Qatar Pa Guidline English

The State of QatarNational Physical ActivityGuidelinesFirst Edition

And your body has a right over you.

Prophet MuhammadPBUH

The State of QatarNational Physical Activity Guidelines

First Edition

4 Qatar National Physical ActivityGuidelines - 2014

Senior Editor

Dr. Khalid Walid Al-Bibi, CETT, CHFS, CNS

Director, Sport ScienceProfessor, Health and Human Performance

College of Arts and SciencesQatar University

Doha, Qatar

5Qatar National Physical ActivityGuidelines - 2014

PREFACE This book was written as a practical guideline reference and not as a scientific resource. Distilled from the latest scientific evidence and driven by local realities, the intention of this book is to be an immediate and easy source of information for practitioners, physicians, educators, and individuals who wish to prescribe or engage in regular physical activity. We limited the number of beneficiary populations in the first edition of the National Physical Activity Guidelines for Qatar (NPAG-Q) to the most prevalent epidemiologies currently facing the nation. Subsequent or special e-addendums will include special populations, such as people with disabilities, cerebral palsy, Down syndrome, restrictive and obstructive pulmonary disease, spinal cord injuries, asthma, multiple sclerosis, cancer patients, etc.

Behavior modification cannot be considered independently from cultural norms, local sensibilities, and environmental factors. Hence, we were careful to address social and environmental factors that are unique to Qatar. Sport scientists, epidemiologists, public health experts, health promotion specialists, health care professionals, and physicians from Qatar and the world contributed to the development of these guidelines.

It is our hope that Qatari citizens and residents alike will use NPAG-Q as a guiding reference as they prepare to lead more physically active lives. It is also our hope that this text becomes ever-present in the office of every health care practitioner in Qatar and shared with patients at every appropriate opportunity. Given the strong scientific body of evidence, it is our belief that the practice of state-of-the-art health care is incomplete without the careful consideration of the physical fitness of its population.

To make the guidelines as useful and as up-to-date as possible, a dedicated companion webpage (www.namat.qa/NPAG-Q) was developed to provide practitioners, educators, and citizens with an extensive array of resources, including data sheets, scientific references, screening tools, health questionnaires, warm-up and flexibility exercises, basal metabolic rate calculators, body mass index calculators, nutrition guidance, and much more. We also added two ask the expert blogs, one for health care practitioners (HCPs) and another for the general public.

Prof. Dr. Khalid Walid Al-Bibi

Professor, Health and Human PerformanceDirector, Sport ScienceQatar University


ACKNOWLEDGMENTSAspire Zone Foundation (AZF) would like to acknowledge the contributions made by various partners in the development of the first National Physical Activity Guidelines for Qatar. Among the notable ones are the Aspetar, Aspire Academy, Qatar University, the Supreme Council of Health, Primary Health Care Corporation, and Hamad Medical Corporation for providing the experts to support the development of these guidelines.

Our sincere gratitude goes to our colleagues; members of the Advisory Group and the subgroups, for their valuable input in ensuring that the guidelines are matched with the latest scientific evidence and tailored towards meeting the various needs of the population of Qatar.

Lastly, our appreciation is extended to Aspetars management for their financial support to this project as a part of their contribution to promote physical activity as a healthy lifestyle in the community.

Dr. Mohamed Ghaith Al-Kuwari

Preventive Medicine ConsultantDirector of Healthy Lifestyle Programme Aspetar Hospital


ADVISORY GROUPDr. Mohamed Ghaith Al-Kuwari

Preventive Medicine ConsultantDirector of Healthy Lifestyle ProgramAspetar HospitalE-mail: [email protected]

Dr. Izzeldin Ibrahim

Preventive Medicine ConsultantCoordinator of Healthy Lifestyle ProgrammeAspetar HospitalE-mail: [email protected]

Dr. Dennis Hatcher

Manager, Exercise & Sport Science DepartmentAspetar HospitalE-mail: [email protected]

Dr. Stephen Targett

Sports Medicine Physician - Athlete Screening Coordination, Sports MedicineAspetar HospitalE-mail: [email protected]

Dr. Paul Dijkstra

Sport Medicine Physician, Sports MedicineAspetar HospitalE-mail: [email protected]

Dr. Farrukh Hamid

Musculoskeletal Pain Specialist, Sports MedicineAspetar HospitalE-mail: [email protected]

Dr. Robbart Vanlinschoten

Sport Medicine Physician, Sports MedicineAspetar HospitalE-mail: [email protected]

Dr. Floor Groot

Sports Medicine Fellow, Sports MedicineAspetar HospitalE-mail: [email protected]

Mr. Fuad Al-Mudahka

Exercise Physiologist, Healthy Lifestyle ProgrammeAspetar HospitalE-mail: [email protected]

Mr. Abdulla Saeed Al-Mohannadi

Researcher in Health Promotion, Healthy Lifestyle ProgrammeAspetar HospitalE-mail: [email protected]

Ms. Ivana Matic

Senior Health Promotion Researcher, Healthy Lifestyle ProgrammeAspetar HospitalE-mail: [email protected]

Dr. Khalid W. Al-Bibi

Professor and Director, Sport ScienceCollege of Arts and SciencesQatar UniversityE-mail: [email protected]

Dr. Walaa Fattah Al-Chetachi

Supervisor Chronic Disease UnitPublic Health DepartmentSupreme Council of HealthE-mail: [email protected]

Dr. Leonieke Richardson

Aspire Active ManagerAspire ActiveEmail: [email protected]

Ms. Vasiliki Topalidou

Head, Events & PartnershipsAspire AcademyEmail: [email protected]

Dr. Veronica Bachiller

Lifestyle Programme LeaderAspire AcademyEmail: [email protected]

Mr. Trevor Smith

Aspire MSSD ManagerAspire AcademyEmail: [email protected]

Dr. Hamad Rashid Al-Madhaki

Head of Healthy Lifestyle ProgrammePrimary Health Care CorporationE-mail: [email protected]

Dr. Madeeha Kamal

Consultant PaediatricianHamad Medical CorporationEmail: [email protected]


EXTERNAL EXPERT READERS

We wish to thank the following experts for lending their valuable expertise in the finalisation of the guidelines:

Dr. Dennis W. Koch, CHFS

Associate Professor of Professional StudiesDirector of Health and Human PerformanceCanisius CollegeBuffalo, New YorkUnited States

Prof. Dr. Yahya Al-Nakeeb, FLFHE

Associate Dean for Academic AffairsCollege of EducationQatar UniversityDoha, Qatar


TABLE OF CONTENTSEvidence, Rationale, and Need 10

First Do No Harm 12

Goal Setting and Relapse Prevention 15

Goal Setting 15

Relapse Prevention 17

The General Principles of Exercise Prescription 18

Components of an ExRx for Enhancing Aerobic Fitness 19

Components of an ExRx for Enhancing Muscular Fitness 24

Healthy Adults: Asymptomatic, apparently healthy 18-64 years 27

Apparently Healthy Older Adults: Asymptomatic, 65+ Years 28

Adults with Hypertension 30

Coronary Artery Disease 31

Adults with Heart Failure 32

Diabetes Mellitus 33

Type I Diabetes 35

Type 2 Diabetes 35

Adults with Osteoarthritis 36

Adults with Metabolic Syndrome 38

Youth (12-17 years) 39

Children (5-11 years) 41

Early Years (0-4 years) 44

Recommendations for asthmatic children and children with chronic pulmonary disease: 48

Preconception, Pregnancy and Post-Partum 49

Environmental Considerations 52

Pregnancy and Heat 53

Fasting Ramadan 54

Tips for the General Public 55

Fasting and Pregnancy 56

Aspetars Guidelines for Exercise and Sport in Hot Weather 56

Glossary 59

Appendixes 63

Contraindications to Exercise 63

PAR-Q and You 64

Perceived Exertion for Physical Exertion (Borgs Scale) 65

PARmed-X for Pregnancy 66

Blank ExRx Sheet 70


Evidence, Rationale, and Need

Lack of regular physical activity is a significant contributing factor for many of the most prevalent acute and chronic diseases that have become alarmingly common in the State of Qatar. Evidence to support the inverse relationship between a physically active lifestyle and the incidence of cardiovascular disease, hypertension, stroke, osteoporosis, type 2 diabetes, obesity, colon cancer, breast cancer, anxiety and depression is indisputable.

