Patients know that regular exercise is important but often need guidance on what's best. A pulmonologist advises on how to asses individual needs, utilize guidelines, and create a plan.
Cardiovascular (CV) exercise can be broken down into 3 components: Frequency, duration, and intensity. While frequency and duration are self-explanatory, intensity could use clarification because the scale is either moderate (increases heart and respiratory rates while allowing for conversation) or vigorous (increases heart and respiratory rates making talking difficult).
What do the guidelines say? The CDC1 and HSS2 have competing guidelines, however, both recommend strength training twice a week (eg, weights, yoga, Pilates, or core-building exercises). Guidelines do not take the type of exercise into consideration. International guidelines from the United Kingdom and Germany mirror the HSS guidelines.3,4
My conversation with a patient always drills down to what type of exercise is planned. Healthy patients with no joint issues will often run or walk briskly, which can be done either outside or on a treadmill. The varying terrain with outdoor exercise ensures foot strikes are not always the same vs the treadmill where the foot strike pattern does not change, causing joints to wear harder. If a patient does plan to exercise outside, however, dissuade them from running on concrete; dirt trails or grass offer a softer surface that is easier on joints.
Does your patient want to get into a vigorous exercise zone? Prescribe stair climbing and cardio exercises. Does your patient have pre-existing joint pain? Limit them to stationary bicycles (spinning), elliptical trainers, or swimming. Swimming is the most efficient total-body exercise that is the easiest on joints. However, people are either swimmers or they are not (I have yet to convert someone into a swimmer from my practice).
Heart-rate-based training is not considered in the national guidelines, but is often used in time circuit training, so questions will come up in clinical practice. The general goal is to keep the heart rate between 55% and 85% of the maximum. Maximum heart rate is calculated as 220 minus one’s age. For example, if a 30-year-old patient's maximum heart rate is 190 beats/min, then 55%-85% of 190 makes the target range 105-162 beats/min. This is a large range, so the intensity could be moderate at the low end or vigorous at the high end.
Counting steps with wearable mobile devices is another way patients quantify their exercise and set goals. There is limited data and the national guidelines have yet to address step counting. Smaller guidelines have tackled this issue and their recommendations can be folded into the broader CV goals previously described. The total step recommendation is 10 000 per day, which is derived from normative data that shows a healthy adult walks 4000 to 18 000 steps/day; of those steps, 3000 should be at moderate exercise intensity (100 steps/min or 30-min brisk walk/day).5
The finished exercise plan should include type, frequency, duration, and intensity. A healthy beginner could run 3, 10-min miles 3x/week and attend 2 Pilates classes. Or the same person could count steps and take 3, 30-min brisk walks and 2 yoga classes/week. An advanced patient could take 2, 60-minute cardio classes, lift weights 1x/week, and take a long run on the weekends. Elite athletes have exercise regimens that go far beyond the national guidelines. The fundamental concept to keep in mind when planning a program is that any exercise is better than none, and there are additional benefits with more activity.
Take Home Messages. According to the CDC, the minimum exercise per week is 60 mins of vigorous exercise and 2 rounds of strength training; CV exercise plan includes type, frequency, duration, intensity; while most time spent is on CV exercise, remind patients to not forget about strength training; there is a dose-response relationship between exercise and health
Dr Schroeder is Clinical Instructor of Medicine at UCLA, David Geffen School of Medicine and Clinical Chief of Pulmonary and Critical Care Medicine, Emeritus, at Cedars-Sinai Medical Center.
1. American College of Sports Medicine, American Heart Association, Haskell WL, et al. Physical activity and public health: Updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Circulation. 2007;116:1081-1093.
2. Piercy KL, Troiano RP, Ballard RM, et al. The physical activity guidelines for Americans. JAMA. 2018;320:2020-2028.
3. O'Donovan G, Blazevich AJ, Boreham C, et al. The ABC of physical activity for health: A consensus statement from the British Association of Sport and Exercise Sciences. J Sports Sci. 2010;28:573-591.
4. FÃ¼zÃ©ki E, Vogt L, Banzer W. German national physical activity recommendations for adults and older adults: Methods, database and rationale. Gesundheitswesen. 2017;79:S20-S28.
5. Tudor-Locke C, Craig CL, Brown WJ, et al. How many steps/day are enough? For adults. Int J Behav Nutr Phys Act. 2011;8:79.
People who regularly exercise feel better, function at higher levels, and reduce their risk of chronic disease. During conversations with my patients, they want to know what type of exercise and how much they need to do per week to make health gains. Often physicians do not know how to answer these questions. And while exercise guidelines aim to improve and maintain health, there are numerous national and international guidelines which can lead to confusion.In this short slide show, I offer recommendations for building individual cardiovascular exercise routines that are based on assimilation of the various guidelines while keeping the same fundamental principle in mind: There is a dose-response relationship between physical activity and health.