Patient Presentation
A 19-year-old male came to clinic for his health supervision visit. He was a freshman in college and had returned for this visit during a fall school break. He said that he was doing well in school, but had noticed that he had gained 6 pounds since the summer. “I used to be so active, but I’m studying so much more and then there’s all the food available in the cafeteria,” he lamented. The past medical history showed a healthy male who had been a runner and swimmer in high school. The pertinent physical exam revealed normal vital signs including a blood pressure of 118/72, body mass index of 26.2, and weight that was 6 pounds more than a visit 3 months previously. His examination was otherwise unremarkable.
The diagnosis of a healthy male with concerns about weight gain and poor exercise was made. The physician discussed building in opportunities for exercise including walking and taking the stairs instead of an elevator. He emphasized that building in exercise into daily life could be in 10-20 minute intervals and didn’t always have to be for long times at a gym. He also counseled to take only one serving of an item on his plate at a meal and second servings should be only fruits and vegetables. Even at a salad bar, he said that the patient had to be careful of adding lots of cheese, protein or oils to the salad that would increase the calories. “Of course, any alcohol has a lot of calories too, so make good decisions not only about alcohol in general but also because of the calories.”
The patient said that he wanted to get back into doing some running or swimming and knew that there was a maximal target heart rate but didn’t know what it was. The physician said that it was around 200 beats/minute for someone his age. He counseled the patient to start slow with only 20 minutes of running at 50-60% of his target heart rate, and then to slowly increase the amount of time and effort over several weeks. Plus, he added, “It might be hard to figure out where to do the running 2-3 times or more a week on a regular basis, so don’t push it and be happy that you are making the effort.” The physician also said that the patient might want to buy an inexpensive pedometer to monitor his steps/day which was another way to check if he was getting enough exercise. “You could also buy a heart rate monitor but those are more expensive, but since you were an athlete before it might help you to keep the intensity at a lower level as you work up, and then you might not try to increase the workouts too fast.”
When he returned 4 months later, he was somewhat happy with his clinical course. He was running or swimming at 30 minutes or more 2-3 times per week which he said helped with the stress of school. He was using a pedometer and said that usually on the days he didn’t work out, he was getting 5000-7000 steps/day. He weight was unchanged. “I think once the spring comes, I can be a little more active, plus I haven’t been very good about watching what I eat,” he noted. “I will try to work on that next.”
Discussion
Being physically active is an important part of health and with the U.S.’s more sedentary lifestyle it can be difficult to get enough activity. Normal transitions are a time where it can be difficult to incorporate old habits or to start new ones. Moving away to college with its new challenges such as erratic schedules, more time needed to study, increased access to food and alcohol can make it difficult for college students to develop good habits and make good choices regarding their health.
Because steps are easy to measure with inexpensive pedometers, the President’s Council on Physical Fitness has a President’s Challenge which recommends the following activity:
- Youth <18 years
- 60 minutes/day
- Activity done in blocks of at least 5 minutes or more
- 5 days/week
- 11-13,000 steps/day
- Adults
- 30 minutes/day
- Activity done in blocks of at least 5 minutes or more
- 5 days/week
- 8500 steps/day
2000 steps is about 1 mile. Activities and the equivalent steps can be found at How Far is 10,000 Steps?
Research has shown that exercise alone may improve fitness and health, but usually will not result in weight loss. Therefore diet and exercise are needed. Interval training with periods of increased intensity and then returning to baseline has been shown to burn more calories than exercising at a consistent exertion level. Other research has shown that music and being around others will also improves the psychological outlook on the exercise and may improve adherence to an exercise routine. Exergaming, that is exercising using videogaming technology, which is increasingly popular has mixed results of increased activity depending on the game type.
The American College of Sports Medicine recommends that adults exercise:
- 3-5 times per week
- at an intensity of 55/65%-90% of maximal heart rate, with lower intensity levels for unfit individuals
- for 20-60 minutes (with a minimum of 10 minute intervals accumulated throughout the day)
- performing an “…activity that uses large muscle groups, which can be maintained continuously, and is rhythmical and aerobic in nature.”
They also recommend resistance and flexibility training as part of overall fitness and health.
Learning Point
Maximal heart rate for adults can be roughly estimated by:
220 beats/minutes – age in years = maximal heart rate
This is an estimate and should be individualized. For children, this author was unable to determine a maximum heart rate, but it would be common sense that it should not be higher than 200 beats/minute and should be greatly individualized for the child and activity.
Questions for Further Discussion
1. What types of resistance training is recommended for overall fitness?
2. What types of flexibility training is recommended for overall fitness?
3. What other tips do you have to help patients and families to improve their physical activity?
Related Cases
- Symptom/Presentation: Health Maintenance and Disease Prevention
- Specialty: Cardiology / Cardiovascular-Thoracic Surgery | General Pediatrics | Orthopaedic Surgery and Sports Medicine
- Age: Young Adult
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Exercise and Physical Fitness and Exercise for Children.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
ACSM Position Stand on The Recommended Quantity and Quality of Exercise for Developing and Maintaing Cardiorespiratory and Muscular Fitness, and Flexility in Adults. Med Sci Sports Exerc. 1998:30(6);975-991. Available from the Internet at http://www.mhhe.com/hper/nutrition/williams/student/appendix_i.pdf (rev. 1998, cited 10/15/13).
Epstein LH, Paluch RA, Kalakanis LE, Goldfield GS, Cerny FJ, Roemmich JN. How much activity do youth get? A quantitative review of heart-rate measured activity. Pediatrics. 2001 Sep;108(3):E44.
Plante TG, Gustafson C, Brecht C, Imberi J, Sanchez J. Exercising with an iPod, friend, or neither: which is better for psychological benefits? Am J Health Behav. 2011 Mar-Apr;35(2):199-208.
Castelli DM, Hillman CH, Hirsch J, Hirsch A, Drollette E. FIT Kids: Time in target heart zone and cognitive performance. Prev Med. 2011 Jun;52 Suppl 1:S55-9.
Kraft JA, Russell WD, Bowman TA, Selsor CW 3rd, Foster GD. Heart rate and perceived exertion during self-selected intensities for exergaming compared to traditional exercise in college-age participants. J Strength Cond Res. 2011 Jun;25(6):1736-42.
Melone L. The Heart Rate Debate. American College of Sports Medicine. Available from the Internet at http://www.acsm.org/access-public-information/articles/2012/01/13/the-heart-rate-debate (rev. 1/13/2012, cited 10/15/13).
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Pediatric Education 