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NEWS
J A N U A RY — M A R C H ,
2 0 1 2
•
V O L U M E
Online Tips and Tools
for Exercise Professionals
PART 2:
Resistance Training
During Pregnancy PAGE 4
Can Phytochemicals
Improve Athletic
Performance? PAGE 6
Social Disparities in
Coronary Heart Disease
PAGE 8
Research on Enhancing
Muscle/Strength
Development Through
Supplemental
Protein/Carbohydrate
Ingestion PAGE 11
PART 1:
Heart Sounds
PAGE 12
Continuing Education
Self-Tests on page 15
2 2 :
PAGE 3
I S S U E
1
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ACSM’S CERTIFIED NEWS
January–March 2012 • Volume 22, Issue 1
In this Issue
Online Tips and Tools for Exercise
Professionals.......................................................... 3
Part 2: Resistance Training During Pregnancy ..... 4
Can Phytochemicals Improve
Athletic Performance?........................................... 6
Social Disparities in Coronary Heart Disease ........ 8
Coaching News............................................................10
Research on Enhancing Muscle/Strength
Development Through Supplemental
Protein/Carbohydrate Ingestion................................11
Part 1: Heart Sounds....................................................12
Self-Tests ........................................................................15
Co-Editors
Peter Magyari, Ph.D.
Peter Ronai, M.S., FACSM
Committee on Certification
and Registry Boards Chair
Deborah Riebe, Ph.D., FACSM
CCRB Publications Subcommittee Chair
Paul Sorace, M.S.
ACSM National Center Certified News Staff
National Director of Certification
and Registry Programs
Richard Cotton
Assistant Director of Certification
Traci Sue Rush
Publications Manager
David Brewer
Editorial Services
Lori Tish
Angela Chastain
Editorial Board
Chris Berger, Ph.D., CSCS
Clinton Brawner, M.S., FACSM
James Churilla, Ph.D., MPH
Ted Dreisinger, Ph.D., FACSM
Avery Faigenbaum, Ed.D., FACSM
Riggs Klika, Ph.D., FACSM
Tom LaFontaine, Ed.D., FACSM
Thomas Mahady, M.S.
Paul Sorace, M.S.
Maria Urso, Ph.D.
David Verrill, M.S.
Stella Volpe, Ph.D., FACSM
Jan Wallace, Ph.D.
For More Certification Resources Contact the
ACSM Certification Resource Center:
1-800-486-5643
Information for Subscribers
Correspondence Regarding Editorial Content
Should be Addressed to:
Certification & Registry Department
E-mail: certification@acsm.org
Tel.: (317) 637-9200, ext. 115
For back issues and author guidelines visit:
http://certification.acsm.org/certified-news
Change of Address or Membership Inquiries:
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Tel.: (317) 637-9200, ext. 139 or ext. 136.
ACSM’s Certified News (ISSN# 1056-9677) is published
quarterly by the American College of Sports Medicine
Committee on Certification and Registry Boards (CCRB). All
issues are published electronically and in print. The articles
published in ACSM’s Certified News have been carefully
reviewed, but have not been submitted for consideration as, and
therefore are not, official pronouncements, policies,
statements, or opinions of ACSM. Information published in
ACSM’s Certified News is not necessarily the position of the
American College of Sports Medicine or the Committee on
Certification and Registry Boards. The purpose of this
publication is to provide continuing education materials to the
certified exercise and health professional and to inform these
individuals about activities of ACSM and their profession.
Information presented here is not intended to be information
supplemental to the ACSM’s Guidelines for Exercise Testing and
Prescription or the established positions of ACSM. ACSM’s
Certified News is copyrighted by the American College of
Sports Medicine. No portion(s) of the work(s) may be
reproduced without written consent from the Publisher.
Permission to reproduce copies of articles for noncommercial
use may be obtained from the Certification Department.
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© 2012 American College of Sports Medicine.
ISSN # 1056-9677
2
NOTES FROM
THE ACSM CERTIFIED
PERSONAL TRAINER
COMMITTEE
®
Tom Spring, M.S., ACSM CPT/HFS/CES, FAACVPR,
ACSM CPT Committee Chair
As the fitness industry continues to evolve and develop into a prominent profession for both
fitness enthusiasts and athletes, a newer generation of personal trainers is emerging. Those who
work with the general public, many of whom have some chronic health concerns, are being
solicited for services to accompany and augment physician recommendations and advice related
to health and physical activity. This evolution, although expected, requires some adjustments within the field from both a professional and an educational standpoint.
The committee responsible for overseeing ACSM’s Certified Personal Trainer® (ACSM CPT)
certification has taken this to heart and recognizes the importance of preparing our trainers
appropriately. Although there are numerous options for aspiring and qualified trainers, our mission is to provide a credential consistent with medical and public health guidelines whenever
appropriate and to challenge candidates to be the best trainers possible to meet this increasing
demand. Whether from a preventive or management standpoint, ACSM trainers are being asked
to raise the bar and stand on the front lines of several public health concerns. Obesity management, chronic disease prevention through lifestyle and behavior change, and identifying and managing risk among those who are reaching ages where chronic disease is prevalent are key areas
of focus for the ACSM CPTs. In response to this evolution, ACSM CPT study resources and guides
are being updated with the most current information available and presented at a level consistent
with our candidates. Look for updates in resources and materials published by ACSM.
In addition, focus on resistance training and the role that coaching and behavior change play in
the personal trainer’s daily life have been discussed and examined. We feel some of the needs of
trainers currently in practice are being reflected in the evolution of the ACSM CPT credential.
Recently, ACSM CCRB committees underwent an exhaustive process of redetermining what
actually happens within several fields related to exercise science, including the personal trainer.
This process, called a Job Task Analysis, led to an overhaul of the credentialing exam and
ultimately the certification process as a whole. Working with our workshop and education
providers, the CPT committee is committed to providing the best possible education for personal trainers and working with other ACSM credentials to ensure the highest level certification possible with the scope defined as a personal trainer. Based on this process and other discussions,
ACSM is progressively increasing educational opportunities, certificate programs, and even certifications to help advance the professionals we serve.
I’m pleased to announce that the ACSM CPT has had its most successful year to date with
more than 4,000 new ACSM CPTs—a great sign of industry growth and exposure for the College.
In addition, the CPT committee has supported the evolution of a new professional designation:
the Exercise is Medicine® credential, which will further acknowledge the ACSM CPT as a leader
in an ever-changing and challenging market place. ACSM’s CPT committee members are proud
to represent this exciting, rapidly growing and evolving field for ACSM and trust that our process
and decisions will continue to both challenge and set the standard for the industry.
ACSM’S CERTIFIED NEWS • JANUARY–MARCH 2012 • VOLUME 22: ISSUE 1
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WELLNESS ARTICLE
ONLINE TIPS AND TOOLS FOR
EXERCISE PROFESSIONALS
By Peter Ronai, M.S., FACSM, RCEP, CES, PD, CSCS-D
Exercise practitioners interested in obtaining current health, medical,
and science information have a number of reputable electronic
resources and tools available to them. As in previous issues of ACSM’s
Certif ied News, this Online Tips and Tools for Exercise
Professionals article will discuss an electronic resource which exercise
professionals can access for free and obtain immediate benefits from.
Exercise Prescription on the Net (www.exrx.net) is a free resource for
the exercise practitioner, student, educator, or person preparing to take
a health/fitness or clinical exercise industry certification and credentialing examination, like those developed and administered by ACSM.
Exercise Prescription on the Net features comprehensive exercise
libraries (>1,300 exercises), fitness assessment calculators, reference
articles, instructional video clips, and educational lectures and diagrams.
On the left side of the homepage for the site, 17 interactive links are displayed. These links provide Exercise Prescription on the Net users with
instant access to science-based and practical information, instructions,
tutorials, and interactive tables, and tools:
• Beginner’s Page
• Exercise Instruction
• Weight Lifting
• Kinesiology
• Aerobic Conditioning
• Exercise Information
• Fitness Testing
• Weight Management
• Diet and Nutrition
• Psychology
• Anabolic Steroids
• Body Building
• Questions/Comments
• Fitness Calculators
• Audio Interviews
• Software Solutions
• ExRx.net Store
The applied anatomical muscle charts, mechanics, and clinical implications links included within the "Kinesiology" section provide excellent
practical, didactic, and visual learning tools, as do all sections of this Web
site. Viewers can play videos of exercises in slow motion or freeze the
video clips while they are playing them. They also can access a series of
stop-action photographs of exercises displayed on videos. This can
enhance learning or teaching of complex skills like Olympic-style
weightlifting and plyometrics.
