could you please summarize this 

There are many chronic conditions a client may have or may develop over their lifetime. A
chronic condition is a health condition or disease that has long-lasting effects. Many are
related to lifestyle and eating patterns and can be addressed with modifications of the same.
However, some chronic conditions are hereditary and require additional adjustments and
considerations. A fitness professional must have a clear understanding of common chronic
conditions they may encounter for several reasons: first, to identify the limitations a client may
have; second, to better create an effective training program with these limitations in mind;
and third, to identify if and when a client should be referred to a health care professional for
further guidance or modifications to treat a chronic condition.
It is important for the trainer to understand that the information presented in this chapter
does not qualify them to adequately serve demographics with chronic conditions. It is meant
to provide foundational knowledge the trainer can then build upon. Fitness professionals
who desire to serve populations with chronic conditions should seek out advanced training,
stay within their scope of practice, and always refer to other professionals when appropriate.
Personal trainers should also be aware of clinical practice guidelines and work to collaborate
with a health care team as a supporting professional.
Before designing a program, a personal trainer should use the client intake paperwork to
collect subjective and objective data on a client. This will help identify any potential chronic
conditions. The trainer may also choose to require a physician’s approval before the client
begins a fitness program.
EXERCISE AND HYPERTENSION
The Centers for Disease Control and Prevention (CDC) reports that one in three adults in the
United States has high blood pressure (HBP) or hypertension. Individuals with hypertension
typically have blood pressure readings of over 140 systolic and 90 diastolic, and this can be
problematic if they are considering starting an exercise program. Hypertension increases the
risk for the two major leading causes of death for Americans: heart disease and stroke.
Unfortunately, there are no signs or symptoms to alert an individual to any problems. The only
way to diagnose the condition is by regularly checking one’s blood pressure.
Of the roughly 75 million people suffering from hypertension, only about half of them have it
under control. Increasingly, youth are being diagnosed with hypertension, and experts expect
a steady rise in diagnosed cases for both populations. Although this condition is silent, there
are risk factors to watch for that may help with prevention and/or early detection.
HYPERTENSION:
High blood pressure
measuring more than
140/90 mm Hg.
BLOOD PRESSURE:
The force of blood pushing
against the walls of the
arteries during the two
phases of the cardiac cycle.
SYSTOLIC:
The pressure in blood
vessels when the
heart beats (ventricular
contraction).
DIASTOLIC:
The pressure in blood
vessels when the heart
rests (ventricular filling).
STROKE:
When the blood flow to the
brain is interrupted long
enough to cause damage.
RISK FACTORS:
Variables associated with
increased risk of disease or
infection.
 ISSA | Certified Personal Trainer | 602
Lifestyle choices relating to diet and exercise affect blood pressure. Preexisting or current
health conditions, including family history, also put individuals at a higher risk for developing
hypertension.
Medications are often prescribed to control blood pressure, although leading research and
treatment organizations suggest the first course of action should be lifestyle modification. Recent
meta-analyses have established that both aerobic and resistance exercises can lower diastolic
blood pressure. Even a small numerical drop in blood pressure values, such as 3 mm Hg, improves
an individual’s chances of surviving a heart attack by 5 percent and stroke by 8–14 percent.
Postexercise hypotension (PEH) is the term used to describe the initial drop in blood pressure
within the first minutes after an exercise session. Symptoms can present themselves in the form
of fatigue, hearing difficulties, nausea, dizziness, and fainting. Not all individuals may present
symptoms, so the personal trainer should remain vigilant. Initial studies regarding PEH have been
conducted on participants in walking and running programs as well as after bouts of resistance
training, high-intensity interval training, yoga, and, most recently, playing active video games.
It is important to make sure clients are well hydrated and incorporate active recovery periods
within the workout when clients appear to be struggling during the session. Additionally, the
personal trainer should collaborate with the health care provider to help clients develop
healthier lifestyle habits, even if hypertension is hereditary, to prevent concurrent conditions
from developing and negatively impacting client health.
TEST TIP!
The prefix “hyper” is a Greek word that means “over.” The difference between
hypertension and hypotension can be distinguished by remembering this as someone
with hypertension has HIGH blood pressure. The opposite would be hypotension.
