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 Contents • vii

Appendix B Cardiorespiratory Assessments 393

B.1 Summary of Graded Exercise Test and Cardiorespiratory

Field Test Protocols . . . . . . . . . . . . . . . . . . . . . . . . . . . . 394
B.2 Rockport Fitness Charts . . . . . . . . . . . . . . . . . . . . . . . . . . . 396
B.3 Step Test Protocols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .398
B.4 OMNI Rating of Perceived Exertion Scales . . . . . . . . . . . . . . . . . . 400
B.5 Analysis of Sample Case Study in Chapter 5 . . . . . . . . . . . . . . . . . 404

Appendix C Muscular Fitness Exercises and Norms 407

C.1 Standardized Testing Protocols for Digital Handheld Dynamometry . . . . . 408

C.2 1-RM Squat and Bench Press Norms for Adults . . . . . . . . . . . . . . . 409
C.3 Isometric Exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411
C.4 Dynamic Resistance Training Exercises . . . . . . . . . . . . . . . . . . . 415

Appendix D Body Composition Assessments 421

D.1 Prediction Equations for Residual Volume . . . . . . . . . . . . . . . . . . 422

D.2 Standardized Sites for Skinfold Measurements . . . . . . . . . . . . . . . . 423
D.3 Skinfold Sites for Jackson’s Generalized Skinfold Equations . . . . . . . . . 428
D.4 Standardized Sites for Circumference Measurements . . . . . . . . . . . . 429
D.5 Standardized Sites for Bony Breadth Measurements . . . . . . . . . . . . . 430
D.6 Ashwell Body Shape Chart . . . . . . . . . . . . . . . . . . . . . . . . . . 431

Appendix E Energy Intake and Expenditure 433

E.1 Food Record and RDA Profile . . . . . . . . . . . . . . . . . . . . . . . . . 434

E.2 Physical Activity Log . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 436
E.3 Gross Energy Expenditure for Conditioning Exercises, Sports,
and Recreational Activities . . . . . . . . . . . . . . . . . . . . . . . . . 437

Appendix F Flexibility and Low Back Care Exercises 441

F.1 Selected Flexibility Exercises . . . . . . . . . . . . . . . . . . . . . . . . . 442

F.2 Exercise Dos and Don’ts . . . . . . . . . . . . . . . . . . . . . . . . . . . 451
F.3 Exercises for Low Back Care . . . . . . . . . . . . . . . . . . . . . . . . . 456

List of Abbreviations 461

Glossary 465
References 475
Index 531
About the Authors 545
 Video Contents

W e continue to offer online streaming video in this eighth edition, including over 70 videos of content
demonstrating key concepts from the book, such as assessments, procedures, tips, stretches, and exer-
cises. You can access the online video by visiting www.HumanKinetics.com/AdvancedFitnessAssessment
AndExercisePrescription. If you purchased a new print book, follow the instructions on the orange-framed
page at the front of your book. That page includes access steps and the unique key code that you’ll need the
first time you visit the Advanced Fitness Assessment and Exercise Prescription website. If you purchased an
e-book from HumanKinetics.com, follow the access instructions that were emailed to you after your purchase.
If you have purchased a used book, you can purchase access to the online video separately by following the
links at www.HumanKinetics.com/AdvancedFitnessAssessmentAndExercisePrescription.
Once at the Advanced Fitness Assessment and Exercise Prescription website, select Online Video in the
ancillary items box in the upper-left corner of the screen. You’ll then see an Online Video page with infor-
mation about the video. Select the link to open the online video web page. From the online video page, you
can select the chapter and then the desired video, numbered as they are in the text.
Following is a list of the clips in the online video.

Video 2.1 Resting BP measurement Video 6.1 Static muscle action

Video 2.2 Sources of BP measurement error Video 6.2 Concentric muscle action
Video 2.3 Measuring exercise BP Video 6.3 Eccentric muscle action
Video 2.4 Measuring resting HR by auscultation Video 6.4 Grip strength testing procedures
Video 2.5 Measuring resting HR by palpation— Video 6.5 Grip endurance testing procedures
radial artery Video 6.6 Side bridge test
Video 2.6 Measuring HR using a heart rate Video 6.7 Spotting exercises
monitor Video 6.8 1-RM testing
Video 2.7 ECG electrode placement—limb leads Video 6.9 Biodex (isokinetic) testing
Video 2.8 ECG electrode placement—chest leads Video 6.10 Pull-up tests
Video 2.9 Exercise ECG Video 6.11 Push-up tests
Video 3.1 Pedometer placement Video 6.12 Vertical jump with VerTec
Video 4.1 Measuring oxygen consumption (VO2) Video 7.1 Incline bench press
Video 4.2 Safely mounting a treadmill Video 7.2 Flat bench press
Video 4.3 Treadmill maximal exercise test Video 7.3 Decline bench press
Video 4.4 Setting workloads on a cycle ergometer Video 7.4 Pronated arm curl
Video 4.5 Cycle ergometer maximal exercise test Video 7.5 Supinated arm curl
Video 4.6 Treadmill submaximal exercise test Video 7.6 Hammer curl
Video 4.7 Cycle ergometer submaximal exercise Video 7.7 Common errors in performing the squat
test Video 7.8 Common errors in performing the
Video 4.8 20 m shuttle run/PACER test bench press
Video 4.9 6 min walk test Video 7.9 Eccentron training

viii

Video 8.1 Guidelines for hydrostatic weighing
Video 8.2 Testing procedures for the Bod Pod
Video 8.3 A-mode ultrasound
Video 8.4 Whole-body BIA measures
Video 8.5 Upper body BIA measures
Video 8.6 Lower body BIA measures
Video 10.1 Shoulder flexion
Video 10.2 Knee flexion
Video 10.3 Ankle flexion
Video 10.4 Inclinometer test procedures
Video 10.5 Modified sit-and-reach test
Video 10.6 Modified back-saver sit-and-reach test
Video 11.1 PNF stretching techniques
Video 12.1 Unipedal stance test
Video 12.2 BESS test
Video 12.3 Functional reach test
Video 12.4 Timed up-and-go test
Video 12.5 Y-balance test
Video C3.1 Chest push
Video Contents • ix
Video C3.2 Shoulder pull
Video C3.3 Triceps extension
Video D2.1 Measurement of the chest skinfold
Video D2.2 Measurement of the subscapular
skinfold
Video D2.3 Measurement of the abdominal
skinfold
Video D2.4 Measurement of the thigh skinfold
Video D2.5 Measurement of the calf skinfold
Video D4.1 Circumference measurement of the
waist
Video D4.2 Circumference measurement of the
hips
Video D5.1 Bony breadth measurement of the
hips
Video D5.2 Bony breadth measurement of the
elbow
Video F1.1 Hamstring stretch
Video F1.2 Chest stretch
 Preface
E xercise professionals need to have extensive
knowledge and technical skills in order to work
safely and effectively. Historically, individuals work-
ing in exercise settings, such as health and fitness
clubs, were not necessarily required to have spe-
cialized education and training in exercise science.
However, survey research indicates that a bachelor’s
degree in exercise science and certification from
the American College of Sports Medicine (ACSM)
or National Strength and Conditioning Association
(NSCA) are strong predictors of a personal trainer’s
knowledge (Malek et al. 2002). To carry the U.S.
Bureau of Labor and Statistics’ job title of “exercise
physiologist,” one must have earned the minimum of
a bachelor’s degree (Simpson 2015). There is also a
growing trend within health care facilities to require
their exercise physiologists to hold a master’s degree
(Collora 2017); this corroborates Wagner’s (2014)
finding that a master’s degree is commonly held by
exercise physiologists working in clinical settings
(69% of 140 survey respondents).
A global survey of fitness trends for 2018 revealed
that “educated, certified, and experienced fitness
professionals” is ranked number 6 in importance,
and this has been a top 10 concern since the annual
survey began more than a decade ago (Thompson
2017). These findings suggest that formal educa-
tion and certification by professional organizations
should be required for personal fitness trainers and
exercise science professionals. Their knowledge and
skills are instrumental in preparticipation screening,
cardiorespiratory fitness testing, muscular fitness
testing, flexibility assessment, results interpretation,
and scientifically sound exercise prescription design.
To promote exercise science as a profession, issues
surrounding accreditation, certification, national
boards, and licensure need to be understood and
addressed.
ACCREDITATION
Organizations and programs are awarded accredita-
tion by meeting or exceeding standards established
x
by an independent third-party accrediting agency.
Although no single accrediting agency exists for
health and fitness and clinical exercise science pro-
grams, exercise science professionals seem to agree
that some form of regulation is needed.
Independent third-party accrediting agencies
such as the Commission on Accreditation of Allied
Health Education Programs (CAAHEP) and the
National Commission for Certifying Agencies
(NCCA) may serve this purpose. The CAAHEP
accredits academic programs—graduate programs
in exercise physiology, baccalaureate programs
in exercise science, and certificate and associate
degree programs for personal fitness trainers. Also,
the American Society of Exercise Physiologists
(ASEP) has developed standards for the profession
of exercise physiology as well as accreditation
standards for universities and colleges offering
academic degrees in exercise science (ASEP 2018).
The NCCA accredits certification programs; many
organizations that provide professional credentialing
or licensing exams in the allied health professions
are accredited through the NCCA (ACSM 2004).
CERTIFICATION
Fitness and exercise science professionals obtain
certification by passing examinations developed
by professional organizations. These organizations
typically offer education and training programs,
administer their own examinations (written and
practical), and issue certifications to individuals
passing the examinations. These certifications are
generally issued for a 2 to 3 yr period; certification is
maintained by taking continuing education courses
and earning continuing education credits. Some
certification programs are accredited by third-party
agencies like the NCCA.
More than 75 organizations offer over 250 cer-
tifications for exercise science and fitness profes-
sionals (Cohen 2004; Pierce and Herman 2004).
Given that there is no governing entity to oversee
the development of certification examinations and