The "Fitness Testing" section provides thorough descriptions, photographs, step-by-step illustrations, and scoring calculators and norm scoring tables for numerous medical and health-related tests, as well as clinical, functional, and performance-based assessments for persons of all
ages.
In addition, section links within the “Weight Training” section regarding resistance exercise program development, periodization and corrective exercise interventions provide very accurate and useful tools, visual
representations, and information regarding exercise program design and
progression. Each of the section links on the homepage provides multiple links to similar resources.
Exercise Prescription on the Net is a National Strength and
Conditioning Association (NSCA) authorized CEU provider. Exercise
Prescription on the Net viewers can enhance their certification examination preparedness by using the link "Study Modules" from the homepage.
Exercise Prescription on the Net is an informative Web site that contains useful and practical materials and tools for educators, students,
exercise professionals, and persons preparing to take professional exercise practitioner certification and credential examinations.
About the Author
Peter Ronai, M.S., FACSM, RCEP, CES, PD, CSCS-D, is
a clinical assistant professor in the Exercise Science
Department at Sacred Heart University in Fairfield
Connecticut. He is a clinical exercise physiologist and
previously was manager of Community Health at the
Ahlbin Rehabilitation Centers of Bridgeport Hospital
in Connecticut and an adjunct professor in the
Exercise Science Department at Southern Connecticut
State University. He is a Fellow of the American College of Sports Medicine
(ACSM). He is past-president of the New England Chapter of ACSM (NEACSM), past member of the ACSM Registered Clinical Exercise Physiologist
(RCEP) Practice Board, Continuing Professional Education Committee, and
current member of the ACSM Publications sub-committee. He is also the
Special Populations column editor for the National Strength and
Conditioning Association's Strength and Conditioning Journal (SCJ) and
a co-editor of ACSM's Certified News.
Reference
1. Exercise Prescription on the Web (ExRx.net) Web site. Health (NHLBI/NIH)
Web site. http://exrx.net/index.html Accessed July 7, 2011
ACSM’S CERTIFIED NEWS • JANUARY–MARCH 2012 • VOLUME 22: ISSUE 1
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HEALTH & FITNESS FEATURE
PART 2: RESISTANCE
TRAINING
DURING PREGNANCY
Resistance training is known to improve muscular strength, is associated with improvements in activities of daily living, preventing disease,
and is recommended by public health organizations.10,12,15,16 Many trainers do not know if resistance training is safe during pregnancy. This is
due, in part, to the fact that most women who participate in resistance
training while pregnant also are doing aerobic exercise. Resistance training is defined as a specialized method of conditioning that involves the
progressive use of a wide range of resistive loads, including body mass,
and a variety of training modalities designed to enhance health, fitness,
and sports performance. During pregnancy, the main goals of resistance
training should focus on making muscles stronger, preventing aches and
pains common to pregnancy,1 and preparing for labor and delivery.
Prior to an appointment, trainers should review absolute and relative
contraindications to exercise during pregnancy, as well as when to stop
an exercise session (1). At the beginning of the appointment, a pregnant
client should complete the PARmed-X, a free questionnaire (found at
www.csep.ca/forms.asp or in ACSM’s Guidelines for Exercise
Testing and Prescription, eighth edition) to determine a woman’s
health status.2,11 You also should identify your pregnant client’s goals for
exercising. Always maintain the physician’s release for exercise with the
client’s file. Once you have established your client’s fitness level and
goals, you can develop an appropriate program.
Main Issues with Resistance
Training while Pregnant
There are four main reasons that the use of weights during pregnancy can be risky. First and foremost is the potential for abdominal trauma
from the barbells and dumbbells. For this reason, a woman who is pregnant typically should not exercise with free weights, particularly if she
does not have previous experience using them appropriately and safely.
Moreover, a woman who has experience using free weights should do
so with extreme caution, to make sure there is absolutely no chance for
a weight to hit or fall on her abdomen. A second issue is breathing while
lifting heavy weights. The Valsalva Maneuver is caused by bearing down
while holding your breath. Since it is not known if this maneuver causes
increased cardiovascular stress to the mother and potential harm on the
baby, women must not do this when they are lifting weights. Thirdly,
pregnant women should avoid lifting heavy resistance or performing ballistic movements. Since pregnancy is associated with joint laxity, it is
imperative to use safe amounts of weight, and controlled movements to
eliminate the potential for harm. Lastly, the supine position should be
avoided past the 13th gestational week. In order to maintain appropriate
venous return to the heart, pregnant women should either lie on an
incline, or on their left side. Exercises that traditionally are done lying
down can be modified and performed on an incline, side, or seated position. For instance, a leg curl can be performed in a seated or standing
position. They also can be performed with the head above the feet, as
in performing an upright crunch. In addition, sit-ups and crunches can be
done on an incline, the side, or even seated. Resistance exercises can be
performed safely during pregnancy, but always make sure your client has
physician approval.
4
By Linda May, Ph.D.
Benefits of Regular Strength
Training while Pregnant
Recent research indicates that participating in resistance training during pregnancy can be beneficial for mother and baby. With a proper
diet, resistance training throughout gestation can lead to decreased
maternal weight gain,4 improved strength and flexibility,6 improved selfimage,9 and decreased symptoms of pregnancy.9,13 In three recent studies, participation in light resistance and toning exercise had no effect on
type of labor and delivery,5,6 but participation in strength training with
aerobic activity during pregnancy decreased cesarean sections required
during delivery.9 Additionally, maternal strength training either caused
no adverse effects or in some cases contributed to better overall maternal health. Research has shown that oxygen availability is preserved during maternal weight lifting.3 Studies have indicated that there are no differences in birth measures (e.g., birth weight, length, Apgar scores)
between babies born to mothers who practiced maternal strength training4,9 and those who did not, respectively. However, there was a dose
response trend toward improved Apgar scores in babies whose mothers participated in greater amounts of strength training, coupled with
aerobic exercise9. Preliminary findings indicate that maternal participation in intermittent activity (strength training, yoga) is associated with
improved fetal cardiac autonomic control (May LE, Suminski RS,
Gustafson KM, unpublished data, 2012). This finding is similar to the
exercise training response seen in an adult study utilizing light prenatal
resistance training failed to detect difference in birth weight or length4
between babies whose mothers performed strength training and those
born to mothers in the control group. The caveat of these research findings is that exercise intensity, time, frequency, and type each will affect
the magnitude of outcomes experienced during a training program.
Current Strength Training Recommendations
Although the American Congress of Obstetrics and Gynecology
(ACOG) states that participation in a range of recreational activities is
safe for pregnant women, ACOG and the American College of Sports
Medicine (ACSM) guidelines specifically addressing resistance training
are lacking. The joint Society of Obstetricians and Gynecologists of
Canada (SOGC) and the Canadian Society for Exercise Physiology
(CSEP) recommend women in uncomplicated pregnancies participate in
aerobic and strength-conditioning exercises7. The current guideline in
healthy pregnancies is to participate in 30 minutes or more of moderate to vigorous exercise, 3 or more days a week. This can include
strength training exercises, but most likely is referencing aerobic exercise. The lack of clarity as it relates to strength training during pregnancy most likely is due to the limited amount of research in the area.
There are four main components to a strength training program during pregnancy. The first component consists of the warm-up session.
The warm-up session can last from 5 to 10 minutes and consist of slow
walking or cycling.4,8,9,13,14 The second component is the strength and toning session. The resistance session can last between 20 and 45 minutes
depending on the number of exercises chosen and can vary from 4 to
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12 exercises.4,8,9,13,14 Regardless of the number of exercises chosen, all
programs should focus on the major muscle groups: quadriceps, hamstrings, back, chest, deltoid, triceps, biceps, and calf muscles.4,8,9,13,14
Although the number of sets per exercise differs between 1 and 3, all
studies suggest repetitions of 10 to 15.4,8,9,13,14 Exercise intensity should
be monitored throughout the session, using the ratings of perceived
exertion scale (RPE). On the 6 to 20 RPE scale, pregnant women should
aim for 13 (somewhat hard) since this represents a moderate intensity
level.4,8,9,13,14 Resistance exercise frequency should be 2 to 3 times per
week.4,8,9,13,14 In recent studies, resistance exercise sessions have been
done with light barbells, weight machines, and resistance bands (e.g.,
elastic bands, Theraband). In some instances, heavier weights and resistance may be well tolerated in both athletic women and those who have
been exercising with heavy weights prior to and throughout their pregnancies.4,9,14
Some studies included a third component of core training with the
resistance training. The core is important in maintaining a pregnant
woman’s posture due to her center of gravity changing. The core also is
important in regard to the labor and delivery process. The core is an
essential area, but it is often overlooked during training. Abdominal
exercises can be done at an angle, on the side, seated, or standing. The
studies that included core training specifically used 8 to 12 repetitions,
with 1 to 2 sets, slow and controlled movements, and ensured proper
exercise breathing techniques.4,13 This portion can last up to 20 minutes.4
The final component of the resistance training routine is the cool
down and stretching period. Either slow walking or slow, steady stretching of major muscle groups can be done. This session should last about
5 to 10 minutes4,14 and allow time for maternal heart rate to return to
pre-exercise levels.