Over the past two decades, numerous epidemiologic studies, enrolling tens of thousands of individuals from around the world, have documented a dose-response relationship between physical activity and risk of cardiovascular disease and premature mortality. The evidence supporting the effect of exercise on the quality of life as well as affective disorders is very strong. A meta-analysis of 23 cohorts, representing over 1.2 million person-years of follow-up, showed a dose-response relationship between physical activity and the risks of cardiovascular disease. It is clear that additional amounts of physical activity or increased physical fitness levels provide added health benefits.

In Qatar, deaths attributable to chronic non-communicable diseases (NCD) collectively ranked as the number one cause of death in the last 10 years. The National STEPS Survey (NSS) recently examined the health and behavior of 2,496 adults in Qatar. The results were alarming, revealing:

41.4% of the respondents were obese

21.9% of the respondents had high blood cholesterol level

16.7% of the respondents had diabetes mellitus (vs. 11.3% in the United States, 4.9% in the United Kingdom, and 2.5% in Yemen) According to International Diabetes Foundation (2012), Qatar ranks as the worlds 8th highest nation in the prevalence of diabetes

To slow down or reverse these trends, health care practitioners (HCP), government institutions, and citizens must work together to increase the levels of physical activity in the nation. The NSS study revealed that between the ages of 18-64 years old, 63.3% of the population reported no participation in recreational physical activity, and 86.2% of the women between 45-65 years old reported no participation in any form of vigorous physical activity. The 2011 Global School-Based Student Health Survey (GSHS), conducted in 32 schools and on 2,021 students in Qatar in grades 7, 8, and 9, showed that only 15% of the students reported being physically active for a total of 60 minutes or more on 5 or more days per week.

Although Qatar is a sports-loving nation, we fall short of meeting our minimal physical activity needs. The dual purposes of the NPAG-Q are: 1) to encourage and help Qataris lead more physically active lifestyles, and 2) to enlist the support of HCPs in monitoring and prescribing more daily physical activity for their patients. Research evidence suggests that patients counselled by their physicians to participate in physical activity are more likely to exercise. Unfortunately, only 13% of patients in this study reported that their physician gives them advice concerning the benefits of regular physical activity


Economic BenefitsThe logical assumption has always been that employees who are more physically active in their place of employment incur lower medical costs, exhibit less absenteeism, reduced disability expense, and are generally more productive. This assumption is supported by research that reports benefit/cost ratio ranging from 0.76 to 3.43, meaning that the return rate can be as high as three times the investment in the physical fitness of the employees. Inactivity greatly contributes to medical costs. As an example, in the United States of America and Canada, the total economic costs of physical inactivity and obesity represented 2.6% and 2.2%, of the total health care costs, respectively. Therefore, investing in the health of employees does not only make common sense, it makes economical sense as well.

The Challenge: Changing The EthosChanging the nations attitude and behaviour towards physical activity will require a multipronged, long-term approach that involves every sector of our society. In Qatar, this is a national priority. Building athletic and recreational facilities is a good start, but this alone will not result in a physically active populace. Nor will dis-articulated efforts by the various health entities lead to a new culture where physical activity is an accepted, expected, and practiced way of life. Lessons learned from nations with a successful record in preventive health management clearly show that all the players must come together to create a strong and sustained effort to change the ethos towards our health and fitness as a nation. This effort will involve the health sector, educators, sport and exercise experts, policy makers, the Supreme Council on Education, the food industry, the health insurance industry, urban planners and real-estate developers, and employers. When these players work in tandem and in a sustained fashion, we will create a permanent cultural ethos towards physical activity that will sustain itself for generations to come.


First Do No Harm

Generally, exercise does not cause untoward events in apparently healthy individuals. When exercise is performed according to established exercise guidelines, the risk of sudden cardiac complications or heart attack is very low in healthy individuals performing low to moderate-intensity activities. There is an increased risk of sudden cardiac death and/or heart attack in individuals performing vigorous exercise with either diagnosed or undetected underlying cardiovascular disease. It is therefore incumbent on the person who wishes to engage in moderate to high intensity physical activity to rule-out such conditions if exercise is to be conducted in clinically unsupervised settings. In clinically diagnosed individuals, carefully prescribed exercise must be conducted under the supervision of trained specialists until medical clearance for unsupervised exercise is given.

The risk of sudden cardiac death in individuals less than 35 years of age is small due to the low prevalence of cardiovascular disease in this population, with the most common causes of death in young individuals being congenital and hereditary abnormalities. The absolute risk of non-traumatic exercise related death among high school and college athletes is one per 133,000 men and one per 769,000 women.

Studies on injuries from exercise show that the most significant factors in determining the risk of injuries are physical condition, age, training intensity, and impact of the activity. Exercise duration can also increase the risk of musculoskeletal and heat-related injuries. For example, the incidence of orthopedic injuries more than doubles when comparing 45 minute exercise sessions versus 30 minute sessions. Table 1 lists common exercises and their impact classification. With appropriate conditioning and gradual increases in duration and intensity, most injuries can be avoided.

For some individuals the risks associated with a high intensity physical activity programme outweigh its potential benefits (Appendix A). In such cases, it is important to seek medical consultation before engaging in high intensity exercise. A pre-exercise test evaluation in the clinical setting generally includes a medical history, physical examination, laboratory tests, and a possible submaximal or maximal graded exercise test. These evaluations provide valuable information that help in individualising the exercise prescription (ExRx), and also assessing the efficacy of the training programme.


Table 1. Impact Classification of Common Exercises

Weight-Bearing/High Impact/ Resistance Activities:

Stair-climbing Hiking Dancing Jogging Downhill and cross-country skiing Aerobic dancing Volleyball Basketball Gymnastics Weight lifting or resistance Football Jumping rope

Weight-Bearing/Low Impact Activities:

Walking Treadmill walking Cross-country ski machines Stair-step machines Rowing machines Water aerobics Deep-water walking Low impact aerobics

Weight-Bearing/Low Impact Activities:

Lap swimming Indoor cycling Stretching or flexibility exercises(avoid forward-bending exercises) Yoga Pilates

The evidence on the effect of regular exercise on the human body is no longer anecdotal. Over the past two decades, much research has been conducted on the effects of regular physical activity on the physiology, psychology and health of human beings. The body of evidence collected over the past two decades has proven unequivocally that regular physical activity can:


Improve general well-being and quality of life

Improve insulin sensitivity and blood sugar control (patients on oral medication or insulin may be able to reduce the dose)

Improve blood pressure, regulate blood lipids and reduce the risk of heart attack and stroke

Reduce joint pain and improve joint function

Improve muscle strength

Improve posture and walking, reducing the risk of falling

Promote weight management/control

Improve mental health better and lower stress levels

Improve sleep, in duration and quality

Are you ready for exercise? Your first step is to self-screen.

There are a number of self-administered instruments that screen physical readiness for engaging in physical activity. The NPAGQ recommends the use of the PAR-Q (Appendix B) for its ease of use and high sensitivity. The PAR-Q is a simple one-page pre physical activity screening tool. It should be completed before starting a moderate to vigorous physical activity programme. If you answer yes to one or more questions on the form, you should seek clearance from a physician before starting a physical activity program.


Goal Setting and Relapse Prevention

An individuals state of health is not a dichotomous condition where they are either healthy or unhealthy. Rather, it exists somewhere on a hypothetical continuum where it is always in flux, edging to one side or another based on the events of the moment. By and large, your daily decisions and actions determine the direction your health takes on this continuum. Our health improves when we make good decisions, and it lapses (deteriorates) when we make the wrong decisions.

We are all at some level of health at any moment. Our goal should be to make and act on correct decisions in an effort aimed at becoming healthier. To succeed in improving your health, it is important to understand that becoming healthier is a process. It takes time, it happens progressively, and there are bound to be lapses along the way. Excluding infectious diseases and acute illnesses, we do not become healthy or unhealthy overnight, and shortcuts to health (e.g. very fast weight loss) are almost always bound to fail.


Goal Setting

Realistic goal setting is a critical part of behaviour modification. Unrealistic goal setting (e.g. to lose 10 Kg of fat weight in three weeks) ultimately leads to failure. This negative experience reinforces ones aversion to the healthy behavior making it tougher to face the same attempt in the future. The NPAG-Q is designed around scientific evidence, which maximises the chances of success by setting realistic goals and minimising the risk of injury and discomfort.

