Warming Up to HIV and Exercise

Regular Exercise is One of the Four Keys to Living with HIV

Over and over again you have been told to exercise as a part of your plan for living with HIV, but no one has told you exactly what you should do. Living with HIV is a multifaceted challenge. No two people living with HIV are exactly the same. However, four treatment factors are usually consistent from one person to the next. These factors are to eat right, get plenty of sleep, manage your stress levels, and get some exercise. However, very few health professionals know what recommendations to make regarding exercise. Exercise and HIV is not as simple as telling you to "just workout." On top of that, the thought of exercise may make you cringe with memories of high school gym class, not to mention the fatigue you may experience on a daily basis.

Exercise may come easily to people who have always exercised or participated in sports. However, if you have never exercised regularly, exercise may seem like learning a new language. In an ideal world you could hire a fitness professional who works with people with HIV to design a program that is perfect for you. However, not all fitness professionals know about the special needs of someone with HIV or you may not be able to afford one. Each of you will come to exercise with a different level of fitness and a different attitude towards exercise. Where you are in your HIV treatment may also determine what types of exercise are appropriate for you. Exercise can play a role in controlling some of your long-term side effects such as altered body composition and elevated elevated cholesterol, triglycerides, and blood glucose.

The Basics of Fitness

Before starting any exercise program, consult with your physician to see if he or she has wants to set any limitations on your activities. It is also important to be in touch with and listen to your body. When you really are not feeling good you should not exercise, but you need to figure out what is just general malaise and what is a more serious fatigue or illness. The general rule of thumb is that if you are feverish, dizzy, have swollen joints, pain in your feet or hands, vomiting, diarrhea, open sores, bleeding gums, or blood in the urine or stool, do not exercise. If you are experiencing neuropathy, you should consult your physician about any exercise restrictions. Otherwise listen to your body. If you get overly tired in the middle of a workout, it is time to stop. Be flexible and be patient with your body and your workout.

You should set some goals. These goals should be realistic, measurable and attainable. You can base some of these goals on simple measurements you can take before starting your program, including weight, Body Mass Index (BMI), and circumference measurements of your arms, legs, chest, stomach, and hips. You can also base goals on body composition if you have access to someone who can measure it for you, ideally using bioelectrical impedance, but if that is not available, then skinfold calipers are also acceptable. If you are new to exercise, you may want to set simple goals such as walking for 5, 10, or 20 minutes every day and doing some form of strength training 1 or 2 times per week.

Once you have seen your doctor and set goals, it is time to get started. If you have been exercising, that's great. Keep it up, and whatever you do, try not to stop exercising. If you are new to exercise, start slowly. Your body needs time to adjust to the new stresses you are putting on it, not to mention all the stress already on your body. It is also important when exercising to keep your body well hydrated. You should drink water before, during, and after your workouts as well as trying to average eight 8-ounce glasses of water (or non-caffeinated/non-carbonated beverages) per day.

Fitness is divided into several different components, all of which are important to a person with HIV. These components are resistance training, cardiovascular training, flexibility training, balance training, and mind-body training.

Resistance Training

Resistance training is probably the most important part of fitness for the person living with HIV. Strength training can help you add muscle mass or enhance the muscle mass you already have. Muscle mass is important because of the role muscle and the proteins in muscle play in your body's immune system. Muscle wasting is a big problem with HIV, and as the muscles waste they lose their function. If you have experienced or are currently experiencing muscle wasting, then resistance training can help slow down or reverse this wasting as well as improve muscle function. Your goal with resistance training is to increase the size of the muscle fibers all over the body. Your goals are not to increase endurance or strength.

Resistance training is moving a force. It can take a variety of forms, the most common being weight lifting. Resistance training can include weight training (with free weights or machines), rubber tubing, body weight (including yoga and T'ai Chi), or a variety of home-made objects. You can use soup cans, filled milk jugs, or any number of objects. Be creative!

Ideally, your resistance training program should take place 3 or 4 days per week (every other day). You should include 10 to 12 major muscles or muscle groups in your workouts. You should lift comfortable weight or resistance 8 to 12 repetitions for 2 or 3 sets. A repetition or rep is a single contraction of the muscle through its full range of motion. A set is a predetermined number of repetitions. You should never do an exercise to exhaustion. Rest at least 45 to 60 seconds between sets. If you are new to resistance training you may need to start with one day per week doing one set of 8 to 12 repetitions for the first couple of weeks and gradually increase the number of sets to 2 or 3 as your body adjusts to the workout.