BLOOD PRESSURE RISK FACTORS
To manually measure blood pressure, a cuff is wrapped around the arm just above the elbow.
The cuff is inflated while the practitioner listens to the pulse at the anterior space of the
elbow where the upper arm and forearm meet. The first number is the systolic and is recorded
when the pulse is first heard. The air in the cuff is then slowly released, and the diastolic is
recorded when the pulse can no longer be heard. Electronic blood pressure monitors can also
be used but, while convenient, may not be as accurate. Values are measured in millimeters
of mercury, or mm Hg. For example, the final value is written as 120/80 mm Hg.
POSTEXERCISE
HYPOTENSION (PEH):
A drop in blood pressure in
the first minutes after an
exercise session.
HEREDITARY:
Relating to the biological
process responsible for
passing on traits from one
generation to another.
MILLIMETERS OF
MERCURY:
The measure of a unit of
pressure.
 ISSA | Certified Personal Trainer | 603
CHAPTER 16 | Chronic Conditions
Table 16.1 Blood Pressure Levels
BLOOD
PRESSURE
SYSTOLIC DIASTOLIC
Normal Less than 120 mm Hg Less than 80 mm Hg
Prehypertension 120–139 mm Hg 80–89 mm Hg
Hypertension 140 mm Hg or higher 90 mm Hg or higher
There are many risk factors for developing hypertension. For most clients, HBP is the result
of a combination of factors such as obesity, an unhealthy diet, and physical inactivity, as well
as smoking and alcohol consumption. A personal trainer can determine if a client is at a high
risk for hypertension by conducting a thorough evaluation before the first training session.
Obesity
Obesity is linked to higher levels of low-density lipoprotein (LDL) cholesterol and triglycerides
and lower levels of high-density lipoprotein (HDL) cholesterol. When artery walls are hardened
and narrowed with cholesterol plaque, the heart must work harder to pump blood through
them, increasing intravenous pressure. Obesity is a major risk factor for hypertension.
Diabetes Mellitus
Diabetes impacts the body in a few ways that may contribute to increased blood pressure. It
changes the way the body manages insulin and damages blood vessels. This leads to
reduced nitric oxide levels, which regulate blood pressure. Low levels of nitric oxide in the
blood can lead to atherosclerosis.
OBESITY:
An abnormal or excessive
accumulation of bodyfat
that may cause additional
health risks.
DIABETES:
A condition characterized by
an elevated level of glucose
in the blood.
ATHEROSCLEROSIS:
The buildup of fats,
cholesterol, and other
substances in the artery
walls.
 ISSA | Certified Personal Trainer | 604
TEST TIP!
About 6 out of 10 people who have diabetes have high blood pressure. This
means nearly 60 percent of people with diabetes mellitus have hypertension.
Diabetes causes sugars to build up in the blood. The body will naturally try to get
rid of excess sugar by urinating, leading to dehydration. This not only leads to
increased blood pressure but also increases the risk for heart disease.
Unhealthy Diet
There are many components to one’s diet that increase the risk for hypertension. High sodium
and low potassium consumption are two components that increase blood pressure. Sodium
intake can increase water retention, which in turn will increase blood flow resistance. It is
important to counterbalance high levels of sodium with potassium. Potassium helps excrete
sodium through urine and lessens resistance in blood vessels.
Physical Inactivity
Sedentary behaviors play a major role in developing hypertension. Staying physically active
helps prevent weight gain and lessens the chance of other health issues developing. It is
recommended to achieve at least thirty minutes of physical activity per day to lower the risk
of hypertension.
Alcohol Consumption
Excessive alcohol consumption can raise blood pressure. The mechanism as to how this
occurs remains inconclusive, but there are theories. One suggested mechanism is that too
much alcohol creates inflammation within the body, which then creates oxidative injury to
blood vessels. To avoid these negative effects, it is recommended to avoid alcohol or to
drink in moderation. According to the Dietary Guidelines for Americans, moderate drinking is
up to one drink a day for women and up to two drinks a day for men. Alcohol can contribute
to unhealthy weight gain and may create a narrowing of blood vessels, both of which may
compound and increase the effects of preexisting HBP.
