ACE 6th Edition Chapter 13: Considerations for Clients with Chronic Disease
ACE 6th Edition Chapter 13: Considerations for Clients with Chronic Disease 1

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Chapter Goals:

  • Be able to explain that most chronic diseases in industrialized countries are associated with lifestyle choices.
  • Be able to describe the role of personal trainers in improving the health and the quality of life of clients through the use of physical activity, healthy eating, and other lifestyle risk factors. 
  • Be able to discuss the increased physical activity effects on other lifestyle risk factors.
  • Make use of the general principles of training and exercise programming to specific chronic diseases and health conditions. 


Regular exercise is well known to help the prevention of many diseases or health conditions. It is also useful in the treatment and management of health problems. It is not unusual for trainers to work with clients that desire to improve both their physical and their mental health. 

These chronic diseases in this chapter will include things such as coronary artery disease, hypertension, dyslipidemia, diabetes, metabolic syndrome, asthma, cancer, and osteoarthritis. 

The factors that determine if modifications should be made are:

  • Characteristics of the disease
  • Any restrictions that the disease places on clients and how they will respond to exercise
  • Safety concerns
  • Activities to emphasize
  • Activities to avoid
  • The severity of the disease

Cardiovascular disease including both stroke and heart disease, is the leading cause of death in men and women in the united states. This is also a leading cause of disability.

Cardiovascular and Cerebrovascular Disorders

Coronary Artery Disease

This is also known as atherosclerotic heart disease, and it is characterized by a narrowing of the coronary arteries that give blood and oxygen to the heart.

Atherosclerosis is the underlying cause of cerebral and peripheral arterial diseases. The manifestations of this include the likes of angina, heart attack, stroke, and intermittent claudication.

Physical inactivity is a major independent risk factor for CAD in both women and men. People that participate in moderate levels of physical activity have a 20% lower risk, while higher amounts raise that to around 30%.

The term low risk is applied to people that have these characteristics:

  • An uncomplicated clinical course in the hospital
  • No evidence of resting or exercise induced ischemia
  • Functional capacity that is greater than or equal to 7 metabolic equivalents 3 weeks following any medical event or treatment that required some form of hospitalization
  • Normal ventricular function with an ejection fraction over 50%
  • No significant resting or exercise-induced arrhythmias


There are two types of hypertension. The first is essential or primary hypertension. Primary has no evidence or known cause for it, and then the secondary hypertension is the result of some identifiable cause. 

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  • Normal systolic is seen as less than 120 and diastolic is less than 80. 
  • Elevated systolic is 120 – 129 and diastolic is less than 80 still. 
  • Stage one hypertension for the systolic number is from 130 – 139 and diastolic is from 80 – 89.
  • Stage two hypertension is greater than or equal to 140 for systolic and for diastolic it is 90 or greater. 

Oftentimes hypertension can come from genetic and environmental factors and their interactions. The risk factors will be with things like stress, body weight, sleep, age, excessive intake of sodium, increases in the intake of alcohol, and being physically inactive.

Some of the modifications that should be done to your daily life are weight reduction, adopting the DASH eating plan, reducing the amount of odium in the diet, physical activity being introduced, and moderating the levels of alcohol taken in. 

Nutrition will play a significant role in the management of hypertension, and that’s why the DASH eating plan is one of the best for this. It focuses on consuming fiber and potassium primarily. 


Strokes will occur when there is compromised blood supply or when a blood vessel in the brain bursts. Like heart attacks that come from blockages in the blood vessels, but these will occur in the brain.

Rehab and training will focus on the optimization of basic activities of daily living. The goal is to get back to normal living, or close to it, so you can then build upon that.

Peripheral Artery Disease

This results from atherosclerosis of the arteries in the lower limbs. The common sites for this will be the lower extremity lesions like the abdominal aorta and the iliac, femoral, popliteal, and tibial arteries. 

This affects around 3 – 10% of adults and in people over 70 years old, it is closer to 20%.

This can be a common disease with people that have CAD and so nutrition is important for preventing it. 

Metabolic Disorders


This has to do with the counts of fatty acids that are throughout the blood. It also is determined by the cholesterol levels. 

The four types of cholesterol are:

  • Low-density lipoproteins are considered to be bad cholesterol. This is due to it being the major carrier for cholesterol in the blood. It contains 60 – 70 percent of the total cholesterol in the body.
  • Very low-density lipoproteins are the major carriers for TG and is only 10 – 15 percent of the total cholesterol in the body.
  • Intermediate density lipoproteins are similar to LDLs and they transport many TG fats and cholesterols in the blood and promote atherogenesis. They are formed from VLDLs breaking down. 
  • High-density lipoproteins are what we consider to be the good cholesterol in the body. these are responsible for 20 30 percent of the total cholesterol and it transports lipids to the liver for recycling and removal. 

The triglyceride level classifications are:

  • Normal is considered to be less than 150 mg/dL
  • Borderline high is considered to be a reading of 150 – 199 mg/dL
  • High is considered to be a triglyceride level of 200 – 499 mg/dL
  • Very high category for triglycerides is considered to be 500 mg/dL or more. 

