3 times per week.

Introduction part I: weeks 1 and 2

Exercise

1 RM (lbs)

% 1 RM

Weight (lbs)

Set one

Set two

Wall squats

10

50

 5

6

6

Machine bench press

20

50

10

6

6

Leg press

100

50

50

6

6

Low rows

40

50

20

6

6

Lat pulldown

40

50

20

6

6

Back extension

60

50

30

6

6

Introduction part II: weeks 3 and 4

Exercise

1 RM (lbs)

% 1 RM

Weight (lbs)

Set one

Set two

Wall squats

10

60

 6

7

7

Machine bench press

20

55

12

7

7

Leg press

100

60

60

7

7

Low rows

 40

55

22.5

7

7

Lat pulldown

 40

55

22.5

7

7

Back extension

 60

55

32.5

7

7

Beginner: weeks 5 and 6

Exercise

1 RM (lbs)

% 1 RM

Weight (lbs)

Set One

Set Two

Wall squats

 10

70

 7

8

8

Machine bench press

 20

60

12.5

8

8

Leg press

100

70

70

8

8

Low rows

 40

60

25

8

8

Lat pulldown

 40

60

25

8

8

Back extension

 60

60

35

8

8

Intermediate: weeks 7 and 8

Exercise

1 RM (lbs)

% 1 RM

Weight (lbs)

Set one

Set two

Wall squats

10

80

 8

8

8

Machine bench press

20

70

15

8

8

Leg press

100

80

80

8

8

Low rows

40

65

27.5

8

8

Lat pulldown

40

65

27.5

8

8

Arm curl

20

70

15

8

8

Arm extension

40

70

27.5

8

8

Back extension

60

65

40

8

8

Advanced: weeks 9, 10, 11, and 12

Exercise

1 RM (lbs)

% 1 RM

Weight (lbs)

Set one

Set two

Set three

Wall squats

10

80

8

8

8

8

Machine bench press

20

70

14

8

8

8

Leg press

100

80

80

8

8

8

Low rows

40

70

28

8

8

8

Lat pulldown

40

70

28

8

8

8

Arm curl

20

75

15

8

8

8

Arm extension

40

75

30

8

8

8

Back extension

60

70

42

8

8

8

Sample resistance exercises for women

Wall squats

A145875_2_En_20_Figa_HTML.jpg Start position

A145875_2_En_20_Figb_HTML.jpg End position

Wall squats with ball

A145875_2_En_20_Figc_HTML.jpg Start position (front view)

A145875_2_En_20_Figd_HTML.jpgEnd position (front view)

A145875_2_En_20_Fige_HTML.jpg Start position (side view)

A145875_2_En_20_Figf_HTML.jpgEnd position (side view)

Machine chest press

A145875_2_En_20_Figg_HTML.jpgStart position

A145875_2_En_20_Figh_HTML.jpgEnd position

Dumbbell arm curl

A145875_2_En_20_Figi_HTML.jpgStart position

A145875_2_En_20_Figj_HTML.jpgEnd position

Machine arm curl

A145875_2_En_20_Figk_HTML.jpgStart position

A145875_2_En_20_Figl_HTML.jpgEnd position

Arm extension

A145875_2_En_20_Figm_HTML.jpgStart position

A145875_2_En_20_Fign_HTML.jpgEnd position

Lat pulldown

A145875_2_En_20_Figo_HTML.jpgStart position

A145875_2_En_20_Figp_HTML.jpgEnd position

Back extension

A145875_2_En_20_Figq_HTML.jpgStart position

A145875_2_En_20_Figr_HTML.jpgEnd position

Leg press

A145875_2_En_20_Figs_HTML.jpgStart position

A145875_2_En_20_Figt_HTML.jpgEnd position

Low row

A145875_2_En_20_Figu_HTML.jpgStart position

A145875_2_En_20_Figv_HTML.jpgEnd position

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