Tobacco
Smoking can make breathing difficult and reduces the amount of oxygen that blood carries.
Chemicals in tobacco, such as nicotine, damage lung tissue and arteries and lead to
increased blood pressure.
 ISSA | Certified Personal Trainer | 605
CHAPTER 16 | Chronic Conditions
As a reminder, the above information can be used to identify whether a client is at a high risk
for hypertension, not to diagnose it. Small lifestyle modifications can help to reduce one’s
risk for chronic disease and promote longevity.
PROGRAM DESIGN
Improvements in diastolic blood pressure, strength, and cardiorespiratory fitness, and an
increase in lean body mass can occur within eight weeks. These changes impact the health
of the client, reducing the risk of HBP. However, one study that followed participants over the
course of eight weeks noted no change in systolic blood pressure. Therefore, eight weeks
may not be enough to start seeing improvements, so a 12-week program may be best.
A client should not expect to see changes in their blood pressure values until around week 12
in their training. Many studies have demonstrated a drop of about 3 mm Hg in systolic blood
pressure after a 12-week fitness program. Again, this has significant value as it reduces
cardiac and stroke morbidity.
Exercise Options
For clients with blood pressure over 160/100 mm Hg, their doctor should be consulted
before beginning a weight-lifting routine as heavy resistance can temporarily increase blood
pressure. Clients should not perform heavy overhead lifts but should vary exercises between
the upper body and lower body.
Table 16.2 Exercise Options for Hypertension
TYPE OF ACTIVITY FITNESS PRESCRIPTION
Cardiorespiratory
exercise
150 minutes of moderate-intensity exercise per week
Or 75 minutes of vigorous activity
Or any combination of moderate and vigorous activity
Resistance exercise Moderate-high intensity exercise two days per week.
Increase intensity over time, warm-up, and cooldown.
Clients can also perform circuit training known as concurrent training, which may be the
most efficient way to help clients lower blood pressure and reduce hypertension risk. It has
a better overall impact on cardiovascular disease risk factors.
CONCURRENT
TRAINING:
Including both
cardiorespiratory exercise
and resistance training into
a fitness program.
 ISSA | Certified Personal Trainer | 606
SPECIAL CONSIDERATIONS
Safety is always a top priority for fitness training. The main goal of designing a fitness program
is to help the client integrate exercise into their lifestyle. Educating the client is a key component
of helping the client develop competency and autonomy. Coaching points include the instruction
of breath control, intensity control, and incorporating both a warm-up as well as a cooldown.
Controlled Breathing
It is important to advise the client not to hold their breath. Holding the breath while exercising
increases intravenous pressure and may cause syncope and injury. Additionally, it is best to
avoid using the Valsalva maneuver for those who have HBP. This maneuver is a technique
used among some weight lifters to engage the core and maximize force production. It is
particularly used when lifting heavy weight.
Maintaining Intensity
If a client is taking medication to control blood pressure, then it is necessary to adjust how the
maximum heart rate is determined. Beta blockers block specific receptors to reduce the effects
of signals sent to increase heart rate. When these receptors are blocked, the heart does not
receive messages to speed up and maintains a slower rate and lower blood pressure.
Thus, to determine the maximum heart rate, a different equation must be used:
162 – (0.7 x age) = estimated maximum heart rate (HRmax)
Another appropriate measure for clients with hypertension is the talk test. If clients can carry
a full conversation, they can pick up the pace. If brief exchanges are manageable, with the
need to pause and breathe, the pace is just right. Clients should slow their pace when short
sentences make them out of breath, or if they need to stop frequently.
Warm-Up and Cooldown
A warm-up is essential for clients with HBP as it allows the blood vessels to slowly expand
to accommodate greater blood flow. A gradual warm-up should help the client achieve their
target heart rate. At least 10 minutes is necessary, more if the client has been inactive for a
long time. The cooldown at the end of the workout is equally important. It is important to not
allow the client to immediately stop activity. The personal trainer can include flexibility or yoga
postures to slowly bring the client’s heart rate back to pre-exercise values. A proper cooldown
will also reduce muscle soreness.