For the LDLs, the categories are:

  • Optimal levels are considered as less than 100 mg/dL in the blood.
  • Near-optimal or above optimal is considered to be 100 – 129 mg/dL
  • Borderline high is going to be 130 – 159 mg/dL
  • High is 160 – 189 mg/dL
  • And lastly is very high at 190 or more

For the HDL cholesterol levels we have these categories:

  • Low is considered to be at less than 40 mg/dL
  • High is anything 60 or more

For the total cholesterol numbers, we have these categories:

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  • Desirable is anything under 200 mg/dL
  • Borderline high is going to be 200 – 239 mg/dL
  • Anything over 240 is going to be a high cholesterol level. 

Nutrition is one of the main ways to prevent this and we have some important guidelines to try and follow here. 

We should consume a dietary pattern that emphasizes eating veggies, fruits, and whole grains. Include some low fat dairy, poultry, fish, legumes, vegetable oils, and nuts into the diet also.

Aim for a diet that is going to achieve 5 – 6% of calories coming from saturated fats. 

Reduce or completely eliminate the consumption of trans fats. 


Diabetes has two main forms and is a group of metabolic disorders that involve absolute or relative insufficiency of secretion for insulin. The main two types we will discuss is type one and two. 

Type 1 diabetes basic descriptors

  • This is usually before 35 years of age.
  • This is an abrupt and sudden onset.
  • It is not always passed down from the parents.
  • The person’s body composition will likely be normal or thinner. 
  • Blood insulin levels will be reduced or completely absent.
  • The resistance to cell insulin will be absent or just minor.
  • The person must use insulin, diet, or exercise to treat hyperglycemia.

Type 2 diabetes basic descriptors

  • This is usually occurring after 40 years of age.
  • The onset is gradual and likely due to many lifestyle factors over time.
  • This can have some family history relations.
  • The person’s body composition is going to be obese.
  • Blood insulin levels are normal or increased.
  • There is the presence of cell insulin resistance. 
  • The treatment is through diet, weight loss, and drugs. 

Nutrition and exercise should be utilized to help with diabetes, and with type one diabetes we will see the need for insulin to be injected for certain reasons specific to this genetic form of diabetes. 

Metabolic Syndrome

This is not a disease per say, but a cluster of conditions that increases someone’s risk for developing things like heart disease, type two diabetes, and stroke. These are the following components that decide if someone has metabolic disorder:

An elevated waist circumference

  • For men a circumference of greater than or equal to 40 inches.
  • For women a waist circumference greater than or equal to 35 inches.

Elevated Triglyceride levels

  • A level greater than or equal to 150 mg/dL

Reduced HDL cholesterol

  • For men an HDL cholesterol level less than 40 mg/dL
  • For women an HDL cholesterol level less than 50 mg/dL

Elevated blood pressure

  • A blood pressure reading greater than or equal to 130/85 mmHg

Elevated fasting blood glucose

  • A blood glucose level greater than or equal to 100 mg/dL

Pulmonary Disorders

Chronic obstructive pulmonary disorder is the result of chronic airway inflammation due to the exposure to substances like tobacco smoke and other various environmental and occupational pollutants.

Some symptoms will be with things like dyspnea, chronic cough, and sarcopenia. 

The three common forms of chronic obstructive diseases are going to be asthma, chronic bronchitis, and emphysema. 


This is a disorder noted by chronic inflammation of the airways where many cells and cellular elements will play a role. People that are susceptible will have recurrent episodes of wheezing, breathlessness, chest tightness, and coughing.

It is possible to have asthma activated by exercise.

One of the important things to remember with this disease is to have the rescue medication, usually the inhaler, on hand when exercising. 

Other Chronic Conditions


This is a collection of around 200 related diseases that are characterized by spread and growth of many abnormal cells. The cells of the body usually grow and divide in an orderly fashion, and when they don’t it is characteristic of this disease. 

The cancer will develop within the DNA of the cells, this is by way of damage to the DNA, and this causes the malfunctions to occur in the cells that follow. 

The classification will be based on the cell type from which the cancer cell comes from. 


This is characterized by lower bone mass and disruptions in the microarchitecture.

Some considerations for exercise that we need to make when a client has osteoporosis are:

  • Avoid excessive levels of flexion, twisting, and compression type movements with the spine.
  • Engage in muscular training and weight-bearing activity and impact. 
  • Incorporate activities with the balance in them.
  • Avoid moves and environments that will likely lead to falling.


This is a chronic degenerative condition within our joints. the most common forms will be osteoarthritis and rheumatoid arthritis. 

This is the leading cause of disability in the united states. 

ACE 6th Edition Chapter 13: Considerations for Clients with Chronic Disease 2
ACE CPT Chapter 1: Role and scope of practice for the personal trainer 2
ACE 6th Edition Chapter 13: Considerations for Clients with Chronic Disease 3

Tyler Read

Tyler Read, BSc, CPT. Tyler holds a B.S. in Kinesiology from Sonoma State University and is a certified personal trainer (CPT) with NASM (National Academy of sports medicine), and has over 15 years of experience working as a personal trainer. He is a published author of running start, and a frequent contributing author on Healthline and Eat this, not that.

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