The Preventive Cardiology department at Henry Ford Health in Detroit, Michigan, employs 18 clinical exercise physiologists (CEPs) across three sites, as well as two registered dieticians (RDs); there are no other allied health professionals on staff. 

The Henry Ford Health CEPs provide a wide variety of services: 

• Adult weight management — counseling patients on physical activity, nutrition (in conjunction with an RD) and adherence to meal plans. 
• Bariatrics — working with patients prior to their surgery to help them understand the role that physical activity plays in weight maintenance. 
• Cardiac rehabilitation (CR) — providing traditional, facility-based CR, including Phase 3 as well as telehealth CR. 
• Cardiopulmonary stress testing — CEPs prepare patients and monitor vital signs during testing. CEPs with a master’s degree or higher supervise testing under the direction of a physician who is located in the immediate vicinity. 
• Exercise oncology — working with patients who have a cancer diagnosis and may or may not be actively receiving treatment. 
• Peripheral arterial disease (PAD) — providing supervised exercise training and risk-factor reduction education to patients with symptomatic PAD. 
• Research — supporting clinical trials where exercise is either being used as an intervention for a chronic disease or where changes in exercise capacity are an expected outcome. 

The 2018 Physical Activity Guidelines for Americans notes that there is no obvious “best amount” of physical activity and no evidence of increased risk, even among those that engage in high intensity activities. However, vigorous physical activity may acutely increase the risk of heart attack and sudden cardiac death in some individuals. Recent studies have shown that large volumes of high intensity physical activity may actually have maladaptive cardiovascular effects, including accelerated rates of cardiac scarring, atrial fibrillation and coronary artery calcium (CAC).

CAC is a highly specific subclinical marker of coronary atherosclerosis and is strongly associated with risk of future cardiovascular disease events, such as heart attack. The higher the CAC, the higher the risk. Traditionally, risk factors for the development of CAC (and heart disease) include high blood pressure, high cholesterol, diabetes and smoking, among others. However, the participants in the studies showing the link between high amounts of physical activity and CAC did not possess these traditional risk factors, leading to the controversial hypothesis that high levels of physical activity may actually increase CAC and subsequent risk of heart disease in otherwise healthy individuals.

In our study, published in the May 2022 issue of Medicine & Science in Sports & Exercise_®, we used data from the Multi-Ethnic Study of Atherosclerosis (MESA) to better understand the relationship between physical activity, CAC and cardiovascular outcomes. MESA is a large and ongoing population-based cohort study of men and women in the United States. This cohort was ideal because it has baseline information on CAC and physical activity with roughly 15 years of follow-up data. MESA includes participants from four different racial/ethnic groups (defined as “White,” “Black,” “Chinese” and “Hispanic”), making the results of our study more broadly applicable. Physical activity was assessed via a questionnaire during the baseline exam. The physical activity data was transformed into quartiles of MET-minutes (the amount of calories expended during one minute of rest) per week, with the lowest quartile serving as the reference group for the purposes of the analyses. Computed tomography scans were done to quantify CAC, and scores were dichotomized as “low CAC” (CAC < 100) and “high CAC” (CAC ≥ 100), which correspond with low and high risk, respectively. Outcomes assessed included mortality and cardiovascular disease, defined as a composite of myocardial infarction, resuscitated cardiac arrest, definite or probably angina, fatal coronary heart disease, fatal and nonfatal stroke, other atherosclerotic death, or other cardiovascular death.

We found that participants with low CAC that engaged in the highest quartile of physical activity had a reduced risk of cardiovascular disease and mortality. Participants with high CAC that engaged in the highest quartile of physical activity had a reduced risk of mortality, and no increased risk of cardiovascular disease. In fact, high levels of physical activity were not associated with an increased risk of cardiovascular disease or mortality regardless of CAC, sex or race/ethnicity. Importantly, these results were established even after controlling for traditional risk factors.

While this study suggests that high amounts of physical activity appear to be safe, even among those at high risk, it was conducted in an observational cohort. Future studies should be done to confirm these data. Additionally, we were unable to account for differences in physical activity levels over time. However, our results should empower patients to be physically active and encourage health care providers to promote physical activity and exercise, even among those at high risk of cardiovascular disease. 

