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May 2011

What to Do When Being Overweight Isn’t Your Client’s Biggest Health Challenge

 

Comorbities 1

By LANCE C. DALLECK, Ph.D.

In 2005, less than half (49.1 percent) of U.S. adults met national physical-activity recommendations, with 23.7 percent reporting no leisure-time activity. Physical inactivity is associated with numerous adverse health conditions, including obesity, hypertension, type 2 diabetes and atherosclerotic cardiovascular disease, and it contributes annually to 250,000 premature deaths (Booth et al., 2000). Older Americans are currently both the least physically active and the most rapidly growing age group. These factors make it increasingly likely that as a fitness professional, you will be interacting with clientele other than apparently healthy adults. Although there are exercise-programming guidelines for older adult and various chronic-diseased populations, these recommendations exclusively address each group separately. This is unfortunate, because rarely does a client posses only one chronic condition; rather it is much more likely that a client will have multiple conditions (comorbidities). So how do you design a comprehensive exercise program for a client like Jackson, who is older (65) and has cardiovascular disease, type 2 diabetes and osteoporosis? This article examines the critical measures you can take to successfully break down complex cases into simple ones and ultimately lead to triumphant outcomes for your clients.

Prevalence of Chronic and Clinical Populations and the Challenge

Current trends show that Americans are living longer while the number of U.S. citizens with chronic diseases continues to increase. In the past 100 years, life expectancy at birth in the U.S. increased from less than 50 years to more than 76 years, and the U.S. Census Bureau has projected that by 2030, the number of adults ages 65 years and older will be approximately 70 million. Approximately 80 percent of individuals aged 65 years or older are living with at least one chronic health problem, and another 50 percent are living with two. Moreover, the presence of specific chronic conditions can lead to an even greater propensity of comorbidities. For instance, almost all clients with diabetes have at least one other chronic condition, and nearly half have three or more comorbidities (Wolf, Starfield and Anderson, 2002). Table 1 lists the most common chronic and clinical populations.

Table 1. Prevalence of Common Chronic and Clinical Populations

Condition Prevalence
Arthritis 40 million

Cardiac disease

80 million
High cholesterol
100 million
Hypertension 74 million
Metabolic syndrome
63 million

Obesity

74 million
Osteoporosis 10 million
Type 2 diabetes
17 million

Source: Modified from American College of Sports Medicine, 2009; Lloyd-Jones et al., 2010.

 

Presently, the American Heart Association (AHA) and the American College of Sports Medicine (ACSM) list sedentary lifestyle as a controllable risk factor for many chronic health conditions. Accordingly, exercise is a common therapeutic intervention strategy. Remembering the SUPER acronym can help you break down the complex scenario of designing an exercise program into five simple and manageable steps: Scenario, Understanding, Prioritize, Exercise Program Design, and Review.

Scenario

Prior to designing an effective exercise program, it is essential to acquire as much information as possible concerning your client. What is the scenario? Exercise training will be relatively safe for the majority of clients with multiple chronic conditions, provided that an appropriate assessment and screening is performed prior to beginning the program (Mangani et al., 2006). The likelihood of an adverse event, although not entirely preventable, can be markedly reduced with baseline assessments, risk stratification and patient education (ACSM, 2009). It is likely that individuals with multiple chronic conditions will be stratified into a high-risk category and therefore require physician clearance and consent to participate in an exercise program. Importantly, both you and your client should check with his or her medical team about any specific limitations that should be considered when designing the exercise program. Baseline assessment and screening will also help identify central problems that can prove useful in recognizing your client’s limitations. For example, insulin resistance is likely to be associated with obesity, hypertension, dyslipidemia and other metabolic disorders. Likewise, a type 2 diabetic may be expected to suffer from complications of neuropathy, retinopathy or other microvascular complications.

After completing the risk assessment, your next step is to understand the unique challenges of working with clients who have multiple chronic conditions.

Understanding

Comorbities 2

To fully appreciate the challenges of working with individuals with multiple chronic conditions, it is paramount to recognize that the presence of these comorbidities may act as competing demands on a client’s self-management resources, thus reducing the time and energy he or she has to devote to each and every condition (Chernof et al., 1999). Accordingly, these clients will require additional guidance and resources to ensure that their other conditions are managed effectively. An individual with a severe and symptomatic condition, such as heart failure, will likely have considerable difficulty managing other conditions (e.g., type 2 diabetes). In these circumstances, a severe limitation should not preclude you from designing a routine that targets each individual condition (Kerr et al., 2007). However, you will need to be creative in modifying the routine to sufficiently accommodate limiting factors, while also ensuring that the thresholds for frequency, intensity and time are also met to elicit positive training effects. Individuals with multiple health challenges may experience symptoms that fluctuate significantly from day to day in terms of severity (e.g., low-back pain, lupus, osteoarthritis, fibromyalgia). Therefore, be prepared to accommodate an ever-changing, chronic-condition landscape, and constantly adjust the session to best serve the client on any given day. Clients with comorbidities require a high degree of monitoring to ensure proper adherence of the established exercise regimen and to determine that the physiological responses to each session are normal. It is important to be knowledgeable of, and able to educate clients on, the potential signs that would warrant the termination of exercise.