eligibility requirements, inequalities exist among
the certifications available to exercise science pro-
fessionals. Some certification programs are more
rigorous than others, having stringent eligibility
requirements; others may or may not be accredited
by a third-party accrediting agency like the NCCA.
To address the inequality among certification pro-
grams, the NCCA formally reviews applications for
the accreditation of certification programs. In 2004,
the International Health, Racquet, and Sportsclub
Association (IHRSA) recommended that all health
clubs belonging to their organization hire only per-
sonal fitness trainers certified by an NCCA-accred-
ited organization or agency. Wagner (2014) reported
results from a survey of 589 exercise physiologists
and indicated that 69% of the respondents held one
certification while 28% held two or more. Neverthe-
less, not all exercise science and fitness certifications
are equal. This leads to confusion for the consumer
in terms of knowing who is and who is not highly
trained and qualified as an exercise professional.
It also complicates selecting the most appropriate
certification for yourself. Some agencies sponsor
certification programs primarily for financial gain,
while others certify professionals in order to promote
exercise science as a profession.
Table 1 lists some of the organizations that offer
certifications accredited by the NCCA. Addition-
ally, the Coalition for the Registration of Exercise
Professionals (CREP), a not-for-profit corporation
composed of organizations that offer NCCA-accred-
Table 1 Selected Organizations Associated With National Commission for Certifying Agencies
(NCCA) and National Board of Fitness Examiners (NBFE)
NCCA affiliates
American Council on Exercise (ACE)
American College of Sports Medicine (ACSM)
Cooper Institute for Aerobics Research
National Exercise and Sports Trainers Association (NESTA)
National Exercise Trainers Association (NETA)
National Federation of Professional Trainers (NFPT)
National Strength and Conditioning Association (NSCA)
International Fitness Professionals Association (IFPA)
National Council on Strength and Fitness (NCSF)
National Academy of Sports Medicine (NASM)
Preface • xi
ited exercise certifications, established a registry of
professionals in the United States certified by any
of six organizations (www.usreps.org). This website
is a convenient means for locating professionals by
location, certification, or name. Registries are also
available for the United Kingdom (www.exercisereg-
ister.org), Europe (www.europeactive.eu/why-ereps),
and New Zealand (www.reps.org.nz).
NATIONAL BOARDS
Some professional organizations in the fitness indus-
try believe there should be alternatives to accred-
itation of certification programs by the NCCA or
other third-party agencies. In the United States, one
such alternative was the establishment of National
Board examinations for fitness professionals.
Unlike the multitude of certification examinations
developed by individual organizations and agencies,
National Boards are standardized tests to assess the
knowledge, skill, and competence of professionals.
Most medical and allied health professions utilize
National Boards.
In 2003, the National Board of Fitness Examiners
(NBFE) was founded as a nonprofit organization
with the twin purposes of defining scopes of practice
for all fitness professionals and determining stan-
dards of practice for various fitness professionals,
including floor instructors, group exercise instruc-
tors, personal fitness trainers, specialists in youth
and senior fitness, and medical exercise specialists.
NBFE affiliates
Aerobics and Fitness Association of America (AFAA)
American Aerobic Association International/International
Sports Medicine Association (AAAI/ISMA)
International Sports Sciences Association (ISSA)
National Association for Fitness Certification (NAFC)
National Council for Certified Personal Trainers (NCCPT)
National Exercise and Sports Trainers Association (NESTA)
National Gym Association (NGA)
National Personal Training Institute (NPTI)
National Strength Professionals Association (NSPA)
xii • Preface
The NBFE established national standards of excel-
lence that certifying organizations and colleges or
universities may adopt. The written portion of the
National Boards for personal fitness trainers is now
offered through the NBFE (for additional informa-
tion, visit www.NBFE.org). The practical portion
of this exam is still being developed and validated
under the supervision of the National Board of Med-
ical Examiners (NBME). The NBME and the NBFE
are engaged in preliminary discussions and planning
that will allow certification organizations to assist in
the delivery of practical exams for personal trainers.
To be eligible to sit for the National Boards, per-
sonal fitness trainers must successfully complete
a personal training certification program from an
approved NBFE affiliate. Affiliate status is avail-
able to qualified groups from the areas of medicine,
certification organizations, fitness professionals,
health clubs, and higher education. In the future, the
NBFE’s National Boards may be used by certifying
organizations, colleges and universities, and U.S.
state licensing programs to test the knowledge, skill,
and competence of fitness professionals (American
Fitness Professionals and Associates 2004). Table
1 lists some of the organizations offering personal
training certifications affiliated with the NBFE.
LICENSURE
Although many practitioners in the fitness and exer-
cise science fields agree that certification ensures
professional competency, other professionals believe
that licensure is better suited for protecting consum-
ers and for enhancing the credibility and profession-
alism of exercise science and fitness professionals
(Eickhoff-Shemek and Herbert 2007). For the first
time in the 12 yr history of the worldwide survey
of fitness trends, licensure for fitness professionals
broke into the top 20 trends (number 16 for 2018)
(Thompson 2017). In the United States, licensure
is decided at the state level; therefore, requirements
may vary from state to state. Louisiana was the first
state to pass a law requiring licensure of all clinical
exercise physiologists (Herbert 1995). Licensure of
clinical exercise physiologists has also been consid-
ered in Maryland, Massachusetts, Michigan, North
Carolina, Texas, and Utah (Clinical Exercise Phys-
iology Association, 2013). Several states including
Georgia, Maryland, Massachusetts, New Jersey,
Nevada, Oregon, and the District of Columbia have
considered licensure for personal trainers (Eick-
hoff-Shemek and Herbert 2008b; Herbert 2004;
Thompson 2017).
To promote exercise science and exercise phys-
iology as a profession, the ASEP is working with
exercise professionals throughout the United States
to develop uniform state licensure requirements
for exercise physiologists. Licensure would place
exercise physiologists and personal trainers on a par
with other allied health professionals (e.g., nurses,
nutritionists, physical therapists, and occupational
therapists) who are required to have licenses to
practice. Licensed fitness professionals may be more
likely to obtain referrals from health care profession-
als and to receive reimbursement for services from
third parties (e.g., insurance companies).
Along with advantages, added responsibilities and
disadvantages are associated with state licensure.
Licensure may limit the scope of practice and ser-
vices that exercise professionals are currently able
to provide to the public. For example, Louisiana
licensure law requires clinical exercise physiologists
to work under the direction of a licensed physician.
Also, the costs of licensure, continuing education
for licensure, and professional liability insurance
may be more expensive compared with the cost
of certifications. Professionals moving from state
to state may be required to obtain another license
because each state could require different creden-
tials for licensure (Eickhoff-Shemek and Herbert
2008a, 2008b).
STATUTORY
CERTIFICATION
Instead of licensure, some American states use
statutory certification for allied health profession-
als. Statutory certification regulates what titles
professionals can use and the qualifications needed
to obtain these titles. Only certified professionals
with the required credentials are allowed to use
the specific title (e.g., certified nutritionist). Other
professionals without the necessary credentials can
still practice in the state but must use a different title.
This approach could be promoted by the fitness and
exercise professions to prevent the use of titles, such
as personal trainer or exercise physiologist, by indi-

viduals having no formal education or professional
certifications.
All these approaches demonstrate the pressing
need to get a handle on certifications for exercise
professionals so we can gain control of who is
practicing in our field. This will ensure the safety
of exercise program participants and enable individ-
uals working in the fitness field to be recognized as
exercise science professionals. Until these issues are
resolved and a list of accredited certification agen-
cies and organizations is finalized, you should select
a professional certification that matches your level
of education and career goals. For more information
about certification programs, visit the websites of
those professional certifying organizations.
Many advantages are associated with obtaining
either state licensure or certification with profes-
sional organizations. You will have a better chance
of finding a job in the health and fitness field because
many employers are now hiring only professionally
Preface • xiii
certified health and fitness instructors. Certification
by reputable professional organizations upgrades the
quality of the typical person working in the field and
assures employers and their clientele that employees
have mastered the knowledge and skills needed to
be competent exercise science professionals. Hence,
the likelihood of lawsuits resulting from negligence
or incompetence may be lessened. Also, certification
and licensure help validate exercise specialists as
health professionals who are equally deserving of
the respect afforded to professionals in other allied
health professions. Individuals holding a Registered
Clinical Exercise Physiologist (RCEP) or Certified
Clinical Exercise Physiologist (CEP) certification
now have a National Provider Identifier code
that may be used for service reimbursement from
insurance companies. For more information on this
development, visit the website of the Clinical Exer-
cise Physiology Association (www.acsm-cepa.org).
 Acknowledgments
T he first edition of this textbook was titled
Designs for Fitness and was published by
Burgess Publishing in 1984. It was a softcover
book of about 200 pages. Dr. Swede Schoeller took
the photos for that edition. Eileen Fletcher, our
department secretary, typed the manuscript on her
Smith-Corona.
The second edition was published by Human
Kinetics in 1991. This edition was a hardcover book
consisting of 350 pages. For this edition, Linda K.
Gilkey took the photos. For the first time, the man-
uscript was typed using a DOS word processing
system, by department secretary Sandi Travis.
In 1998, the third edition was published by
Human Kinetics. The book grew in size from a 7"
× 9" format to an 8.5" × 11" format. Once again,
Linda K. Gilkey took the photos, and the computer
graphics were done by Dr. Robert Robergs, Dr. Brent
Ruby, and Dr. Peter Egan.
The fourth edition, published by Human Kinet-
ics in 2002, was 370 pages. Our colleagues Dr.
Christine Mermier, Dr. Virginia Wilmerding, Dr.
Len Kravitz, and Dr. Donna Lockner shared their
excellent ideas and expertise. The developmental
editors, Elaine Mustain and Maggie Schwarzen-
traub, meticulously edited this edition.
In 2006, the fifth edition was released. For this
edition, the total number of pages increased to 425,
and Human Kinetics updated all the photos. Sarah
xiv
Ritz did an excellent job organizing and taking
these photos. Dr. Dale Wagner contributed the test
question bank that accompanied this edition.
The sixth edition was released in May 2010. For
the first time, this book was also published as an
ebook. The book expanded to 465 pages. Dr. Dale
Wagner updated the test question bank, and Dr.
Ann Gibson prepared the slides for the presentation
package.
The seventh edition, published in 2014 by Human
Kinetics, was coauthored with Dr. Ann Gibson.
In addition to being published as an ebook, the
537-page seventh edition was supplemented with
instructional videos.
The eighth edition is coauthored with Dr. Ann
Gibson and Dr. Dale Wagner. Dr. Wagner’s exten-
sive background as a researcher and professor of
exercise science has been invaluable in updating
and revising this edition. We also acknowledge Cyn-
thia McEntire, our Human Kinetics developmental
editor, Martha Gullo, who obtained the publication
permissions for this edition, and Amy Stahl, the
senior managing editor assigned to this edition.
Many individuals have contributed to the con-
tinued success of Advanced Fitness Assessment
and Exercise Prescription. We are indebted to each
person who played a role in the metamorphosis of
this book.
 1
Chapter 1
Physical Activity, Health,
and Chronic Disease
KEY QUESTIONS
Are adults in the United States and other coun-
uu
tries getting enough physical activity?
How does physical inactivity differ from seden-
uu
tarism?
What diseases are associated with a sedentary
uu
lifestyle, and what are the major risk factors for
these diseases?
What are the benefits of regular physical activity
uu
in terms of disease prevention and healthy aging?
A lthough physical activity plays an important
role in preventing chronic diseases and reduc-
ing the hazardous effects of extended periods of
sitting time, an alarming percentage of adults in
the United States report no physical activity during
leisure time. One of the national health objectives for
the year 2020 is to increase to 47.9% the proportion
of people aged 18 yr and older who regularly (pref-
erably daily) engage in moderate physical activity at
least 30 min per day (U.S. Department of Health and
Human Services 2010). According to a U.S. national
survey, in 2014 only a small percentage (21.5%) of
adults over the age of 18 met the 2008 federal phys-
ical activity guidelines for adults in terms of both
aerobic and muscle strengthening activities. Slightly
more than half (53.2%) met either the aerobic activity
or the muscle-strengthening guidelines, but not both
(Centers for Disease Control and Prevention 2015a).
Generally, women (50%) are less likely to meet the
full aerobic and muscle-strengthening recommenda-
tions than men (43.4%), and older (≥65 yr) adults are
less likely (58.7%) to meet them than younger (18-24
yr) adults (40.8%) (Centers for Disease Control and
Prevention 2015a).
CHAPTER
uuHow does physical activity improve health?
uuHow much physical activity is needed for
improved health benefits?
uuWhat kinds of physical activities are suitable
for typical people, and how often should they
exercise?
Physical inactivity, the failure to meet the rec-
ommended physical activity guidelines, is not just
a problem in the United States; it is a global issue
and the fourth leading cause of global mortality
(World Health Organization 2010). Cardiovascular
diseases, diabetes, obesity, chronic respiratory disor-
ders, and cancers as a group of noncommunicable
diseases (NCDs) are the leading causes of death
worldwide. These chronic conditions are heavily
influenced by poor lifestyle factors including phys-
ical inactivity and unhealthy diet (World Medical
Association 2017). NCDs accounted for approxi-
mately 52% of worldwide deaths occurring before
age 70 in 2012 (World Health Organization 2016d).
Physical inactivity became a targeted priority of the
World Health Organization’s Global Action Plan
for 2013-2020 (World Health Organization 2013);
a global goal was set to reduce physical inactivity
levels by 10% by the year 2025 (Sallis et al. 2016).
Results from survey data collected from 146
countries representing all income levels estimated
that 23% of the global adult (≥15 yr) population
was physically inactive in 2016. However, an 8%
decrease in physical inactivity between 2012 and
1
2 • Advanced Fitness Assessment and Exercise Prescription

USING TECHNOLOGY TO INCREASE

PHYSICAL ACTIVITY AT WORK
Active workstations (e.g., treadmill desks or pedal desks) and adjustable-height work surfaces that allow
employees to stand (sit-stand desks) are becoming more commonplace. They provide a means to reduce
prolonged periods of sitting. Some employees have their own active workstations, while others have access
to one located in a common area. A recent review of studies about active workstations (Cao et al. 2016)
indicates that the calories burned may increase two- to fourfold for employees who change from sitting in
a chair (~70-90 kcal·h−1) to active workstations. Additionally, daily step counts and physical activity (min/
day) increase dramatically for those using active workstations during the workday. Crandall and colleagues
(2016) found that using sit-stand workstations reduces sitting time by approximately 85 min/day. They also
reported that employees using a shared treadmill desk accumulate slightly fewer than 9,000 steps·day−1
while at work. Ongoing longitudinal research in this area may identify long-term effects of using active
workstations on employee health. Currently, these effects are not well documented.

