ACSM CPT Chapter 20: Metabolic Disease and Cardiovascular Disease Risk Factors
ACSM CPT Chapter 20: Metabolic Disease and Cardiovascular Disease Risk Factors 1

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Chapter Objectives:

  • Discuss exercise programming for clients that have cardiovascular Disease, Diabetes, Dyslipidemia, and Hypertension.
  • Discuss exercise programming for Clients with Obesity.
  • Know how to make exercise programs for people that have comorbidities.

Programming for Clients with Cardiovascular Disease

Around 21.5 million American Adults have at least one type of CVD.

The prevalence of death from CVD has decreased since the 1980s, but it still remains the leading cause of death in the US.

A primary goal for personal trainers should be to help clients with the prevention of things like atherosclerotic risk factors.

Programming Goals for Cardiovascular Disease

The modifications of positive risk factors will be the main goal of the aerobic exercise program for clients with CVD.

Maximal cardiorespiratory fitness, also known as the max ability to consume oxygen to make energy, is a significant marker for health outcomes and stratification of risks.

CVD risk is highest in people that have a low cardiovascular fitness level.

Design Considerations for Aerobic Exercise Training for Clients with CVD

Exercise training is safe for the most part for the majority of clients with CVD.

The use of baseline assessments, preparticipation screening, education of patients, and client adherence can all help reduce any remaining risk for issues occurring during workouts.

Exercise Intensity Considerations for Clients with Cardiovascular Disease:

  • Deconditioned and lower-capacity clients may need to start at lower intensities of less than 40% Heart Rate Reserve or VO2 Reserve.
  • Target exercise intensity needs to be between 10 – 15 beats per minute lower than a heart rate which previously was recorded as having abnormal clinical symptoms.
  • Beta-blockers and other heart rate-lowering meds decrease the accuracy of exercise intensity prescription methods based on an age-predicted max heart rate.
  • RPEs of 11 – 14 will usually correspond to the target heart rate for clients with CVD. RPE may progress to the range of 14 – 16.

Designing Resistance Training Programs for Clients with CVD

The two main goals will be:

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  • To keep and improve muscular fitness levels for performing activities of daily living.
  • To reduce the cardiovascular demands that come with performing these tasks.

Resistance training is safe for most patients that have their CVD controlled, provided that they emphasize proper form in the movements and avoid using the Valsalva maneuver and gripping too tight on the weights or bars.

Resistance Training Guidelines for Clients with Cardiac Disease:

  • Exercise mode: isometric exercise is not ideal for CVD clients; dynamic muscle-strengthening exercises are good and should include machine, free weight, calisthenics, resistance bands, and similar exercises that use major muscle groups.
  • Exercise frequency: resistance training should be done 2 – 3 days a week and never in back-to-back days.
  • Exercise intensity: do 10 – 15 reps per exercise to moderate fatigue levels, so around an RPE of 11 – 13.
  • Exercise session duration: do one set of each exercise initially and build up to three sets; perform 8 – 10 different exercises focusing on the major muscle groups; allow for adequate rest between exercises.
  • Progression: increase slowly as patients adapt, in the realm of 1 – 5 pounds per week for the upper body and 5 – 10 pounds per week for the lower body.

Programming for Clients with Diabetes

Diabetes mellitus is a metabolic disorder stemming from abnormal pancreatic insulin production and diminished peripheral action of insulin.

Diabetes is known to seriously compromise the heart and vascular system and is the 7th leading cause of death in the US.

Preventing diabetes is appropriate for all people, not just those that are obese, but also for older adults and at-risk children.

Type 1 diabetes results from an autoimmune response in which the body’s own immune system mistakes the insulin-producing cells in the pancreas and destroys these cells.

Type 1 diabetes accounts for only around 5 – 10% of all cases of diabetes.

The remaining 90 – 95% of cases come from type 2 diabetes.

Type 2 diabetes is associated with a sedentary lifestyle, whereas the main risk factors include things like age, family history, ethnicity, obesity, high alcohol intake, a high-fat diet, high blood pressure, and gestational diabetes.

There is a high demand for competent trainers due to the growth of diabetes in the US.

Pathophysiology of Diabetes

The main goal of diabetes management is to adequately control blood glucose levels.

Diabetes is diagnosed when there is a fasting blood glucose of 126 mg/dL or higher on 2 or more occasions or 2-hour plasma glucose of at least 200 mg/dL.