Although exercise can be applied as powerful therapeutic intervention, there are nonetheless reasonable limitations to its overall effectiveness with each condition. There is convincing evidence for a favorable relationship between exercise volume and numerous conditions, including risk of coronary artery disease mortality, obesity, dyslipidemia, type 2 diabetes and colon cancer (Kujula, 2004; Roberts and Barnard, 2005; ACSM, 2009). However, other conditions, such as chronic obstructive pulmonary disease, Alzheimer’s disease and chronic low-back pain, may not see a marked improvement as a result of the exercise program (Kujala, 2006).

Prioritize

A critical shortcoming to our current healthcare model for the management of chronic conditions is that the treatment has historically been approached in a singular fashion. For example, an endocrinologist might offer recommendations for a type 2 diabetic, while a rheumatologist can provide guidance to an arthritic patient; yet it would be unusual for either medical professional to make note of the concurrent chronic condition when devising a therapeutic intervention. In fact, it has been noted that patients rarely receive guidance from medical professionals on prioritizing and managing multiple chronic conditions (Kerr et al., 2007). It is important to recognize that this philosophy also extends to current exercise guidelines for chronic conditions, with each recommendation based on a single chronic condition. However, given the strong likelihood that your client will possess multiple chronic conditions, you must be prepared to meet the challenge of developing a suitable comprehensive exercise program that addresses each of the client’s chronic conditions.

A requisite task is to initially create two separate lists that prioritize the chronic conditions of a client in terms of (1) long-term mortality risk and (2) symptom-limiting considerations. The chronic condition topping the list in terms of mortality risk should ideally be the primary focus of the exercise program. For example, an individual with heart disease, osteoporosis and arthritis should be most concerned about management of the heart disease. Epidemiological data clearly shows an individual is more likely to die from heart disease compared to the two other chronic conditions (Lloyd-Jones et al., 2010). Yet a primary focus on the management of the heart disease in this instance should not be misinterpreted to mean a singular and exclusive focus on only that condition. The exercise program similarly needs to also be formulated with the aim of positively modifying each of the other two conditions. Concurrent to designing an exercise program based upon the “long-term mortality risk” list is a requirement to adjust parameters of the training routine in accordance with the “symptom-limiting” list. As previously mentioned, there will undoubtedly be occasions where an individual’s unstable condition (e.g., arthritis) dictates that the exercise session or program revolves around the limiting symptom(s). For instance, although specific weekly energy-expenditure volume and exercise-intensity thresholds must be surpassed to positively modify coronary heart disease, these limits may be unattainable amid an arthritic flair-up. In view of these circumstances, you may elect to amend the routine in various ways, such as decreasing the exercise volume and/or intensity, altering the exercise modality from land- to water-based, or rescheduling the exercise session to another day when the client’s symptoms are less restrictive.

Exercise Program Design
In general, exercise program design for individuals with comorbidities can follow the Frequency, Intensity, Time and Type (FITT) framework. Table 2 summarizes the basic evidence-based guidelines for common clinical populations. This resource can assist with establishing the basic parameters of the exercise program around the various conditions of an individual. Let’s consider an individual who has arthritis, dyslipidemia, hypertension and type 2 diabetes. As discussed in the previous section, there are different strategies to establishing the overall exercise program. One approach is to follow the specific exercise recommendation for the chronic condition that poses the greatest risk of mortality for the individual. In this instance, type 2 diabetes is generally considered to be the most significant risk factor for heart disease and all-cause mortality (Xu, Kochanek, Murphy and Tejada-Vera, 2010). However, the other chronic conditions and specific limiting symptoms must also be carefully considered when formulating the program. For this example, the frequency and time parameters of the exercise program for each condition is comparable. Yet there are some marked differences in the exercise-intensity recommendations between conditions. While both moderate (40% to <60% HRR or VO2R) and vigorous (60% to 80% HRR or VO2R) exercise intensity are recommended for individuals with type 2 diabetes and dyslipidemia, vigorous intensity exercise is not recommended for either hypertensive or arthritic populations (see Table 2). Therefore, it would be prudent to adopt the exercise-intensity recommendations for type 2 diabetes in this scenario, provided the exercise intensity was restricted to a moderate category.

Table 2. Exercise Recommendations for Common Chronic and Clinical Populations

Condition Frequency Intensity Time
Arthritis 3–5 days/wk 40% to <60% HRR or VO2R 20–30 min/day
Cardiac disease 4–7 days/wk 40% to 80% HRR or VO2R 20–60 min/day
Dyslipidemia ≥5 days/wk 40% to 75% HRR or VO2R 30–60 min/day
Hypertension ≥5 days/wk 40% to <60% HRR or VO2R 30–60 min/day
Metabolic syndrome 5 days/wk 40% to 75% HRR or VO2R 50–60 min/day
Obesity ≥5 days/wk 40% to <60% HRR or VO2R 30–60 min/day
Osteoporosis 3–5 days/wk 40% to <60% HRR or VO2R 30–60 min/day
Type 2 diabetes
3–7 days/wk 50% to 80% HRR or VO2R 20–60 min/day

* Modified from ACSM, 2009; Haskell et al., 2007.

