Amping up your Fitness Program

Cardiorespiratory Fitness Program

The idea of the aerobic fitness program is to progressively increase your fitness level regardless of where you are starting off.  For example, if you are sedentary, you need to get active.  If you are active, then you need to begin some regular cardiovascular exercise.  If you already do that then you need to push up the duration and intensity of your exercise to achieve your highest possible level of capacity. 

The choice here is between performing low intensity exercise of adequate duration (an active lifestyle or endurance program) or performing high intensity exercise during some days of the week and maintaining your lower intensity exercise at the same time. Ultimately the goal is to improve your exercise capacity (or V02 Max). This measurement, or an estimate of it, will form the basis for the cardiovascular exercise experiment.

You first need to estimate your maximum effort level in METS, you can later compare that to V02 max.  Then, you will choose one of the programs below to try and "level up" your fitness.

The graded fitness program has 3 levels based on your ability at the start of the program.  An overview of the levels is shown in the table below:

Graded Fitness Program

Level	Type	Intensity	Duration	Frequency
Active Lifestyle	Water Aerobics Walking Light Calisthenics Gardening Weightlifting Pilates	Try to achieve 5 METS: Walking up hills or with a light weight.	150 minutes per week	5 days per week with 2 rest days
Endurance Program	Jogging/Running Cycling: 13 MPH Slow Swimming Heavy Calisthenics Weightlifting	Try to achieve 8 METS:  Cycling: 13 MPH, Running Approximately 12-minute mile and	180 minutes per week	5-6 days per week.  Weightlifting on rest day.
V02 Max Training	Interval training.  Adjust intensity to match V02 Max targets.	Add sprint Intervals within 85-90% of V02 Max.  Adjust intensity of endurance program to measured Zone 2.	180 minutes per week.  Build up to 4-8 minutes of sprint per week at 30 seconds to 1 minute per sprint.	4-5 days of typical Zone 2, adjusted for V02 Max.  1-2 days of sprint interval training.

Active Lifestyle Program

If you are considering this program, it is because you are not yet able to achieve 5 METS or you are mostly sedentary.  5 METS is the level of effort that would be required for a brisk walk (at 4 mph) or to ride a stationary bike.  You have already done your fitness assessment and you have passed the hurdle of being cleared to do any exercise at all by your physician.  In most cases, people who are cleared for exercise, and do not have any physical limitations to exercise are simply deconditioned.  If you are mostly sedentary during the day, this is possible.  To get you moving, we recommend starting slowly  and gradually increasing intensity and duration of exercise to build endurance over time.  All cardiovascular fitness programs have 4 elements:  Intensity, Frequency, Duration and Type of Exercise.  For the Active Lifestyle Program we recommend the following:

Intensity:  Start with low to moderate intensity exercise in the 2-5 MET range.  Try to achieve a steady pace that does not make you immediately out of breath.  One way to tell if your intensity is right is that you are able to hold a conversation while doing the activity but it is not that easy.

Frequency:  We recommend starting with three sessions per week.  Build to 5 or more as your fitness improves.

Duration:  The goal will be more than 150 minutes per week as you progress, but in the beginning start with 15-20 minute sessions and make sure that you are not feeling sore at the end of each week.

Type of Exercise:  Try to avoid impact on your joints and don’t require a lot of learning to adopt.  The items below are all good choices.

• Walking:  Any pace is fine to qualify as an active lifestyle but try to maintain the briskest pace that you can sustain.  Walking is a 2-3 MET activity depending on how fast you walk.
  

• ·Water Aerobics:  This is an excellent 2-3 MET activity that is easy on the joints, fun and interactive.
  

• Swimming:  Very slow swimming is in the range of 4-5 METS depending on your technique.
  

• Calisthenics:  One way to get and stay active is to do light calisthenics such as push-ups, sit-ups, squats and lunges.   Light calisthenics is an activity that is just shy of 4 METS.  As such it is almost a step beyond an active lifestyle activity and borders on an endurance training activity.
  

• Biking: A leisurely pace on a bike is a great way to stay active and if you use it to get to the grocery store to buy healthy foods, it is a nice way to combine elements of the lifestyle program.  Biking at a leisurely pace is about 4 METS making it a fantastic way to stay active and get good exercise.
  

• Progression:  Increase the duration of each session by 5 minutes every 1-2 weeks.  Add 4th and 5th sessions at around 3-4 weeks.  You should start to feel improvements relatively quickly.  Once you get to 150 minutes per week, you should start to feel like 5 METS is more possible.

Safety Notes:  Since you have already spoken to your doctor about exercise, you should keep that dialogue open as you progress in your program.  You should stop exercising if you feel any pain, discomfort, difficulty breathing, dizziness or any new symptom.  Remember to start slowly and warm up before you exercise to avoid injury.

Going from Sedentary to Active

If you are currently sedentary, you can start with a very brief activity sessions for as little as 10 minutes per day.  Try to do this on most days, however with only one day for rest each week.  As you begin to feel stronger, lengthen the sessions until you are active for 30 minutes at a time at least 5 days per week.  You can go longer if you are feeling good, you have the time and your muscles are not sore.