Charles A. German, M.D., M.S., is an assistant professor and preventive cardiologist at the University of Chicago. He is the current director of cardiac rehabilitation and serves on the editorial board of the Journal of Cardiopulmonary Rehabilitation and Prevention. He also serves on the physical activity committee and obesity committee for the American Heart Association. His research interests focus on accelerometry-based physical activity; relationships between physical activity, sleep, and sedentary behavior; and the safety of physical activity in high risk populations. He can be reached at cagerman@uchicago.edu or on Twitter @DrGermanMD.

Viewpoints presented in SMB commentaries reflect opinions of the authors and do not necessarily represent ACSM positions or policies. Active Voice authors who have received financial or other considerations from a commercial entity associated with their topic must disclose such relationships at the time they accept an invitation to write for SMB.

Thank you to everyone who attended the March 10, 2022 Gatorade Sports Science Institute webinar on "How to Effectively Communicate the Science Behind Performance With Your Athletes."

Below is a series of follow-up questions and answers provided by presenter Kevin Luhrs.

The course is still available here along with 1 CEC. Save up to 50% on CEC quizzes by  joining ACSM today.

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Q: Would too many messages be a barrier as well? Ex. giving too many messages without enough time for them to process or implement?

Yes. Having multiple messages as well as too much information is one of the many barriers in communicating the science. In keeping your message simple, this also includes not including too many points, messages, and information. Less is definitely more.

Q: If you can just get your athlete to believe in you and your instruction and then they see results on the football field for example do you find them to engage better going forward more than the initial meeting? Results are the best way to get them to engage in my past experience.

Yes. This goes along with appealing to how they feel instead OR in addition to the science and is a success story in and of itself. The athlete can then be a spokesperson for you as well. Other athletes will then be able to see the proof of your messaging that is back by science.

Q: What are favorite sources of nutrition for athletes? What do they read, friends? Does the source set the level you respond at?

There are great nutrition resources for athletes coming from AND’s Sports and Human Performance Nutrition DPG (formerly SCAN) and the Collegiate and Professional Dietitians Association. In addition, Gatorade Performance Partner is an excellent resource that is fairly new and brings a lot of different realms of sports performance together (sports nutrition, athletic training, strength & conditioning, etc). GSSI web has some tools for athletes that can give them an idea of how their current habits are sufficient or not.

Q: Apologies if I missed this (I had to drop off due to bedtime story duties) but how do you bridge the gap in applying sports nutrition research findings from one sport to another? 

Fortunately for some, but unfortunately for others, there are certain sports that garner more research than others partly to due to the very black and white performance indicators. A good example of this are endurance sports (running, cycling, swimming, triathletes, etc) since performance indicators are more objective (i.e. time trials) and can somewhat able to be replicated in the lab and studied in the field. Team sports are a little more difficult in that it is a little more difficult to pinpoint performance indicators (especially objective ones) and is a complicated research project both in the lab and in the field. However, certain team sports like soccer and rugby are a little more widely studied and therefore there may be some conclusions from these sports that can be extrapolated into other sports given the anaerobic nature of these sports under an aerobic umbrella. Overall, you have to be realistic and practical, however, and know that it will probably be difficult to get a 300 lb team sport athlete to consume 7g/kg carbohydrate on competition day.

Q: Are there certain sports where athletes are more knowledgeable on nutrition than others?

I don’t like to categorize an entire group based on some or even many. And I definitely don’t want to create any stereotypes. There are certainly some athletes within each sport/team that think they know more than they actually do. But I do believe but not necessarily be able to prove quantifiably that endurance athletes are a little more in-tune with their bodies on physiological level and therefore focus on what they to do on a more in-depth level. This could be because their sports are definitely more objective than other sports with regards to performance which makes it more black and white. If what goes into an athlete’s body directly correlates to my performance plus able to be measured, then they are more apt to pay attention to those sorts of details.

Q: What platform do you use for your videos?