 

An alternative strategy is to use the exercise guidelines for a single chronic condition that proves to be the most limiting of the multiple conditions for each client. This approach is warranted when the client is symptomatic or the condition is not stable. Arthritis, for example, is characterized by periodic episodes of acute inflammation. Pain and discomfort are common throughout these flares, and without sufficient caution, exercise can actually exacerbate the symptoms (ACSM, 2009). Under these circumstances it would be ill-advised to pursue the exercise guidelines for type 2 diabetes, despite the fact that it tops the greatest risk for mortality list. In this instance, it would be more appropriate to follow the exercise recommendations for arthritis instead.

Review

The final step in all evidence-based practice programs is the review of performance. You should regularly review the first four steps (Scenario, Understand, Prioritize and Exercise Program Design) and seek ways to continuously improve your client’s progress and program. Given the aforementioned complexity of exercise program design for individuals with multiple chronic conditions, frequently reviewing all aspects of the program is mandatory. Furthermore, it is absolutely paramount to comprehend and fully appreciate the unstable nature of most chronic conditions (Roberts and Barnard, 2005; Kerr et al., 2007). Simply put, the aims of your exercise program are unpredictable and moving targets. You will be required to revise your mortality risk and symptom-limiting lists multiple times. Likewise, you must also be prepared to modify the exercise routine to accommodate the sudden worsening of a symptom-limiting condition.

The review process also offers you the opportunity to provide clients with valuable feedback on the effectiveness of the program. Understanding what typical improvements (if any) might be expected for each chronic condition through an exercise intervention, along with the estimated timetable necessary to achieve this modification, will make it possible for you to provide meaningful feedback to your clients. Remember, an improvement for all chronic conditions is not always a realistic expectation (Kujala, 2006). For some clients, simply maintaining functional capacity or stabilizing the disease process can, and should, be viewed as a successful outcome.

Learn More: For continuing education courses on working with special populations, visit the ACE ConEd Center

References

American College of Sports Medicine. (2010). ACSM’s Guidelines for Exercise Testing and Prescription (8th Ed). Philadelphia: Woters Kluwer/Lippincott Williams & Wilkins.

Booth, F.W., Gordon, S.E., Carlson, C.J. and Hamilton, M.T. (2000). Waging war on modern chronic diseases: Primary prevention through exercise biology. Journal of Applied Physiology, 88, 774–787.

Chernof, B.A. et al. (1999). Health habit counseling amidst competing demands: Effects of patient health habits and visit characteristics. Medical Care, 37, 8, 738–747.

Haskell, W.L. et al. (2007). Physical activity and public health: Updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Circulation, 116, 1081–1093.

Kerr, E.A. et al. (2007). Beyond comorbidity counts: How do comorbidity type and severity influence diabetes patients’ treatment priorities and self-management? Journal of General Internal Medicine, 22, 12, 1635–1640.

Kujala, U.M. (2006). Benefits of exercise therapy for chronic diseases. British Journal of Sports Medicine, 40, 1, 3–4.

Kujala, U.M. (2004). Evidence for exercise therapy in the treatment of chronic diseases based on at least three randomized controlled trials: Summary of published systematic reviews. Scandinavian Journal of Medicine and Science in Sports, 14, 339–345.

Lloyd-Jones, D. et al. (2010). Heart disease and stroke statistics--2010 update: A report from the American Heart Association. Circulation, 121, 7, e46–e215.

Mangani, I. et al. (2006). Physical exercise and comorbidity. Results from the Fitness and Arthritis in Seniors Trial (FAST). Aging Clinical and Experimental Research, 18, 5, 374–380.

Roberts, C.K. and Barnard, R.J. (2005). Effects of exercise and diet on chronic disease. Journal of Applied Physiology, 98, 3–30.

Wolf, J.L., Starfield, B. and Anderson, G. (2002). Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Archives of Internal Medicine, 162, 20, 2269–2276.

Xu, J., Kochanek, K.D., Murphy, S.L. and Tejada-Vera, B. (2010). Deaths: Final data for 2007. National Vital Statistics Reports, 58, 19, 1–135.

_______________________________________________________________

Lance C. Dalleck, Ph.D., is academic coordinator of the Cardiac Rehabilitation/Clinical Exercise Physiology postgraduate program at the University of Auckland in New Zealand. His research interests include improving exercise performance and health outcomes through evidence-based practice, quantifying the energy expenditure of outdoor and non-traditional types of physical activity, and studying historical perspectives in health, fitness and exercise physiology.


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