It is important to remember that everyone struggles to reach his or her health goals (e.g. smoking cessation, better eating habits, weight loss, exercising regularly). We all experience numerous lapses on our way to reaching our goals. The primary mistake committed by individuals who embark on behaviour modification is that they consider lapses as failure by telling themselves that they cannot control their behaviour or that they do not deserve to succeed. This is far from the truth, as we all are subject to lapses in any behaviour modification endeavour we may embark on.

In the context of becoming healthier by becoming more physically active, the goal is to increase the amount of physical activity in your daily life. The NPAG-Q will provide you with an optimal but regimented way to do that. However, whenever complying with the exercise prescription becomes impossible (travel, visitors, family matters, weather, work) there are numerous creative ways to continue to supplement physical activity into your daily schedule (Table 2).

No matter how many times you lapse, you can still reach your goal as long as you do not give up

(collapse).


1. Accept responsibility

2. Examine the context

3. Rehearse new actions

Table 2. Simple ways to add more activity into your daily routine

Take the stairs instead of the elevator

Power-walk the mall hallways before the shops open

Park your car further away from your destination and walk the rest of the way

Get off the couch and walk around the house during TV commercial breaks

When the weather and distance permit it, walk to your friends house instead of driving there

Utilise the facilities at Aspire Park and the Corniche whenever the weather allows it. Even better, walk and talk with a friend or take your family members and make it a regular family habit

If you have children, be their role model. Your children are very impressionable at any age. Children will mimic their parents behaviours well into their old age. One of the best gifts you can give loved ones is the gift of a good health behaviours.

Do some work in and around your house: wash your car by hand, do some gardening and house cleaning yourself

Relapse Prevention

Relapse prevention (RP) is a self-management technique to improve behaviour modification by predicting future lapses (slips) and developing coping strategies to better manage high-risk situations. RP is based on the understanding that lapses are natural and are to be expected. If you are willing to learn from your mistakes, lapses become useful because they can help you develop tools to avoid bad behaviour in the future.

RP encompasses identifying situations in which you are more likely to lapse and developing coping skills that will help you overcome these situations when encountered again. RP consists of: 1) accepting responsibility for your actions and decisions that led to the lapse, 2) examining the context in which the lapse took place, and 3) examining alternative actions you could use should you find yourself in the same situation again. You can improve your chances at success dramatically by learning more about RP. You can get more information about RP on www.namat.qa.


The General Principles of Exercise PrescriptionThe scientific principles for a safe and effective exercise programme presented in the NPAG-Q are intended to assist in the development of an individually tailored exercise prescription. These principles are based on the application of scientific evidence and include all health-related components of physical fitness. For more information about indicated (safe) and contraindicated (unsafe) exercises please visit www.namat.qa for a more comprehensive list. In this chapter the general components of an ExRx are presented. Chapter V will cover population and condition-specific modifications to the general ExRx. The NPAG-Q provides recommendations for basic activity (i.e. minimal or maintenance) as well as aerobic activity (optimal).


Exercise most days of the week

Minimal 3 days per week

Components of an ExRx for Enhancing Aerobic Fitness

1. Warm-up: This phase consists of a minimum of 5-10 minutes of low-to-moderate intensity cardiovascular (aerobic) and muscular endurance activity designed to increase body temperature. The purpose of a good warm-up is to slowly increase your heart rate to the prescribed exercise intensity. The warm-up phase improves the mechanical efficiency of the circulatory system by decreasing the viscosity of joint fluids and

inducing vasodilation of muscle vessels, making it easier for the heart to pump the blood throughout the body.

2. Pre-Exercise Stretching: This phase should focus on range of motion exercises that targets the joints most used in the conditioning phase of the ExRx. For example, if swimming is the exercise mode, one should perform range of motion exercises for the shoulder, neck, and hip.

3. Conditioning (stimulus phase): This is the phase that stimulates the cardiovascular system to adapt and become stronger and more efficient with time. The components of the conditioning phase can best be described and memorised using the FITT principle, an acronym that stands for Frequency, Intensity, Time, and Type of exercise. It is also important to consider the progression, or when and by how much the frequency, intensity, time, or type of exercise is adjusted.

Frequency (how often should I exercise?): Moderate intensity aerobic exercise done at least 5 days per week, vigorous intensity aerobic exercise done at least 3 days per week, or a weekly combination of moderate and vigorous intensity exercise is recommended for the majority of healthy/asymptomatic adults to achieve and maintain health/fitness benefits.

Intensity (how hard should I exercise?): Exercise intensity is the toughest component of the ExRx to quantify. There are many techniques that can be used to measure exercise intensity. The two most practical ways are heart rate reserve (HRR) and ratings of perceived exertion (RPE). RPE is a simple but highly valid method for measuring exercise intensity. Moreover, unlike heart rate (HR), RPE is not affected by the most commonly prescribed cardiac medications (e.g. beta-blockers) and is considered more robust because it is affected to a much lesser extent by medication. RPE correlates highly

with HR and oxygen consumption (VO2) and can therefore be used as a good measure of exercise intensity1.

12-13 on RPE scale for most adults

Deconditioned individuals can benefit from intensities as low as 9-11 on RPE scale


Figure 1. Ratings of Perceived Exertion (RPE) Scale

Rating of Perceived Exertion Borg RPE Scale

6

7

8

9

10

11

Very, very light

Very light

Fairly light

How you feel when lying in bed or sitting in a chair relaxed.

Little or no effort

12

13

14

15

16

Somewhat hard

Hard

Target range: How you should feel with exercise or activity.

17

18

19

20

Very hard

Very, very hard

Maximum exertion

Hoow you felt with the hardest work you have ever done.

Dont work this hard!


How to Use the Ratings of Perceived Exertion (RPE) Scale

While doing physical activity, rate your perception of exertion (Appendix C). This feeling should reflect how heavy and strenuous the exercise feels to you, combining all sensations and feelings of physical stress, effort, and fatigue. Do not concern yourself with any one factor such as leg pain or shortness of breath, but try to focus on your total feeling of exertion.

Look at the RPE Scale while you are engaging in an activity. The scale ranges from 6 to 20, where 6 means no exertion at all and 20 means maximal exertion. Choose the number that best describes your level of exertion. This will give you a good idea of the intensity level of your activity, and you can use this information to decrease or increase the exercise intensity to reach your desired range. Examples of common physical activities by intensity of effort can be found in Table 3.


Table 3. Examples of Common Physical Activities by Intensity of Effort

Light Moderate/Somewhat Hard Hard

Walking, slowly

Cycling, stationary

Swimming, slow treading

Calisthenics, stretching

Golf, power cart

Fishing, sitting

Boating, power

Home care, sweeping/vacuuming

Mowing lawn, riding mower

Horseback riding (slow gait)

Walking, briskly

Cycling, pleasure

Swimming, moderate

Calisthenics, general

Racket sports (leisure)

Golf, pulling/carrying clubs

Fishing, standing/casting

Canoeing, leisure

Home care, general cleaning

Horseback riding (fast gait)

Walking, briskly uphill

Cycling, fast or uphill

Swimming, fast treading

Calisthenics, aerobic dance

Racket sports (competitive)

Fishing, heavy and sustained pulling

Canoeing, rapid

Moving furniture

Mowing, hand mower


There is a positive continuum of health and fitness benefits with increasing exercise intensity. A minimum intensity threshold - an intensity level below which the body is not challenged sufficiently to adapt - exists for most people, with the possible exception of very deconditioned persons. Exercise of at least moderate intensity that increases heart rate and breathing is recommended as the minimum exercise intensity for adults to achieve health/fitness benefits. However, a combination of moderate and vigorous intensity exercise is ideal for the attainment of improvements in health/fitness in most adults. It is important to take into consideration that in moderate to low fit individuals, high exercise intensity is the primary reason for failing to comply with an ExRx.

Time (how long should I exercise?): Moderate intensity exercise performed for at least 30 minutes 5 days per week, or vigorous intensity aerobic exercise done for at least 20 minutes 3 days per week is recommended for maintaining health and preventing disease. To promote or maintain weight loss, 50-60 minutes per day or more of daily exercise is recommended. Performance of intermittent exercise of at least 10 minutes in duration to accumulate the minimum duration recommendations above is an effective alternative to continuous exercise. Total caloric expenditure and step counts may be used as surrogate measures of exercise duration.

For an exercise training programme that emphasises fat loss, time must be adjusted to allow for the expenditure of 1,000-2,000 Calories per week. In addition, irrespective of the exercise intensity, expending 2,000 Calories per week has been shown to offer protective health benefits and is the level at which optimal weight loss occurs.