When I worked full-time in sports I used a team communication platform called Teamworks. This was great since anyone that was on our team had an account with all of their contact information within. You could directly reach out to specific athletes or groups of athletes (i.e. position groups) or the entire team without having to collect any contact information. With this platform, I had the capability of posting my videos within the platform along with a notification that would go directly to their phones for them to watch the videos. I could also tell how much traffic there was for each video so as to let me know which videos/topics were more interesting than others for feedback. I have also posted other videos on YouTube that were unrelated to my work but that also talk about nutrition.

Q: Many of the exercise and nutrition research done by the academic institutes only use a small number of study subjects and lack in statistical power. Do you find it disappointing to have not enough good data which are statistically powered?

I don’t necessarily find it disappointing in the sense that we all know that research takes time and that both sports nutrition and exercise science are relatively young fields. I do feel there has been a lot of statistical power in many studies but maybe not as much in others. But over time the more and more research that comes out on a particular topic the more fine tuned we become in acquiring knowledge on that topic. This is evident in the reviews and meta-analytics of several original research studies that may/may not have statistically powered findings but within those consolidated studies they gather more and more power to them the more research that comes out. For instance, carbohydrate in endurance sports was never predicated on one particular statistically powered study but many studies throughout years of research. Do I find it frustrating when I get to the end of an article and it says, “findings are inconclusive at this time and more research is needed”? Of course. But at the same time you can’t chop down a tree with one swing. It takes many, many, many swings before that tree falls. But the other question is, when is research in a particular topic considered finished?

Q: How is age a factor in athletes being open? Are older athletes more or less open?

I don’t think the question necessarily is if older/younger athletes are more open to education but what are they open to? Meaning- the younger athletes seem to be more open to education and messages that are directly tailored towards enhancing performance. So the questions they ask are- “Kevin, what can I do to get better on the field/court/rink/pitch/etc?” Whereas, older athletes are more focused on recovery plus overall health. So with these athletes, education is a little more tailored to how they can feel better which may indirectly/inherently affect performance. Overall, I don’t think age plays a factor in whether they are open or not as I think this motivation is mixed within age groups. But I think the focus on direct performance outcomes tends to take a back seat to health and recovery as one ages. This could be tied indirectly to performance but could also be tied to an adjustment in priorities (long term health for self, family, kids, life after sports, etc.).

Q: What are some of your favorite tips to share with everyday people?

I like to focus on principles such as balance of foods, variation of foods, meeting energy needs, meeting hydration needs, meal frequency and snacking, food first and supplements to supplement, as well as pre/refueling if they are an avid exerciser. A huge battle with many is that even though they may know what to eat, there are still a couple of challenges that lay ahead before they can actually eat those foods. And that is- grocery shopping and cooking. These are often overlooked but are key teaching points to focus on since if you don’t know how to shop and don’t know how to cook, then how are you going to be able to follow through with proper nutrition without spending a lot of money on restaurants/food delivery/etc.?

Q: How does your approach change when working with different levels of athletes? e.g. high school vs. professional

For younger athletes, I believe it’s safe to assume that they know absolutely nothing about nutrition from certain foods to broader foods groups and especially specific nutrients. So you may start out talking about foods and their respective food groups particularly and how important it is to eat all meals with snacks throughout the day. However, you might be surprised about how many professionals need this elementary advice as well and need to build their foundation. I think it’s always best to start with the basics regardless of the level but with the professional athlete probably preface with the fact that you will build more on the basics and get more into the details.

The professional athlete has evolved in their awareness and knowledge/education of the different variables that go into performance and recovery. Plus sports science/ athlete monitoring is taking shape to where personalization is becoming more common. So you have to take this into consideration as well. Again, you still need to build a solid foundation before you can focus on more advanced focal points. You can’t graduate college before passing kindergarten.

Q: Do you have any tips if you only have a small amount of time with a client? Say 2-3 minutes and you can't communicate as deeply as you would like?

