Exercise Prescription in an Unfit Adult with at Least One Cardiovascular Risk Factor

Introduction

There is a large body of evidence based medicine showing a dose-response relationship between physical activity and health outcomes¹. The current American Heart Association (AHA) and American College of Sports Medicine (ACSM) recommendations are moderate intensity physical activity for 30 minutes per day on five or more days in a week OR vigorous intensity activity for 20 minutes per day on three or more days in a week². A combination of these can also be implemented. Muscular strength and endurance activities should be performed at least two times per week¹.

The risk of sudden cardiac death in middle-aged adults is higher than the younger population. Nevertheless the absolute risk is somewhat trivial with an estimate of one death per year for every 15000 individuals³. The rates increase with sedentary unfit individuals performing unaccustomed and infrequent exercise³.  Although the risk increases transiently during exercise, the benefits gained from exercise outweigh the risks.

Case study patient- Mr. VK

• 37 years old Indian male.
• Has been living in Auckland for the last 12 years.
• Married with one infant.
• Currently does not undertake any physical activity during the week.
• Seen in clinic with raised lipid profile on routine blood test.

Pre-participation Health Screening

Risk classification was done for Mr. VK based on the presence or absence of cardiovascular risk factors, signs/symptoms and known past medical history. He was assessed by his health care provider (me) prior to exercise prescription (ExRx). Below is a list of symptoms and signs asked as screening⁴:

• Chest/Jaw/Arm pain, dyspnea, dizziness, orthopnoea, paroxysmal nocturnal dyspnea (PND), pedal oedema, palpitations, intermittent claudication, unusual fatigue, and known heart murmur.

Mr. VK signed the Physical Activity Readiness Questionnaire (PAR-Q)⁵. It was found Mr. VK is an asymptomatic male with three known risk factors i.e. hyperlipidemia, borderline BMI and family history of myocardial infarction (father – age 39).  Based on this, the plan was to start him on a moderate intensity (40-60%) workout routine by starting low and progressing slowly.

Pre-exercise evaluation⁴

Medical History:

• Medical diagnosis- hyperlipidemia (cholesterol 5.9, triglycerides 2.1, LDL 4.0, HDL 0.97 mmol/L), congenital right renal agenesis (normal eGFR). Nil other past medical history.
• History or symptoms- Nil symptoms reported and no orthopaedic problems.
• Medications- Not on any regular medications. No known drug allergies.
• Social history- Nonsmoker. No alcohol intake. No drug use. Daily caffeine intake in the morning.
• Work- Auditor (mainly desk job).
• Nutrition- Vegetarian. Has three meals/day. Drinks 6 glasses of water/day. Doesn’t take any vitamin supplements.
• Family history- Myocardial infarction (father), cervical cancer(mother).

Physical Examination:

Body weight (kg)- 61                           Height (cm)- 158                     BMI(kg/m²)- 24.44

Circumference (cm)- Abdomen- 84, Chest- 86, Arm- 28, Thigh- 51.5, Buttock- 91.5

Waist-to-hip ratio- 0.90

Fat calipers (mm) = Abdomen- 47, Chest- 20, Thigh- 45

Body density⁶ = 1.10938 – 0.0008267(sum of 3 skin folds) + 0.0000016(sum 3 skin folds)² –

                           0.0002574(age)

                        = 1.10938 – 0.0008267(47+20+45) + 0.0000016(47+20+45)² – 0.0002574(37)

                        = 1.0273362

% body fat⁷               = 495/Body Density – 450

                        = 495/1.0273362 – 450

                        = 31.83%

Peak expiratory flow rate (PEFR) = 460 + 490 + 480

                                                           = 477 L/min

Resting pulse rate (radial) – 74 beats per minute, regular.       

Resting BP (left arm)-  130/86 (average of two 133/86 and 126/85).

General appearance- Small built male with central adiposity. No xanthelasma. Normal gait and posture.

Chest- Normal apex heartbeat. Dual heart sounds, no murmurs. Normal vesicular breath sounds. No bruits in carotids.

Abdomen- Soft, non-tender. No organomegaly.

Pulses- 3/3 palpable femoral, popliteal, posterior tibial and dorsalis pedis. Normal sensation in feet. No callosity noted.

Joints- No swelling/crepitus with full range of motion.

Skin- Unremarkable.

Submaximal testing:

Informed consent was obtained from Mr. VK prior to testing. Purpose of the test, attendant risks, benefits and responsibilities of participant was explained verbally to Mr. VK⁴. Testing was done at an indoor gym at 3 pm.