Type (what mode of exercise is best?): The best type of exercise is inevitably the one that you are more likely to perform again and again. However, rhythmic, aerobic (cardiovascular endurance) exercise of at least moderate intensity that involves large muscle groups and requires little skill to perform is recommended for all adults to improve health/fitness and offers the best results. The simplest exercise that meets this criterion for most people is walking. Other exercise and sports requiring skill to perform or higher levels of fitness are recommended only for individuals possessing adequate skill and fitness to perform the activity continuously and without frequent interruptions. When choosing the exercise type, the individuals goals, current physical ability, health status,

and available equipment should be considered. Table 4 provides general recommendations for the types of exercises to be included in a health/fitness exercise training programme for apparently healthy adults.

Moderate: 30 minutes, 5 days per week

Vigorous: 20 minutes, 3 days per week

Avoid vigorous intensity exercise performed more than 5 days per week

Use large muscles in rhythmic, repetitive and continuous motion that can be sustained throughout the duration of the session

For weight loss, lower intensity and extend duration

Expend 1,000-2,000 Calories per week


Table 4. Modes of Exercise to Improve Aerobic Fitness

ExamplesRecommended forExercise DescripitionExercise Group

Walking leisurely cycling ,aqua aerobics slow dancing

All adults

Endurance activities requiring minimal skill or physical fitness to perform

A

Jogging,runningRowing,aerobicsSpinning,ellipticalExercise,steppingExercise,fast dancing

Adults (as per the prepar- ticipation screening guidelines in chapter 2) who are habitually at least average physical fitness

Vigorous intensity endurance activities requiring minimal skill

B

Swimming cross- country skiing, skating

Adults with acquired skill and/ or at least average physical fitness levels

Endurance activities requiring skills to perform

C

Racquet sports, basketball, football down skiing, hiking

Adults with a regular exercise programme and at least average physical fitness

Recreational sportsD

Rate of Progression: The recommended rate of progression in an exercise programme depends on the individuals health status, exercise tolerance, and exercise programme goals. Progression may consist of increasing any of the components of the FITT framework. During the initial phase of the exercise programme, increasing exercise duration is recommended. An increase in exercise duration per session of 5-10 minutes every 1-2 weeks over the first 4-6 weeks of an exercise training programme is reasonable

for the average adult. After the individual has been exercising regularly for one month or more, the frequency, intensity and/or time of exercise is gradually adjusted upward over the next 4-8 months or longer for older adults and very deconditioned persons. Any progression in any of the FITT exercise prescription components should be made gradually. Avoid large increases in any of the FITT components.

Components of an ExRx for Enhancing Muscular Fitness

Further health/fitness benefits can be added by supplementing an aerobic training programme with resistance training. In addition to the many benefits gained from increasing muscular fitness, a well-developed resistance-training programme makes everyday activities less stressful. A resistance-training programme usually takes the form of weight lifting using free-weights or machines, but may also include exercises that utilise body weight, such as push-ups and pull-ups. When performed correctly, resistance training improves all components of muscular fitness including strength, endurance, and power. Resistive exercise also improves bone density and coordination, minimising the incidence of injury consequent to falling, which is common in the elderly population. For these reasons, resistance training in the elderly population should play a significant role in their training.

Increase duration first, by 5 -10 minutes every 1-2 weeks.Changes should be made in small increments.


1. Warm-up: This phase consists of a minimum of 5-10 minutes of low intensity cardiovascular (aerobic) and muscular endurance activity designed to increase body temperature. Knee lifts, walking in place or around a track while doing shoulder circles, or light stationary cycling are all good forms of a gentle and proper warm-up.

2. Pre-Exercise Stretching: This phase should focus on range of motion exercises that targets the joint(s) most used in the conditioning phase of the ExRx. For example, if you plan to focus on strengthening your shoulder or chest muscles, one should perform range of motion exercises for the shoulder.

3. Conditioning Phase:

Frequency:

For general muscular fitness, particularly among those who are untrained or recreationally trained, an individual should resistance train each major muscle group 2-3 days per week with at least 48 hours separating the exercise training sessions for the same muscle group. Depending on the individuals daily schedule, all muscle groups

to be trained may be done so in the same session (whole body) or each session may split the body into selected muscle groups so that only a few of them are trained in any one session. For example, muscles of the lower body may be trained on Mondays and Thursdays, while upper body muscles may be trained on Tuesdays and Fridays. This split weight training routine entails 4 days per week to train each muscle group twice weekly; however, each session is of shorter duration than a whole body session used to train all muscle groups of the body. Both methods are effective as long as each muscle group is trained 2-3 days per week. Having these different resistance training options provides the individual with more flexibility in scheduling, which may help to improve the likelihood of incorporating a resistance-training regimen into his/her daily schedule.

Intensity and Volume:

Intensity in resistive training is the weight that is used to train relative to the maximal force that each muscle group can perform maximally (i.e. % of the resistance that the muscle can perform once only). The process of finding any given muscles maximal force production, called one-repetition maximal (1RM), is derived via trial and error and involves the progressive increased loading of a muscle until the exercise can only be performed once. The resistance is noted for each muscle group and the intensity for the ExRx is calculated as a percentage of the 1RM.

Training volume is the product of sets and repetitions (reps). A rep is the number of times an exercise is repeated. A set is the number of times the exercise is repeated for the set number of repetitions. For example, if you do

10 pushups and then relax, and then you repeat this sequence 2 more times, then that means that you performed 3 sets of 10 reps of pushups. The number of sets and reps and be varied to modify the volume of training for each specific muscle group.

Exercise 2-3 days per weekAllow for 48 hours recovery

To focus on muscle toning, use lightweights or none. Perform three sets, but increase the repetitions to 12.Rest for at least 60 seconds in between sets. However, to focus on muscle endurance, lower rest time to less than 30 seconds.


Adults:

Should train each muscle group for a total of 2 - 4 sets with 8 -12 repetitions per set with a rest interval of 2 - 3 minutes between sets to improve muscular fitness.

For older adults and very deconditioned individuals:

1 set of 10 - 15 repetitions of moderate intensity (i.e., 60% 70% 1-RM), resistance exercise is recommended.

Type:

Resistance training regimens should include multi-joint or compound exercises, i.e. exercises that affect more than one muscle group. These exercises should focus on the major muscle groups of the chest, shoulders, upper and lower back, abdomen, hips, and legs. Examples of multi-joint exercises include the chest press, shoulder press, pull-down, dips, lower-back extension, abdominal crunch/curl-up, and leg press. Single joint

exercises targeting major muscle groups, such as biceps curls, triceps extensions, quadriceps extensions, leg curls, and calf raises, can be included in a resistance-training programme.

In order to avoid creating muscle imbalances that may lead to injury, train opposing muscle groups. Examples of these types of complementary resistance exercises are lower back extensions (to target for the lower back muscles) and abdominal crunches (to target the abdominal muscles). For a more complete listing of exercises please visit www.NPAGQ.com.

Use multi-joint exercisesTraining opposing muscles equally


Population-Specific ExRx Guidelines

Healthy Adults: Asymptomatic, apparently healthy 18-64 years

Basic Activity Aerobic Fitness

FREQUENCY3 days per week v

5 days per week or more of moderate exercise or 3 days per week or more of vigorous exercise or a combination of moderate and vigorous exercise 3 to 5 days per week

INTENSITY

Light to moderate intensity

RPE = 10-13

Moderate: RPE = 11-13 or

Vigorous: RPE = 13-15

TIME15 to 30 minutes per day

30 to 60 minutes per day of moderate exercise or 20 to 60 minutes per day of vigorous exercise

TYPE

Low to moderate impact continuous physical activity utilising large muscle groups such as walking or leisurely cycling

Low to high impact physical activity utilising large muscle groups such as power walking, jogging, cycling, swimming or combination of such exercises (cross training)

STRENGTH

At least two days a week. Physical activities that strengthen muscles involve using body weight or working against a resistance. This should involve using all the major muscle groups. Examples include: carrying or moving heavy loads such as groceries, activities that involve stepping and jumping, aerobics.