I would definitely develop an elevator pitch and be clear if there are specific points you want them to remember. Be clear in the differentiation of those points (“point A, point B, point C,…etc” or “1,2,3, etc) then come back to those points and repeat them (maybe a third time as well). After that have them repeat what you said. Repetition is very valuable in any case.

Q: You spoke about starting with the WHAT with athletes, how would you approach the conversation if speaking with a Doctor?

You might be surprised about how little doctors know about nutrition. And those who are big proponents of nutrition may/may not promote specific diets and supplements. Nevertheless, it is important to approach this conversation with the most backed-by-science information as possible since doctors are familiar and hopefully reliant on peer-reviewed research. Therefore, sharing the science and references are appropriate even early in the conversation. Doctors may listen to a Registered Dietitian before it gets to that point of bringing in credible research but some may not. Also, it is important to remember not to be defensive if there is a debate since this can turn the doctor off completely from listening to you. This is ultimately because doctors disseminate information to many patients, clients, and potential athletes so ethically you want to try and persuade the doctor as much as possible to change this act of disseminating false information. This is especially important if you are a Registered Dietitian for a team to make sure that everyone on staff (including doctors) are communicating the same message as you.

Q: How do you prioritize what information to highlight when simplifying complex info for athletes?

What I like to do is create my own foundations or principles of nutrition (or whatever the specialty/expertise may be). This may be 3, 5, or 10 principles that may set the foundation and can fully outline your topic and even your “curriculum” so to speak. These are the essentials. Then from there create subunits within each principle and separate topics. You can go as deep as you would like. Mapping it out on your own can be a great exercise for yourself and allow you to simplify the complexity of your topic. For instance, one of the principles of nutrition for me is nutritional balance. From there, I can go into food groups, then I can talk about macronutrients, then I can talk about carbohydrate, then carbohydrate and sports, glycogen, foods that have carbohydrate, etc. You can keep splicing until you get into more complex subtopics such as metabolism which would be probably more advanced than you would need, especially for athletes.

Q: What do you find is the best nutrition knowledge assessment tool you have found when onboarding new athletes?

I personally like the new 49 Item Sports Nutrition Knowledge Instrument (49-SNKI). This should be used ideally with adult athletes but could be adapted for youth athletes by selecting certain questions over others. Also, even though slightly different than a knowledge survey, I would also urge the use of the GSSI’s Fuel Habits Survey since it is a very quick and comprehensive tool that provides an objective measure of your athletes current habits that may reflect their knowledge.

Q: What do you recommend for active older adults who remember feeling great in their lifetime but now are experiencing injuries maybe even age related and chronic conditions. What is the goal body composition for those active older adults to reduce those injuries? Do you change the sports nutrition requirements for those individuals?

I think with older athletes there is a balance between adjusting expectations of how they should compare oneself to what they used to be able to do compared to what they can do now AND also realizing that just because they are older doesn’t mean they need to stop doing the things they love to do. I don’t necessarily think improving body composition will directly affect injuries but may reduce the risk very indirectly. Since RMR may be affected through lower mass/metabolic rate of individual organs having an overall decrease in metabolic rate resulting in lower fat-free mass, maintaining or at least slowing the loss of fat-free mass may be a focus. So monitoring of overall calorie intake, protein intake, and resistance training are a must in ensuring best results for fat-free mass retention. Therefore, body composition will be personalized to the individual based on typical fat-free mass measurements.

Q: When you have a disconnect with a person, how do you get them to listen to you again?

Unfortunately, they may have to fail in order to get them to start listening. In addition, peer pressure is also valuable especially for younger athletes. You may have to shift your efforts to other athletes who are listening since efforts focused on those who are not listening is a disservice to those who are seeking your help. In other words, sometimes you have to let the non-listeners go only to be ready if they do end up returning to you with a more open mind.

Q: Weight loss vs performance nutrition. Would you agree some populations should steer towards going lower carbohydrate for weight loss purposes if they have trouble losing weight due to increased appetite when eating a performance-based diet in the normal to high zone for carbohydrate intake?