As always, a pregnant woman should feel relatively comfortable in her
workout environment. She should exercise in a comfortable temperature. Prior to, during, and after her workout she must stay hydrated,
along with consuming a well-balanced diet. During exercise, it is important
to wear clothing that will allow unrestricted movements, and also provide
support for her abdomen and breast tissue. It also is safest to have someone else present to supervise or assist during workout activities.
Following these points will help ensure a safe and healthy pregnancy.
Summary
Resistance training is an important part of an exercise routine, even
during pregnancy. You and your client must determine their current fitness level, establish appropriate goals, document health care provider
permission, and maintain progress notes throughout the pregnancy.
Ensure client safety by: enforcing proper breathing and exercise techniques, implementing appropriate exercise modifications, and monitoring exercise responses for signs and symptoms of exercise intolerance.
Resistance training alone, or in combination with aerobic exercise, is safe
and even beneficial for mother and baby. An appropriate routine for
pregnancy consists of four components: warm-up, strength/toning, core
training, and a cool down. Make sure to choose a frequency (2 to 3
times per week), intensity (RPE scale 13 or less), time (30 to 60 minutes
per session), and type of exercise and equipment appropriate for your
pregnant client’s fitness level, and goals. Ensure that your client is hydrated, comfortable, and safe during all exercises. Most importantly, participating in a regular exercise program, which includes aerobic and anaerobic exercises, will maximize the benefits during pregnancy, labor and
delivery, and possibly afterwards.
About the Author
Linda May, Ph.D., an assistant professor
at Kansas City University of Medicine
and Biosciences, teaches histology, gross
anatomy, and physiology to graduate and
medical students. Her research looks at
effects of exercise during pregnancy on
fetal/neonatal heart and autonomic
nervous system development. Away from
work, she enjoys time with her family,
exercising, gardening, cooking, and
baseball.
References
1. ACOG Committee opinion. Number 267, January 2002: exercise during
pregnancy and the postpartum period. Obstet Gynecol. 2002;99(1):1713.
2. ACSM’s Guidelines for Exercise Testing and Prescription, eighth edition. Baltimore (MD): Lippincott Williams and Wilkins; 2010. p. 186-7.
3. Avery ND, Stocking KD, Tranmer JE, Davies GA, Wolfe LA. Fetal
responses to maternal strength conditioning exercises in late gestation. Canadian journal of applied physiology (Revue canadienne de
physiologie appliquee). 1999;24(4):362-76.
4. Barakat R, Lucia A, Ruiz JR. Resistance exercise training during pregnancy and newborn’s birth size: a randomised controlled trial.
International journal of obesity. 2009;33(9):1048-57.
5. Barakat R, Ruiz JR, Stirling JR, Zakynthinaki M, Lucia A. Type of delivery
is not affected by light resistance and toning exercise training during
pregnancy: a randomized controlled trial. American journal of obstetrics and gynecology. 2009;201(6):590 e1-6.
6. Clapp JF, 3rd. Exercise during pregnancy. A clinical update. Clin Sports
Med. 2000;19(2):273-86.
7. Davies GA, Wolfe LA, Mottola MF, MacKinnon C. Joint SOGC/CSEP
clinical practice guideline: exercise in pregnancy and the postpartum
period. Canadian journal of applied physiology (Revue canadienne de
physiologie appliquee). 2003;28(3):330-41.
8. de Barros MC, Lopes MA, Francisco RP, Sapienza AD, Zugaib M.
Resistance exercise and glycemic control in women with gestational
diabetes mellitus. American journal of obstetrics and gynecology.
2010;203(6):556 e1-6.
9. Hall DC, Kaufmann DA. Effects of aerobic and strength conditioning
on pregnancy outcomes. Am J Obstet Gynecol. 1987;157(5):1199-203.
10. Haskell WL, Lee IM, Pate RR, et al. Physical activity and public health:
updated recommendation for adults from the American College of
Sports Medicine and the American Heart Association. Medicine and
science in sports and exercise. 2007;39(8):1423-34.
11. Kaufman C, Berg K, Noble J, Thomas J. Ratings of perceived exertion of
ACSM exercise guidelines in individuals varying in aerobic fitness.
Research quarterly for exercise and sport. 2006;77(1):122-30.
12. Kushi LH, Byers T, Doyle C, et al. American Cancer Society Guidelines
on Nutrition and Physical Activity for cancer prevention: reducing
the risk of cancer with healthy food choices and physical activity. CA
Cancer J Clin. 2006;56(5):254-81; quiz 313-4.
13. O’Connor PJ, Poudevigne MS, Cress ME, Motl RW, Clapp JF, 3rd.
Safety and efficacy of supervised strength training adopted in pregnancy. J Phys Act Health. 2011;8(3):309-20.
14. Oostdam N, van Poppel MN, Eekhoff EM, Wouters MG, van Mechelen
W. Design of FitFor2 study: the effects of an exercise program on
insulin sensitivity and plasma glucose levels in pregnant women at
high risk for gestational diabetes. BMC pregnancy and childbirth.
2009;9:1.
15. Williams MA, Haskell WL, Ades PA, et al. Resistance exercise in individuals with and without cardiovascular disease: 2007 update: a scientific
statement from the American Heart Association Council on Clinical
Cardiology and Council on Nutrition, Physical Activity, and
Metabolism. Circulation. 2007;116(5):572-84.
16. Wolfe RR. The underappreciated role of muscle in health and disease.
The American journal of clinical nutrition. 2006;84(3):475-82. also
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WELLNESS ARTICLE
CAN PHYTOCHEMICALS IMPROVE
ATHLETIC PERFORMANCE?
By Benjamin T. Gordon, M.S., CES, CSCS
Lifestyle factors significantly impact athletic performance, and one of the principal behavioral factors is an athlete’s diet.
Proper food choices often can mean the difference between winning and losing. Because of the influential role diet plays in
an athlete’s performance, knowing what foods can positively affect performance and why is essential. Recent scientific
information has defined that some specific plant-derived food provides more sports performance benefits than other food.
These recent discoveries are due to a large influx of plant-derived food
nutrition intervention studies; however, most of these studies were
designed for evaluating nutrition change and chronic disease prevention,
not sports performance. A few studies, however, now have been published where athletic performance outcomes are directly measured. The
various interventional treatments used in these studies fluctuated in
chemical composition and nutritional content. Nevertheless, there is an
intriguing common link: all treatments were derived from plants having
large amounts of phytochemicals. The remaining question is, however:
do phytochemicals provide a food source for enhancing athletic
performance?
What are Phytochemicals?
Phytochemicals are a group of chemical compounds produced naturally by plants. As secondary metabolites, these substances function
as the plant’s natural defense against disease and infection7.
“Phytochemical” actually is a general term describing a non-nutrient
that offers no energy-based value in human diets. The potential benefit for consumption lies in their ability to modulate cellular activity.
Unlike vitamins and minerals, there is no regulated recommended
daily amount established for phytochemicals.
Among the various phytochemicals, the most important differentiating factor facing consumers is the effects these compounds elicit
within the body. As previously stated, the effects are generated
chiefly through the phytochemical’s ability to modulate cellular activity. Originally, phytochemicals were sought after by athletes because
of their antioxidant characteristics.8 Free radicals produced during
exercise can contribute to muscle fatigue. The free radicals and associated fatigue were thought to be reduced by antioxidants.
Nonetheless, recent scientific evidence has shown the fatigue-reducing ability of antioxidants illusory.8 Aside from antioxidants, phytochemicals have been touted as anti-inflammatory agents, mitochondrial boosting agents, central nervous system stimulants, anti-microbial,
anti-viral, cancer fighting agents, and even anti-aging agents. Many of
these effects could have major applications in sports performance.
However, even if phytochemicals are shown to enhance athletic performance, thousands of these compounds exist, and sport performance improvement to this point has been studied only in a select few.