Frequency Do These Types of Exercises

At least 5 days per week

Moderate intensity (RPE = 11-13) aerobic (cardiovascular endurance) activities, weight bearing exercise, flexibility exercise

At least 3 days per week

Vigorous intensity (RPE= 13-15) aerobic activities, weight bearing exercise, flexibility exercise

3-5 days per week A combination of moderate and vigorous intensity aerobic activities, weight bearing exercise, flexibility exercise

2-3 days per week Muscular strength and endurance, resistance exercise, calisthenics, balance and agility exercise


Apparently Healthy Older Adults: Asymptomatic, 65+ Years


FREQUENCY 3 days per week

5 days per week or more of moderate exercise. For those who are already moderately active 5 days per week or more, 3 days per week or more of vigorous exercise or a combination of moderate and vigorous exercise 3 to 5 days per week is appropriate

INTENSITY

Initial workload should be light. Additional increase in intensity should be incremental and small

RPE = 10-13

RPE = 13-15

TIMEUp to 50 minutes per day

At least 50-60 minutes per day of moderate intensity activity.

This can be done in bouts of 10 minutes or more one way to approach this is to do 30 minutes on at least 5 days a week.

For those who are already regularly active at moderate intensity, comparable benefits can be achieved through 75 minutes of vigorous intensity activity spread across the week or a combination of moderate and vigorous activity

TYPE

Stationary equipment is preferred initially, particularly for those with poor balance (e.g. cycle ergometers). Leisurely walking

Brisk walking, jogging, water activities

STRENGTH

At least two days a week. Physical activities that strengthen muscles involve using body weight or working against a resistance. This should involve using all the major muscle groups. Examples include: carrying or moving heavy loads such as groceries, and activities that involve stepping.


Adults with HypertensionHypertension (high blood pressure) is a medical condition where the blood pressure (measured on more than one occasion under standardised conditions) is too high (systolic blood pressure of 140 mm Hg or more or diastolic blood pressure of 90 mmHg or more). Untreated high blood pressure leads to many complications affecting blood vessels, the heart, kidneys, eyes and the brain.

The basis of treatment is a combination of interventions to lower the blood pressure, such as an increase in physical activity, diet modification, smoking cessation, and reducing stress. Medication might be prescribed when blood pressure is very high or when it does not respond to lifestyle changes alone.


FREQUENCYMost days of the week

3-5 sessions per week

INTENSITY Light: RPE= 10-12 Moderate: RPE = 11-13

TIME>30 minutes every day

30-60 minutes, which can be accumulated over the day

TYPEWalking, climbing stairs, gardening

Walking, jogging, cycling, swimming, ball sports, skating, fitness class, rowing

Avoid upper body-only exercises, such as arm ergometers, and avoid Valsalva maneuvre (holding breath while exerting) during any exercise

STRENGTH

It is important to include a warm-up and cool-down activity of a lower exercise intensity.

Resistance training should be done 2-3 times per week. The focus should be on more repetitions and low resistance

1-3 sets of 8-10 different exercises, each 20-30 repetitions


Coronary Artery DiseaseCoronary Artery Disease (CAD) is hardening of the blood vessels that feed the working muscles of the heart. A significant block in these arteries may lead to angina (chest pain) or a myocardial infarction (heart attack).

The basis of CAD treatment is a combination of short and long-term interventions to improve the blood supply to the heart muscle, such as medication or invasive widening of the artery using a stent or bypass graft surgery. Physical activity, exercise, and accompanying life-style behaviour modification are essential components for treating and preventing coronary artery disease.

Patients with coronary artery disease should perform regular aerobic, strength and flexibility type exercises as well as maintaining a good baseline physical activity. Limit low activity pastimes (watching television, computer work, playing electronic games) to no more than 2 hours per day.


FREQUENCY Every day 3-5 sessions per week

INTENSITY

Talking is still possible but heart rate and breathing will be increased

RPE = 10-12

Until out of breath

RPE = 12-13

TIME >30 minutes every day 20-60 minutes total over 24 hours

TYPE

Walking, climbing stairs, gardening

NOTE: increase standing and walking at work and at home

Brisk walking, jogging, cycling, swimming, ball sports, skiing, skating, fitness class

STRENGTH


8-10 different exercises, each 8-12 repetitions or until near muscle exhaustion

Movements using body weight as resistance, resistance bands, weights, resistance equipment


Adults with Heart FailureHeart Failure is a medical condition where the heart (muscle) is unable to pump enough blood (to provide oxygen) to the body. The most important causes of this is hardening of the blood vessels of the heart muscle and high blood pressure. There might be other reasons why the heart muscle is not strong enough like diabetes, heart valve disease, abnormal heart rhythm, and other diseases.

The basis of treatment is a combination of interventions to improve the function of the heart muscle. This includes medication, dietary adjustments, and the strengthening of the myocardium as well as skeletal muscles through exercise.

Limit pastimes where you are sitting (watching television, computer work, playing electronic games) to no more than 2 hours per day.



INTENSITY

Talking is still possible but heart rate and breathing will be increased

RPE = 10-12

Until out of breath

RPE = 12-13


TYPE



Walking, jogging, cycling, swimming, ball sports, skating, fitness class, rowing

STRENGTH


Until near muscle exhaustion

8-10 different exercises, each 8-12 repetitions


Please refer to the general precautions and exercise tips earlier in this chapter. In addition you need to consider the following:

Water exercises (hydrotherapy) are a good form of exercise for patients with heart failure

Training of respiratory muscle 3-7 times per week for 30-60 minutes will help to improve the symptoms of heart failure


Diabetes MellitusType 1 diabetes is a chronic disease characterised by high blood sugar levels due to the body not being able to make enough insulin. Regular physical activity and a low carbohydrate diet help to reduce insulin requirements and will lower the risk of heart disease and stroke.

SPECIAL CONSIDERATIONS FOR DIABETICS:

Blood Glucose Levels

Physical activity greatly affects blood glucose levels. Hence, patients must consult with their physician about medication adjustments (time of day, dosage).

Diabetics need to consult with a dietician about pre- and post exercise meals in relation to the intensity and the exercise session.

If ketones are present in urine, exercise will be contraindicated until blood level is below 13mol/l

If blood glucose < 6.0 mmol/L, take 20-30g carbohydrate before exercising

Do not exercise if blood glucose > 15.0 or ketotic

Exercise 1-2 hours after food and more than one hour after your last dose of insulin

Reduce the last insulin dose by 30-50% if the exercise bout will be long or intense

Do not inject the insulin in the muscle that will be used extensively in the exercise

Carry a carbohydrate snack with you in case of a hypoglycemic episode and try to exercise with a partner who is able to help in an emergency

Wear a medic alert bracelet


Footwear and Clothing

Footwear should be comfortable and breathable to help avoid injury during exercise. Diabetics are predisposed to neuropathy, which can decrease sensation in the feet. Avoiding bruises and blisters is important because these injuries will take longer to heal, thus preventing the patient from exercising for an extended period of time

Clothing needs to allow breathability and be appropriate for the exercising environment. Clothing that retains heat and moisture is not appropriate for patients during exercise, especially in hot or humid environments. An increase in core temperature can lead to a rapid onset of dehydration

Hydration: Proper hydration should be easily accessible during exercise

Hydration should not be with sodas or sugary beverages, which will alter blood glucose levels

Hydration with water should occur before the onset of thirst

Sugar Snack

A sugary snack can be given to increase the blood glucose concentration before exercise if it is below 6 mmol/L

A sugary snack should also be available during exercise, and not only in vending machines. The risk of hypoglycemia is decreased with the intake of a sugary snack

A carbohydrate snack should be eaten for every 30 minute session of exercise

Aerobic Exercise versus Resistive Training

Aerobic exercise is the best form of exercise for Type 1 or 2 diabetic patients because it does not require quick bursts of energy

Resistance training may also be appropriate, depending on overall health status


TYPE I DIABETES

Basic Activity(diabetes well controlled)

Aerobic Fitness (diabetes well controlled)


INTENSITYTalking is still possible but heart rate and breathing will be increased

Moderate: RPE = 11-13 or Vigorous: RPE = 13-15


TYPE



Brisk walking, jogging, cycling, swimming, ball sports, skating, fitness class, rowing

STRENGTH

2-3 sessions per week Until near muscle exhaustion

8-10 different exercises, each 8-12 repetitionsMovements using body weight as resistance, resistance bands, weights, resistance equipment

TYPE 2 DIABETES

Type 2 diabetes is a chronic disease characterised by high blood sugar, which can lead to heart attack, stroke, and abnormal blood lipids. Regular physical activity, a weight loss programme, and a low carbohydrate diet help to reduce insulin or oral medication need and will lower the risk of heart disease and stroke.



