A 10-Week Physical Activity Program for a Hypertensive Obese Adult

Abstract

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 predisposes to cardiovascular disease, are associated with obesity. In adults, the occurrence of hypertension rises with increasing body weight. This report outlines the application of a hypertensive obese man with BMI of 30 kg/m². The BMI test was used to measure the percentage % of his body fat (2,3).  His blood pressure was on medication under good control. Both aerobic (endurance) and muscle strengthening (resistance) exercises were included on physical activity program.    Before and after the exercise of each session a sphygmomanometer was used to measure blood pressure (BP) in order to avoid risk of high blood pressure and to stop exercise under these circumstances. The exercise program was shown the beneficial effects for the obese adult. After ten weeks of matched, evidence-based intervention, Mr X demonstrated a loss of weight and improved his cardiorespiratory and muscular fitness. He no longer had pain in his back or knees because of his weight loss.

Introduction

Client Characteristics

Mr X is a 45-year-old man with known history of hypertension on medication under good control. He works as a taxi driver eight hours per day. He smokes one and a half pack of cigarettes per day and has done so for over 20 years. His father died from a heart attack at age 60. He has no signs and symptoms of cardiorespiratory disease. He has just completed a body check-up and the report showed body height of 173cm and body weight of 88kg, whereas blood test showed total cholesterol was found to be 8 mmol/L and fasting glucose of 5.4 mmol/L. His BMI (2,3) is 30 kg/m2, his hip circumference is 40 inches (102 centimeters) and his waist girth is 47 inches (119 centimeters).

Case Presentation

Mr X has many risk factors;    

• cigarette smoking
• hypertension (because he is on medication, even though his current blood pressure is under controlled)
• hypercholesterolaemia (based only on knowing his total cholesterol)
• obesity - his BMI which has recently been calculated to be 30 kg/m² and is regarded to be obese according to the WHO’s International Classification of adult underweight, overweight (2,3).
• sedentary because of the non-physical nature of his job and daily activities

Mr X does not have a family history of heart disease for screening purposes because his father’s heart attack occurred after the age of 60. His fasting glucose is normal.

Although Mr. Maps is considered to be young (less than 45 years old), he is in the moderate risk category because he does not have any signs or symptoms of cardiorespiratory disease like pulmonary, cardiovascular or metabolic disease but he is in the low risk category for exercise participation. He was concerned about his body shape and about the symptoms of the overweight such as the pain in his joints.   

Management and Outcomes

Mr X was started on a program of regular aerobic and muscle strengthening exercises as primary preventative measures for future cardiovascular events. To start him on low- to moderate- intensity physical activity, further medical work-up and exercise testing are not necessary (although a sub-maximal exercise test of his cardiovascular fitness could offer a comprehensive appraisal of his condition). However, before embarking on a vigorous exercise program after completion of the initial low-to-moderate ten week program, he would need further medical clearance from specialists or equivalent professionals 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 to 20 minutes of physical activity every other day during the first week or two in order to minimise potential muscle soreness and fatigue (thus enhancing compliance with the program). If he had difficulty completing this level, the physiotherapist would reduce the intensity/duration. If Mr X found that the initial level was very easy, the physiotherapist would increase 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 exercise for at least five days a week at a moderate intensity. Considering he had four risk factors and he had led a sedentary lifestye up to that point, his target heart rate was kept at about 40% of his VO₂R (9,10).  To calculate this, his resting HR and age-predicted HR_max 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.

Program:

Aerobic exercise -  5 times per week for 20 min (8,10). 

• Warm Up: 5-10 minutes
• Dynamic Stretching of entire body. The main goal of this is to get blood flowing and the heart rate increased.
• Walking/ a track or on a 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 was increased progressively in a variety of ways.
• Cool Down: 5 to 10 minutes of slow walk to gradually decrease an elevated heart rate but still keep muscles moving to avoid cramping
• Stretching: 10 minutes of a variety of static stretches that engage the whole body, especially the legs)

Resistance Training (8,12): 2 times per week after the aerobic exercise. It is my goal to improve his muscular endurance and technique. Each exercise requires approximately <1 minute rest in between each set. The program is designed so that while one muscle group is resting, the other can be worked by alternating the exercises 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, Mr X demonstrated a loss of his weight, with the BMI test showing a loss of 5 kg/m² after the exercise program. His cardiovascular endurance was improved and he increased responsiveness to antihypertensive medications.

Discussion

Studies showed that physical activity provides many health benefits. Being physically active and fit reduces obesity-related chronic diseases and decreases risk for early death. In this study the patient demonstrated a loss of weight after 10 weeks of physical activity. Systematic reviews (14,15,16,17) consistently report 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 attenuation in the longer-term, with a decrease of about 6 mm Hg in SBP per 10 kg of weight loss. Intervention programs appropriate for obesity-hypertension combine diet, physical activity, and behavioral modification and aim to achieve long-term change in health-related behaviors. Aerobic exercise can reduce weight and BP. In a meta-analysis (18) that included assessment of ambulatory BP it was reported that in studies lasting 4 to 52 weeks, with physical activity as the only intervention, aerobic exercise reduced BP by 3/2.4 mm Hg. A few studies (18) also examined the effects of resistance training on BP. 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.