Much of the current research has examined three phytochemicals:
curcumin, quercetin, and resveratrol. The remainder of this article is
focused on known information regarding these phytochemicals and
their ability to improve sports performance.
6
Curcumin
Curcumin (diferuloylmethane) is a component of the herb
Curcuma longa (Tumeric) and has gained fame in the realm of enhancing sports performance because of its anti-inflammatory properties.
Curcumin’s anti-inflammatory characteristics have been extorted
medically in Asia for centuries.1 With respect to exercise, anti-inflammatory supplements are thought to provide important benefits, especially for older athletes. These individuals tend to have greater
amounts of joint inflammation and are known to take multiple supplements to alleviate the pain and to avoid prescription medications.
Funk et al., 4 using an arthritis rat model, found that curcumin prevented joint inflammation and improved locomotion capability.4 In 2007,
Davis et al. 3 examined the effects of curcumin during recovery following a downhill running protocol in mice. They reported that curcumin significantly improved performance recovery, while decreasing
muscle damage induced by inflammation.
Quercetin
Quercetin is a flavonoid (subclass of phyotchemical), found in a
variety of fruits and vegetables and is most concentrated in apples,
onions, and berries.7 Quercetin has been the focus of more sports
performance based research than any other phytochemical. With
increased popularity, quercetin has exploded as a marquee ingredient
in ergogenic aids. The most significant proposed effects of quercetin
are its ability to increase mitochondria number and improve mitochondrial function resulting in improved endurance performance. The
evidence that supports this claim results from a handful of sources.
Davis et al. 2 found that supplementing quercetin for two weeks
improved both O2max, and time to fatigue on a bicycle ergometer
test performed by healthy untrained men and women. Concordantly,
MacRae et al. 6 reported that a commercial beverage, which contained
quercetin, improved bike time trial performance in highly trained
cyclists. Conversely, studies do exist that report no performance
improvement with quercetin use. For example, Quindry et al. 9
reported quercetin supplementation had no effects upon performance time at the Western States 100-mile road race.
Resveratrol
Resveratrol is a stilbene (another subclass of phytochemical) and has
many less edible food sources than the other phytochemicals. The primary source of resveratrol is from the skins of grapes. As a result, the
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primary resveratrol food source for humans is wine. This is the main reason this rare phytochemical has been studied so zealously. Resveratrol
was once thought of as the missing link in the “French paradox”: an
observation that people from France consume more saturated fats than
Americans, yet they have a lower incidence of heart disease. French
wine consumption is hypothesized as a factor for their lower heart disease rates.11 Regardless of the validity of resveratrol causing the paradox, resveratrol has shown promise for improving endurance performance much in the same manner as quercetin. Lagouge et al. 5 found that
resveratrol improved markers of aerobic capacity and time to fatigue in
mice. They also found that resveratrol reduced the negative effects of a
high fat diet. Sun et al.10 replicated the findings for improved endurance
performance induced by resveratrol supplementation.
Summary
Curcumin, quercetin, and resveratrol all show promising results for
positively affecting athletic performance. However, much evidence is
needed before considering phytochemicals as a beneficial human
ergogenic aid. Most research is in preliminary stage development and
lacks proper clinical translation. Truly establishing the long-term
effects of any supplement for human consumption is a long and
daunting task. Before phytochemicals are considered as standards in
human supplementation, further research of these products in placebo-controlled, randomized controlled clinical trials is needed to
ensure safety and to maximize potential benefits.
ABOUT THE AUTHOR
Benjamin T. Gordon, M.S., CES, CSCS, is currently
pursuing a Ph.D. in applied physiology from the
University of South Carolina. He is also an
investigator in the Psychoneuroimmunology and
Nutrition Lab directed by J. Mark Davis, Ph.D., at the
University of South Carolina.
References
1. Aggarwal BB, Harikumar KB. Potential therapeutic effects of curcumin, the anti-inflammatory agent, against neurodegenerative, cardiovascular, pulmonary, metabolic, autoimmune and neoplastic diseases. International Journal of Biochemical Cell Biology
2009;41:40-59.
2. Davis JM, Murphy EA, Carmichael MD. Effects of the dietary
flavonoid quercetin upon performance and health. Current Sports
Medicine Reports 2009;8:206-13.
3. Davis JM, Murphy EA, Carmichael MD, et al. Curcumin effects on
inflammation and performance recovery following eccentric exercise-induced muscle damage. American Journal of Physiology,
Regulatory, Integrative and Comparative Physiology
2007;292:R2168-73.
4. Funk JL, Oyarzo JN, Frye JB, et al. Turmeric extracts containing curcuminoids prevent experimental rheumatoid arthritis. Journal
Natural Products 2006;69:351-5.
5. Lagouge M, Argmann C, Gerhart-Hines Z, et al. Resveratrol
improves mitochondrial function and protects against metabolic
disease by activating SIRT1 and PGC-1alpha. Cell 2006;127:1109-22.
6. MacRae HS, Mefferd KM. Dietary antioxidant supplementation combined with quercetin improves cycling time trial performance.
International Journal of Sport Nutrition and Exercise Metabolism
2006;16:405-19.
7. Manach C, Scalbert A, Morand C, Remesy C, Jimenez L.
Polyphenols: food sources and bioavailability. Am J Clin Nutr
2004;79:727-47.
8. Powers SK, Jackson MJ. Exercise-induced oxidative stress: cellular
mechanisms and impact on muscle force production. Physiolical
Reviews 2008;88:1243-76.
9. Quindry JC, McAnulty SR, Hudson MB, et al. Oral quercetin supplementation and blood oxidative capacity in response to ultramarathon competition. International Journal of Sports Nutrition and
Exercise Metaboblism 2008;18:601-16.
10. Sun M, Qian F, Shen W, et al. Mitochondrial nutrients stimulate
performance and mitochondrial biogenesis in exhaustively exercised
rats. Scandinavian Journal of Medicine and Science in Sports.
[Epub ahead of Print]
11. Wu JM, Hsieh TC. Resveratrol: a cardioprotective substance. Annals
of the New York Academy of Sciences;1215:16-21.
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CLINICAL FEATURE
SOCIAL DISPARITIES IN
CORONARY HEART DISEASE
By Clinton A. Brawner, M.S., RCEP, FACSM
Cardiovascular disease, which includes coronary heart disease
(CHD), heart failure, cerebrovascular disease, and peripheral vascular
disease, is the leading cause of death among both men and women in
the United States with an overall death rate in 2007 of 251 per
100,000 deaths.10 This represents approximately 1 out of every 3
deaths in the United States.10 CHD alone accounts for approximately
1 out of every 6 deaths in the United States.10 While mortality and
morbidity due to CHD have declined over the past 50 years, the
degree of improvement has not been observed equally in all subgroups. This paper will briefly review social disparities in the epidemiology of CHD and the utilization of cardiac rehabilitation.
Epidemiology of Coronary
Heart Disease
Based on data from the 2005 to 2006 and 2007 to 2008 National
Health and Nutrition Examination Surveys (NHANES), the prevalence of CHD is 7.0% among adults (≥20 years) in the United States;
8.3% among men and 6.1% among women. The prevalence of CHD
tends to be higher among non-Hispanic whites and the greatest discrepancy between genders is observed in this group. The lowest
prevalence is among American Indians/Alaska Natives. The smallest
discrepancy between genders is among non-Hispanic blacks. Within
the United States, the highest prevalence of CHD is in Virginia (6.5%)
and the lowest is in the District of Columbia (1.9%).
The annual death rate due to CHD in the United States is 191 per
100,000 deaths.2 Death rates due to CHD are highest in men and
non-Hispanic blacks.10 Mortality due to CHD decreased 59% between
1950 and 1999 and decreased 26% between 1997 and 2007.10
Although the overall mortality and morbidity due to CHD continues
to decline, disparities in both of these measures persist.7 Between
1985 and 1999, the largest reductions in CHD mortality were
observed in white men, with smaller reductions observed in women
and other race and ethnic groups.6 It is estimated that 47% of the
reduction in CHD deaths is due to improved treatment strategies for
acute events, heart failure, and secondary prevention; and another
44% is due to improved risk factors.10
Disparities in the incidence and mortality of CHD exist by various
social and economic factors, such as gender, race, ethnicity, educational level, income, and residential location. Groups most affected by
these disparities include non-Hispanic blacks, Hispanics, persons with
low socioeconomic status, persons with less than an high school education, and residents of the southeastern United States and
Appalachia.7 Death rates for CHD by gender and select race/ethnic
groups in the United Sates between 1980 and 2007 are shown in the
Figure.