Muscle groups that should be worked include the chest (pectoralis major and minor), the back (latissimus dorsi, the rhomboids, and the lower trapezius), the shoulders (deltoids and upper trapezius), the arms (biceps and triceps), the legs (the quadriceps, hamstrings, gluteals, calves, and tibialis anterior), the abdominals and the erector spinae muscles of the neck and back.

Cardiovascular Training

Cardiovascular training or aerobic training involves activities of moderate intensity that use the major muscle groups for an extended period of time (12 minutes or more). These activities can include walking, running, swimming laps, bicycling, and aerobic dance to name a few. When choosing cardiovascular exercise, select an activity you can do easily and you will enjoy.

When including cardiovascular training in your workout regimen it is extremely important to avoid over-training. Cardiovascular training improves overall health by helping to control blood pressure, blood sugar, blood lipids, and stress, but over-training can have negative effects on the person with HIV, such as the loss of lean body mass (muscle) and suppression of immune responses. Interestingly enough, the signs of over-training are similar to the worsening of HIV disease. Signs of over-training include decreased ability to exercise, changes in mood, general fatigue, depression, irritability, sore muscles, over-use injuries, elevated resting heart rate, weight loss, insomnia, and increased susceptibility to upper respiratory infections and gastrointestinal disturbances. Since it is difficult to tell the difference between over-training and worsening HIV disease, you should take some time off from working out. If in a few days you do not start to feel better, it is time to call your physician. When recovering from a secondary infection you may want to take some time off from the cardiovascular training, but continue with the resistance training.

When training on a treadmill be very careful if you have developed any balance problems. If you have few limitations and want to be challenged, the stair climbers, elliptical trainers, or group exercise classes can add variety and fun to your workouts, as well as a challenge. If you enjoy exercising outside continue to work out outside as much as possible, but monitor pollution levels, pollen levels, and other allergens in the air in your area. You may also want to take note of where the restrooms are on your route and carry water so you do not become dehydrated.

If you are accustomed to doing cardiovascular training, by all means continue doing so. If you are new to it, start slow, especially if your CD4 T-cell count is less than 500 cells/mL. Slow means one or more times per week, for as long as you can tolerate (sometimes only 5 to 10 minutes), then progressing as comfort permits. Walking and stationary cycling are generally the easiest forms of cardiovascular exercise, but set your own pace. Pay attention to your body. If you start to get short of breath or hurt somewhere, stop what you are doing immediately. You can also monitor your intensity by using "perceived exertion." There are several scales of "perceived exertion" -- The Borg Scale (1-20) is used with cardiac rehab patients while the "simple scale" is used with many other populations. The "simple scale" is a scale of 1 - 2 - 3 (1 = easy, 2 = moderate, 3 = difficult).

Recommendations for your cardiovascular exercise program vary depending on your overall health and your CD4 count. Again, these are general recommendations and you should confer with your physician on an individual basis before undertaking new exercise programs.

Asymptomatic Person with HIV (CD4 count over 500 cells/mL) -- You might start working out 2 or 3 times per week for 20 to 30 minutes at the easy level. Over the next several weeks, consider increase the time up to 30 minutes but probably not over 60 minutes per session for up to five times per week, working mostly in the moderate range but every so often going into the difficult range (not staying there for long).

Symptomatic Person with HIV (CD4 count ranging from 200-500 cells/mL) -- You might start off working out up to three times per week in the easy range for 15 to 20 minutes or as tolerated. Some days you may be able to go longer and other days you may not. As you get stronger, you may be able to gradually move up into the moderate range for as long as 40 minutes per session up to four times per week. Monitor yourself and do not overtrain. If you are overly fatigued or exhausted, take a couple of days off to recover. Then start exercising again at a slightly lower intensity.

Persons living with AIDS (CD4 <200 cells/mL) will want to begin very gently. You might workout up to 15 to 20 minutes, up to three times per week as tolerated. You should progress cautiously over the next several weeks up into the moderate range for 20 to 30 minutes 3 times per week at the most. The rule of thumb here is to do what you can do but do not overdo it. Be aware of your fatigue and exhaustion level and stop before you reach critical.

