Developing Evidence-based, Pressure-tested Programs for ... · Why is daily cardio activity the preferred recommendation Developing Evidence-based, Pressure-tested Programs for Your

Developing Evidence-based, Pressure-tested Programs for Your Clients 1

Presented by Cedric X. Bryant, Ph.D., FACSM

Chief Science Officer2/3/2018

Getting people moving

Developing Evidence-based, Pressure-tested Programs for Your Clients with Hypertension


Discuss new BP guidelines and their implications

Review the pathophysiology and complications of hypertension (HTN)

Describe the treatment options for HTN with a specific focus on effective lifestyle

intervention strategies (weight loss, nutrition, & physical activity)

Provide a brief overview of the pharmacologic treatment options

Discuss behavior-change strategies for driving program success

Ground rules (Questions & Slides)

Presentation ObjectivesPresentation Outline


New Categories of BP in Adults*

BP Category SBP DBP

Normal <120 mm Hg and <80 mm Hg

Elevated 120–129 mm

Hg

and <80 mm Hg

Hypertension

Stage 1 130–139 mm

Hg

or 80–89 mm Hg

Stage 2 ≥140 mm Hg or ≥90 mm Hg

*Individuals with SBP and DBP in 2 categories should be

designated to the higher BP category.


Prevalence of Hypertension Based on 2 SBP/DBP Thresholds

SBP/DBP ≥130/80 mm Hg or

Self-Reported Antihypertensive

Medication

SBP/DBP ≥140/90 mm Hg or Self-

Reported Antihypertensive

Medication

Overall, crude 46% 32%

Men

(n=4717)

Women

(n=4906)

Men

(n=4717)

Women

(n=4906)

Overall, age-sex

adjusted

48% 43% 31% 32%

Age group, years

20–44 30% 19% 11% 10%

45–54 50% 44% 33% 27%

55–64 70% 63% 53% 52%

65–74 77% 75% 64% 63%

75+ 79% 85% 71% 78%

Race-ethnicity

Non-Hispanic White 47% 41% 31% 30%

Non-Hispanic Black 59% 56% 42% 46%

Non-Hispanic Asian 45% 36% 29% 27%

Hispanic 44% 42% 27% 32%


BP Thresholds & Recommendations for Treatment and Follow-

Up (continued on next slide)


Basic Pathophysiology of Hypertension


The Role of Shear Stress In Atherogenesis


Complications of Hypertension:

TIA, stroke

Retinopathy

Peripheral vascular

disease

Renal failure

LVH, CHD, HF

Hypertension

is a risk factor


Impact of a Modest (5 mmHg) Decrease in BP

ReductionOverall Risk Reduction

Stroke (CVA) 14%

Coronary Heart Disease 9%

All Cause Mortality 7%


Lifestyle Modifications & BP

ModificationApproximate SBP Reduction

(range)

Weight reduction* 5-15 mmHg

Adopt DASH eating plan 8-14 mmHg

Dietary sodium reduction 2-8 mmHg

Physical activity 4-9 mmHg

Moderation of alcohol

consumption2-4 mmHg

*1.0 kg decease in BW = 1.0 mmHg decrease in SBP


Weight Loss

Diet/NutritionPA/Exercise

Lifestyle

Change

Behavior

First Line of Defense: Lifestyle Behavior Change


Energy Intake vs Energy Expenditure: No Contest

Large burger 3 540 180

Activity Duration Cost Efficiency

(min) (kcal) (kcal/min)

70% VO2max 60 540 9

40% VO2max 90 540 6

Vs.


It’s Simply A Question Of Energy Balance ???


Wei

ght

Cha

nge

(kg)

-6

-4

-2

0

2

4

6

8

10

12

14

Women

Increased Physical Activity & BW Change

✓ BW decreases

✓ BW does not change

✓ BW increases

Why variability of responses?


Theory: Reduced Daily Energy Expenditure Pattern


Washburn et al. Clinical Obesity, Feb 2014

No reductions in non-exercise

activity thermogenesis (NEAT) in

response to prescribed physical

activity/exercise training

✓ 100% of cross-sectional studies

(n=4)

✓ 90% of short-term studies (n=10)

✓ 50% of non-randomized trials

(n=10)

✓ 100% of randomized controlled

trials (n=7)

NEAT Appears To Be Unchanged


Theory: Physical Activity and Appetite Control

PA has the potential to adjust appetite control by:

✓ Improving the sensitivity of the physiological satiety signaling system

✓Adjusting macronutrient preferences or food choices

✓Altering the hedonic (pleasurable) response to food

Available research suggests that individuals can be separated in two

groups:

✓Compensators and non-compensators.