8
Disparities in Myocardial Infarction
Incidence and Survival
Using data from the Atherosclerosis Risk in Communities (ARIC)
study, Rose et al.11 examined the impact of neighborhood median
household income on incident myocardial infarction in the United
States between 1993 and 2002. Launched in 1987, the ARIC study is
an ongoing community-based surveillance system of CHD in four
racially different communities in Maryland, Minnesota, Mississippi, and
North Carolina.11 Due to selection bias that typically limits the external validity of cohort trials, community-based surveillance systems
may be better able to estimate the true rates and temporal trends of
myocardial infarction, especially among persons of lower socioeconomic position who might not participate in a clinical trial.11 Rose and
colleagues11 observed an inverse association between neighborhood
median household income and incidence of hospitalization due to
myocardial infarction. The relationship was present whether income
was categorized based on standardized (i.e., tertiles of income for the
entire cohort) or community-specific (i.e., tertiles of income within a
community) cut-points. Across all communities and within all race and
gender groups, individuals living in neighborhoods with the lowest
median income had the greatest risk of myocardial infarction. The
strongest associations were seen among women and blacks. A widening of the disparity in incident myocardial infarction by income was
not seen over the 10-year surveillance period of the study. Rates of
myocardial infarction did not vary significantly by race within groups
stratified by income and gender. However, among blacks, the majority of myocardial infarction cases occurred among residents of neighborhoods within the lowest income tertiles; among whites the cases
Figure.
Figure: Death rates for CHD by gender and select race/ethnic groups in the
United States between 1980 and 2007. Based on data from National Center for
Health Statistics. Health, United States, 2010: With Special Feature on Death
and Dying. Hyattsville, MD. 2011. Data available at www.cdc.gov/nchs/data/
hus/hus10.pdf
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were more evenly distributed across tertiles of neighborhood
income. This is concerning as it suggests a greater burden of morbidity among people who are black living in disadvantaged neighborhoods, potentially increasing their risk of future mortality.11
In a separate analysis of the ARIC surveillance data, Ding et al.3 studied factors that may contribute to disparities in mortality rates from
29 days to 3 years after a myocardial infarction. Although the severity of myocardial infarction and time between symptom onset and
arrival at the hospital were not different between black and white subjects, there were fewer cardiac interventions among the black subjects. No disparity in mortality was seen by race after adjustment for
body mass index, smoking status, alcohol consumption, lipid profile,
hypertension, diabetes, level of sports-related activity, education level,
household income, severity of myocardial infarction, and
treatment/intervention. A prior analysis of the ARIC dataset similarly
did not show a disparity by race for mortality within the first 28 days
after a myocardial infarction; however, in that analysis the rate of mortality before reaching the hospital was higher among black subjects.14
In a study of residents in a neighborhood at the lower end of the
socioeconomic scale, but in a country (Scotland) with universal health
care coverage, a gradient still was evident with the most disadvantaged individuals experiencing the highest rate of myocardial infarction.8 In addition, at the time of their myocardial infarction, the most
disadvantaged individuals were more likely to die before reaching the
hospital and during the event. The authors concluded that these disparities in health outcomes by levels of socioeconomic status may be
due partly to a lack of awareness of the symptoms related to a
myocardial infarction, which may delay getting medical care. In addition, the increased mortality rate may be due to factors that contribute to disease severity, such as the prevalence of cigarette smoking, access to care, and treatment decisions.
sons of low socioeconomic status from starting and completing cardiac rehabilitation.
Suaya et al.13 conducted a study to assess the effects of cardiac
rehabilitation on survival in older patients with CHD. This was a
retrospective observational analysis of Medicare beneficiaries 65 years
and older who were hospitalized for CHD in 1997 in non-federal acute
care hospitals in the United States. Among 70,000 individuals, the
utilization of cardiac rehabilitation was 12%. Cardiac rehabilitation
participants were more likely to be male, white, younger, not receiving
Medicaid, admitted for a myocardial infarction or a coronary
revascularization procedure, and had fewer comorbid conditions.
Individuals who participated in cardiac rehabilitation had lower
mortality rates after 1 year (58% lower) and 5 years (34% lower)
compared to those who did not participate. This benefit was seen
within all subgroups based on gender, age, and race. The reduction in
mortality rates due to cardiac rehabilitation increased with age and
was greater among women in each age group. Based on the
multivariable analysis, the mortality benefit of cardiac rehabilitation
was greatest among those 75 years and older and women, but was not
significantly different by race.13
Conclusion
Although improvements have been made in the incidence, survival,
and medical management of CHD, social disparities persist. Several
determinates have been revealed, but solutions are likely complex.
Health care providers, policy makers, and the public need to be
aware of these disparities and the underlying determinates so that
community-based solutions and public policies can be developed. It is
important to continue to monitor social disparities and CHD outcomes so that interventions can be assessed and new avenues for
intervention can be identified.
Cardiac Rehabilitation
About the Author
Cardiac rehabilitation is considered standard of care for the
secondary prevention of CHD.12 It is estimated to reduce the
incidence of secondary events by 20% to 30%.5 It also reduces all-cause
mortality, improves functional capacity, quality of life, and some comorbidities, and facilitates return to work.5 Participation in cardiac
rehabilitation has been estimated to be as low as 10% to 20%.1 due to
physician referral rates, patient motivation, insurance coverage, and
program access.5
In a retrospective study of patients with CHD who were discharged from a hospital in Scotland, researchers evaluated whether
socioeconomic status affected participation in cardiac rehabilitation.9
Among patients who were eligible and referred to cardiac rehabilitation, 59% started and 58% of these patients completed the program.
Significant predictors to being referred included the hospital to which
they were admitted, age, gender, and referring physician (primary
care vs. cardiologist). Socioeconomic status was not related to program referral, but it was related to starting the program, along with
index hospital and referring physician. Finally, the only significant
determinate of program completion was socioeconomic status.
Further research is needed to understand those factors that limit per-
Clinton A. Brawner, M.S., RCEP, FACSM, is a clinical
exercise physiologist at Henry Ford Hospital, Detroit,
MI where he provides consultation and oversight on
cardiopulmonary exercise testing for sponsors of
multi-site clinical trials. He is the chair of ACSM’s
Registered Clinical Exercise Physiologist® practice
board and a president of the Clinical Exercise
Physiology Association (CEPA; www.cepa-acsm.org.)
References
1. Ades PA. Cardiac rehabilitation and secondary prevention of coronary
heart disease. New Eng J Med. 2001;345:892–902.
2. Centers for Disease Control and Prevention. Division for heart disease
and stroke prevention: Data trends & maps. 2011. Retrieved from
http://apps.nccd.cdc.gov/NCVDSS_DTM/LocationSummary.aspx?state=
United+States
3. Ding J, Roux AVD, Nieto FJ, et al. Racial disparity in long-term mortality
rate after hospitalization for myocardial infarction: The
Atherosclerosis Risk in Communities study. Am Heart J.
2003;146:459–464.
4. Kurian AK, Cardarelli KM. Racial and ethnic differences in cardiovascular disease risk factors: a systematic review. Ethnicity & Disease.
2007;17(1):143-152.
Disparities (continued on page 13)
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COACHING NEWS:
CLIENT SCENARIO
— HALFHEARTED ENGAGEMENT
By Margaret Moore (Coach Meg), M.B.A.
This column marks the start of a new format for our Coaching News column. We will
explore a variety of client scenarios, one scenario for each column. I will describe a few tips
from my science-based coaching toolbox to
help you help your clients engage fully in a fit
lifestyle that allows them to thrive, whatever
thriving means in their lives.
In this column, we explore how to coach a
client, Alice, who is working out but not sticking to the workout program that you gave her.
She is rushing through her gym program and
seems to be neglecting all the things she does
not like. Those things happened to be the most
important parts of her program!
Let’s consider what is driving Alice.
Self-motivation
— Alice’s power source
Our first and primal drive as human beings
is autonomy. We want to march to our own
drummers, to be “the boss of me.” This drive
is so strong that it triggers a deeply wired and
very fast response to being told what to do—
to resist or rebel—without a whole lot of analysis. Our knee-jerk rebellion is so powerful that
it can lead us to do things that are not in our
best interest.
If you have teenage kids, you can appreciate
how telling kids what to do for 13 years turns
them into rebellious teenagers who are sick
and tired of living a life with too little autonomy
at home and school. We never lose our natural and spontaneous aversion to being told
what to do, especially in response to a “knowit-all” expert who doesn’t fully empathize and
appreciate what it’s like to walk in our shoes
and what is important to us. Sometimes we are
compliant with what an expert asks us to do in
order to please the expert, avoid conflict, and
stay out of trouble. But sometimes we are defiant; we quietly or loudly resist the authoritative
expert and their control over our destiny.