Endurance Program

Once you are able to consistently achieve 5 METS, you are ready to go beyond the active lifestyle stage and start a more formal endurance training program using moderate to moderately vigorous exercise.  Conceptually, this level of exercise is often called the “fat burning” zone.  This is because at the level of exercise intensity, your body can stay in aerobic metabolism and burn fat as its primary fuel source.  The longer that you stay in this fat burning zone the more quickly you will be able to address the body fat percentage in our assessment and the more successful your experiment will be.  We need to pause once again at this point and review the contraindications to exercise and re-emphasize safety tips.  If you are not cleared to exercise by your doctor, please pause to get cleared so that you can move along this fitness spectrum.  From a safety perspective, you are reminded to stop exercise if you feel chest pain, shortness of breath, dizziness or any other new symptoms.  If such symptoms occur, you should contact your doctor immediately.  At this stage, you may also want to consider investing in a training watch so that you can monitor your heart rate during exercise.

Hear Rate Monitoring:  Heart rate monitoring is an excellent way to ensure that you are exercising at the right level of intensity and not too high or too low.  There are many excellent training watches and other devices on the market for this purpose.  For this particular program, you are trying to target a heart rate of around 60-70% of your maximum provided that you don’t have a condition or take medicines that will slow down your heart rate.  To calculate your maximum heart rate, you can use the simple approach of 220-age.  Using this approach, a 40 year-old person will have a maximum heart rate of 180.  You would then take 60-70% of that to determine your fat burning, moderate intensity zone.  This would mean that you want to maintain a heart rate not less than 108 and not more than 126.  This is a bit of an over-simplification, but it is a decent rule of thumb.  The Karvonen formula is an even better way to look at heart rates and zones.  The Karvonen Formula looks at your

Intensity:  The goal here is moderate to moderately vigorous intensity of exercise in the 5-8 MET range.  Some good examples of this are shown below.  You can judge intensity using a heart rate monitor as described above, or you can judge based on breathlessness.  For the level of intensity we are trying to achieve it should be difficult for you to carry on a conversation while exercising.

Frequency:  You should try to get at least 5 sessions per week in on this program.  If you don’t have time for 5 sessions due to time restraints, it is reasonable to do 4 but increase the duration to 45 minutes to an hour so that you can get up to the total duration described below.

Duration:  The goal in this program is 180 minutes or more of total weekly duration.  Each session should be no less than 30 minutes to get the full benefit.

Type of Exercise:  Remember, we are trying to elevate the heart rate into the fat burning zone and not beyond.  You can modify the type of exercise you are doing to make it easier to achieve this intensity.  For example if you started the active lifestyle program with walking and then progressed to brisk walking, now you need to add carrying a light weight or hills to get up to the higher intensity.  Some good choices for 5-8 METS are shown below.

• ·Hiking and Backpacking:  Hiking with a light pack is considered to be a 6 MET activity, but as the pack gets heavier, you are doing as many as 7-8 METS of activity.  Try to do progressively more difficult hikes on hills and with heavier packs to increase your endurance.
  

• ·Running:  Jogging at a 12-minute mile pace is about 7 METS of activity.  A good choice for the Endurance training program if you do not have any problems with your joints or other reasons that running and jogging won’t work.  

• ·Stairmaster and Elliptical Trainer:  Climbing stairs is about an 8 MET activity depending on how fast you are climbing.  This makes it a good choice for endurance training program.
  

• ·Swimming:  If you swim at moderate pace. You are doing a little more than 8 METS.  We always recommend swimming in our program because it is easy on the joints, many people really enjoy it and it is a good, whole-body exercise.
  

• ·Biking:  To get to 8 METS you need to bike at about 13 mph.  This is an excellent endurance activity as it also combines the fun and travel aspects of biking.
  

• ·Rowing:  Rowing on an ergometer machine is an excellent way to get a whole body workout.  We highly recommend it for people who have a way to do this and enjoy the workout.  Rowing at a steady pace achieves just over 8 METS and when you really push you hard, you can go as high as 12 METS.
  

Going from Active to an Endurance Training Program

If you are already active, then you can move up to an endurance level of training by increasing the intensity of your exercise to focus on 8 MET activities as opposed to activities in the 5 MET range.  Classic 8 MET activities are things like vigorous jogging or running at relatively comfortable pace.  Start doing that and try to get your intensity up to the point where it would be very difficult to hold a conversation given what you are doing.  You can also maintain your energy at that level by using a heart rate monitor and trying to target zone 2 based on the Karvonen formula above.  To get the full benefit of the endurance training program, you should try to achieve 180 minutes per week of zone 2 exercise.

V02 Max Program

This an advanced program for people who want to achieve the very highest level possible for cardiorespiratory fitness.  To understand this program, you need to understand the concept of V02 Max.