INTENSITYTalking is still possible but heart rate and breathing will be increased

Until out of breath


TYPE



Brisk walking, jogging, running, cycling, swimming, ball sports, skating, fitness class, rowing

Strength






Adults with OsteoarthritisOsteoarthritis (OA) is a very common chronic disease characterised by the deterioration of the articular cartilage in a joint. Most people complain of joint pain and a loss of joint function, and some patients report associated stiffness.

The basis of treatment is exercise to improve joint function and lose weight where appropriate. Medication is sometimes prescribed to reduce pain and stiffness. For some individuals with advanced OA, joint replacement surgery might be recommended.

Patients with osteoarthritis should do regular aerobic, strength, and flexibility exercises and also maintain a good baseline physical activity to improve posture, gait and increase strength and joint flexibility. This will lower the risk of falling and reduce joint pain.



INTENSITY

Normal talking is still possible during the exercise but heart rate and breathing will be increased

RPE = 12-13


TYPE

Weight bearing exercises such as walking, climbing stairs, and resistive exercise.


Brisk walking, cycling, swimming, skating, fitness class, rowing.

Jogging and ball sports might aggravate osteoarthritis seek advice first

STRENGTH

2-3 sessions per week. The focus should be on more repetitions and low resistance

Low to moderate muscle contractions




Special Considerations for Osteoarthritis:

People with osteoarthritis should match the type and amount of physical activity to their abilities and the severity of their condition. A physician should do this as part of the pre-exercise medical assessment

Extra care much be considered when participating in contact sports e.g. football, basketball, handball and rugby, especially if cases of advanced OA or increased symptoms of pain and swelling

Patients with generalised osteoarthritis should keep the intensity of the exercise at a low level for a prolonged period of time

Strenuous exercise should be avoided when joints are very painful or stiff

Pain may increase in the first 4 weeks after beginning exercise. This can be treated with normal painkillers or anti-inflammatory medication

Proper seat height is important to ensure knee flexion is not less than 90 degrees


Adults with Metabolic SyndromeMetabolic Syndrome is a disease consisting of a number of factors such as abdominal obesity, insulin resistance, abnormal blood lipids, and high blood pressure. Patients with metabolic syndrome have an increased risk of cardiovascular disease, type 2 diabetes, dementia, Alzheimers disease and some common forms of cancer (prostate, colon and breast).

The basis of treatment is changing lifestyle behaviours. The two key elements are increasing physical activity and weight loss.


FREQUENCY Most days of the week At least 3-5 sessions per week

INTENSITYTalking is still possible

RPE = 11-13

Until out of breath but not hyperventilating

RPE = 13-15

TIME >30 minutes every day20-60 minutes total over 24 hours

Increased duration will be more beneficial for obesity

TYPE



Brisk walking, jogging, cycling, swimming, ball sports, skating, fitness class, rowing

STRENGTH

2-3 sessions per week. The focus should be on more repetitions and low resistance





Youth (12-17 years)For healthy adolescents, we recommend 60 minutes of daily physical activity and reducing sedentary activities. This can be accomplished by the following:

Adults should act as role models

Youth should participate in a variety of enjoyable and safe physical activities that support their natural development. Expose children to a variety of activities and let them select what they enjoy to participate in regularly

Daily activity can be accumulated in various settings: at home, in school and in the community

Remove TV and computers from bedrooms and limit screen time (TV, computer, iPad, mobile phones, video games, etc.) to less than 2 hours a day

Take an activity break after every hour of sitting time

Register children in extracurricular activities, such as youth leagues in football, skating, etc. Parents should encourage their children by taking them to the training sessions and providing support from the sidelines. Verbally reward them for their effort



FREQUENCY Everyday At least 3 times per week

INTENSITY

Moderate: Heart is beating faster and breathing is harder than normal. It is still possible to talk during the activity

RPE = 10-12

Vigorous: Heart is beating much faster and breathing is much harder than normal. It is very hard to talk during the activity

RPE = 13-15

TIME 60 minutes per day 60 minutes per day

TYPEBrisk walking, bike riding, skate boarding, leisurely skating

Running, football, basketball, swimming, jumping, basketball, volleyball, and most forms of competitive sports

STRENGTH

At least 3 times per week

Calisthenics: Push-ups, Sit-ups, Pull-ups, etc.

High intensity weight training is permissible if physical maturity is reached.

Safety tips

Base activities on physical maturity rather than chronological age to reduce the risk of injury

Use of appropriate protective equipment (bicycle helmets, shin guards, etc.)

Use appropriate footwear


Children (5-11 years)For healthy children, we recommend 60 minutes of daily physical activities, along with reducing sedentary activities. This can be accomplished by the following:


Less active children can start with smaller amounts of physical activity and gradually increase duration, intensity and frequency

Children should participate in Physical Education classes

Enroll children in scheduled age specific sporting activities

Daily activity can be accumulated in various settings (including outdoor activities whenever possible): at home, in school and in the community

Encourage children to progressively reduce amount of time spent sitting and in front of electronic devices

Remove TV and computers from bedrooms

Take an energy break after every one hour of sitting


Basic Activity

FREQUENCY Every day of the week

INTENSITYModerate to vigorous physical activity. Children should not be forced to overexert

TIME At least 60 minutes per day

TYPE

Bike riding, tricycle, scooter, playground activities (races, tag, etc.), sport games (football, basketball tennis), swimming, gymnastics, jumping, running, folk dancing

Exercise should not be over-structured for this age group. Children want to make their own gameplay rules. Excessive over-structuring of gameplay reduces the fun and discourages the children from the game

STRENGTH

Children should not be discouraged from participating in strengthening exercise, but they should not be pushed to overexert. Children generally know their physical limitations and are prone to get injured more readily when subjected to external pressure

Safety tips

Base activities on physical maturity rather than chronological age to reduce the risk of injury

Use of appropriate protective equipment (bicycle helmets, flotation devices, sun screen lotion, shin guards, etc.)

Use appropriate footwear

Exercise in the Heat

Avoid participation in physical activity during the hottest parts of the day

Use shaded areas whenever possible and especially between 10 am and 3 pm, when the sun is at its hottest

In cases of extreme heat and humidity, restrict excessive physical activities outdoors

Remind children to drink enough water before, during and after physical activity

Drinking milk after physical activity in the heat can be good for replacing the fluids because it contains salt

Children should wear loose-fitting white or light-coloured clothes and clothes that expose the skin to the air in order to help sweat evaporate and cool the body

Use sunscreen (sunblock) 20 minutes before going outdoors to protect your childs entire skin exposed to the sun (SPF of at least 30)

Physical activities in hot weather should only be at moderate level

Splash your childs body with water to cool down before physical activity and during breaks


Any child or adolescent should avoid or limit exercise, sport participation, or other physical activity in the heat if he or she is currently ill or is recovering from an illness especially those involving gastrointestinal distress (e.g., vomiting, diarrhoea) and/or fever

Warning signs: dizziness, headache, nausea (desire to vomit), shivering, hot dry skin, exhaustion, or collapse. In these cases get professional medical help without delay.

Vitamin D deficiency

Vitamin D deficiency continues to be prevalent in this group and supplementation may be needed. The amount of sun exposure needed to meet the bodys vitamin D requirements varies from one person to another and is also dependent on location, skin colour, time of year, time of day, and atmospheric conditions. However, as a general guide, exposure to the sun with the appropriate exercise attire, for 15 minutes per day will help reduce or eliminate the need for vitamin D supplementation.

Early Years (0-4 years)Caregivers should minimise time children spend being sedentary during waking hours, including prolonged sitting or being restrained in a stroller or a high chair for more than an hour at a time.

Infants:

< 1 Year Old

Toddlers:

1-2 years old

Preschoolers:

3 4 years old

FREQUENCY Several times per day

INTENSITY At own At ownAt own but encourage more active play

TIMEKids should not be confined for any extended duration of time

180 minutes of play per day progressing to include more energetic play by the age of 5

TYPE

Unstructured Play

Interaction with caregiver

Tummy time and floor time- time spent on the stomach or back during waking hours including rolling and playing on the floor

Reaching out and grasping objects (e.g. rough, soft), pulling and pushing

Crawling

Body awareness

Introduce to music

Include a greater variety of physical activity options, including:

Climbing stairs and moving around the house

Playing outside and safely exploring their environment

Crawling, running and walking, hopping, sliding, galloping, leaping

Bouncing, catching, kicking, throwing

Rhythmic activity

Any activity that gets children moving, including playing with water


How to reduce the sedentary behaviour?