2016 may be less reflective of changes in activity
levels than in updated physical activity recommen-
dations (150 min of moderate-intensity activity or
75 min of vigorous-intensity activity per week, or
combination thereof). The current recommendations
changed the frequency of exercise bouts from 5 days
per week (moderate-intensity) or 3 days per week
(vigorous-intensity) to weekly totals of minutes.
The prevalence of physical inactivity ranges from
approximately 38% in the eastern Mediterranean
countries to a low of 14.8% in southeast Asia; by
World Bank income classification, the low- and low-
er-middle-income countries were more physically
active than their upper-middle- and high-income
counterparts (Sallis et al. 2016). In England and
Scotland, more than 65% of men and at least 50%
of women met the government’s physical activity
guidelines in 2012 (British Heart Foundation 2015a).
However, only 18% of Canadian adults responding
to the 2014-2015 Canadian Health Measures Survey
met the recommendation of 150 minutes of mod-
erate-to-vigorous intensity activity in bouts lasting
at least 10 minutes (Statistics Canada 2017). Thus,
as an exercise specialist, you face the challenge of
educating and motivating your clients to incorporate
physical activity as a regular part of their lifestyles
and to reduce the amount of time spent being seated
(Benatti and Ried-Larsen 2015; Bergouignan et al.
2016; Levine 2015; Same et al. 2016).
This chapter deals with the physical activity
trends, risk factors associated with chronic noncom-
municable diseases, the role of regular exercise and
physical activity in disease prevention and health,
physical activity guidelines and recommendations
for improved health, and the importance of includ-
ing exercise and physical activity as one of the vital
signs (i.e. heart rate, blood pressure, etc.) monitored
during annual visits to the doctor. For definitions of
terminology used in this chapter, see the glossary.
PHYSICAL ACTIVITY,
HEALTH, AND DISEASE:
AN OVERVIEW
Technological advances affecting nearly every facet
of life have substantially lessened work-related
physical activity as well as the energy expenditure
required for performing activities of daily living
like cleaning the house, washing clothes and dishes,
mowing the lawn, and traveling to work. What
would have once required an hour of physical work
now can be accomplished in just a few seconds by
pushing a button or setting a dial. Survey results
from 23 low-income and 25 upper-middle-income
countries suggest that access to modern technolog-
ical conveniences underlies an inverse relationship
between both education level and financial assets
with the prevalence of physical inactivity (Allen
et al. 2017). The unfortunate fact is, however, that
many individuals do not engage in physical activity
during their leisure time and sit too much at work
and after hours.
Although the human body is designed for move-
ment and strenuous physical activity, exercise is
not part of the average person’s lifestyle. Industri-
alization and urbanization have led to increased
 Physical Activity, Health, and Chronic Disease • 3

sedentarism and sedentary behaviors (performing
activities of ≤1.5 METs while in a sitting or reclining
posture) (Benatti and Ried-Larsen 2015; Sedentary
Behaviour Research Network 2012). One cannot
expect the human body to function optimally and to
remain healthy for extended periods if it is abused
or is not used as intended.
Physical inactivity is recognized as a major
contributor to the physical and economic burden of
disease nationally and globally. The identification of
physical inactivity as the fourth leading risk factor
for mortality supports what experts noted nearly a
decade ago—physical inactivity may well be the
most important public health problem in the 21st
century (Blair 2009). To highlight this, a global
action plan was developed to increase the number
of people meeting the recommended weekly amount
of physical activity by 10% (World Health Organi-
zation 2013). The World Health Organization (2014)
reported that physical inactivity causes an estimated
3.2 million deaths annually. Data from large cohort
studies conducted around the world were pooled
and analyzed; resulting estimations revealed that
between 6% and 10% of coronary heart disease, type
2 diabetes, and breast and colon cancers are due to
physical inactivity (Lee et al. 2012). As a risk factor,
physical inactivity is basically equivalent to the
combined risk of smoking and obesity. Sedentarism
has repeatedly been identified as an independent risk
factor associated with an increased risk for all-cause
mortality and metabolic and heart disorders (Benatti
and Ried-Larsen 2015). Individuals who do not
exercise regularly and sit too much are at greater risk
for developing chronic noncommunicable diseases
such as those in figure 1.1.
For years, exercise scientists as well as health and
fitness professionals have maintained that regular
physical activity is the best defense against the devel-
opment of many diseases, disorders, and illnesses.
The importance of regular physical activity in
maintaining a high quality of life and in preventing
disease and premature death received recognition as
a national health objective in the first U.S. surgeon
general’s report on physical activity and health
(U.S. Department of Health and Human Services
1996). This report identified physical inactivity as a
serious nationwide health problem, provided clear-
cut scientific evidence linking physical activity to

Coronary heart disease Congestive heart failure

Cardiomyopathy Cardiovascular Hypertension

diseases
Hypercholesterolemia Atherosclerosis
Over fat Low back pain
Osteoarthritis

Metabolic Musculoskeletal
Obesity
disorders disorders

Bone fractures and

Diabetes Physical Inactivity connective tissue tears
and
Osteoporosis
Breast Sedentary Lifestyle
Colon Depression

Cancer Psychological Mood

disorders

Prostate
Lung Anxiety
Pulmonary
diseases
Emphysema Asthma
Chronic bronchitis

FIGURE 1.1 Role of physical activity and exercise in disease prevention and rehabilitation.

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4 • Advanced Fitness Assessment and Exercise Prescription

numerous health benefits, presented demographic
data describing physical activity patterns and trends
in the U.S. population, and made physical activity
recommendations for improved health. In 1995, the
CDC and the American College of Sports Medicine
(ACSM) recommended that every U.S. adult should
accumulate 30 min or more of moderate-intensity
physical activity on most, preferably all, days of the
week (Pate et al. 1995). This recommendation has
since been adopted by many international organi-
zations.
Since 1995, new scientific evidence increased our
understanding of the benefits of physical activity
for improved health and quality of life. In light of
these findings, the American Heart Association
(AHA) and the ACSM updated physical activity
recommendations for healthy adults and older adults
(Haskell et al. 2007; Nelson et al. 2007). These rec-
ommendations address how much and what type of
physical activity are needed to promote health and
reduce the risk of chronic disease in adults. Table 1.1
summarizes the ACSM and AHA physical activity
recommendations for adults.
The recommended amounts of physical activity
are in addition to routine activities of daily living
(ADLs) such as housework, cooking, shopping, and
walking around the home or from the parking lot.
The intensity of exercise is expressed as a metabolic
equivalent of task (MET). An MET is the ratio of
the person’s working (exercising) metabolic rate to
the resting metabolic rate, with 1 MET defined as
the energy cost of sitting quietly. Moderate-intensity
aerobic activity (3.0-6.0 METs or 5 or 6 on a 10-point
perceived exertion scale) is operationally defined as
activity that noticeably increases heart rate and lasts
more than 10 min (e.g., brisk walking at 3.0-4.0 mph
[4.8-6.4 km·hr−1]). Vigorous-intensity activity (>6.0
METs or 7 or 8 on a 10-point perceived exertion
scale) causes rapid breathing and increases heart
rate substantially (e.g., jogging or running at 4.5
mph [7.2 km·hr−1] or higher). For adults (18-65 yr)
and older adults (>65 yr), the ACSM recommends a
minimum of 150 min of moderate-intensity aerobic
activity per week or 75 min of vigorous-intensity
aerobic exercise per week. It is also recommended
that these totals be spread over the course of a week
to avoid injury). They also recommend moderate- to
high-intensity (8- to 12-repetition maximum [RM]
for adults and 10-RM to 15-RM for older adults)
resistance training for a minimum of 2 nonconsecu-
tive days per week. Balance and flexibility exercises
are also suggested for older adults.
Table 1.2 summarizes the physical activity
guidelines (U.S. Department of Health and Human

Table 1.1 ACSM/AHA Physical Activity Recommendations

MUSCLE-STRENGTHENING FLEXIBILITY AND
AEROBIC ACTIVITIESa ACTIVITIES BALANCE ACTIVITIES
Population Durationb Frequency Intensity or # of Frequency
group (min/day) Intensity (days/wk) Sets exercises (days/wk)
Healthy 30 Moderate Minimum 5 1 8-RM to 12-RM; 8-10 ≥2 noncon- No specific recommen-
adults (3.0-6.0 exercises for major secutive dation
18-65 yr METS) muscle groups days

20 Vigorous Minimum 3
(>6.0
METS)
Older adults 30 Moderate Minimum 5 1 10-RM to 15-RM; 8-10 2 noncon- For flexibility at least 2
>65 yr (5 or 6 exercises for major secutive days/wk for at least 10
on 10 pt. muscle groups; days min each day; include
scale) Moderate intensity (5 balance exercises for
or 6 on 10 pt. scale) those at risk for falls
20 Vigorous Minimum 3 Vigorous intensity (7
(7 or 8 or 8 on 10 pt. scale)
on 10 pt.
scale)
a
Combinations of moderate and vigorous intensity may be performed to meet recommendation (e.g., jogging 20 min on 2 days and brisk walking
on 2 other days).
b
Multiple bouts of moderate-intensity activity, each lasting at least 10 min, can be accumulated to meet the minimum duration of 30 min.
 Table 1.2 2008 Physical Activity Guidelines for Americans
BONE- FLEXIBILITY
STRENGTHENING AND BALANCE
AEROBIC ACTIVITIES MUSCLE-STRENGTHENING ACTIVITIES ACTIVITIES ACTIVITIES
*
Population group Duration Intensity Frequency Sets Intensity* Frequency
Children and adoles- ≥60 min Moderate Daily Moderate to high 3 days/wk 3 days/wk
cents 6-17 yr
Vigorous 3 days/wk
Adults 18-64 yr
Inactive 60-150 min/wk Light (1.1-2.9 METs) to 1 Light to moderate 1 day/wk All adults should
moderate (3.0-5.9 METs) stretch to main-
tain flexibility for
Active 150-300 min/wk Moderate (3.0-5.9 METs) ≥1 Moderate to high ≥2 days/wk
regular physical
or 8-RM to 12-RM activity (PA) and
75-150 min/wk Vigorous (≥6.0 METs) activities of daily
living (ADLs).

Highly active >300 min/wk Moderate (3.0-5.9 METs) 2 or 3 Moderate to high ≥2 days/wk
>150 min/wk Vigorous (≥6.0 METs)
Older adults ≥65 yr
Inactive 150 min/wk Light (RPE = 3 or 4) to 5 days/wk 1 Light (RPE = 3 or 4) to 2 or 3 days/ Older adults
moderate (RPE = 5 or 6) moderate (RPE = 5 or 6) wk should stretch to
maintain flexibil-
Active 150-300 min/wk Moderate (RPE = 5 or 6) ≥3 days/wk ≥1 Moderate (RPE = 5 or 6) ≥2 days/wk,
ity for regular PA
or to high (RPE = 7 or 8) nonconsec-
and ADLs.
8-RM to 12-RM utive days
≥3 days/wk
75-150 min/wk Vigorous (RPE = 7 or 8) balance
*
Intensity is expressed in METs and repetition maximums (RM) for adults; for older adults, intensity is expressed as a rating of perceived exertion (RPE; 0-10 scale) and RM.

5
6 • Advanced Fitness Assessment and Exercise Prescription
HEALTH BENEFITS OF PHYSICAL ACTIVITY
Lower risk of
• dying prematurely;
• coronary artery disease;
• stroke;
• type 2 diabetes and metabolic syndrome;
• high blood pressure;
• adverse blood lipid profile;
• colon, breast, lung, and endometrial cancers;
and
• hip fractures.
Data from U.S. Department of Health and Human Services 2008.
Services 2008) for children and adolescents (6-17
yr), adults (18-64 yr), and older adults (≥65 yr). The
key message in these guidelines is that for substan-
tial health benefits, adults should engage in aerobic
exercise at least 150 min/wk at a moderate intensity
or 75 min/wk at a vigorous intensity or an equivalent
combination thereof. In addition, adults of all ages
should do muscle-strengthening activities at least 2
days/wk. In addition to stretching to support physical
activity and activities of daily living, those who are
at risk for falling should also perform balance exer-
cises. Children should do at least 60 min of physical
activity every day. Most of the 60 min per day should
be either moderate or vigorous aerobic activity and
should include vigorous aerobic activities at least 3
days/wk. Part of the 60 min or more of daily physical
activity should be muscle-strengthening activities (at
least 3 days/wk) and bone-strengthening activities
(at least 3 days/wk).
The term exercise deficit disorder (EDD) has
been used to identify children who do not attain
at least 60 min of moderate- to vigorous-intensity
physical activity (MVPA) on a daily basis (Faigen-
baum and Myer 2011). Children with EDD are at
an increased risk for developing harmful health
effects in their adolescent and adult years due to
a physically inactive lifestyle (Stracciolini, Myer,
and Faigenbaum 2013). For example, results from
a study that monitored children for 14 yr revealed
that those who maintained their active childhood
MVPA levels through adolescence were less likely
Reduction of
• abdominal obesity and
• feelings of depression and anxiety.
Helps in
• weight loss, weight maintenance, and preven-
tion of weight gain;
• prevention of falls and improved functional
health for older adults;
• improved cognitive function;
• increased bone density; and
• improved quality of sleep.
to become obese as young adults (Kwon et al. 2015).
Exercising 150 min/wk equates to expending
approximately 1,000 kcal·wk−1. Results from a
meta-analysis (Sattelmair et al. 2011) indicated
that individuals meeting the 2008 physical activity
guidelines decrease their risk for coronary heart
disease by 14% compared with those reporting no
leisure-time physical activity (LTPA). Participating
in regular physical activity and exercise on a daily
basis provides numerous preventative benefits for
no fewer than 25 chronic medical conditions (War-
burton and Breden 2016) such as cardiovascular
disease, hypertension, diabetes, stroke, dementia,
and several types of cancer. Disease risk is further
reduced when moderate-intensity physical activity
(150-180 min/wk) is performed throughout the week
(i.e., 30 min/day on 5 days/wk) and in bouts lasting
at least 10 min as opposed to in one single session
(Kesäniemi et al. 2010).
Sattelmair and colleagues (2011) reported that
300 min/wk of moderate-intensity physical activity
results in a 20% reduction in the risk for coronary
heart disease (CHD). Furthermore, a review of
studies on asymptomatic adults (19-65 yr) revealed
that 90 min of vigorous-intensity physical activity
accumulated throughout the week (90 min/wk) in
increments of no fewer than 10 min reduces the risk
of all-cause mortality by 30%, as well as the risk
for cardiovascular disease (CVD), hypertension,
stroke, type 2 diabetes, and breast and colon cancer
(Kesäniemi et al. 2010).

