A 10-Week Physical Activity Program for a Hypertensive Obese Adult
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Obesity is a chronic health problem affecting increasing numbers of people worldwide and is now recognized as a global epidemic. Many serious medical problems, including hypertension which is a predisposing factor for cardiovascular disease, are associated with obesity. In adults, the occurrence of hypertension rises with increasing body weight. This study outlines the case of a hypertensive obese man with BMI of 30 kg/m2. The BMI test was used to measure the percentage of his body fat.  His blood pressure was under good control using medication.
Both aerobic (endurance) and muscle strengthening (resistance) exercises were included in his physical activity program.    Before and after each exercise session, a sphygmomanometer was used to measure blood pressure (BP) in order to avoid the risk of a hypertensive event by stopping exercise if BP became too elevated. Exercise programs of this type have been shown to result in beneficial effects for the obese adult. After ten weeks of matched, evidence-based intervention, Mr X demonstrated a loss of weight and improved cardiorespiratory and muscular fitness. He no longer had pain in his back or knees because of his weight loss.
Mr X was a 45-year-old man with a history of hypertension that was under good control using medication. He worked as a taxi driver for eight hours per day. He smoked one and a half pack of cigarettes per day and had done so for over 20 years. His father died from a heart attack at age 60. He had no signs or symptoms of cardiorespiratory disease. He had just completed a medical check-up and the report showed body height of 173cm and body weight of 88kg, total cholesterol of 8 mmol/L and fasting glucose of 5.4 mmol/L. His BMI was 30 kg/m2, his hip circumference was 40 inches (102 centimeters) and his waist girth was 47 inches (119 centimeters).   
- Cigarette smoking
- Hypertension (even though his blood pressure was under control with medication)
- Obesity - his BMI had recently been calculated as 30 kg/m2 and was regarded to be obese according to the WHO’s International Classification.  
- Sedentary because of the non-physical nature of his job and daily activities
Mr X did not have a family history of heart disease that require specific screening because his father’s heart attack occurred after the age of 60. His fasting glucose was normal. Although he was considered young at less than 45 years old, he was in the moderate risk category because he did not have any signs or symptoms of cardiorespiratory disease but was sedentary. He was concerned about his body shape and about the symptoms of the overweight such as joint pain.  
Management and Outcomes
Mr X was started on a program of regular aerobic and muscle strengthening exercises as a primary preventative measure against cardiovascular events. To start him on low- to moderate- intensity physical activity, further medical work-up and exercise testing was not necessary (although a sub-maximal exercise test of his cardiovascular fitness would have providded a comprehensive appraisal of his condition). Before embarking on a vigorous exercise program after completion of the initial ten week program, however, he would need further medical clearance from specialists according to the recommendations from the American College of Sports Medicine: Prescribing Exercise to Obese Adult Program.     
Mr X was sedentary therefore he had to build up his physical activity targets over several weeks, starting with 10-20 minutes of physical activity every other day during the first week or two in order to minimise potential muscle soreness and fatigue (which could negatively affect compliance with the program). If he had demonstrated difficulty completing the initial level, the physiotherapist would have reduced the intensity/duration. If Mr X had found the initial level very easy, the physiotherapist would have increased the intensity/duration until it felt somewhat hard.
Walking is the most commonly recommended type of physical activity. Weight-bearing physical activity may be difficult for an obese man, however. Gradually increasing moderate-intensity physical activities was therefore encouraged. Based upon Mr X's information, the program was designed to be of moderate intensity. This meant he exercised for at least five days a week at a moderate intensity. Considering he had four risk factors and had led a sedentary lifestye up to that point, his target heart rate was kept at about 40% of his VO2R.  To calculate this, his resting HR and age-predicted HRmax were put into the Karvonen equation and the desired intensity was between 40% and 50% of that number. From this equation, Mr X's target HR was calcualted and then monitored throughout his workouts to determine if an increase or decrease in intensity of any exercise component was required.
- Warm Up: 5-10 minutes of dynamic stretching of the entire body in order to increase Mr X's heart rate
- Walking on a track or treadmill for 20 minutes  Mr X was instructed to walk for one minute on an incline to be increased followed by one minute at a leisurely walking pace. He was not able to jog because of the pain in his joints. As his fitness improved, the duration and intensity of the walking were increased progressively in a variety of ways
- Cool Down: 5-10 minutes of slow walking to gradually decrease his elevated heart rate but still keep his muscles moving to avoid cramping
- Stretching: 10 minutes of a variety of static stretches that engage the whole body, especially his legs
Resistance Training:  Two times per week after the aerobic exercise. The goal was to improve Mr X's muscular endurance and technique. Each exercise required approximately one minute of rest in between each set. The program was designed so that while one muscle group was resting, another could be worked by alternating the exercises in each set.
- Leg extension: 3 x 10
- Leg curls: 3 x 10
- Bench Press: 3x12
- Row: 3x12
- Dumbbell Shoulder: 3x 12
- Tricep kickbacks: 3x 12
- Bicep curls: 3x 12
- Abdominal crunches: 4x 10
- Side crunches: 4x 10
- Back extensions: 3x10
- Cool Down/Stretch: A variety of static stretches focusing on the muscles that were exercised
After ten weeks of the above exercise program, Mr X demonstrated some weight loss with the BMI test showing a loss of 5 kg/m2. His cardiovascular endurance had improved and his responsiveness to antihypertensive medications and increased. 
Studies have shown that physical activity provides many health benefits. Being physically active and fit reduces obesity-related chronic diseases and decreases the risk of premature death. In this case study, Mr X demonstrated a loss of weight after ten weeks of physical activity.
The authors of several systematic reviews have consistently reported a decrease in Systolic Blood Pressure (SBP) of about 1 mmHg per kg of weight loss with follow-up of 2 to 3 years.    There is also attenuation in the longer-term with a decrease of about 6 mmHg in SBP per 10 kg of weight loss. Intervention programs appropriate for obesity-hypertension combine diet, physical activity and behavioural modification, aiming to achieve long-term changes in health-related behaviours. Aerobic exercise can reduce weight and BP. In a meta-analysis that included assessment of ambulatory BP, it was reported that in programs lasting 4 to 52 weeks (with physical activity as the only intervention) aerobic exercise reduced BP by 3/2.4 mmHg.
The effects of resistance training on BP have also been studied. The estimated decrease in was similar to the effects of aerobic exercise, although not statistically significant for SBP and without statistically significant weight change.
In conclusion, a moderate intensity exercise intervention produced improvement in body weight, BMI, waist and hip circumferences and blood pressure.
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