V02 Max Measurement

As we age, we can expect to see about a 10% decline in cardiorespiratory fitness levels every decade after 40.  But to maintain metabolic health and avoid chronic disease we need to maintain capacity at the highest achievable level regardless of age.  So whether you are in your 20s and able to achieve very high levels of energy output or in your 70s and not able to go as hard you used to, we recommend direct measurement of your capacity for everyone who can achieve 8 METS or more.  Capacity is measured by using a test called the V02 Max Test. 

The V02 Max Test is a measurement of oxygen utilization that incorporates the efficiency of the entire cardio-pulmonary system.  It is a measure of how quickly oxygen can be extracted from the air you are breathing and how quickly that oxygen can be transported to your working muscles and consumed.  It represents the top speed of your cardiovascular engine.  V02 Max has been extensively studied and it correlates very well with maximum capacity and it has a strong correlate with decreases in metabolic problems and overall longevity. 

The test itself involves placing a mask over your nose and mouth and measuring the disappearance of oxygen and the creation of carbon dioxide from the breath.  Then the test participant runs on a treadmill or uses an exercise bike to go as fast you can before you become fatigued.  Oxygen extraction and carbon dioxide production proceeds until your system can no longer extract and produce.  At this point, you will become fatigued, and you will have to stop the test.  The V02 max test needs to be done with a coach or trainer encouraging you so that you go as far and as fast as you can.  Norms for V02 Max by age and gender are shown below.

Men

Age	Poor	Fair	Average	Good	Excellent
< 29	< 25	25-34	34-44	44-53	> 53
30-39	< 23	23-31	31-42	42-50	> 50
40-49	< 20	20-27	27-39	39-45	> 45
50-59	< 18	18-25	25-38	36-43	> 43
60-69	< 16	16-23	23-36	36-41	> 41

Women

Age	Poor	Fair	Average	Good	Excellent
< 29	< 24	24-31	31-39	39-49	> 49
30-39	< 20	20-28	28-37	37-45	> 45
40-49	< 17	17-25	25-35	35-42	> 42
50-59	< 15	15-22	22-34	34-40	> 40
60-69	< 13	13-21	21-33	33-37	> 37

V02 Max Program:

Intensity:  To improve the V02 Max you need so spend more time at the highest levels of intensity.  We tell our patients to do this by focusing on Zone 4-5 training which is around 85-95% of your maximum heart rate.  Using the example of a 40-year-old person with a maximum heart rate of 180 from above.  This would mean that this person would need to target a heart rate between 153 and 171.  A very intense level of exercise indeed.  This level of intensity is not sustainable for a long time, so we generally recommend that people maintain the zone 2 exercise for most of their 180-minute duration and then push up the intensity for about a minute.  Then you would repeat that 1-minute sprint for 3-4 sessions during the workout.  This is what is known as high intensity interval training (HIIT).  This HIIT session would replace one of the sessions you would be doing on the standard endurance training program.  In this manner, the Advanced Program is really a slightly more intense version of the endurance program with one or two HIIT sessions replacing endurance training sessions.

Frequency:  5-6 sessions per week.  At least one session should be a HIIT session and two is most desirable.  Generally, the day after the HIIT session should be a rest day.  The other sessions should be slightly higher intensity endurance training sessions.

Duration:  The duration for the advanced program and the endurance program is the same: 180 minutes per week.  The sprint sessions can start at 1 minute when you are just starting the program and progress to 2-4 minutes as you improve.

Frequency:  We recommend 6 sessions per week with one rest day.  If you are doing 2 HIIT sessions, you can do 5 sessions per week with 2 rest days.  In such cases, you will need to increase the duration of your regular endurance sessions to achieve your 180 minute per week goal.

Type:  The types of exercise are similar once again to the endurance training program.  The difference here is the HIIT sessions.

• ·Hiking and Backpacking:  Try to do progressively more difficult hikes on hills and with heavier packs to increase your endurance.  When you are ready to do your sprint, you will need to identify a hill or specific part of your hike where you will push the intensity for at least a minute at a time.
  

• Running:  Running at a 10-minute mile pace is considered to be 10 METS of activity.  Perfect intensity for the advanced training program. For your HIIT session, you will be doing a “fartlek” run where you increase your speed above the 10-minute mile pace for at least a minute or two before dropping back down to the slower pace.  

• Stairmaster and Elliptical Trainer:  Many of the machines in gyms now have HIIT training programs.  This makes them an ideal way to train this way.
  

• ·Swimming:  If you swim at moderate pace. You are doing a little more than 8 METS.  Depending on our swimming technique you will achieve about 10 METS (or possibly more) by swimming 75 yards in a minute.  As you improve you can swim up to 75 to even as high as 150 yards at a time.  

• ·Biking:  Biking 15 mph is a 10 MET activity.  This is perfect intensity for the advanced training program.  Sprint sessions on the bike are similar to fartlek sessions described under running above.
  

• Rowing:  Rowing is an excellent high intensity workout modality.  You can row at a steady pace and then increase your intensity for your 30 second sprints by using an ergometer or heart rate monitor.