✓More studies are needed to further classify individuals who are

compensators vs non-compensators & to identify the mechanisms

responsible for the rates of compensation and its limits.


Could Exercise Intensity Be A Key Factor?


Don’t Forget The Rest Of The Story: What Would We

Miss If We Choose To Focus On Food Alone?

Improved overall cardiometabolic health

Enhanced weight maintenance

Enhanced mood and psychological outlook

Improved physical functioning

Improved cognitive functioning

Always Think Total Impact!


NWCR: Learning from Successful Losers

Slow & steady = long-term success

Eat early, diet late (food = fuel for an active, healthy lifestyle)

Practice mindful eating (Brian Wansink)

Choose a lower-fat (<25% fat) eating plan

Consume foods high in nutrient density (nutrients per calorie of food)

Consume foods low in energy density (calories per weight or volume of food)

Limit alcohol consumption (7 kcal/g)


NWCR: Learning from Successful Losers (cont.)

Eat consistently, and maintain the same eating patterns on weekends as on weekdays

Weigh themselves regularly but not obsessively

Get sufficient amounts of sleep

Accumulate about an hour of moderate-intensity physical activity on most days

Combo of weightbearing and non-weightbearing activity is encouraged


Regions of Abdominal Fat:

1. Subcutaneous

2. Visceral

A Important Exercise Target: Abdominal Visceral Fat


Weight Loss


Lifestyle

Change

Behavior



Exercise professionals should have knowledge of the

following nutrition-related concepts when working with

clients who have HTN:

✓ Dietary Approaches to Stopping Hypertension

(DASH) eating plan

✓ Mediterranean-style eating plan

✓ Diets advocating excessive restriction of certain

macronutrients are likely inadequate and typically are

not adhered to over the long term

HTN: Diet/Nutrition ConsiderationsNutrition Essentials & Hypertension


DASH Eating Plan

✓Emphasizes fruits, vegetables,

grains, seafood, poultry, lean

meats, and low-fat diary products

✓Low in saturated fat, cholesterol,

and total fat

✓Reduced red meat, sweets, and

sugary beverages

✓Low in sodium (< 2300 or 1500

mg per day)

✓Rich in magnesium, potassium,

calcium, protein, and fiber


Mediterranean-style Eating Plan


What the real scoop on sodium?✓Sodium raises BP in some people

(Sodium sensitivity: 25 – 35% of

population)

▪ Older adults

▪ Blacks

▪ Overweight/obesity

✓All individuals with HTN should

limit sodium intake

✓Sodium is found in many foods

in the grocery store (Read food

labels!)

✓Physical activity has been

associated with a reduction in

sodium sensitivity


Help Your Clients with Portion Control


Nutrition & The Exercise Professional

Don’t be afraid to talk nutrition with your clients (disseminate credible,

evidence-based information:

(www.eatright.org,www.heart.org,www.acefitness.org)

Provide evidence-based information and industry-accepted guidelines

but not individualized or personal recommendations Empower

clients with valid info to make healthy nutrition choices

When discussing nutrition, ask yourself: “Is this within my defined

professional boundaries, expertise and skills?”

Respect scope of practice and refer when needed

http://www.heart.org,www.acefitness.org/


Weight Loss


Lifestyle

Change

Behavior



Frequency: 4-5 days/week, preferably daily

Intensity: Zone 1 with brief periods in Zone 2—using

ACE 3-Zone Model

Time: 30-60 min/session

Type: Low-impact aerobic exercise supplemented by

an increased NEAT

Cardio Exercise Programming Guidelines (FITT)


Post-exercise hypotensive

(PEH) response:

Transient reduction in BP

immediately after PA—typically

5 – 20 mmHg compared to pre-

exercise levels

Why is daily cardio activity the preferred recommendation




ACE 3-Zone Model (40 – 70% HRR)



an increased NEAT



During exercise, higher intensities

increase respiratory rates linearly with

the exception of two key deflection

points where significant ventilatory

changes occur:

VT1 - First Ventilatory Threshold -

due to increased CO2 production as

primary fuel utilized changes (fat

carbohydrate); corresponds with initial

accumulation of blood lactate

VT2 - Second Ventilatory Threshold -

associated with a rapid increase in

blood lactate (lactate > 4.0 mmol)