In 2009, an international consensus conference
was convened to review Canada’s Physical Activity
Guide to Healthy Active Living (Health Canada
2003). The consensus panel recommended that
asymptomatic Canadian adults (19-65 yr) accu-
mulate 150 min/wk of moderate-intensity physical
activity or 90 min/wk of vigorous-intensity activity
as a primary prevention against cardiovascular
disease, stroke, hypertension, colon cancer, breast
cancer, type 2 diabetes, and osteoporosis. They also
recommended multiple exercise sessions in a week,
with each session lasting a minimum of 10 min
(Kesäniemi et al. 2010). In addition to the aerobic
exercise, they recommended strength activities (2-4
days/wk) and flexibility activities (4-7 days/wk). The
duration of the activity depends on the intensity or
effort: Perform light activities (e.g., walking, video
gaming that promotes light effort, gardening, car-
rying small children, or hairstyling) for 60 min,
moderate activities (e.g., brisk walking, swimming,
vacuuming, moving furniture, or chopping wood) for
30 to 60 min, and vigorous activities (e.g., jogging,
hockey, wheelchair basketball, felling large trees,
or rollerblading) for 20 to 30 min.
Improvements in health benefits depend on the
volume (i.e., combination of frequency, intensity,
and duration) of physical activity. This is known as
the dose-response relationship (Loprinzi 2015).
Because of the dose-response relationship between
physical activity and health, even a low level of
100
Percent of potential improvement achieved
80
60
40
20
0
0 500
FIGURE 1.2 Dose-response relationship for health benefits and volume of physical activity.
E7227/Gibson/F01.02/589291/mh-R1
Courtesy of N. Gledhill and V. Jamnik of York University School of Kinesiology and Health Science.
Physical Activity, Health, and Chronic Disease • 7
MVPA each week is better than none; doses less
than one-half of the recommended guidelines may
lead to notable health benefits for those with elevated
risks for chronic conditions and premature mortality
(Warburton and Breden 2016). Exceeding the min-
imum recommended MVPA dose by a factor of 5
(i.e., 750 min/wk or ≥10,000 MVPA MET-min/mo)
may confer the greatest reduction in all-cause mor-
tality risk; no additional mortality-related benefit is
associated with a dose 10 times higher than recom-
mended (Arem et al. 2015; Loprinzi 2015). MVPA
MET-min/mo is easily computed by multiplying
the respective MET level for the specific activities
(see appendix E.3) by the number of minutes one
engages in those MVPA activities within a month.
Figure 1.2 illustrates the general dose-response
relationship between the volume of physical activity
participation and selected health benefits (e.g., mus-
cular strength and aerobic fitness) that do not require
a minimal threshold intensity for improvement. The
volume of physical activity participation needed for
the same degree of relative improvement (%) varies
among health benefit indicators. For example, to
improve triglycerides from 0% to 40% requires 250
kcal·wk−1 of physical activity compared with 1,800
kcal·wk−1 for the same relative improvement (0%-
40%) in high-density lipoprotein (HDL; see figure
1.2). It appears that aerobic-style activities that can
be maintained for longer periods (e.g., bicycling,
dancing, jogging) are positively related to beneficial
Triglycerides (TG)
Blood pressure
Body composition
High-density
lipoproteins (HDL)
1000 1500 2000 2500 3000
Volume of physical activity (kcal/wk)
8 • Advanced Fitness Assessment and Exercise Prescription

changes in HDL (Loprinzi 2015). Jogging at a slow
or average pace ≤3 days/wk for a total of 60 to 150
min/wk confers a favorable increase in heart func-
tion and a similar decrease in mortality, whereas
decades-long strenuous endurance training routines
(≥12 METs) in preparation for extreme endurance
competitions may actually damage the cardiovas-
cular system (Schnohr et al. 2015). Therefore, too
much physical activity, defined as engaging in 5 hr
of structured high-intensity activity per week, may
be associated with negative health consequences or
overuse injuries.
Although no specific dose of sedentary behavior
has been found, a direct linear relationship between
total daily time in sedentary behavior and negative
health indicators associated with metabolic syn-
drome (high triglycerides, high fasting blood glu-
cose, and low HDL-C) has been reported (Gennuso
et al. 2015). Each 60 min increase in daily time spent
being sedentary is associated with a 9% increase
in the odds of satisfying the criteria for metabolic
syndrome (Gennuso et al. 2015).
Although the physical activity guideline—a min-
imum of 150 min of moderate- to vigorous-intensity
aerobic activity weekly, preferably performed on a
daily basis—reduces disease risk, additional physical
activity is needed to mitigate weight gain over time
(Moholdt et al. 2014). Levine (2015) describes how
standing and walking double the energy expended as
compared with sitting; he also illustrates how office
workers can expend approximately 1,000 kcal·day−1
and increase time spent being active by incorporat-
ing walking meetings and short activity breaks in
the typical business day. In 2002, the Institute of
Medicine (IOM) recommended 60 min of daily mod-
erate-intensity physical activity. In the IOM report,
the expert panel stated that 30 min of daily physical
activity is insufficient to maintain a healthy body
weight and to fully reap its associated health benefits.
The IOM recommendation addresses the amount of
physical activity necessary to maintain a healthy
body weight and to prevent unhealthful weight gain
(Brooks et al. 2004). The IOM recommendation of
60 min of daily physical activity is consistent with
recommendations for preventing weight gain made
by other organizations (i.e., Health Canada, Inter-
national Association for the Study of Obesity, and
World Health Organization) (Brooks et al. 2004).

EXAMPLES OF MODERATE-INTENSITY AND

VIGOROUS-INTENSITY AEROBIC ACTIVITIES
This list provides several examples of moderate- and vigorous-intensity aerobic activities. Some activities
can be performed at varied intensities. This list is not all-inclusive; examples are provided to help people
make choices. For a detailed list of energy expenditures (METs) for conditioning exercises, sports, and
recreational activities, see appendix E.3 and http://links.lww.com/MSS/A82. Generally, light activity is
defined as <3.0 METs, moderate activity as 3.0 to 6.0 METs, and vigorous activity as >6.0 METs.
Moderate Intensity Vigorous Intensity
• Walking briskly (3.0 mph [4.8 km·hr−1] or faster, • Race walking, jogging, running, or vigorous
but not race walking) lap swimming
• Skateboarding (noncompetitive) • Tennis (singles)
• Water aerobics and water calisthenics • Dancing (e.g., folk, line, competitive ballroom)
• Bicycling slower than 10 mph (16 km·hr−1) • Bicycling 10 mph (16 km·hr−1) or faster
• Tennis (doubles) • Jumping rope
• Ethnic and cultural dancing (e.g., Middle East- • Backpacking
ern, salsa, merengue, swing) • Circuit training (resistance based with some
• General gardening aerobics and minimal rest intervals)
• Yoga (e.g., hatha, power)

Data from http://links.lww.com/MSS/A82 (accessed June 28, 2018).


The bottom line is that 150 min/wk of moder-
ate-intensity physical activity provides substantial
health benefits but may be insufficient to prevent
weight gain for many individuals. It is a good initial
goal and a sufficient amount of activity to move
individuals from a sedentary to low physical activ-
ity level (Brooks et al. 2004). As individuals adopt
regular physical activity and improve their lifestyle
and fitness, they should increase the duration of
daily physical activity to a level (60 min) that pre-
vents short-term weight gain and provides additional
health benefits. Progression to daily engagement in
physical activity, inclusive of resistance training,
for 60 to 90 min is important for long-term weight
maintenance after weight loss (Bray et al. 2016;
Ryan and Heaner 2014). Although there appears to
be little overall effect on long-term weight loss based
Balance activities
• 3 or more days a week, for
prevention of falls
• Tai chi, yoga, Pilates,
and dance improve balance
Resistance exercise
• 2 or more days a week
• 8-12 repetitions
• 8-10 exercises
• Rest at least one day
between workouts
Activities of
daily living
• Daily physical activity is the base for physical fitness
• Try to be active for at least 30 min every day
FIGURE 1.3 The Exercise and Physical Activity Pyramid.
Adapted by permission from “Exercise and Activity Pyramid,” Metropolitan Life Insurance Company, 1995.
E7227/Gibson/F01.03/589292/mh-R1
Physical Activity, Health, and Chronic Disease • 9
on exercise type (aerobic vs. resistance) or intensity
(lower vs. higher), the reduced time requirement
for equivalent energy expenditure of high-intensity
exercise as compared with low-intensity exercise
may increase exercise adherence and, hence, weight
maintenance (Bray et al. 2016).
The Exercise and Physical Activity Pyramid
illustrates a balanced plan of physical activity and
exercise to promote health and to improve physical
fitness (see figure 1.3). Encourage your clients to
engage in physical activities around the home and
workplace on a daily basis to establish a foundation
(base of pyramid) for an active lifestyle. Strategies
for increasing energy expenditure in the workplace
are built on encouraging active breaks from sitting
in order to move around (e.g., step in place, walk
laps around the office, perform light calisthenics,
Sports and recreational activities
• 2-3 days a week
• Intersperse days of training with a variety
of sport and recreational activities
• Follow safety rules for each activity
• Wear protective equipment
Flexibility exercise
• 2 or more days a week, preferably daily
• 10 min duration minimum
• 3-4 repetitions
• Hold each stretch 10-30 sec
Aerobic exercise
• 30 min, moderate-intensity
(3-6 METs), 5 days a week or
• 20 min, vigorous-intensity
(>6 METs), 3 days a week
• Activity can be continuous or
in multiple segments of at
least 10 min
10 • Advanced Fitness Assessment and Exercise Prescription
walk down the hall to a colleague’s office instead
of calling or e-mailing to deliver a message, climb
a flight of stairs to get a drink of water or use the
restroom). Your clients should perform aerobic
activities a minimum of 3 days/wk; they should do
weight-resistance exercises and flexibility or balance
exercises at least 2 days/wk. Recreational sport activ-
ities (middle levels of pyramid) are recommended
to add variety to the exercise plan. High-intensity
training and competitive sport (top of pyramid)
require a solid fitness base and proper preparation
to prevent injury; most adults should engage in these
activities sparingly.
CARDIOVASCULAR
DISEASE
Cardiovascular disease (CVD) is projected to
cause more than 26 million deaths by 2030 (World
Health Organization 2011b). CVD caused 17.9
million deaths (46% of the deaths attributed to all
noncommunicable diseases) worldwide in 2015. Of
the deaths due to CVD in 2015, the combination
of stroke and ischemic heart disease accounted for
the great majority (85%) (GBD 2015 Mortality and
Causes of Death Collaborators 2016). More than
75% of cardiovascular deaths occurred in low- and
middle-income countries (World Health Organiza-
tion 2016a). CVD is the principal cause of premature
death in Europe, accounting for a nearly equal per-
centage of all deaths before age 75 in women (36%)
and men (35%). Interestingly, however, CVD was
surpassed by cancer as the leading cause of death
in several Western European countries (Townsend
et al. 2016). CVD is also a leading cause of disease
burden in developing low- and middle-income coun-
tries; deaths due to CVD range from a low of 10%
in sub-Saharan Africa to 58% in Eastern Europe
(Wagner and Brath 2012).
In a 2015 report by the CDC identifying the
underlying causes of death in the United States
between 1999 and 2003, diseases of the heart and
blood vessels claimed the lives of about 610,000
people (Centers for Disease Control and Prevention
2015a). CVD accounted for 25% of all deaths (one
out of every four) in the United States. Extrapolating
to 2014 levels, the CDC estimated that more than 92
million Americans have some form of CVD such
as hypertension (~86 million), CHD (27.6 million),
or stroke (7.2 million) (American Heart Association
2017). Among American adults 20 yr of age or older,
the estimated age-adjusted prevalence of coronary
heart disease is higher for black men and women
compared with Hispanic and white men and women
(American Heart Association 2017).
One myth about CVD is that it is much more
prevalent in men than in women. Between 2011 and
2014, the prevalence of CVD in adult women (35.9%)
and men (37.7%) in the United States was similar
(American Heart Association 2017). Nearly 399,000
females died from CVD in 2014 in the United States.
Another misconception about CVD is that it afflicts
only the older population. Although it is true that
older people are at greater risk, more than 50%
of the people in the United States with CVD are
younger than 60 yr (American Heart Association
2017), and CVD ranks as the second-leading cause
of death for children under age 15 (American Heart
Association 2012).
The prevalence of American adults with CHD
was 45.1% in 2014 (American Heart Association
2017). In Europe, CHD accounts for more than 1.7
million deaths, with nearly 19% of those occurring
in adults below the age of 65 (Townsend et al. 2016).
Coronary heart disease (CHD) is caused by a lack
of blood supply to the heart muscle (myocardial
ischemia) resulting from a progressive degenerative
disorder known as atherosclerosis. Atherosclerosis
is an inflammatory process involving a buildup of
low-density lipoprotein (LDL) cholesterol, scav-
enger cells (monocytes), necrotic debris, smooth
muscle cells, and fibrous tissue. This is how plaques
form in the intima, or inner lining, of the medium-
and large-sized arteries throughout the cardiovas-
cular system. As more lipids and cells gather in the
plaques, they bulge into the arterial lumen (Barquera
et al. 2015). In the heart, these bulging plaques
restrict blood flow to the myocardium and may
produce angina pectoris, which is a temporary sen-
sation of tightening and heavy pressure in the chest
and shoulder region. A myocardial infarction, or
heart attack, can occur if a blood clot (thrombus) or
ruptured plaque obstructs the coronary blood flow.
In this case, blood flow through the coronary arteries
is usually reduced by more than 80%. The portion
of the myocardium supplied by the obstructed artery
may die and eventually be replaced with scar tissue.