First of all, it is extremely important to conduct a food recall for any fat loss or fat-free mass gain athletes. The reason being- to highlight any macronutrient intakes that may be over in abundance (fat, carbohydrate, protein). Often times, we focus on carbohydrate intake from the very start when the problem could be coming from too much from any of the other two macronutrients or all macronutrients. So I would definitely start with this and see what macronutrients you can decrease. In addition, if there is a needed reduction in macronutrient/energy intake, do this very slowly and preferably in the offseason so the concomitant training can allow for adaptations of joints, muscles, and other tissues. So to answer your question, if carbohydrate is the only macronutrient that is consumed in unnecessarily excessive amounts then reduce carbohydrate steadily overtime to support fat loss while retaining as much fat-free mass as possible.

Most adults recognize exercise and physical activity is good for them, so why do so many individuals struggle to weave this important lifestyle behavior into their life? Further, among individuals motivated to enroll in exercise interventions, 20-30% drop out and return to their previously sedentary lifestyles. Unfortunately, there is a lack of researcher follow-up among these individuals who drop out, especially in collecting information regarding why they drop out, when they drop out and the association between the two.

The three Studies of Targeted Risk Reduction Intervention through Defined Exercise (STRRIDE) randomized trials — which examined the differential effects of exercise amount, mode, and intensity on cardiometabolic health — clearly defined dropout and collected information regarding when and why individuals did so. Thus, providing an opportunity to explore these important questions. 

Within the three STRRIDE trials, 69% of individuals completed the exercise intervention, and 31% dropped out. Following our analyses, we found two-thirds (66%) of individuals who dropped out did so prior to the end of month one of the exercise intervention — primarily during the ramp period that was put in place to allow for gradual adaption to the exercise prescription.

Not surprisingly, the most common reported reason for dropping out was lack of time (40%), with lack of time being attributed to work, family, motivation, travel and overall time. Intriguingly, individuals who dropped out because they changed their mind (9%), did so earlier on in the study period — during the inactive control period or run-in phase  — compared to individuals who dropped out due to lack of time and other measured reasons.

We also assessed if there was variation in adherence to exercise training across the STRRIDE trials among individuals who completed one of the interventions. We found adherence generally remained constant across the duration of the six- to eight-month exercise interventions.

We believe this study provides several translational takeaways, especially for those involved in designing and implementing exercise interventions:

1. First, most individuals will drop out before or within two to three months of exercise training onset. Placing greater targeting efforts during this early exercise adoption period may promote better exercise intervention adherence.
2. Second, the majority of individuals dropped out during the ramp phase of the exercise intervention, suggesting the way current interventions ramp up to exercise prescriptions may be too lofty for sedentary individuals with overweight or obesity. Researchers and interventionists should consider adjusting the design of the ramp-up phase of the exercise intervention to compensate for individuals who struggle incorporating exercise into their daily routine.
3. Third, those individuals who changed their mind did so during the inactive control or run-in period of the exercise intervention. When designing an exercise intervention, avoiding a long inactive control period and starting the exercise portion immediately may prevent these individuals from changing their minds. In addition, further exploration of participant perceptions during the inactive control and ramp phases may assist with improved intervention design and in turn adherence.
4. Fourth, once individuals make it past the initial two- to three-month ramp period (i.e., adoption period), they typically are consistent in adhering to a six- to eight-month exercise intervention. Furthering efforts on inactive control and ramp periods can leverage this new evidence that once an individual adopts the exercise behavior, they will most likely adhere to the intervention for at least six to eight months.

To read more about our findings and gain further insight into how variability of behavior change can lead to variation in when and why individuals dropout from an exercise intervention, view the full article in the Translational Journal of the American College of Sports Medicine (TJACSM).

 

Katherine A. Collins, Ph.D., is a postdoctoral fellow at the Duke Molecular Physiology Institute in the Duke University School of Medicine. She completed both her master of science (M.S.) and doctoral degrees in exercise physiology at the University of Pittsburgh. Her research focuses on identifying predictors of dropout and adherence to lifestyle interventions, characterizing phenotypic and genotypic profiles of individuals at risk for dropout and poor adherence, and utilizing personalized-medicine approaches to target these at-risk individuals.