Ventilatory Markers & Exercise Intensity


Zone 1 Zone 2 Zone 3

VT1 VT2

VT1 & VT2

Below VT1 VT1 to just below VT2 VT2 and Above

HR HR < VT1 HR > VT1 to HR < VT2 HR > VT2

Talk Test Can talk comfortablyNot sure if talking is

comfortable

Definitely cannot talk

comfortably

RPE Terms

Moderate to Somewhat hard Hard Very hard to Extremely hard

RPE 3 – 4 or 12 – 13 5 – 6 or 14 – 16 7 – 10 or 17 – 20

Cardio Exercise Intensity: ACE 3-Zone Model




ACE 3-Zone Model (40 – 70% HRR)



increased NEAT



Make Movement Your Mission: Tips for Increasing NEAT


Frequency: 2 days/week, focused on major muscles

Intensity: Think MED until stability, mobility, & proper

movement mechanics are achieved; RPP

Repetitions: Generally, vary inversely with intensity

Sets: One set/multiple sets; experience & preference

Type: Variety of options; experience & preference

Resistance Exercise Programming Guidelines (FIRST)


Rate Pressure Product (RPP) = SBP x HR / 100

SBP = Systolic blood pressure

HR = Heart rate

Resistance Exercise & Myocardial Oxygen Demand


Relative load (% 1RM)Single-arm curl ( ), single-leg press ( ), and double-leg pressure ( )

RPP

250240230220210200190180170160150140

20 40 60 80

60%

85%

100%

RPP Response to Difference Types of Exercises


Frequency: 2-3 days/week, particularly for relative beginners

Intensity: Think MED until stability, mobility, & proper

movement mechanics are achieved; RPP

Repetitions: Generally, vary inversely with intensity

Sets: One set/multiple sets; experience & preference

Type: Variety of options; experience & preference

Resistance Exercise Programming Guidelines (FIRST)


Limited body of research with promising results

Lowers BP to a similar degree as steady-state exercise

Other potential benefits have been observed:

✓ Increased nitric oxide response (endothelial function)

✓ Increased pulse wave velocity (arterial stiffness)

Extend warm-up & cool-down periods

Exercise greater caution with poorly controlled, older (>

50 years) or long-standing (> 10 years) HTN clients

regardless of their age

HITT & Hypertension


Keep cardio activity below Zone 2 regardless of fitness level

(exception: athlete with approval from medical provider)

Resistance training is important for functional performance

Mind-body activities can be integrated (caution with certain postures)

Understand the effect of meds on exercise responses

Be aware of environmental stressors

Know the signs of a cardiac problem

Special Exercise Considerations & Precautions


Does the pain get better or worse with a change in body position?

Is the pain better or worse with respirations?

Is the pain intense, knifelike, or more like a dull ache or pressure?

Is the pain deep or close to the surface?

Is the pain associated with other symptoms like difficulty breathing,

nausea or sweating?

Is the pain diffuse or localized?

Cardiac vs Non-cardiac Chest Pain

If in doubt, treat it as cardiac chest pain


Improved BP control

Reduced rate and severity of complications

Reduced dosage of medication required to control BP (Health & Financial +)

Improved CHD risk factor profile

Enhanced mood and psychological status

Improved cognitive health and function

Improved overall quality of life

Exercise & Hypertension: The Benefits


Pharmacologic Sites of Action

Diuretics

Aldosterone Ant.

Nitrates

ACE Inhibitors

ARBs

Beta Blockers

Ca+ Channel

Blockers

Alpha 2 Blockers

Vasodilators

Ca+ Channel

Blockers

Alpha 1 Blockers

ACEI

ARB

HeartArteries

Veins

Note: Many of the meds can effect exercise responses; consult physician and/or PDR


Help your client to establish effective support systems

Proper goal setting = good initial adherence

✓ Process before performance

✓ Emphasis progression not perfection

Positive experience + empowerment = self-reliance + better long-term

adherence

How a person thinks and feels drives their decision-making and eventually

their actions

Behavior-Change Strategies to Drive Program Success


Ultimate Goal = Long-term lifestyle change

40–65% of new exercisers will suffer attrition within 3–6 months, with the

highest risk occurring within the first few weeks.

Identify readiness to change & use motivational interviewing techniques (OARS)

Open-ended questions

Affirmations

Reflective listening

Summarizing

Behavior-Change Strategies to Drive Program Success


Optimal Healthcare Is The Ultimate Team Sport


✓ Encourage your clients with hypertension to make a firm

commitment to exercise, because even a small amount of

regular exercise (and the subsequent reduction in BP) can

help reduce the long-term consequences of hypertension.

✓ “People won’t care what you know, until they first know

that you care” –John Wooden

Concluding Thoughts


Cedric X. Bryant, Ph.D., FACSM

American Council on Exercise

Chief Science Officer

E-mail: [email protected]

Twitter: @drcedricbryant

Website: www.acefitness.org

Thank You!

mailto:[email protected]

http://www.acefitness.org/

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Developing Evidence-based, Pressure-tested Programs for ... · Why is daily cardio activity the preferred recommendation Developing Evidence-based, Pressure-tested Programs for Your