10
Alice likely doesn’t agree with you on what’s
important in her workout and may not yet be
interested or curious enough to deepen her
understanding of how different exercises
impact her physical strength and fitness. She
simply may be rebelling against your insistence
on what she should do and expressing her
need for autonomy by doing what she wants
to do.
A coaching inquiry might include asking
Alice open-ended questions, with a smile and
not even a smidgeon of impatience, such as:
1. What do you hope will be the benefit of
physical strength and vitality for you?
2. How will engaging in your workout make
your life better?
3. Would you like to brainstorm with me on
how the various exercises in your workout will contribute to the benefit of exercise in making your life better?
4. What is working for you with the current
workout and what is not?
5. How can I better support you to realize
the benefit of physical fitness?
Your goal is to help Alice dig out and fire up
her self-motivation, the kind that is future-oriented—why the exercises really matter to her
and how they will make her life better later
today, tomorrow, and in the future. You will
help Alice discover and tap into her own
future-oriented power source or drive to
engage in the exercises she doesn’t like or
seem to want to do.
We inadvertently create resistance to our
advice when we convey a know-it-all attitude
through what we say, how we say it, our body
language, and unsaid words. This can send a
message which seems judgmental and autonomy-depleting to Alice, causing her to pull away
and not open up with you. Really start to listen
intently to Alice without thinking about what
you are going to say next, or any other distraction. This will help Alice get the message that
you really care about what it’s like to walk in
her shoes, what matters to her most, and that
you’re completely focused on her well-being,
not on her compliance to your prescribed
workout.
The more genuine interest you show about
what makes Alice’s life worth living and lights
up her eyes, the more she will tell you about
what matters most to her. Then a collaborative conversation on how her workout can
make it possible for Alice to have a better life
and will lead to a new workout design that
Alice helped create, leading to her full engagement in a workout that she owns. Now she
can march through her workout to her own
drummer, a drummer that wants a bigger life,
one made possible by a body which is fit,
strong, and brimming with energy.
About the
Author
Margaret Moore/Coach
Meg, MBA, is the founder
and CEO of Wellcoaches
Corporation, a strategic
partner of the ACSM,
widely recognized as setting a gold standard
for professional coaches in health care and
wellness. She is co-director of the Institute of
Coaching, at McLean Hospital/Harvard
Medical School and co-directs the annual
Coaching in Leadership & Health care
Conference offered by Harvard Medical
School. She co-authored the ACSM-endorsed
Lippincott, Williams & Wilkins Coaching
Psychology Manual, the first coaching
textbook in health care.
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HEALTH & FITNESS COLUMN
RESEARCH ON ENHANCING MUSCLE/STRENGTH
DEVELOPMENT THROUGH SUPPLEMENTAL
PROTEIN/CARBOHYDRATE INGESTION
By Wayne L. Westcott, Ph.D.
Throughout my college training and the majority of my career in
the fitness profession, I was taught that most Americans eat plenty of
protein and that supplementation of this nutrient is neither necessary
nor effective for enhanced muscle development. However, since
2000, several research studies have demonstrated that ingesting supplemental protein in close proximity to resistance training sessions
can result in greater strength gains and muscle hypertrophy.
The common factor in these studies is the timing of the protein or
protein/carbohydrate ingestion. Although eating extra-large servings
of protein-rich foods at mealtimes may not be a productive strategy,
it appears that post-exercise protein supplementation enhances protein synthesis and muscle hypertrophy.
An early study by Esmarck and associates3 compared the effects of
a moderate amount of supplemental protein/carbohydrate (10 g
protein, 7 g carbohydrate, 3 g fat) taken immediately or two hours
after resistance training sessions. The 13 older exercise participants,
mean age 74 years, trained 3 days each week for a period of 12
weeks. Magnetic resonance imaging (MRI) showed significant increases in muscle cross-sectional area (quadriceps) in the subjects who
ingested the supplement immediately after their workout but not in
those who took the supplement two hours after training.
A 2006 study examined the effects of milk ingestion on net muscle protein synthesis following resistance exercise. The 24 young men
and women2 (mean age 26 years) drank either 237 g of fat-free milk,
237 g of whole milk, or 393 g of fat-free milk with the same caloric
value as the whole milk, one hour after performing 10 sets of knee
extension exercise (eight repetitions per set). The results revealed
that post-exercise milk ingestion stimulated net muscle protein synthesis, with whole milk associated with greater uptake of available
amino acids for muscle anabolic processes.
That same year an impressive study on supplement timing was conducted by Cribb and Hayess.1 Seventeen recreational male bodybuilders (mean age 23 years) completed a 10-week program of heavy
resistance exercise. All of the study subjects ingested a protein/carbohydrate supplement twice each training day (four times per week).
One group consumed the supplement just before and just after each
workout, while the other group took the supplement in the morning
and evening of the training days (at least five hours before and after
the workout). Participants were prescribed 1 g of supplement per
kilogram of bodyweight. The supplement dose for an 80-kg participant was 80 g, which included 32 g of protein, 34 g of carbohydrate,
and 6 g of creatine monohydrate. Following the training period, the
group that consumed the protein/carbohydrate supplement immediately before and after each workout attained significantly greater
increases in lean mass (2.8 kg vs. 1.5 kg), one repetition maximum
squat strength (20.4 kg vs. 16.1 kg), and one repetition maximum
bench press strength (12.2 kg vs. 9.0 kg), as well as significantly
greater increases in cross-sectional area of Type IIa and IIx muscle
fibers, This group also experienced significantly greater increases in
contractile protein content and muscle glycogen concentrations.
These findings clearly support the efficacy of ingesting supplementary
protein and carbohydrate in close time proximity to resistance training sessions.
In a 2007 article, Hoffman reported results of several studies that
examined the effects of protein/carbohydrate supplementation on
muscle/strength development.4 He summarized the research as follows:
“…evidence strongly indicates that the proper timing of protein
ingestion provides a distinct advantage in stimulating muscle protein synthesis rates and subsequent muscle adaptations” (page
32).
A 2010 review article by Poole and colleagues addressed the role
of post-exercise nutrient administration on muscle protein synthesis
and glycogen synthesis.5 They concluded that “The supplementation
of protein and/or amino acids following a resistance training bout
results in a net positive protein balance that enables skeletal muscle
hypertrophy to take place … carbohydrates are vital to replenish
glycogen stores diminished from prolonged or high intensity exercise”
(page 360).
A 2011 study examined the effects of a combined strength and
endurance exercise program with and without protein/carbohydrate
supplementation on muscle mass and bone mineral density.6 Fifty-two
participants (mean age 59 years) completed a nine-month research
program in one of three study groups: (a) a control group that did
not exercise or take nutritional supplements; (b) an exercise group
that performed strength and endurance training, but did not take
nutritional supplements; and (c) an exercise plus nutrition group that
performed strength and endurance training, and also consumed nutritional supplements. The exercise program was performed 2 or 3
days/week (Tuesdays and Thursdays or Mondays, Wednesdays, and
Fridays) and consisted of one set of 8 to 12 repetitions completed for
each of the 12 resistance machines in the circuit and 25 minutes of
recumbent cycling performed in an interval training format.
Resistance exercise load was increased by approximately 5% when at
least 12 repetitions were completed in proper form. Participants in
the exercise and nutrition group drank a protein/carbohydrate shake
(24 g protein fortified with free l-leucine; 36 g carbohydrate) immediately after each training session, and also took a daily vitamin/mineral complex that contained 1,200 IU of vitamin D and 500 mg of calcium. Only the exercise and nutrition group attained a significant
increase in lean weight (5.2 pounds) over the 36 week training period. Although not significant statistically, the control group experienced a 1.0% decrease in bone mineral density, the exercise group
maintained their bone mineral density (no loss or gain), and the exercise plus nutrition group experienced a 1.0% increase in bone mineral density.
Based on the results of these studies and research reviews, it
would appear that ingesting a protein/carbohydrate snack in close
Research (continued on page 13)
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CLINICAL COLUMN
PART 1:
HEART SOUNDS
By Paul Visich, Ph.D., MPH
The education and skills of Clinical Exercise Physiologist (CEP) graduates vary somewhat among programs, and CEP skill sets aren’t always
well understood by other health care professionals. Improving the level
of proficiency in the area of cardiovascular and pulmonary assessment
reflects positively on the profession and demonstrates competency and
credibility of CEPs especially in a field that is striving for licensure.