Instructions on day of testing- Avoid eating 3 hours before test; refrain from alcohol/tobacco/caffeine; adequate hydration and rest; loose fitting sports clothing.

• 6-Minute Walk Test⁸

–     Completed 570 metres

       –     Peak Borg’s scale of 4⁹.

–    Heart rate on completion 120 beats/min and Blood pressure was 153/87.

• Cooper 12-min test⁴
• On a treadmill at an inclination of 0.01
• Completed 1.65 km
• Peak Heart rate of 148
• VO2 max¹⁰ = (distance covered in metres – 504.9)/44.73 = 25.6 mls/kg/min
• Muscular strength
• Bench press 1-rep max – 45 kg
• Leg press machine 1-rep max – 155 kg
• Muscular endurance
• Max press ups till failure – 25
• Max sit ups till failure – 20
• Flexibility not tested formally

All of this information was gathered and used for the development of the Mr. VK’s short- and long term goals plus forming the basis of the initial ExRx and monitoring progress.

Exercise Prescription (ExRx) for Dyslipidaemia:

                                    AEROBIC TRAINING                            RESISTANCE TRAINING

Note:

Primary goal is aerobic exercise that involves large muscle group with incorporation of resistance training and flexibility exercise.

HR_max = 220- Age; HRR = [(HR_max – HR_rest) X % intensity desired] + HR_rest

Components of Exercise Training Session: Warm-up, Conditioning, Cool-Down, Stretching

Resistance training involves training each muscle group 2-4 sets with 10-15 repetitions. Rest interval of 1 minute. With “progressive overload” principle, the number of sets are increased with lower repetitions and higher intensity⁴. Exercise starts off with compound exercises (e.g. chest press, pull-down, shoulder press, dips, deadlift, squats, leg press, abdominal crunch) and ends with isolated exercises (e.g. quad extension, hamstring curl, calf raise, biceps curl, triceps extension). Proper technique/form and breathing technique (inhale during eccentric phase and exhale during concentric phase) are employed.

Flexibility training done 3 days/week. Static stretching for 30 seconds of 3 reps. Stretching until mild discomfort following aerobic workout of major muscle groups⁴.

8-week progress (in his own words):

• Strength – “Positive attitude and commitment towards Exercise Prescription”
• Weaknesses – “Workaholic”. Interestingly Mr. VK puts work as a high priority in his current lifestyle.

• Expected hurdles along the way – “Family situation and work commitments”. On some days he had to miss gym due to work commitments. He also has a new born baby and had to sacrifice gym most weekends to spend family quality time.

• Compliance – “Reasonable”. Despite having multiple commitments being a father to a new born and the breadwinner of the family, he managed to gym at least four times a week.

• Unanticipated issues – “Sickness in the family one-by-one”. He fell sick and missed one week of gym workout. Also his wife and child were sick which affected his gym routine.

• Overall management of programme- “Very helpful and improved his health”. Managed to exercise 30-45 min at least four times a week.

• Nutrition – Emphasized on diet rich in fruits, low-fat dairy products, vegetables, reduced saturated fat, and low dietary sodium¹¹. Advise to take whey protein due to poor protein intake. This will aid muscle recovery and reduce soreness from delayed onset muscle soreness (DOMS). Also took multi vitamin supplements.

Reassessment of risk factors/fitness:

Weight- 59 kg                          BMI- 23.6 kg/m²                      Abdominal circumference- 83 cm

Lipids- cholesterol 5.1, triglycerides 1.3, LDL 3.3, HDL 0.95 mmol/L

Cooper’s test – 1.9 km

Bench press 1-rep max – 50 kg

Leg press 1-rep max – 170 kg

Note: Improvement in lipid profile (without statin), cardiorespiratory fitness and muscle strength.

Future compliance and recommendation for maintenance

Include a variety of aerobic and resistance training exercises. This is to avoid staleness and assure he continues exercising without getting bored.

Find a gym partner/spotter who can help motivate and push each other to achieve their goals together.

Join a gym class e.g. Pump class. Working out in a group is fun and motivating with a gym instructor!

Encourage him to use SMARTS principle (e.g. Specific, Measurable, Action-oriented, Realistic, Timely, Self-determined) in goal-setting¹².

Use of Health Belief Model(HBM) to prompt Mr. VK to make some lifestyle changes. This was used to prime an action by him based on his current health issues and implications on his future if no action was taken. Ergo, motivating him to be physically active primarily for health.

In conclusion, I believe Mr. VK has gleaned a lot from this study and will walk away with a lot from this 2-month exercise stint. The onus is on him to continue to adopt this new healthy lifestyle.