CARDIOVASCULAR
DISEASE RISK FACTORS
Epidemiological research indicates that many factors
are associated with the risk of CVD. The greater
the number and severity of risk factors, the greater
the probability of CVD. The positive risk factors
for CVD are
•• age,
•• family history,
•• hypercholesterolemia,
•• hypertension,
•• tobacco use,
•• diabetes mellitus or prediabetes,
•• overweight and obesity, and
•• physical inactivity.
An increased level (≥60 mg·dl−1) of high-density
lipoprotein cholesterol, or HDL-cholesterol (HDL-
C), in the blood decreases CVD risk. If the HDL-C
is high, you should subtract one risk factor from
the sum of the positive factors when assessing your
client’s CVD risk.
PHYSICAL ACTIVITY
AND CORONARY HEART
DISEASE
Approximately 12% of CHD deaths in the United
States can be attributed to a lack of physical activ-
ity (American Heart Association 2017). As cited in
American Heart Association (2017), the percentage
of physically inactive people worldwide in 2012
(35%) surpassed the percentage of those who smoked
(26%); however, Sallis and colleagues (2016),
reported the global percentage of physically inactive
adults to be closer to 23%. As an exercise scientist,
you must educate your clients about the benefits of
physical activity and regular exercise for preventing
CHD. Physically active people have lower incidences
of myocardial infarction and mortality from CHD
and tend to develop CHD at a later age compared
with their sedentary or less active counterparts
(American Heart Association 2017). Leading a phys-
ically active lifestyle and sitting less than 4 hr a day
may reduce cardiovascular disease mortality rates
by 23% to 74% (Ekelund et al. 2016). Alternatively,
in their analysis of multiple studies investigating
Physical Activity, Health, and Chronic Disease • 11
sedentary behavior and incidence of CVD, Biswas
and associates (2015) reported an increase in odds
ranging from 6% to more than doubled.
Physical activity, just like sedentary behavior and
cardiorespiratory fitness levels, exerts its effect inde-
pendently of other risk factors related to premature
death from CHD and all causes (Bouchard, Blair,
and Katzmarzyk 2015). Another conclusion about
the independent effect of sedentary behavior (Carter
et al. 2017) is that evidence increasingly points to the
likely link between sedentarism and its ability to fur-
ther exacerbate the traditional, modifiable CV risk
factors (Benatti and Ried-Larsen 2015; Bergouignan
et al. 2016; Same et al. 2016). Also, in a meta-analy-
sis of studies dealing with the dose-response effects
of physical activity and cardiorespiratory fitness on
CVD and CHD risk, Williams (2001) reported that
cardiorespiratory fitness and physical activity have
significantly different relationships to CVD and
CHD risk. Although physical fitness and physical
activity each lower the risk of developing CVD and
CHD, the reduction in relative risk was almost twice
as great for cardiorespiratory fitness as for physical
activity. These findings suggest that in addition to
physical activity level, low cardiorespiratory fitness
level should be considered a potential risk factor
for CHD (U.S. Department of Health and Human
Services 2008).
HYPERTENSION
Hypertension, or high blood pressure, is a chronic,
persistent elevation of blood pressure. Individuals
with this diagnosis are often prescribed antihy-
pertensive medicine. Elevated blood pressure is
the term used to identify systolic blood pressure
(SBP) values between 120 and 129 mmHg, even
if diastolic blood pressure (DBP) is lower than 80
mmHg. Stage 1 hypertension describes a value of
130 to 139 mmHg for SBP or a DBP value of 80 to 89
mmHg; stage 2 hypertension denotes SBP values
≥140 mmHg or DBP values ≥ 90 mmHg (Whelton
et al. 2017). An expanded link exists between hyper-
tension and several forms of CVD (Rapsomaniki et
al. 2014). The World Health Organization (2011b)
identified hypertension as the leading cardiovascular
risk factor, attributing 13% of deaths worldwide to
high blood pressure. If not kept in check, hyperten-
sion becomes a primary risk factor for stroke, heart
12 • Advanced Fitness Assessment and Exercise Prescription
attacks, heart and kidney failure, dementia, and
blindness (World Health Organization 2014). In the
United States, hypertension attributes to about 40%
of all adult deaths from CVD (Yang et al. 2012).
In 2014, about 22% of the global adult population
(≥18 yr of age) had hypertension (World Health
Organization 2014). As of 2015, hypertension is
more prevalent in low-income countries in sub-Saha-
ran Africa and south Asia than in high-income coun-
tries; however, elevated blood pressure continues to
be problematic in Eastern and Central Europe (NCD
Risk Factor Collaboration 2017). With an estimated
1.4 billion adult diagnoses worldwide, hypertension
is touted as being the leading preventable cause
of death before age 70. Its prevalence is lower in
high-income countries (28.5%) as compared with
low- and middle-income countries (31.5%), which
reflects differences in awareness levels as well as
treatment and control of the condition (Mills et
al. 2016). Nearly one out of every three adults has
blood pressure values in the elevated rage (Centers
for Disease Control and Prevention 2016). In the
United Kingdom, approximately 14% of adults are
hypertensive, with Northern Ireland having a lower
prevalence compared with England and Scotland
(British Heart Foundation 2015b). In comparison,
the prevalence of hypertension is estimated to be
higher for adults in Latin America and the Caribbean
(~39%) than for the Pacific and East Asian region
(~36%), Europe and Central Asia (~32%), South Asia
(~29%), and Africa (~27%) (Sarki et al. 2015).
In the United States, more men than women are
hypertensive prior to age 65; after that the percentage
of hypertensive women surpasses that of their male
counterparts (American Heart Association 2017).
Up to age 45 yr, the percentage of American men
with hypertension (11%-23%) is slightly higher than
that of women (8%-23%). Between ages 45 and 54
yr, the prevalence of hypertension is similar for men
(36.1%) and women (33.2%). Likewise, for those
between 55 and 64 yr, men have a slightly higher
(57.6%) prevalence of hypertension than do women
(~55.5%). After age 65, the percentage of women
(65.8%) with high blood pressure is somewhat higher
than that of men (63.6%). Women with hypertension
have a 3.5 times greater risk of developing CHD
than do women who have normal blood pressure
(normotensive). Also, the prevalence of high blood
pressure for blacks in the United States (45.5%) is
among the highest in the world and is substantially
greater than that of American Indians or Alaskan
Natives, Asians or Pacific Islanders, Hispanics, and
whites in the United States (American Heart Asso-
ciation 2017). Table 1.3 summarizes the risk factors
associated with developing hypertension.
For individuals with elevated blood pressure
values, healthy lifestyle changes and periodic BP
reassessments are recommended as part of the
treatment plan. For people whose blood pressure is
in the stage 1 range, their risk for stroke and CVD
within the next 10 yr should be assessed using the
atherosclerotic cardiovascular disease risk calculator
(http://static.heart.org/riskcalc/app/index.html#!/
baseline-risk) (Whelton et al. 2017). Sharman, La
Gerche, and Coombes (2015) combined data from
studies investigating the effect of exercise on blood
pressure values in people diagnosed with hyper-
tension. They indicate that while both aerobic and
resistance training can reduce blood pressure, aer-
obic training is the preferred method. Their study
also reports on the combination of exercise and
antihypertensive medications, with a cautionary
note about monitoring postexercise blood pres-
sure responses. Regular physical activity prevents
hypertension and lowers blood pressure in younger
and older adults who have normal, elevated, stage
1, or stage 2 values. Compared with normotensive
individuals, training-induced changes in resting
systolic and diastolic blood pressures (5-7 mmHg)
are greater for hypertensive individuals who partic-
ipate in endurance exercise. However, even modest
reductions in blood pressure (2-3 mmHg) by endur-
ance or resistance exercise training decrease CHD
risk by 5% to 9%, stroke risk by 8% to 14%, and
all-cause mortality by 4% in the general population
(Pescatello et al. 2004). See Exercise Prescription
for Individuals with Hypertension for an exercise
prescription that the ACSM endorses to lower blood
pressure in adults with hypertension.
 Table 1.3 Summary of Factors Associated With Disease Risk
Factor CHD Type 2 diabetes Hypertension Hypercholesterolemia Low back pain Obesity Osteoporosis Cancer
Age ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑
a b b b
Gender M>F F>M F>M F>M F=M F>M F>M
Race B > W > AA, AI, AN, B, H > B > A, AI, H, W B, H, W > A, AI AI, B, H, W A,W > AI, B, H
AN > H A, W >A
Family history ↑ ↑ ↑ ↑ ↑ ↑ ↑
SES ↓ ↓ ↓ ↓ ↓ ↓ ↑
Alcohol use ↑ ↑ ↑ ↑
Smoking ↑ ↑ ↑ ↑ ↑ ↑
Nutrition
Na+ intake ↑
++
Ca intake/vitamin D ↓
Fat/cholesterol intake ↑ ↑ ↑ ↑ ↑
CHO intake ↑
Intake > expenditure ↑
Physical activity ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓
Exercise amenorrhea ↑
Flexibility ↓
Muscular strength ↓ ↓
Skeletal frame size ↓
Other diseases
Anorexia nervosa ↑
Diabetes ↑
Hypertension ↑
Hypercholesterolemia ↑
Obesity and overweight ↑ ↑ ↑ ↑ ↑ ↑
↑ = Direct relationship; as factor increases, risk increases.
↓ = Indirect relationship; as factor increases, risk decreases.
CHD = coronary heart disease; CHO = carbohydrate; A = Asian; AI = American Indian; AN = Alaska Native; B = Black; H = Hispanic; W = White; Na = sodium; Ca = calcium; SES = socioeconomic status
(reflects income and education levels).
a
Males (M) at higher risk than females (F) up to age 55 yr.
b
Menopausal females at higher risk than males.