Proficiency in the ability to recognize the more common heart sounds
comes with practice and experience over time. The following information may help you become more proficient in listening and recognizing
the more common heart sounds that a CEP may encounter in a cardiac
rehabilitation program or when performing diagnostic exercise testing.
pressure to seal the rim to the skin surface. Readers interested in viewing narrated lessons on listening to heart sounds are directed to the
University of Florida medical School “Online Physical Examination
Assistant” (accessed at http://medinfo.ufl.edu/cardio/CV_main.html).
Physiology
Anatomical Sites to Assess Heart Sounds
Heart sounds are made primarily by closure of heart valves. In addition, whenever these valves leak and allow blood to flow backwards
(regurgitation) additional sounds are heard that are referred to as murmurs. Under normal conditions, the two common heart sounds are
“lub” and “dub” representing the closure of the atrioventricular valves followed by the semilunar valves respectively. These two sounds are categorized as S1 and S2. S1 reflects ventricular contraction (systole) and S2
reflects ventricular relaxation (diastole). Ventricular relaxation can be
further broken down to two additional heart sounds: S3, when blood is
passively flowing from the left atrium to the left ventricle, and S4, when
blood is being pushed from the left atrium to the left ventricle when the
atrium is contracting (atrial kick). S3 and S4 are sounds typically
observed in older individuals with some form of cardiac pathology but
also may occur in healthy individuals. Therefore, it is important to competently recognize the heart sounds and evaluate them in the context
of an individual’s complete medical history to determine their significance and the need for further evaluation.1
Stethoscope
It is important to have your own stethoscope that you can adjust for
your ears and that feels comfortable. Better quality stethoscopes produce clearer sounds and are well worth the additional cost. A mid-range
or better stethoscope with a diaphragm and bell is recommended.
Those that may struggle to hear the sounds may consider a cardiology
version. Newer stethoscopes allow you to switch from the diaphragm
to bell by altering the pressure on the head of the stethoscope when
placed on the chest, whereas the older units require you to twist the
head when switching from the bell to diaphragm. The advantage of the
newer head is that you don’t have to take the head of the stethoscope
off the chest wall to switch from the bell to the diaphragm. The
diaphragm is used for detecting high pitch sounds, S1, S2, and regurgitation of the mitral and aortic valve. The diaphragm should be pressed
firmly to the skin surface. The bell is used primarily for low pitch sounds,
S3, S4 and mitral stenosis and is placed lightly on the chest, but enough
12
The examiner can start at the base or apex of the heart. To start at
the base, the stethoscope should be placed over the second intercostal
space at the right sternal border. This represents the aortic valve area.
The stethoscope then is moved over to the left sternal border, second
intercostal space, which would represent the pulmonary valve area. The
stethoscope should be moved slowly down the left sternal border to the
fifth intercostal space, then over to the apex that represents the tricuspid and mitral valve area, respectively. Defining S1 (systole) and S2 (diastole) can be challenging. To help distinguish these two sounds, you would
expect S2 to be louder than S1 at the base, and at the apex, S1 should
be louder than S2. Being able to distinguish between systole and diastole
becomes of greater importance when you also are detecting S3, S4, and
murmurs.2
Helpful tips to assess heart sounds:
1) Use a quiet room, if at all possible.
2) Find access to an examination table or bed.
3) The head of the stethoscope should be warmed prior to placing it on the skin surface.
4) Place the stethoscope head on the skin’s surface rather than
over clothes.
5) The patient should be in a reclined supine position to assess heart
sounds. For greater cardiac examination of the left lateral decubitus position, the patient should be asked to lean forward while
seated, which can increase the examiner’s ability to recognize certain heart murmurs (mitral stenosis, aortic regurgitation).
Part 2 will cover the common abnormal heart sounds that you may
encounter in a clinical setting, along with helpful hints to detect these
sounds.
AUTHOR’S NOTE: The author would like to thank Joyce O’Connor
M.S., RN, NP-C for reviewing and providing comments to improve
the quality of this article.
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About the Author
Paul Visich, Ph.D., MPH, is the current chair and
professor of the Exercise and Sports Performance
Department at the University of New England in
Biddeford, Maine and was previously a professor of
health promotion and rehabilitation at Central
Michigan University. Paul brings more than 35
years of experience as a researcher, author, clinical
exercise physiologist, and educator to his new
appointment as ACSM’s Certified News clinical columnist. Along with
Jon Ehrman, Steven Keteyian, and Paul Gordon, he served as a team editor
of the textbook, Clinical Exercise Physiology, published by Human
Kinetics. Paul served as a member of the Practice Board for ACSM’s
Registered Clinical Exercise Physiologist (RCEP) credential, the
chairperson of the ACSM Professional Education Committee, and a
member of ACSM’s Committee on Certification and Registry Boards
(CCRB). Paul has authored and co-authored numerous peer-reviewed and
refereed articles and will be sharing his clinical knowledge and expertise
with us and the readers of ACSM’s Certified News. We are thrilled to
have him as our new clinical columnist.
References
1. Bates L.S., Bates’ Guide to Physical Examination and History Taking,
10th Edition, Lippincott Williams and Wilkins, Philadelphia, PA, 2009.
2. Chizner, MA, Clinical Cardiology, 2nd Edition, MedMaster, Inc.,
Miami, FL, 2007.
Research (continued from page 11)
time proximity to resistance training workouts produces significantly
greater increases in muscle mass and strength than taking no supplementation or consuming supplemental protein/carbohydrate two or
more hours removed from the exercise session. Although minimum
levels have not been established a range of 8 to 40 g of protein and
up to 40 g of carbohydrate have been prescribed in the studies presented. A general recommendation for post-exercise nutritional
snacks would appear to be about 8 to 30 g of protein, and a more
specific guideline might be approximately 1 g of
both protein and carbohydrate for every 5 to 7
pounds of bodyweight.
Disparities (continued from page 9)
5. Leon AS, Franklin BA, Costa F, et al. Cardiac rehabilitation and secondary prevention of coronary heart disease: an American Heart
Association scientific statement from the Council on Clinical
Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and
Prevention) and the Council on Nutrition, Physical Activity, and
Metabolism (Subcommittee on Physical Activity), in collaboration with
the American Association of Cardiovascular and Pulmonary
Rehabilitation. Circulation. 2005;111:369-376.
6. Lillie-Blanton M, Maddox TM, Rushing O, Mensah GA. Disparities in
cardiac care: Rising to the challenge of Healthy People 2010. J Am Coll
Cardiol. 2004;44(3):503-508.
7. Mensah GA, Mokdad AH, Ford ES, Greenlund KJ, Croft JB. State of disparities in cardiovascular health in the United States. Circulation.
2005;111:1233-1241.
8. Morrison C, Woodward M, Leslie W, Tunstall-Pedoe H. Effect of socioeconomic group on incidence of, management of, and survival after
myocardial infarction and coronary death: analysis of community coronary event register. Br Med J. 1997;314(7080):541-546.
9. Pell J, Pell A, Morrison C, Blatchford O, Dargie H. Retrospective study
of influence of deprivation on uptake of cardiac rehabilitation. Br Med
J. 1996;313(7052): 267-268.
10. Roger VL, Go AS, Lloyd-Jones DM, et al. on behalf of the American Heart
Association Statistics Committee and Stroke Statistics Subcommittee.
Heart disease and stroke statistics—2011 update: a report from the
American Heart Association. Circulation. 2011;123: e1–e192.
11. Rose KM, Suchindran CM, Foraker RE, et al. Neighborhood Disparities
in Incident Hospitalized Myocardial Infarction in Four US Communities:
The ARIC Surveillance Study. Ann Epidemiol. 2009;19(12):867–874.
12. Smith SC Jr, Benjamin EJ, Bonow RO, et al. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other
atherosclerotic vascular disease: 2011 update: A guideline from the
American Heart Association and American College of Cardiology
Foundation. Circulation. 2011;124(22):2458-73.
13. Suaya JA, Stason WB, Ades PA, Normand ST, Shepard DS. Cardiac rehabilitation and survival in older coronary patients. J Am Coll Card.
2009;54(1):25-33.
14. White AD, Rosamond WD, Chambless LE, et al. Sex and race differences
in short-term prognosis after acute coronary heart disease events: the
Atherosclerosis Risk in Communities (ARIC) study. Am Heart J.
1999;138(3 Pt 1):540-548.
About the Author
Wayne L. Westcott, Ph.D., teaches exercise science
and conducts fitness research at Quincy College in
Quincy, MA.
