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Learning from Exercise Prescription–based Case Studies

Feito, Yuri, Ph.D., MPH, FACSM, ACSM-CEP, EIM Level III

doi: 10.1249/FIT.0000000000000468
Columns: ACSM Certification
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Yuri Feito, Ph.D., MPH, FACSM, ACSM-CEP, EIM Level III, is an associate professor of Exercise Science at Kennesaw State University, Kennesaw, GA. As a professor, Dr. Feito’s emphasis is to provide a “bridge” between scientific knowledge and skill application. He holds ACSM’s RCEP and CEP credentials, and before his academic appointment, he was involved in the medical fitness industry as a practitioner and administrator. Follow him on Twitter @DrFeito.

Over the past several months, the ACSM Certification column has provided some level of insight in regard to something happening within the Committee on Certification and Registry Boards. In 2019, our focus will shift to a case study approach that will highlight important concepts pertaining to exercise prescriptions. Many of the principles will be familiar to you as a practitioner, and others may not be as clear. Here, we hope to clarify some of those and provide opportunities to expand your knowledge, as well as the application of those concepts.

In addition to this column, we will review and provide additional interpretation of this initial case presentation in an interactive workshop both Editor-in-Chief Brad A. Roy, Ph.D., FACSM, and I will be conducting at ACSM’s International Health & Fitness Summit titled “Prescreening, Programming, and Everything In Between: Interactive Case Study Scenarios.” So, if you are attending the conference, make sure to stop by (Friday, March 22 from 10:45 a.m. to 12:15 p.m., or on Saturday, March 23 from 2:45 to 4:15 p.m.), and if you are not, consider attending this great opportunity to meet and interact with other professionals in the field. It is going to be a great Health & Fitness Summit!

The case studies used will come from real-life scenarios provided or from previous editions of the ACSM Certification Review text. If you are interested in submitting a case study for consideration, please email it to HFJournal@acsm.org.

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CASE STUDY:

You are an exercise physiologist at a hospital-based wellness facility. A client, Drew, a 47-year-old man, recently joined your facility. He currently weighs 315 pounds, and is 5 feet, 11 inches tall with a current waist circumference of 127 cm. Because of his waist girth and weight, body composition estimation was not possible via skinfolds. He currently does not engage in any regular physical activity. At his initial consultation, you measured his resting heart rate at 58 bpm, and his resting blood pressure was 138/72 mmHg. At his most recent doctor’s visit (18 months ago), his fasting blood measures were as follows: total cholesterol = 192 mg/dL, HDL-C = 41 mg/dL, LDL = 117 mg/dL, triglycerides = 169 mg/dL, and glucose = 137 mg/dL. On his health history questionnaire, Drew states that he has previously been diagnosed with high cholesterol, high blood pressure, and diabetes mellitus. He reports no symptoms suggestive of ischemia. He is currently on several medications including Lipitor (statin for cholesterol), Atenolol (beta-blocker for blood pressure), and Metformin (biguanide for glucose control). He reports that his father was diagnosed with diabetes in his 40s and had a nonfatal heart attack at age 52. He denies any other medical condition or any bone, joint, or soft tissue problems.

During your initial consultation, Drew discussed his desire to improve his overall health and prevent the occurrence of a premature myocardial infarction. He realizes that he is not in good health and not physically active. He wishes to make the necessary changes to lose weight, to improve his risk factor profile, and hopefully not to go down the same path as his father.