13
14 • Advanced Fitness Assessment and Exercise Prescription
EXERCISE PRESCRIPTION
FOR INDIVIDUALS WITH
HYPERTENSION
Mode: Primarily endurance activities supple-
mented by resistance exercises
Intensity:
. Moderate-intensity endurance (40%-
60% VO2R),* rate of perceived exertion of
12-13, and resistance training (60%-80%
1-RM)
Duration: 30 min or more of continuous or
accumulated aerobic physical activity per
day, and a minimum of two sets (8-12 reps) of
resistance training exercises for each major
muscle group
Frequency: Most, preferably all, days of the
week for aerobic exercise; 2 or 3 days/wk for
resistance training
. LDLS, HDLS, AND TC
*VO2R is the difference between the maximum
. and the rest-
ing rate of oxygen consumption. See the VO2 Reserve (MET)
Method section in chapter 5 for more information.
Based on American College of Sports Medicine 2018.
HYPERCHOLESTEROL-
EMIA AND
DYSLIPIDEMIA
Hypercholesterolemia, an elevation of total choles-
terol (TC) in the blood, is associated with increased
risk for CVD. Hypercholesterolemia is also referred
to as hyperlipidemia, which is an increase in blood
lipid levels; dyslipidemia refers to an abnormal
blood lipid profile. Approximately 18% of strokes
and 56% of heart attacks are caused by high blood
cholesterol (World Health Organization 2002a).
Between 2011 and 2014, the number of adults (≥20
yr of age) having a TC value ≥240 mg∙dl–1 fell for all
racial and ethnic subgroups; however, this decrease
may be due to an increase in medication prescrip-
tions instead of exercise or diet (American Heart
Association 2017). Results from the longitudinal,
biracial CARDIA study (Schneider et al. 2016)
indicate that although TC dropped initially, values
stabilized and appear to be reversing toward the end
of the 25 yr observation period.
More than 94.6 million Americans age 20 yr
and older have total blood cholesterol levels of
200 mg·dl–1 or higher. According to data gathered
between 2011 and 2014, 28.5 million American
adults (≥20 yr) have TC levels classified as high risk
(>240 mg·dl–1); more women (16.4 million) than men
(10.6 million) have TC levels equaling or exceeding
240 mg·dl–1 (American Heart Association 2017). Of
note, the prevalence of TC, when adjusted for age,
decreased in the 2013-2014 period as compared
with the 2011-2012 period for both men and women
across the four major racial and ethnic groups; the
one exception is a 2.6% increased prevalence for
non-Hispanic Asian males. Compared with Western
countries, the average TC levels for adults in China,
Japan, and Indonesia are uniformly lower (190-207
mg·dl–1) (American Heart Association 2001). Risk
factors for hypercholesterolemia are identified in
table 1.3.
Cholesterol is a waxy, fatlike substance found in
all animal products (meats, dairy products, and
eggs). The body can make cholesterol in the liver
and absorb it from the diet. Cholesterol is essential
to the body, and it is used to build cell membranes,
produce sex hormones, and form bile acids neces-
sary for fat digestion. Lipoproteins are an essential
part of the complex transport system that exchanges
lipids among the liver, intestine, and peripheral
tissues. Lipoproteins are classified by the thickness
of the protein shell that surrounds the cholesterol.
The four main classes of lipoproteins are chylo-
micron, derived from the intestinal absorption of
triglycerides (TG); very low-density lipoprotein
(VLDL), made in the liver for the transport of tri-
glycerides; low-density lipoprotein (LDL), a product
of VLDL metabolism that serves as the primary
transporter of cholesterol; and high-density lipo-
protein (HDL), involved in the reverse transport of
cholesterol to the liver. The molecules of LDL are
larger than those of HDL and therefore precipitate
in the plasma and are actively transported into the
vascular walls. Excess LDL-cholesterol (LDL-C)
stimulates the formation of plaque in the intima of
the coronary arteries. Plaque formation reduces the
cross-sectional area and obstructs blood flow in
these arteries, eventually producing a myocardial
infarction. Therefore, LDL-C values less than 100
mg·dl−1 are considered optimal for reducing CVD

and CHD risk (National Cholesterol Education
Program 2001). The prevalence of borderline high
levels (≥130 mg·dl−1 to <160 mg·dl−1) of LDL-C is
nearly identical for adult women (31%) and adult
men (32.5%) in the United States (Roger et al. 2012).
The smaller HDL molecules are suspended in the
plasma and protect the body by picking up excess
cholesterol from the arterial walls and delivering it to
the liver, where it is metabolized. HDL-cholesterol
(HDL-C) values less than 40 mg·dl−1 are associated
with a higher risk of CHD. Based on data collected
between 2011 and 2014, 19% of men and women
in the United States who are older than 20 yr have
low (<40 mg·dl−1) HDL-C levels (Zwald et al. 2017).
Individuals with low HDL-C or high TC levels
(dyslipidemia) have a greater risk of heart attack.
Those with lower HDL-C (<37 mg·dl−1) are at higher
risk regardless of their TC level. This emphasizes the
importance of screening for both TC and HDL-C
in adults.
PHYSICAL ACTIVITY AND
LIPID PROFILES
Regular physical activity, especially habitual MVPA
aerobic exercise, positively affects lipid metabo-
lism and lipid profiles (Lin, Zhang, et al. 2015).
Cross-sectional comparisons of lipid profiles in
physically active and sedentary women and men sug-
gest that physical fitness is inversely related to TC
and the TC/HDL-C ratio (Despres and Lamarche
1994; Shoenhair and Wells 1995).
Data from 160 randomized controlled trials were
pooled to examine the effects of aerobic exercise
on cardiometabolic biomarkers such as lipids and
lipoproteins in a large number of adults. Results
show that compared with control groups, adults in
moderate-intensity and vigorous-intensity aerobic
exercise interventions, respectively, reduce TC (4.3
and 3.87 mg·dl−1), LDL-C (3.09 and 4.64 mg·dl−1),
VLDL-C (1.93 and 7.35 mg·dl−1), and TG (5.31 and
5.31 mg·dl−1) and increase HDL-C (1.16 and 2.71
mg·dl−1) (Lin, Zhang, et al. 2015). However, Lin
and colleagues found no differences across exer-
cise-intensity subgroups, which lends support to
the premise that moderate- and vigorous-intensity
exercise training confer similar favorable results
for cardiometabolic health. A 1% reduction in TC
has been shown to reduce the risk for CHD by 2%;
Physical Activity, Health, and Chronic Disease • 15
likewise, a 1% reduction in HDL-C increases CHD
risk by 2% to 3% (Gordon et al. 1989). However, for
individuals with hyperlipidemia, lifestyle changes
(e.g., healthy diet) or pharmacologic interventions
(e.g., statins), in addition to aerobic exercise, may
be necessary for optimizing lipid and lipoprotein
profiles (Kelley and Kelley 2006).
Increases in HDL-C in response to aerobic exer-
cise appear to be related to the training dose (inter-
action of the intensity, frequency, and duration of
each exercise session and the length of the training
period), and they are less dramatic in women than in
men. Across adult age ranges, those who met (17.7%)
the physical activity guidelines (≥150 min of MVPA
per week) had higher HDL-C levels than did those
American adults (21.0%) who did not meet the meet
the guidelines. Interestingly, the prevalence of low
HDL-C values decreased with increasing age for
adults meeting the physical activity guidelines; for
those ≥60 yr old, only 12.6% of the active seniors
had low HDL-C values compared with approxi-
mately 19% for the younger age groups (Zwald et
al. 2017). Based on results from a longitudinal study
of biracial adults, a high level of aerobic fitness
as a young adult in combination with a continued
physically active lifestyle confers favorable results
for blood lipid levels in the middle-age adult years
(Sarzynski et al. 2015).
The research on the effect of resistance training on
cholesterol levels continues to remain inconclusive.
Ribeiro and associates (2016) reported improve-
ments in HDL-C for the older, physically indepen-
dent women (67.6 ± 5.1 yr) randomly assigned to 8
wk of traditional (three sets of 8-RM to 12-RM) or
8 wk of pyramid (12-RM/10-RM/8-RM) styles of
resistance training. After a 12 wk washout period,
the women switched training styles. There were
numerous favorable responses, including increases
in HDL-C, by the end of each 8 wk period; however,
there were no differences between training styles.
Similarly, 12 wk of a nonlinear resistance training
program designed to increase strength significantly
improved HDL-C and other variables compared
with the normally active controls in a sample of
adults (18-60 yr) living with HIV and taking pre-
scribed highly active antiretroviral medications
(Zanetti et al. 2016). Conversely, 16 wk of combined
aerobic (30 min) and resistance (27 min) training
produced no significant improvements in HDL-C
16 • Advanced Fitness Assessment and Exercise Prescription

in postmenopausal women as compared with those from smoking tobacco, the risk of death from CHD
in the aerobic training (52 min) group (Rossi et al. increases by 30% in those exposed to environmental
2016). It is possible that the resistance training por- tobacco smoke at home or at work (American Heart
tion of their combined group (three or four sets of Association 2004).
12-RM to 15-RM) may not have provided the exer- Smoking is one of the largest preventable causes
cise intensity needed to invoke significant changes of disease and premature death. Nearly 33% of
in HDL-C in their postmenopausal sample. CHD deaths are due to first- and secondhand expo-
sure to smoke (American Heart Association 2017).
TOBACCO Cigarette smoking is linked to CHD, stroke, and
chronic obstructive pulmonary disease. It causes
cancer of the lungs, larynx, esophagus, mouth, and
Although tobacco usage (e.g., cigarettes and cigars)
bladder and is also associated with no fewer than
is declining in the United States and other countries,
eleven cancers (Carter et al. 2015). Compared with
there continues to be a steep increase worldwide
nonsmokers, smokers have more than twice the
(American Heart Association 2017). Ng and col-
risk of heart attack and die, on average, at least 10
leagues (2014) attribute the increase in the number
yr earlier (American Heart Association 2017). As
of smokers to the world’s population growth. The
mentioned previously, cigarette smoking is a major
World Health Organization (2011) estimates there
cause of stroke. It also multiplies the effect of CHD
are approximately 1 billion smokers in the global
risk factors such as elevated blood lipid levels, dia-
population. According to age-standardized results
betes mellitus, and untreated hypertension. Some
for smoking prevalence (Ng et al. 2014), between
researchers who study adults ≥55 yr of age are
16.5% and 19.7% of men in the United States,
encouraging further investigations of the possible
Canada, Brazil, and Australia smoke, while 34.7%
associations between smoking and deaths resulting
to 61.1% of men in Russia, China, Eastern Europe,
from infections, respiratory diseases, prostate and
Egypt, and Turkey smoke. The lowest prevalence
breast cancer, intestinal ischemia, kidney failure,
(0.5%-2.6%) of female smokers is found in Africa,
and hypertensive heart disease. The relative risk of
China, and the Persian Gulf, whereas the prevalence
dying from these conditions drops with each year
exceeds 25% in Austria, Chile, France, and Hun-
subsequent to quitting (Carter et al. 2015). Addi-
gary. Of the 187 countries included in the study, the
tionally, although not well studied at this time, the
age-adjusted prevalence of men who smoke daily
inhaled vapors from electronic cigarettes deliver
exceeds that of their female counterparts in all but
nicotine and other substances for which the health
one country: Sweden. Although the prevalence
risks are not yet known.
of tobacco usage is lower for women than men
When individuals stop smoking, their risk of
across the majority of the predominant race and
CHD declines rapidly, regardless of how long or
ethnic groups in the United States, the prevalence
how much they have smoked. Although health
is slightly higher for Native American and Alaskan
benefits associated with smoking cessation happen
Indian women and nearly equal for non-Hispanic
within weeks or months, the relative risk of a former
white women compared with their respective male
smoker dying from CHD approximates that of a
counterparts (American Heart Association 2017).
nonsmoker within 10 yr of quitting (American Heart
Approximately 13.7% of American women and
Association 2017).
16.7% of American men currently smoke (Amer-
ican Heart Association 2017). Smoking cessation
strategies in Canada, Iceland, Mexico, and Norway DIABETES MELLITUS
have cut smoking rates in half since 1980 (Ng et
al. 2014) and may provide invaluable assistance Diabetes is a global epidemic with rising prevalence
for curbing tobacco use in other countries. In a rates, especially in the low- and middle-income
study of school-aged adolescents (average age 15 countries. Consequently, there is a commitment by
yr) representing 50 schools in six European cities world leaders to reduce, by one-third, the rates of
(Lorant et al. 2015), 17.4% of the 11,000 participants premature mortality from diabetes and the other
self-reported being a smoker. Even if people abstain priority NCDs by 2030 (World Health Organiza-