References
B
TEST 4
B
B
TEST 3
C
TEST 2
A
C
D
TEST 1
2
1
D
E
E
A
A
3
B
C
E
C
4
C
B
E
A
5
————————————————————— QUESTION —————————————————————
ACSM’S CERTIFIED NEWS • JANUARY–MARCH 2012 • VOLUME 22: ISSUE 1
SELF-TEST ANSWER KEY FOR PAGE 15
1. Cribb P, Hayes A. Effects of supplement timing and resistance exercise on
skeletal muscle hypertrophy. Medicine & Science in Sports & Exercise.
2006; 38(11):1918-1925.
2. Elliot T, Cree M, Sanford A, et al. Milk ingestion stimulates net muscle
protein synthesis following resistance exercise. Medicine & Science in
Sports & Exercise. 2006; 38(4):667-674.
3. Esmarck B, Andersen J, Olsen S. et al. Timing of post-exercise protein
intake is important for muscle hypertrophy with resistance training in elderly humans. Journal of Physiology. 2001; 535:301-311.
4. Hoffman J. Protein intake: Effect of timing. Strength and Conditioning
Journal. 2007; 29(6):26-34.
5. Poole C, William C, Taylor L, Kerksick C. The role of post-exercise nutrient administration on muscle protein synthesis and glycogen synthesis.
Journal of Sports Science and Medicine. 2010; 9:354-363.
6. Westcott W, Varghese J, DiNubile N, et al. Exercise and nutrition more
effective than exercise alone for increasing lean weight and reducing
resting blood pressure. Journal of Exercise Physiology online. 2011;
14(4):120-133.
13
CNews22.1.PP3_ACSM template 2/24/12 4:37 PM Page 14
CNews22.1.PP3_ACSM template 2/28/12 12:25 PM Page 15
January–March 2012 Continuing Education Self-Tests
Credits provided by the American College of Sports Medicine • CEC Offering Expires March 31, 2013
a. She should avoid kettlebells, since it
SELF-TEST #1 (1 CEC): The following
might affect her breathing (cause
questions are from “Online Tips and
Valsalva maneuvers).
Tools For Exercise Professionals”
published on page 3.
b. She should use small kettlebells to
begin with.
1. Exercise Prescription on the Net
provides viewers with _____interactive
c. She should not use kettlebells due
links:
to the potential for trauma.
a. Four
b. Eight
d. She should not start a workout
routine now.
c. Twelve
d. Seventeen
e. She should do only aerobics and
2. Descriptions of senior fitness testing
not strength training.
would appear in the_____ section:
2. At 15 weeks gestation, your pregnant
a. Resistance Training
client is on her third week of an
b. Kinesiology
exercise routine, which includes
c. Fitness Testing
resistance training. She is lifting the
d. Nutrition
same weight as last week on all of the
8 machines, but doing 13-17
3. Exercise Prescription on the Net
repetitions for each exercise, for all 2
directs viewers to information
sets. To determine if it really is okay to
regarding certification examination
increase her weight, what is an
preparation for which organization:
appropriate intensity level while she is
a. American College of Sports
lifting weights?
Medicine (ACSM)
a. When she can’t have a conversation
b. American Heart Association (AHA)
b. When her HR less than 130 bpm.
c. National Academy of Sports
c. RPE about 10.
Medicine (NASM)
d. RPE about 13.
d. Centers for Disease Control and
Prevention (CDC)
E. It’s not safe to increase her weight,
since she is doing 2 sets of 8
4. Information regarding exercise and
exercises.
behavior change would occur in the
____ section:
3. One of your friends just found out she
is pregnant. She has worked out for
a. Exercise Instruction
more than 10 years. Her workout
b. Exercise Information
routine has always included weights
c. Psychology
(free weights and machines), aerobic
d. Fitness Calculators
exercise, and abdominal training. Since
she knows you are a trainer, she asks
5. The services can be accessed by
what type of exercise she can start
navigating through the following Web
now. What would be your best
site:
recommendation for her strength
a. www.ExRx.net
routine based on her previous exercise
b. www.acsm.org
experience?
c. www.AHA.org
a. Free weights and core training.
d. www.nsca-lift.org
b. machines and core training.
c. Resistance bands and sit-ups on the
SELF-TEST #2 (2 CECs): The following
floor.
questions are taken from “Part 2:
d. Only sit-ups.
Resistance Training During Pregnancy”
e. She can continue everything now
published on page 4.
that she did previously.
1. A pregnant mother, now 13 weeks
4. You start a pregnant woman (14
along, would like to start a workout
weeks pregnant) on an exercise
routine. She was to get toned and
routine, which includes resistance
strong to prepare for labor and
training. She is reluctant because she
delivery. Although she has not worked
heard that aerobic activity was okay,
out previously with weights, she tells
but that lifting heavy weights was not
you that Kettlebell workouts look
safe during pregnancy. What can you
interesting. What is the best advice
tell her to educate her about exercise
you can give her?
during pregnancy?
ACSM’S
CERTIFIED
NEWS®
a. Resistance training will increase her
heart rate after she exercises, and
baby’s too.
b. Resistance training will increase her
weight gain, and baby’s weight.
c. Aerobic and resistance training
might increase her labor and
delivery time.
d. She right, only aerobic exercise is
safe during pregnancy.
e. Exercise (aerobic and resistance
training) is safe during pregnancy.
5. Since the maternal body undergoes
many changes as the pregnancy
progresses, what special modifications
should you educate your client’s about
concerning resistance exercises?
a. Keep movements steady and
controlled.
b. Do not wear restrictive clothing.
c. Do not hold your breath (especially
while pushing hard).
d. Do not lay flat on your back.
e. All of the above.
SELF-TEST #3 (1 CEC): The following
questions are taken from “Can
Phytochemicals Improve Athletic
Performance?” published on page 6.
1. Phytochemicals are:
a. The chemicals that convert sunlight
into energy in plants.
b. Secondary metabolites of plants.
c. Growth factors secreted from
special glands in the plant.
d. All of the above.
2. True or false: Quercetin has been
shown to increase O2max in human
subjects
a. True
b. False
3. For humans the daily recommended
amount of phytochemicals is:
a. 200mg
b. 500mg
c. 1000mg
d. 1200mg
e. There is no daily recommended
amount.
4. Both quercetin and resveratrol have
shown promise in sports performance
enhancement by:
a. Being anti-inflammatory.
b. Being CNS stimulants.
c. Increasing the number of
mitochondria in muscle.
d. Increasing blood glucose during
exercise.
5. True or False: Based off of the current
body of research it is safe to assume
that supplementing with
phytochemicals will improve
performance.
a. True
b. False
SELF-TEST #3 (1 CEC): The following
questions are taken from “Social
Disparities in Coronary Heart Disease?”
published on page 8.
1. What is the leading cause of death
among women in the United States?
a. Breast cancer
b. Cardiovascular disease
c. Heart failure
d. Stroke
2. According to data from the National
Health and Nutrition Examination
Surveys, which group has the highest
rate of mortality due to coronary
heart disease?
a. Hispanic men
b. Non-Hispanic black men
c. Non-Hispanic white men
d. None of the above
3. Which of the following is NOT a factor
to disparities in the incidence and
mortality of coronary heart disease?
a. Gender
b. Race
c. Education level
d. Residential location
e. All of the above are factors
4. All studies have shown disparities
between races for mortality due to
myocardial infarction.
a. True
b. False
5. Which of the following outcomes was
NOT observed in the study of
Medicare beneficiaries by Suaya et al.
(13)?
a. Survival benefits of cardiac
rehabilitation increased with
increased age
b. Women who participated in cardiac
rehabilitation showed lower
mortality rates compared to men
c. Survival benefits of cardiac
rehabilitation were greater among
whites compared to blacks
d. Survival benefits of cardiac
rehabilitation were seen in all
subgroups by gender, age, and race.
To receive credit, circle the best answer for each question, check your answers against the answer key on page 13,
and mail this entire page with check or money order payable in U.S. dollars to: American College of Sports Medicine,
Dept 6022, Carol Stream, IL 60122-6022
ACSM Member (PLEASE MARK BELOW)
Please Allow 4-6 weeks for processing of CECs
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TOTAL $_________________
[ ] No- $20
($25 fee for returned checks)
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January–March 2012 Issue EXPIRATION DATE: 3/31/13• SELF-TESTS SUBMITTED AFTER THE EXPIRATION DATE WILL NOT BE ACCEPTED • Federal Tax ID number 23-6390952
Tip: Frequent self-test participants can find their ACSM ID number located on any ACSM CEC verification letter.
ACSM’S CERTIFIED NEWS • JANUARY–MARCH 2012 • VOLUME 22: ISSUE 1
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