Provide equipment to encourage movement (balls of different sizes and textures, beanbags, scarves, ropes, push scooter etc.).

Older children should be encouraged to engage in more energetic play.

Create safe spaces for play. Restrict access to swimming pools without adult supervision. Make sure there are no small or sharp objects accessible.

Provide opportunities for children to interact with other same age children.


Exercise in the Heat- Children and Young Adults

Keep your children away from direct sun and try to avoid hottest parts of the day

Use shaded areas whenever possible especially between 10 am and 2 pm when the sun is hottest

In cases of extreme heat and humidity, restrict excessive physical activities outdoors

Remind children to drink enough water before, during and after physical activity

Drinking milk after physical activity in the heat can be good for replacing the fluids because it contains salt

Children should wear loose-fitting white or light-coloured clothes and clothes that expose the skin to the air in order to help sweat evaporate and cool the body

Use sunscreen (sunblock) 20 minutes before going outdoors to protect your childs entire skin exposed to the sun (SPF of at least 30).

Physical activities in hot weather should only be at moderate level

Splash your childs body with water to cool down before physical activity and during breaks

Any child or adolescent should avoid or limit exercise, sport participation, or other physical activity in the heat if he or she is currently ill or is recovering from an illness especially those involving gastrointestinal distress (e.g., vomiting, diarrhoea) and/or fever.

Warning signs: dizziness, headache, nausea (desire to vomit), shivering, hot dry skin, exhaustion, or collapse. In these cases get professional medical help without delay.


Vitamin D deficiency

In infants and children, requires a supplementation of vitamin D of 400 IU. Vitamin D deficiency continues to be prevalent in this group and doses may need to be increased, especially in light of the evidence that the amount of vitamin D needed for sufficiency can vary with weight or BMI. Overweight and obese children are at higher risk for vitamin D deficiency and may need a higher intake.

Sun exposure

The amount of sun a person needs to meet their vitamin D requirements varies hugely, depending on location, skin type, the time of year, the time of day, and even the atmospheric conditions. However, it is safe to state that 5 to 30 minutes of exposure to the face, arms, back or legs (without sunscreen) two times every week is sufficient. Individual factors that influence how much Vitamin D a person needs include: 1) how much time they spend outdoors 2) the colour of their skin, 4) age, 5) diet, and 6) body weight.


Recommendations and ExRx Adjustments for children with asthma and diabetes Children with well-controlled diabetes or asthma should be able to be physically active and reduce sedentary life style.

TYPE 1 DIABETES MANAGEMENT:

Parents should inform the school nurse and physical trainer that their child is a Type I diabetic prior to starting physical activity

The child should also have a medic alert ID

The school should have a diabetes management plan. Parents should check with the school for the existence of such a plan before they allow their children to engage in vigorous physical activity at the school

Type I diabetic children, their teachers and parents should always have the required medication and sugars required for treatment of hypoglycemia available when they exercise

Keep child well hydrated. Water should be consumed ad-libitum (at will) and encouraged throughout the day. Water fountains should be available throughout the training/exercise area

In the summer, children should be called in regularly to consume water

Monitor blood glucose before and after physical activity

If blood sugar is below target range before exercise, the suggested intake is 15g of carbohydrate (may need to be less in younger children)

For prolonged vigorous exercise, monitor blood glucose hourly during exercise and after completion of exercise to gauge carbohydrate intake and insulin dose adjustment

RECOMMENDATIONS FOR ASTHMATIC CHILDREN AND CHILDREN WITH CHRONIC PULMONARY DISEASE:

Physical activity/exercise should be conducted indoors if the outdoor environment is dusty and polluted

Asthmatic children should use their prescribed medications (b2 agonists, inhalers, etc.) 15 to 30 minutes prior to beginning exercise, or as indicated by their peadiatrician

The school must have an emergency plan to manage asthma attacks. Parents should check with the school for the existence of such a plan before they allow their children to engage in vigorous physical activity at the school

Children who had experienced asthma symptoms during the previous 24 hours should consult with their physicians before allowing their children to participate in vigorous physical activity

The child should be free of asthma symptoms immediately prior to physical activity

No coughing or wheezing

No difficulty breathing or chest tightness


Preconception, Pregnancy and Post-Partum Women of childbearing age should be physically active. For many women, pregnancy is an appropriate time to modify behaviours and adopt a healthier lifestyle. These habits can affect the future health of both mothers and their babies. Exercise improves overall health and maternal cardiovascular fitness, prevents and controls hypertension and gestational diabetes mellitus, improves self-esteem and decrease risk of depression, makes postpartum weight loss easier, decreases fetal stress during delivery and increased neurological development, and decreases the risk of infant obesity.

Current research suggests that moderate levels of regular exercise performed over the course of a low risk pregnancy bear minimal risk to the fetus while delivering numerous metabolic and cardiorespiratory health benefits to the mother. Therefore, initiating or continuing exercise is recommended in most pregnancies to achieve the associated health benefits. In a recent study, 42% of women of childbearing age reported exercising during pregnancy and having a strong desire to continue exercising post-delivery.

The PARmed-X for pregnancy document (Appendix D) is a complimentary form to consider utilising during medical prescreening, monitoring, and exercise prescription for pregnant women.

Inactive or Unfit(high risk)

Active and Fit(low risk)

FREQUENCY Seek medical direction 3-4 days per week

INTENSITYLow intensity

RPE = 9-11

Moderate Intensity

RPE = 12-15

TIME10-minute bouts performed 5-6 times daily or 15-minute bouts performed 3-4 times daily

40-50 minutes per day accumulated in 15 30 minute exercise bouts

TYPE Walking, cycling, light swimming Prenatal Yoga, swimming, jogging, power walking, cycling

STRENGTH

2-3 times per week.

40-60% 1RM, Pilates, Yoga, Kegel exercises

Pregnancy is not a time to lose weight, diet, nor train to compete. Intense or vigorous exercise is discouraged. Exercise intensity should not exceed pre-pregnancy levels.

Additional Precautions:

Avoid hot and humid places.

Pool temperature should be 28-31C.

The following conditions should be considered contraindications to exercise during pregnancy. Women with these conditions should not exercise:

Pregnancy-induced hypertension


Pre-term rupture of membranes

Pre-term labor during the prior or current pregnancy or both

Incompetent cervix/cerclage

Persistent second or third trimester bleeding

Intrauterine growth retardation

ExERCISE GUIDELINES FOR PREGNANCY AND THE POSTPARTUM PERIOD

There are no data in humans to indicate that pregnant women should limit exercise intensity because of potential adverse effects. For women who do not have any additional risk factors for adverse maternal or perinatal outcomes, the following recommendations may be made:

During pregnancy, women can continue to exercise and derive health benefits even from mild to moderate exercise routines. Regular exercise (at least 3 times per week) is preferable to intermittent activity

Women should avoid exercise in the supine position after the first trimester. Such a position is associated with decreased cardiac output in most pregnant women; because the remaining cardiac output is preferentially distributed away from the uterus during vigorous exercise, such regimens are best avoided during pregnancy. Prolonged periods of motionless standing should also be avoided

Women should be aware of the decreased oxygen available for aerobic exercise during pregnancy. They should be encouraged to modify the intensity of their exercise according to maternal symptoms. Pregnant women should stop exercising when fatigued and not exercise to exhaustion. Weight-bearing exercises may under some circumstances be continued at intensities similar to those before pregnancy throughout pregnancy. Non-weight-bearing exercises, such as cycling or swimming, minimise the risk of injury and facilitate the continuation of exercise during pregnancy

Morphologic changes in pregnancy should serve as a relative contraindication to types of exercise in which loss of balance could be detrimental to maternal or fetal well-being, especially in the third trimester. Further, any type of exercise involving the potential for even mild abdominal trauma should be avoided

Pregnancy requires an additional 300 kcal/day to maintain metabolic homeostasis. Thus, women who exercise during pregnancy should be particularly careful to ensure an adequate diet.