tion 2016b). As of 2014, an estimated 422 million
adults (8.5%) worldwide have the disease (World
Health Organization 2016b). Factors linked to this
epidemic include urbanization, aging, physical
inactivity, unhealthy diet, and obesity (Wagner and
Brath 2012). At least 43% of the deaths attributable
to elevated blood glucose levels occur in people
younger than 70 yr of age (World Health Organiza-
tion 2016b). Diabetes is a major contributor toward
the development of CHD, stroke, specific cancers,
kidney failure, and cognitive disability (World
Health Organization 2016b). This increased risk
of CHD and stroke is higher for women than men
with diabetes for a variety of reasons: higher-level
CVD risk factors and obesity at time of diagnosis,
longer exposure to an elevated risk profile when in
the prediabetic stage, and relative undertreatment
following diagnosis (Peters, Huxley, and Woodward
2014). In the United States, diabetes was the seventh
leading cause of death in 2010 (American Diabetes
Association 2017).
In 2012, 29 million adults in the United States
had type 2 diabetes, while 86 million ≥20 yr of age
were identified as having prediabetes (American
Diabetes Association 2017). In China and India,
there are 138 million people with diabetes (Danaei
et al. 2011). Danaei and colleagues (2011) also esti-
mated that approximately 42 million people with
diabetes are from Brazil, Indonesia, Japan, Mexico,
and Pakistan. Furthermore, in 2008, they reported
the highest prevalence of diabetes was found in
countries located in Oceania, northern Africa, the
Middle East, and the Caribbean. Conversely, the
lowest prevalence of diabetes was in southeast Asia,
east Africa, and Andean Latin America (Danaei et
al. 2011).
The prevalence of diabetes for adults (≥20 yr)
in the United States was 12.3%; 1.7 million people
in this age group were diagnosed with diabetes for
the first time in 2012 (Centers for Disease Control
and Prevention 2014). Compared with white adults
in the United States, the prevalence of diabetes and
impaired blood glucose levels for blacks (13.2%),
Hispanics (12.8%), and American Indians/Alaska
Natives (15.9%) is higher (Centers for Disease Con-
trol and Prevention 2014). The age-adjusted preva-
lence of diabetes for American Indians and Alaska
Native adults is region dependent; American Indians
in southern Arizona have a prevalence of diabetes
Physical Activity, Health, and Chronic Disease • 17
(24.1%) that is four times that of Alaska Natives
(Centers for Disease Control and Prevention 2014).
Prediabetes, in addition to being a positive risk
factor for CVD, is a medical condition identified
by fasting blood glucose or glycated hemoglobin
(HbA1c) levels that are above normal values but
lower than the threshold for a diagnosis of diabetes.
HbA1c is an indicator of the average blood glucose
over the past 2 to 3 mo (Centers for Disease Control
and Prevention 2014). Fortunately for the 86 million
American adults (Centers for Disease Control and
Prevention 2014) and others worldwide, prediabetes
appears to respond favorably to weight loss, dietary
changes, and increases in physical activity. The
age-adjusted percentage of prediabetes in U.S. adults
during the period 2009 to 2012 was nearly identi-
cal for non-Hispanic whites, non-Hispanic blacks,
and Hispanics (35%, 39%, and 38%, respectively)
(Centers for Disease Control and Prevention 2014).
Type 1 diabetes, formerly referred to as insu-
lin-dependent diabetes mellitus (IDDM), usually
occurs in children and adolescents but can develop
at any age. Type 2 diabetes, previously known as
non-insulin-dependent diabetes mellitus (NIDDM),
is more common and no longer occurs primarily
in middle-aged and elderly adults; 90% to 95% of
individuals diagnosed with diabetes mellitus have
type 2 diabetes (Centers for Disease Control and Pre-
vention 2014). Risk factors for developing diabetes
are presented in table 1.3. Type 1 diabetes may be
caused by autoimmune, genetic, or environmental
factors, but the specific cause is unknown. Unfortu-
nately, although clinical trials are under way, there
is currently no known way to prevent type 1 dia-
betes (World Health Organization 2016b). Healthy
nutrition and increased physical activity, however,
can reduce the risk of type 2 diabetes by as much
as 67% in high-risk individuals (Sanz, Gautier, and
Hanaire 2010). Regular physical activity, as part of
a modest weight loss intervention, has reduced the
risk of developing type 2 diabetes by a maximum
of 58% for those in the high-risk category (Colberg
et al. 2010). Too much body fat is recognized as the
dominant risk factor for type 2 diabetes. Elevated
waist circumferences and BMI values also increase
the risk, but the associated risk varies by geographic
region (World Health Organization 2016b).
The effect of exercise alone as an intervention for
people with type 2 diabetes is not well known beyond
18 • Advanced Fitness Assessment and Exercise Prescription
its ability to improve glucose control (Handelsman
et al. 2015). However, a minimum of 150 min/wk
of MVPA is recommended and should include
flexibility and strength training (Handelsman et al.
2015). Of note, though, for continued benefits, the
exercise program needs to be performed regularly
and include both strength and aerobic training to
help those with type 2 diabetes achieve optimal
health. Decreasing the time spent being sedentary,
in addition to increasing daily physical activity, is a
viable means of decreasing the risk for developing
type 2 diabetes. As reported in a review of five stud-
ies, the pooled hazard of developing type 2 diabetes
is nearly double for those reporting high amounts of
sedentary time (Biswas et al. 2015). Although few
adverse effects or diabetic complications resulting
from exercise have been reported, being watchful
for acute postexercise hypoglycemia and transient
hyperglycemia is prudent (Colberg et al. 2010).
Research that associates physical activity with
weight loss, fat loss, and glycemic control suggests
that regular physical activity in accordance with
the recommended guidelines reduces one’s risk of
developing type 2 diabetes (Colberg et al. 2010). In
a small sample of overweight and obese participants,
an intensive 6 mo nonrandomized lifestyle interven-
tion consisting of exercise and behavioral weight
loss counseling reduced baseline HbA1C values
(6.8 ± 0.2% to 6.2 ± 0.3%), consequently precluding
the need for medications to reduce blood glucose
levels. Numerous other aspects (e.g., insulin levels,
insulin resistance, blood pressure, body mass, body
composition) were also favorably affected (Ades et
al. 2015). The frequency of exercise is crucial for
those with diabetes. If daily exercise is not possible,
it should not be skipped 2 days in a row. Specific
guidelines for prescribing exercise programs for
people who have type 1 and type 2 diabetes are
available elsewhere (American College of Sports
Medicine 2018).
OBESITY AND
OVERWEIGHT
Adult overweight and obesity are classified using
the body mass index (BMI) (BMI = weight [kg]
/ height squared [m 2]). According to traditional
BMI values, individuals ≥20 yr of age with a BMI
between 25 and 29.9 kg/m2 are classified as over-
weight; those with a BMI of 30 kg/m2 or more are
classified as obese (Smith and Smith 2016). As the
result of research on people from various population
subgroups, more conservative BMI cut-points for
identifying overweight (23-24.9 kg/m2) and obesity
(≥25 kg/m2) have been identified for Asians and
South Asians (Seidell and Halberstadt 2015). Conse-
quently, as noted by Seidell and Halberstadt (2015),
the prevalence of obesity in the world may be under-
stated because many Asians would be erroneously
classified based on BMI. Although BMI has utility
as a simple index of obesity, it cannot account for
relative fatness, and including some additional deter-
mination or estimation of abdominal fat distribution
is recommended for understanding actual health risk
(Seidell and Halberstadt 2015). The World Health
Organization (2012b) defines overweight and obesity
as having abnormal or excessive fat accumulation
that may impair health. Regardless, overweight
and obesity ranks as the fifth leading risk factor for
death worldwide.
More than 2.1 billion people worldwide are
classified as being overweight or obese (Smith
and Smith 2016). Globally, more than 1 in 3 adults
(≥18 yr) is overweight, and more than 1 in every 10
adults is obese (World Health Organization 2016b).
The countries in the World Health Organization’s
Region of the Americas have the highest prevalence
of obesity, while those countries categorized into the
South-East Asian Region have the lowest (World
Health Organization 2016b). In England, fairly equal
percentages of men (24%) and women (27%) were
categorized as obese based on BMI in 2014 (NHS
Digital 2014). Self-reported heights and weights for
the 48,000 Canadian adults responding to the Cana-
dian Community Health Survey in 2012 were used
to calculate BMI for the younger (age 30-59 yr) and
older (age 60-80+ yr) age groups. Nearly 55% of the
younger and 60% of the older group were overweight
or obese (Cohen, Baker, and Ardern 2016). In 2014,
China surpassed all other countries for adult obe-
sity, with their obese men and women representing
16.3% and 12.4% of the world’s sex-specific obesity
prevalence; the United States ranked second for
both sexes (men: 15.7%; women: 12.3%) (NCD Risk
Factor Collaboration 2017). For a detailed report
of changes in global BMI levels between 1975 and
2014 based on data from about 99% of the world’s

population, see the work of the NCD Risk Factor
Collaboration group (2017).
In the United States, approximately 35% of
adults are classified as obese, and one of every three
children and adolescents falls into the overweight
or obese categories (Smith and Smith 2016). The
age-adjusted prevalence of obesity for American
men is approximately 35% for whites and 12.6%
for Asians, respectively; the obesity prevalence is
approximately 38% for non-Hispanic black and His-
panic men. For American women, the age-adjusted
prevalence of obesity based on BMI is 40.4%, 46.9%,
57.2%, and 12.4%, respectively, for white, Hispanic,
black, and Asian women. For those having a BMI in
the class 3 obesity range (≥40 kg/m2), the prevalence
for both men and women across the four racial and
ethnic groups ranged between 5.5% and 9.9%, with
the exception being 16.8% for black women (Flegal
et al. 2016). Asian adults in the United States con-
tinue to have a much lower prevalence of obesity
compared with whites, blacks, and Hispanics (Flegal
et al. 2016).
Childhood obesity (≥95th percentile for sex and
age) is also a global problem (see chapter 9). Over-
weight adolescents have a 70% chance of becoming
overweight adults; this increases to 80% if one or
both parents are overweight or obese (American
Heart Association 2012). In England, 33% of boys
and 35% of girls, ages 2 to 15 yr, were either over-
weight or obese (British Heart Foundation 2006).
Similarly, in the United States, the prevalence of
overweight and obesity in children and adolescents,
ages 2 to 19 yr, was approximately 33% in 2014,
with 17.2% being classified as obese (American
Heart Association 2017). That year’s prevalence of
obesity in children increased with each age group
and ranged from 9.4% (preschool children 2-5 yr)
to 20.6% for adolescents (12-19 yr); the prevalence
was 17.4% for grade school–aged children (Amer-
ican Heart Association 2017). The World Health
Organization (2018b) reported that approximately
41 million children (0 to 5 yr) globally are either
overweight or obese, and nearly 340 million chil-
dren (5 – 19 yr) are overweight or obese). Table 1.3
summarizes factors associated with increased risk
of obesity.
Excess body weight and fatness pose a threat to
both the quality and duration of one’s life. A rare
longitudinal study spanning 40 yr tracked over 900
Physical Activity, Health, and Chronic Disease • 19
men to document changes in BMI and cardiometa-
bolic outcomes (Xian et al. 2017). BMI trajectories
were modeled based on assessments at ages 20, 40,
56, and 62 yr. Compared with the men who were
normal weight in their 20s but attained an over-
weight BMI at age 62, those having normal-weight
BMIs at baseline and ending with BMIs in the obese
range (normal-obese) had significantly greater risks
of hypertension, diabetes, dyslipidemia, and inflam-
mation; the same is true for the men having baseline
BMI values in the overweight range and entering the
obesity level by age 40 and attaining the highest level
of obesity (≥40 kg/m2) at age 62 (overweight-obese
level 3). However, the overweight-obese level 3 group
had more than three times the risk of hypertension,
double the risk of inflammation, and a 60% higher
risk of diabetes compared with the normal-obese
group. Interestingly, there were no differences in the
three groups for ischemic heart disease.
Although obesity is strongly associated with
CHD risk factors such as hypertension, glucose
intolerance, and hyperlipidemia, the contribution
of obesity to CHD appears to be independent
of the influence of obesity on these risk factors.
Interestingly, an obesity paradox has been iden-
tified; paradoxically and counterintuitively, when
investigating the short- and long-term prognosis for
cardiovascular diseases, such as hypertension, atrial
fibrillation, and heart failure, prognosis is improved
for those who are overweight or mildly obese as
compared with leaner clients (Lavie et al. 2014). For
a comprehensive review of the effects of obesity on
cardiac performance, cardiac remodeling, aerobic
fitness level, and the obesity paradox, see the work
of Lavie and colleagues (2014).
Obesity, the fifth leading cause of death, may
be caused by genetic and environmental factors as
well as gut biome. Although studies suggest that
genetic factors contribute to some of the variation in
body fatness, there has been no substantial change
in the genotype of the American population since
the 1960s (Hill and Melanson 1999). Nevertheless,
in terms of prevalence, obesity varies across ethnic
groups. Obesity clusters within families have been
reported, as have hereditability estimates. Genome-
wide association studies (GWASs) are now under
way, and upwards of 90 possible areas of genetic
variation associated with obesity and BMI have been
identified (Chen et al. 2017). Without any doubt, our
20 • Advanced Fitness Assessment and Exercise Prescription
environment and culture are additional key contribu-
tors to the increases being seen in the rates of obesity.
In addition to the countless calorically dense food
options we have and technological advancements
that reduce energy expenditure through physical
activity and manual labor, we are exposed daily to
innumerable chemical compounds (e.g., pesticides,
personal and home care products, food additives,
industrial waste) that promote obesity through their
interference with the endocrine system and meta-
bolic pathway functions (Regnier and Sargis 2014).
As an exercise specialist, you play an important
role in combating the obesity-related health epidemic
by encouraging a physically active lifestyle, planning
scientifically sound exercise programs, and consult-
ing with your clients and trained nutrition profes-
sionals to formulate appropriate diets. Restricting
caloric intake and increasing caloric expenditure
through physical activity and exercise are effective
ways of reducing body weight and fatness while
normalizing blood pressure and blood lipid profiles.
METABOLIC
SYNDROME
Metabolic syndrome (MetS) refers to a combina-
tion of CVD risk factors associated with hyperten-
sion, dyslipidemia, insulin resistance, and abdominal
obesity. According to clinical criteria adopted by
the National Cholesterol Education Program (2001),
individuals with three or more CVD risk factors
are classified as having metabolic syndrome (see
table 1.4). Although there is some overlap, these
Table 1.4 Risk Factors for Metabolic Syndrome
Risk factor
Waist circumference
Blood pressure (BP)
Fasting blood glucose
Triglycerides
HDL-C
Note: Metabolic syndrome is defined as three or more risk factors.
Data from National Cholesterol Education Program 2001.
criteria vary among different organizations such as
the International Diabetes Federation (IDF), World
Health Organization (WHO), European Group for
the Study of Insulin Resistance (EGIR), American
Association of Clinical Endocrinology (AACE), and
American Heart Association/National Heart, Lung,
and Blood Institute (AHA/NHLBI). A side-by-side
comparison of similarities and differences in criteria
is available in the article by O’Neill and O’Driscoll
(2015). Body mass index is an acceptable criterion
according to the World Health Organization; how-
ever, all of the other organizations use waist cir-
cumference as the reference for abdominal obesity.
Sex- and ethnic-specific references for the waist
circumference criteria are also now defined (O’Neill
and O’Driscoll 2015). Alberti and colleagues (2009)
present extensive information regarding the history
of metabolic syndrome and the ongoing efforts of
major organizations to reach a consensus on a single
set of criteria. Likewise, Steinberger and associates
(2009) highlight similar issues for determining
metabolic syndrome in children and adolescents.
Data reviewed by O’Neill and O’Driscoll (2015)
indicate that approximately 34% of the men and 35%
of the women (≥20 yr) in the United States met the
National Cholesterol Education Program’s Adult
Treatment Panel III (NCEP-ATPIII) criteria for
metabolic syndrome, as did 17% of the men and 19%
of the women of similar age living in India. O’Neill
and O’Driscoll also present results from numerous
studies of adults from Australia, China, Denmark,
Ireland, and South Korea. By far, the prevalence
of metabolic syndrome in adults is higher in adults
from the United States, but disparate age ranges
Risk criteria
>102 cm (>40 in.) for men
>88 cm (>35 in.) for women
≥130 mmHg (systolic BP) or
≥85 mmHg (diastolic BP) or both
≥110 mg·dl−1 or ≥6.1 mmol·L−1
≥150 mg·dl−1 or ≥1.6 mmol·L−1
<40 mg·dl−1 or <1.04 mmol·L−1 for men
<50 mg·dl−1 or <1.29 mmol·L−1 for women
Another random document with
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Established January 1, 1843
 Thos. Kent Manufacturing Co.
MANUFACTURERS OF
Woolen Goods, Blankets, Flannels, Uniform Cloths and Worsted Yarns
U. S. Standard Olive Drab Covert Cloths, Flannels and Serges a Specialty
SPECIAL BLANKETS
For Hospitals and Institutions
UNION MILLS ROCKBOURNE MILLS
RUNNYMEDE MILLS
Bell Telephone, 160 Lansdowne, Pa.
Clifton Heights, Pennsylvania
 Alpha
Photo-
Engraving
company.
Engravings for the Printer, Merchant & Manufacturer
N E Cor Howard and Fayette Streets
BALTIMORE, MD.
Army and Navy Academy
WASHINGTON, D. C.
SPECIAL COACHING
for the
U. S. Military and Naval Service Examinations
Candidates are thoroughly prepared, both in class and by private
individual instruction, for the following examinations:

WEST POINT, Military Academy, Entrance Examination.

ANNAPOLIS, Naval Academy, Entrance Examination.
U. S. ARMY, 2d Lieutenant, Entrance Examination.
U. S. NAVY, Asst. Paymaster, Entrance Examination.
U. S. MARINE CORPS, 2d Lieut., Entrance Examination.
REVENUE CUTTER, Cadet, Entrance Examination.

Remarkable Success in all the Service Examinations.

For Particulars Address
M. DOWD,
Principal
1410 Harvard St.

“WE PRINT ANYTHING”

 KOHN & POLLOCK, Inc.
Complete Book, Catalog
Railroad Printers
315-317 WEST GERMAN STREET
Baltimore, Maryland

AMERICAN SECURITY AND TRUST

COMPANY
WASHINGTON, D. C.
COMPARATIVE STATEMENT FROM ORGANIZATION TO DATE

DEPOSITS CAPITAL ASSETS

Surplus and
Undivided
Profits
Dec. 31, 1891— $ 588,715 $1,320,238 $ 2,159,704
1893— 809,261 1,462,097 2,905,658
1895— 1,266,201 1,533,184 3,777,185
1897— 2,627,182 1,587,455 5,149,138
1899— 3,702,594 1,738,455 5,807,569
1901— 3,943,832 1,838,108 6,012,165
1903— 4,061,215 4,606,856 8,680,468
1905— 5,555,065 4,709,706 10,311,840
1907— 5,753,260 4,904,048 10,712,722
Nov. 30, 1908— $7,450,174 Assets $12,407,298

Amount Paid to Customers in Interest $1,285,735.18

Amount Added to Capital for Protection of Customers $1,750,000.00
Amount Added to Surplus for Protection of Customers $1,967,124.47

From the foregoing it will be seen that the business of the Company has
steadily grown from year to year, and, while the shareholders have
received a fair return on the capital invested, the directors have always
borne in mind that their first duty was protection to the depositors, which
they have accomplished by adding over four million dollars, making a
guarantee fund to its clients, including shareholders’ liability, of EIGHT
MILLION DOLLARS, a record shown by few banking corporations in the
United States.
This statement does not include our Trust Department, the securities of
which, under the law, are kept entirely separate and distinct from the
assets of the Company, and our relations being of a confidential nature, no
published statements are made. The growth has, however, been much
greater than the above.
Accounts Solicited Interest Paid on all Deposits, Large
or Small
STATEMENT OF
 The Commonwealth Title Insurance and
Trust Company
PHILADELPHIA, PA.
AT THE CLOSE OF BUSINESS OCTOBER 31, 1908

ASSETS
Loans Secured by Collateral $2,023,470.08
Bonds and Mortgages 316,643.00
Bonds 3,000,564.74
Ground Rents 18,000.00
Accrued Interest 46,185.86
Real Estate, Furniture and Fixtures, including Safe
Deposit Vaults 1,358,679.90
Miscellaneous 87,367.33
Reserve—(Cash on hand, in Bank and Municipals) 937,865.33
Total $7,788,776.24

LIABILITIES
Capital Stock $1,000,000.00
Surplus 1,100,000.00
Undivided Profits 155,631.99
Miscellaneous 2,060.50
Dividend payable November 10th 60,000.00
Deposits 5,471,083.75
Total $7,788,776.24

Trust Funds—Invested $7,469,022.03

Trust Funds—Uninvested 57,635.91
Total $7,526,657.94

DIMNER BEEBER, President JAMES V. ELLISON, Treasurer

The Safest Investments

Are those that do not fluctuate during disturbed conditions of the money or
stock markets. First deed of trust notes (first mortgages), well secured on
real estate in the District of Columbia, constitute “gilt-edge” investments.
They do not depend upon the financial responsibility of individuals or
corporations for their stability, and are exempt from taxation as personal
property. We can supply such investments in amounts from $500 upward.
Send for booklet, “Concerning Loans and Investments.”

Swartzell, Rheem & Hensey Co.

727 15TH STREET N. W. WASHINGTON, D. C.

Huyler’s
CHOCOLATES BONBONS
FRESH DELICIOUS

Fancy Baskets, Boxes and Novelties filled with our Delicious Candies
make most acceptable gifts.
1119 F St. N.W. Washington, D.C.

Telephone, N 4372

Great Bear
Spring Water
Fifty Cents per Case of 6 glass-stoppered bottles
New Warehouse and Office
322 R Street Northeast
Washington, D. C.
NATIONAL ENGRAVING CO.
 Designers, Halftone, Line
and Color Engravers
Phone, Main 1679
Office, 506-508 Fourteenth Street, Cor. Pennsylvania Ave.
Washington, D.C., U. S. A.
QUALITY DISPATCH

SAFE DEPOSIT AND

TRUST COMPANY
OF BALTIMORE
CHARTERED
EIGHTEEN HUNDRED AND SIXTY FOUR

NATIONAL HOTEL
WASHINGTON, D. C.
Pennsylvania Avenue and Sixth Street
THE NATIONAL HOTEL, situated about midway on the famous
Pennsylvania Avenue between the Capitol and the White House, is one of
the largest and most centrally located houses in Washington. The principal
street-car lines of the Capital pass the door, thus giving quick and easy
access to all public buildings and points of interest. This house has just
been thoroughly overhauled and modernized throughout. Steam heat,
electric light and telephone in every room; new cafe and other modern
improvements, rendering it one of the most comfortable hotels in the
Capital city.
SCHEDULE OF RATES:
AMERICAN PLAN—$2.50 and $3.00 per day each person. For rooms with
private bath attached, $4.00 per day; two persons in room with bath,
$7.00 per day.
EUROPEAN PLAN—Rooms, $1.00, $1.50 and $2.00 per day; Rooms with
bath attached, $2.50 for one person and $4.00 per day for two
persons.
 C. F. SCHUTT, Manager

KNEESSI’S SONS
MANUFACTURERS OF
TRUNKS, SUIT CASES
TRAVELING BAGS
LEATHER NOVELTIES
425 SEVENTH STREET N. W.
PHONE, M 2000
SPECIAL TRUNK FOR NURSES AND MEDICAL PURPOSES

Professional Nursing
A Powder
Very inexpensive, which, when dissolved in water, makes a pleasant,
non-irritating, non-poisonous lotion, not staining the linen, and which has a
Specific Action against those peculiar pathogenic germs which Infest the
Genito-Urinary organs (Male as well as Female); hence is a
VALUABLE REMEDY FOR ALL
CONDITIONS REQUIRING
ANTISEPTIC TREATMENT
If intelligently used, according to directions, it will relieve all cases,
including the acute cases and the stubborn chronic ones as well.
Also very effective in Pruritus of the genital regions.
Its use is most agreeable to the patient, affording quick relief and
proceeding steadily to a cure.
The formula, together with bacteriological and clinical potency of the
preparation, is furnished the medical profession.
A two-ounce box of TYREE’S ANTISEPTIC POWDER (enough to make
two gallons of antiseptic lotion) will be sent Free. This would make about
seven dollars’ worth of the usual bottled antiseptic solutions. This is all
pure capital—you pay for no water. You can take it with you—no liquids to
carry.
J. S. TYREE, Chemist
Washington, D. C.
Woodward & Lothrop
 New York—Washington—Paris

Columbia Theatre
The Leading Theatre of Washington, D. C.
COLUMBIA THEATRE CO., Proprietors
FRAME METZEROTT,
PRESIDENT
OLIVER METZEROTT,
TREASURER
FRED. G. BERGER,
MANAGER
Washington, D. C.

Hotel Rudolph
ATLANTIC CITY, N. J.
American and European
JOEL HILLMAN,
Proprietor

Bailey, Banks & Biddle Co.

Designers and Makers of the

OFFICIAL INSIGNIA
for the
American National Red Cross
for
National and State Officers

14-K. Gold and Enamel, $10

Silver, Gilt and Enamel, $5
Issued upon receipt of permit, which can be obtained from Secretary
Charles L. Magee, War Department, Washington, D. C.
1218-20-22 Chestnut St., Philadelphia, Penna.
AN ABDOMINAL SUPPORTER IN HARMONY WITH MODERN
SURGERY
 The “Storm” Binder and Abdominal
Supporter
PATENTED
IS ADAPTED TO USE OF MEN, WOMEN, CHILDREN AND BABIES

No Whalebones
No Rubber Elastic
Washable as Underwear
Light
Flexible
Durable
Comfortable

The invention which took the prize offered by the Managers of the
Woman’s Hospital of Philadelphia.
The “Storm” Binder may be used as a SPECIAL support in cases of
prolapsed kidney, stomach, colon and in ventral and umbilical hernia; as a
GENERAL support in obesity and general relaxation; as a POST-
OPERATIVE Binder after operation upon the kidney, stomach, bladder,
appendix and pelvic organs, and after plastic operations and in conditions
of irritable bladder to support the weight of the viscera.
WOMAN’S BELT—Front View MAN’S BELT—Front
View
Illustrated folder, giving styles, prices and diagram for measuring, and
partial list of physicians using “Storm” Binder sent on request. A comfort to
athletes, especially horseback riders. Of marked value in the prevention
and relief of intestinal disorders.
Mail Orders Filled Within 24 Hours on Receipt of Price
KATHERINE L. STORM, M. D. 1612 DIAMOND
STREET, PHILADELPHIA

EBBITT HOUSE
 AMERICAN PLAN
WASHINGTON, D. C.

ARMY AND NAVY

HEADQUARTERS
H. C. BURCH
PROPRIETOR

ARTHUR P. GREELEY
Attorney and Counsellor in Patent and Trademark Causes
Washington Loan and Trust Building
WASHINGTON, D. C.

R. Pluym
Ladies’ Tailor
Habit Maker.
1216 14TH STREET
PHONE, N. 6289 WASHINGTON, D. C.

Residence, 2018 First St. N.W. Tel., North 5749

ALEX. MILLER
Carpenter and Builder
2215 OHIO AVENUE N. W. WASHINGTON, D. C.
TEL., MAIN 1281
(Send for Nurses’ Catalog N)