Flexibility Training

Flexibility training is probably the most neglected component of everyone's workout. It is easy to get in a rush and skip the stretching and flexibility exercises. However, as we age, we lose flexibility. Flexibility exercises are an important component of any workout and can make a so-so workout into a great workout.

The type, intensity, and duration of a flexibility workout will also depend on your condition. If you have a lot of joint pain and discomfort then you may not feel like stretching; however stretching can play a vital role in maintaining your muscle mass and tone, as well as enabling you to carry out your normal daily activities. Various forms of flexibility exercises can also assist you in stress management and pain control.

You should only stretch after thoroughly warming up your body and muscles. Never stretch cold, since you risk injuring the muscles without a warm-up. Your stretching regimen should include static stretches (stretches with very little movement) as well as movements that take the muscles and joints through their full range of motion. Hold each stretch for 10 to 30 seconds, taking full deep breaths during the stretch. Do not hold your breath. Select stretches that will complement your resistance training workout and cardiovascular workout as well as any areas that are tight or sore. You can also perform your flexibility exercises on your off days as well on your workout days.

Basic forms of T'ai Chi and yoga can also provide an interesting format for flexibility exercises as well as strengthening the muscles.

Balance Training and Mind-Body Training

Balance training can also be an important component of your workout. It works best with a workout partner or a trainer for assistance. Any illness that can affect your neuromuscular activities will affect your balance. Over time HIV and some of the HIV medications can affect your neuromuscular activities. You will notice how your sense of balance has changed. You may have trouble walking or standing still at times. Balance training is a simple technique of putting your body in situations that challenge your sense of balance. It can be as simple as standing in the middle of a room with both feet on the floor and your hands at your sides with your eyes closed. More advanced techniques involved standing on one leg and changing the position of your arms and other leg, again with your eyes closed. The idea is that you are re-training your muscles and nerves to balance again. Balance training can be done on a daily basis but with supervision. Again, T'ai Chi and yoga both work to improve balance and body awareness.

Mind-body fitness is one of the newest trends in the fitness industry. Mind-body fitness is the integration of the your mental, spiritual, emotional, and physical awareness into one component. Many Eastern philosophies have done this for years in the forms of yoga, T'ai Chi, martial arts, and meditation. It can be seen is some Western disciplines in visualization and ballet bar stretches. These mind-body activities can help you create a connection between what is going on with your body and your emotions and feelings, and help with stress management.

Other Suggestions

Commit yourself to your workout program. There are a variety of ways to do this. Some people sign a contract with themselves. Others get a workout partner. Some people make the financial commitment of joining a gym or hiring a trainer. It is easier to stay motivated with a workout partner or a trainer. They help you not to miss workouts. Consistency really is the key to success in a workout program.

Safety is the most important consideration. Learn the proper techniques for every exercise you need to do. Review the proper form. An injury could cause permanent damage as well as discourage you from continuing your workout. Safety is another reason to have a workout partner or use a personal trainer.

Keep a workout logbook. A logbook will help you to track your progress as well as provide encouragement as you progress from a single, simple workout per week up to three or four more complex and challenging workouts per week. The logbook will also help you to focus on your goals. Keep the goals in the book and review them periodically and change them as you progress through your workouts. The logbook is also hard evidence that you are working out, which you can share with your physicians and nurses.

Working out is an important component of every person with HIV's treatment regimen. It is often overlooked or underemphasized. The proper combination of resistance, cardiovascular, flexibility, balance, and mind-body training can help keep the person with HIV healthy for many years to come. It is important to find the right balance and to find things that you enjoy and will participate in. Exercise can also help you to minimize some of the long term side-effects of many medications including changes in body composition and elevated blood pressure, cholesterol, triglycerides, and blood sugars. You should make exercise just as important as your daily medication regimen.

Glenn R. Preston, M.S., R.D., L.D. is the CEO of Real World Fitness, Inc. in Kansas City, Missouri. HIV-positive since 1985, he is a registered dietitian and combines fitness and nutrition with personal training for people with HIV and other chronic medical conditions.

Back to the February 2001 Issue of Body Positive Magazine.