Pregnant women who exercise in the first trimester should facilitate for heat dissipation by ensuring adequate hydration, appropriate clothing, and optimal environmental surroundings during exercise. Avoid body temperatures above 38C (hot tubs, saunas, prolonged exercise in heat and humidity)

Many of the physiologic and morphologic changes of pregnancy persist 4 to 6 weeks postpartum. Thus, pre-pregnancy exercise routines should be resumed gradually based on a womans physical capability. Acceptable guidelines are to resume activity 1 week after vaginal delivery and 6 to 10 weeks following a cesarean section

Strenuous exercise should not exceed 15 minutes and may require adjusting as the pregnancy advances


Environmental Considerations

In Qatar, the weather, traditions, culture, and faith play a very important role in how we schedule our daily work and school routines, our social life, and our physical activities throughout the day. Although winters are very pleasant and conducive to outdoor activities, summers tend to be hot with strong and dominant sunshine. When considering partaking in physical activity in the summer, precautions must be considered to safeguard our health from untoward consequences of overexposure to the elements. This chapter will discuss precautions that must be considered for healthy individuals, individuals with known disease, during pregnancy, as well as for fasting the holy month of Ramadan.

Heat illness and all its variants (Table 5) are preventable illnesses, and can also include dehydration (loss of body fluid), heat cramps (cramping of skeletal muscle), that result from exposure to environmental temperature (classic or non-exertional) or from strenuous exercise (exertional) and can progress to severe and life-threatening illnesses characterised by a core body temperature that rises above 40C that is accompanied by hot, dry skin and central nervous system alterations (delirium, convulsions or coma). These illnesses are often fatal and under diagnosed.

Sequence of Events in the Progression of Heat Illness.

DEFINITIONCONDITION

Three or more consecutive days during which the air temperature is >32.2oC Perceived discomfort and physiological strain associated with exposure to a hot environ ment especially during physical workServe illness characterised by a core temperature >40oC and central nervous system. Abnormalities such as delirium, convulsions or come resulting from exposure to environmental heat (classic heat stroke) or strenuous physical exercise (exertional heat stroke)Mild-to-moderate illness due to water or salt depletion that results from exposure to high environmental heat or strenuous physical exercise sign and symptoms include intense thirst, weakness, discomfort, anxiety , dizziness, fainting, and headache,core temperature may be normal, below normal,or slightly elevated (>32.2oC but >40oC)A rise in body temperature above the hypothalamic set point when hear-dissipating mechanisms are impaired (by drug or disease) or overwhelmed by external (environmental or induced)nor internal (metabolic) heatContinuum of changes that occure in more than one organ system after an insult such as trauma, sepsis or heat stroke

Heat wave

Heat stress

Heat strock

Heat exhaustion

Hyperthermia

Multiorgan- dysfunction

syndrome


In Saudi Arabia, for example, incidence varies seasonally, from 22 to 250 cases per 100,000 population and the mortality rate associated to these conditions is 50 percent. It is important to highlight that there are genetic factors that determine the susceptibility to develop these illnesses.

The balance between heat production and heat loss determines the body temperature. Normal body function depends upon a relatively constant core temperature because biochemical reactions function optimally at narrow temperature ranges. In response to the rise of heat, the mechanisms of cutaneous vasodilation, sweating, and increased respiration come into effect to increase heat loss. Once blood temperature increases, thermal sweating is initiated. This will also cause heart rate to go faster (tachycardia), increasing the work from the heart as well as the volume of blood ejected (Cardiac Output) and the respiratory frequency (minute ventilation). Nonetheless, most people might be able to adapt to hot environments.

Some physiologic conditions like pregnancy, cardiovascular diseases and some medications may interfere with the cardiac function and impair heat tolerance increasing the susceptibility to develop any heat illness. If heat production exceeds heat dissipation capacity, for example during exercise in hot, humid conditions or during very high intensity exercise, the core temperature will continue to rise. During prolonged exercise, loss of fluid as sweat may compromise heat dissipation. Maintenance of euhydration (good or appropriate hydration) is critical to heat balance.

Pregnancy and HeatPregnant women and their fetuses are not excluded from the harmful effects of extreme heat exposure. Therefore, thermoregulation is especially important for the physically active pregnant women and even more in hot weathers like in Qatar. Exercise in hot and humid environments is a great challenge to temperature regulation because if sweating is excessive and fluids are not replaced, blood volume falls and core temperature may rise to lethal levels.

During pregnancy, basal metabolic rate, and therefore heat production, is increased above non-pregnant levels. The increase in body temperature during exercise is directly related to the intensity of the exercise. During moderate intensity, aerobic exercise in thermoneutral conditions, the core temperature of non-pregnant women rises an average of 1.5C during the first 30 minutes of exercise and then reaches a plateau if exercise is continued for an additional 30 minutes.

Fetal body core temperatures are about 1C higher than maternal temperatures. In animal studies, an increase in maternal core temperature of more than 1.5C during embryogenesis has been observed to cause major congenital malformations. These data coupled with the results of human studies suggest that hyperthermia in excess of 39C during the first 4560 days of gestation may also be teratogenic in humans. However, there have been no reports that hyperthermia associated with exercise is teratogenic in humans. There is no evidence on the impact of heat associated with exercise and the adding effect of environmental heat. Recent studies that have led to the conclusions that the fetus is granted some thermal protection when the mother experiences thermal stress. This is referred to as fetal thermal inertia, which appears to protect the fetus and prevents the rise or fall of fetal temperature to the extent of the maternal responses.

During swimming, a relatively smaller rise in temperature is obtained due to better heat dissipation. Maternal exercise in the water may be more beneficial than exercise on land because heat loss can be facilitated through the water. However, care must be taken if the water temperature is hot as the body is more apt to experience heat illness.


The best ways to prevent heat illnesses are acclimatise to heat, schedule outdoor activities in the coolest time of the day (early morning and late at night), reduce the level of physical activity, increase the amount of water drank daily, ensure electrolytes such as sodium and potassium, and try to be in air conditioned areas as much as possible.

Exercise recommendations for preventing hyperthermia suggest that the pregnant woman should:

Acclimatise gradually to ambient conditions

Exercise during the cooler times of the day or in well-ventilated and air-conditioned environments

Wear comfortable clothing that will permit free evaporation of sweat. Clothing should be lightweight, loose fitting, and light in colour

Drink plenty of fluids before, during, and after exercise

Be aware of the early symptoms of heat illness: nausea, dizziness, headache, poor coordination, and apathy

Train with a partner who is aware of the symptoms of heat disorders (heat cramps, heat syncope, heat exhaustion, and heat stroke)

Exercise at her own pace, and at a length of personal comfort

Avoid swimming in warm or hot water and avoid immersion in hot tubs

Fasting RamadanThe holy month of Ramadan incorporates refraining from food or fluids during the daylight hours of the holy month. This can last from12-16 per day and is dependent on the season the holy month of Ramadan coincides with. There have been many concerns regarding the engagement of exercise and physical activity during Ramadan, especially during the summer months. Research has shown that fasting for 30 consecutive days without any form of exercise or physical activity results in decrease of strength and fitness. Therefore, Muslims should maintain their physical activities level during the month of fasting in comprehensive ideal way to avoid any health complications.

Physical Activity should be undertaken in non-competitive settings in dark hours (post fasting). If the activity is in competitive settings, it should be performed on non-consecutive days. Efforts to optimise sleep and to stay hydrated before and after the activity are of paramount importance to avoid any possible deleterious effects of intense physical activity during Ramadan. Also, an individual can perform the activities in very early morning after the last meal of the post-fast (Suhor), but as this activity will not be followed by any food and liquid replenishment, it has to be light in intensity, and short in duration. Also, avoid direct exposition to the sun and/or heat for this early day exercise.

During cold/temperate seasons:

Ninety minutes before sunset would be a good time to perform in non-competitive activities (e.g. walking).

During hot season:

When Ramadan coincides with the summer months any pre-Iftar (pre-fast-break) moderate or vigorous activities are not recommended in open-sky settings unless it is of short duration. If the individual cannot perform any form of activity at night, it would be recommended that she/he should find an air-conditioned space to practice.


Modifications to the ExRx During Fasting

Component Intensity Duration

Warm-up (Light) RPE = 10 7-10 minutes

Stretching(Light) and Stop stretching when muscles start to cause pain

5 minutes: ~20 seconds per limb/muscle group

Aerobic Training

(Light) RPE = 10-11 ~20 minutes

Strength training

(Light) 50-60% of 1-Repetition Maximum (1-RM)

~20 minutes: 2 sets of 8-12 reps (1.5 to 2 minutes rest in-between sets)

Cool-down (Light) RPE = 9 5 minutes

Table 6 shows the structure of a proposed session with either (1) cardiovascular training, or (2) strength training as a core of the session. Warm-up

Documents

Qatar Pa Guidline English