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HERE ARE SOME QUESTIONS FOR YOU TO CONSIDER ON THIS CASE:

According to the most recent edition of ACSM’s Guidelines for Exercise Testing and Prescription (10th edition), answer the following questions:

  1. What is Drew’s body mass index?
    1. 44.0 kg/m2
    2. 35.8 kg/m2
    3. 58.4 kg/m2
    4. 44.3 kg/m2
  2. As part of a preparticipation assessment, what would be recommended for Drew prior to beginning a light-to-moderate intensity exercise program?
    1. Physical activity Questionnaire
    2. Physical Activity Readiness Questionnaire (PAR-Q+) form
    3. Graded treadmill exercise test
    4. Medical clearance from physician
  3. Aside from reducing blood pressure, what other effect would Atenolol have that must be considered when designing Drew’s exercise program?
    1. Increases his resting heart rate
    2. Increases his exercise tolerance
    3. Decreases his exercise breathing rate
    4. Decreases his exercise heart rate
  4. Drew states during his initial consultation that he does not feel his recent glucose reading of 137 mg/dL reflects his usual level of glucose control, and that he usually “does better.” What test would you recommend Drew to discuss with his medical professional that would BEST determine Drew’s level of glucose control over the past few months?
    1. Another fasted blood glucose test
    2. An oral glucose tolerance test
    3. A hemoglobin A1C test
    4. No follow-up test is needed based on Drew’s current glucose reading
  5. Given Drew’s extensive cardiovascular risk profile and diagnosed metabolic disease, what potential cardiovascular complication possibility exists with his performing physical activity?
    1. Silent ischemia
    2. Hyperglycemia
    3. Ketoacidosis
    4. Peripheral neuropathy
  6. Based on Drew’s eagerness to start an exercise program, what would be the most effective goal to get him started?
    1. Start walking around the block
    2. Join the group exercise program at the facility and plan on attending 3-days/week
    3. Walk on the treadmill for 10 minutes at a self-selected walking speed on 3 alternating days
    4. Walk on the treadmill at 80% HRR for 30 minutes

And here is a discussion question you may be able to elaborate with your colleagues.

  • 7. What do you believe to be Drew’s major health concern and what should Drew’s main goal be as he begins his lifestyle program?

What did you think? As mentioned previously, we will be covering this and many other case studies in our interactive workshop during ACSM’s International Health & Fitness Summit in Chicago this year, come join us!

The idea with this approach is to provide more “real world” applications of common concepts and learn from them. So, reach out and let me know what you think (@DrFeito). Big shout out to Doug Jackson, M.S., ACSM-EP, from Personal Fitness Advantage (Miami, FL) who read the last column and reached out on LinkedIn — thanks for reading Doug!

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MULTIPLE CHOICE ANSWERS FOR CASE STUDY I:

  1. A. 44.0 kg/m2 [Resource: ACSM GETP10 (p. 70)]
  2. D. Medical clearance from physician [Resource: ACSM GETP10 (p. 28–37)]
  3. D. Decreases his exercise heart rate [Resource: ACSM GETP10 (p. 279–283)]
  4. C. A hemoglobin A1C test [Resource: ACSM GETP10 (p. 268–275)]
  5. A. Silent ischemia [Resource: ACSM GETP10 (p. 268–275)]
  6. C. Walk on the treadmill for 10 minutes at a self-selected walking speed on 3 alternating days [Resource: ACSM GETP10 (p. 389–391)]
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DISCUSSION QUESTION ANSWERS FOR CASE STUDY I:

  • 7. Drew’s main concern at this juncture is his diabetes diagnosis, related to his excess body fat. Drew’s main goal should be to increase his physical activity as tolerated and avoid periods of prolonged sitting throughout each day in order to maximize his caloric expenditure and ultimately improve his glucose control and body composition. While Drew’s blood pressure is in the “pre-diabetes” category, his fasting glucose strongly suggests that he has type 2 diabetes. His physical inactivity, high BMI, and girth measurement, suggestive of high body fat, places him at high risk for CVD. By working to improve his body composition and glucose control through exercise and appropriate nutrition, Drew also may have a positive impact on his blood pressure.
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Acknowledgment

Portions of this case study were adapted from Trent A. Hargens, Ph.D., in ACSM’s Certification Review, 4th edition (Editor Gregory B. Dwyer). Wolters Kluwer. 2014, p. 153.

© 2019 American College of Sports Medicine.