Programming Goals for Those with Diabetes

The main programming goals for people with diabetes are:

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  • improve the insulin sensitivity and blood glucose control while decreasing the requirements for insulin
  • improve cardiorespiratory fitness level
  • improve blood lipid profile
  • reduce blood pressure
  • improve muscular strength and endurance through the enhancement of skeletal muscle mass
  • improve joint range of motion and flexibility
  • reduce overall body weight
  • help with decreasing the risk of diabetic complications

One of the most important aspects of diabetes care is consistency in a daily routine.

Aerobic Training for Clients with Diabetes

Frequency: 3 – 7 days per week with no more than 2 consecutive days between sessions, due to benefits of exercise-induced improvements.

Intensity: a range of 40 – 59% VO2R or HRR is ideal for clients with diabetes.

Time: there should be an accumulation of at least 150 minutes of moderate to vigorous activity per week, gradually going up to 300 minutes per week.

Type: the activity needs to be something that the person enjoys doing so that they adhere to exercising regularly.

Progression: personal trainers should progressively increase the exercise duration, both continuous and accumulated, while also combatting any boredom that may arise.

Resistance Training for Clients with Diabetes

Resistance training is essential for clients with diabetes, and it is useful for assisting in the management of diabetes and associated complications.

Beginning training intensity needs to be moderate, in the realm of 10 – 15 reps per set.

Special Considerations for Clients with Diabetes

  • Know the warning signs of hypoglycemia and hyperglycemia
  • Avoid exercise when hypoglycemic medication is working at its peak
  • Clients need to eat 1 – 2 hours before exercise
  • Check blood glucose before exercise to see if a snack is needed
  • Clients need to exercise with a partner for safety
  • Have fruit juices or candies available if blood glucose is too low
  • Check blood glucose after exercise to see if a snack is warranted

Programming for Obese Clients

Obesity is defined as a BMI of 30 or higher, and there has been a considerable rise in the number of people meeting this classification in the US, around 39.8%.

Programming Goals

  • maximize caloric expense
  • keep or increase lean body mass to help the resting metabolic rate
  • improve metabolic profile
  • lower the risk of comorbidities
  • lower mortality risk
  • promote appetite control
  • improve mood state

Aerobic Training for Obese Clients

Frequency: build up to 5 or more days per week to maximize energy expenditure.

Intensity: moderate to vigorous aerobic activity; initial intensities need to be based on the individual and their fitness level, typically around 40 – 60% VO2R or HRR.

Time: around 30 minutes per day for 150 minutes per week, increasing to 60 or more minutes per day.

Type: Regular exercise is important, and any mode of exercise that involves large muscle groups and can be enjoyed by the exerciser is ideal.

Resistance Training for Obese Clients

These programs of resistance training should not be used as a replacement for aerobic exercise but should accompany one.

The benefits for obese clients are nearly identical to the benefits for all apparently healthy adults.

The guidelines set in chapter 14 should be followed.

Weight loss expectations may be too high for obese clients, and thus it should be reinforced that exercise is not the only thing that should be focused on for effective weight reduction.

Some other considerations for obese clients would be modifications based on the presence of other conditions, like CAD, hypertension, and other issues discussed in this chapter.

Programming for Clients with Hypertension

Hypertension is known as the silent killer, as it has a lack of noticeable signs and symptoms until there are very serious problems.

Nearly half of the adult population has hypertension, and it remains one of the most prevalent risk factors for CVD in the US.

Programming Goals

  • lower the systolic and diastolic BP at rest and in exercise
  • lower the mortality risk from CVD
  • lower risks for other comorbidities
  • incorporate opportunities for clients to pursue other lifestyle changes

Aerobic Training for Clients with Hypertension

Frequency: exercise should be done on most, if not all, days of the week. At least 150 minutes of activity per week.

Intensity: Moderate intensity is ideal, in the realm of 40 – 59% VO2R or HRR.

Time: 30 – 60 minutes of continuous or accumulated exercise per session is ideal.

Type: Clients should engage in aerobics that involves large muscle groups and is rhythmic in nature.

Progression: Gradual progression and avoid big increases in any FITT-VP variables.

Resistance Training for Clients with Hypertension

Resistance activity should be prescribed to supplement aerobics and not as a main form of activity for clients with hypertension.

Intensity should be 60 – 70% of one rep max. and progress to around 80%.

ACSM CPT Chapter 20: Metabolic Disease and Cardiovascular Disease Risk Factors 2
ACSM CPT Chapter 20: Metabolic Disease and Cardiovascular Disease Risk Factors 3
ACSM CPT Chapter 20: Metabolic Disease and Cardiovascular Disease Risk Factors 4

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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