AUTONOMY:
The need for selfgovernance and control
over one’s own behaviors.
COMPETENCY:
The ability to do something
successfully or efficiently.
SYNCOPE:
Temporary loss of
consciousness related to
insufficient blood flow to
the brain.
VALSALVA MANEUVER:
The act of forcibly exhaling
with a closed windpipe,
where there is no air that
is exiting via the nose or
mouth.
BETA BLOCKERS:
One of the most widely
prescribed classes of drugs
to treat hypertension.
TALK TEST:
The ability to speak during
exercise as a gauge of the
relative intensity.
 ISSA | Certified Personal Trainer | 607
CHAPTER 16 | Chronic Conditions
Healthy Food Choices
Dietary suggestions should be handled carefully. Personal trainers should check local laws to
determine what information they are allowed to dispense within legal parameters. In most
cases, it is acceptable to share widely published general nutrition knowledge. In this case,
personal trainers may suggest the Dietary Approaches to Stop Hypertension (DASH) diet.
This DASH diet promotes eating plenty of vegetables, fruits, and whole grains. It suggests
limiting fatty foods and sugars. This means eating fish, poultry, beans, and nuts but avoiding
fatty meats, dairy, and tropical oils. Clients should choose foods that are low in sodium, low
in saturated and trans fats, and rich in potassium, calcium, magnesium, fiber, and protein.
Figure 16.1 DASH Diet
EXERCISE AND DIABETES
When someone eats a meal, the food is converted into energy for the body to use. In healthy
individuals, the pancreas secretes insulin. Insulin regulates many metabolic processes that
provide cells with energy. This helps the cells collect glucose from the blood to turn it into energy.
In the case of diabetic clients, the body either doesn’t make enough insulin to collect glucose
from the blood, or the body doesn’t use the insulin efficiently. In either case, what results is
excess glucose in the blood, leading to heart disease, vision loss, or kidney disease over time.
DIETARY
APPROACHES TO STOP
HYPERTENSION (DASH)
DIET:
A low-sodium, wholefood diet created for the
treatment of hypertension.
INSULIN:
A hormone produced in the
pancreas to regulate blood
sugar.
HEART DISEASE:
A term used to describe
several different heart
conditions.
 ISSA | Certified Personal Trainer | 608
Men with diabetes are two to three times more likely to suffer a cardiovascular diseaserelated event than men without diabetes. Women with diabetes are three to five times more
likely than women without diabetes to suffer the same. Also, deaths related to myocardial
infarction (heart attack) for men and women with diabetes are double that of their healthy
counterparts. Diabetes negatively impacts the body through cardiometabolic conditions.
Prediabetes is the presence of diabetic indicators that are above normal and may possibly
evolve into type 2 diabetes without proper intervention and control. In the US, one in three
adults have prediabetes, many of whom have no idea they have the condition. Type 1 diabetes
makes up just 5 percent of diagnosed cases of diabetes, while type 2 diabetes makes up the
remaining 90–95 percent. Cases of diabetes have more than tripled in the last 20 years,
costing over $325 billion in medical expenses and lost work and wages. Prediabetes, type 2
diabetes, and gestational diabetes are lifestyle diseases and can be reduced or prevented
by participation in a lifestyle modification program.
TEST TIP!
A personal trainer can remember the purpose of insulin by thinking of insulin as
the door of a castle that controls when glucose gets “in.”
TYPES OF DIABETES
All carbohydrates are broken down into glucose in the blood. When the pancreas cannot
produce insulin, the body is unable to transport this glucose from the blood to cells in the
body. As a result, blood glucose levels rise, which leads to hyperglycemia. There are three
main types of diabetes with each disease determined by insulin response.
Type 1 Diabetes
Type 1 diabetes is thought to be an autoimmune response in which the body attacks and
destroys its own beta cells in the pancreas that make insulin. Nutrition and lifestyle habits
do not cause this condition, and individuals with type 1 need to take insulin shots (or wear
an insulin pump) every day.
CARDIOMETABOLIC:
A combination of metabolic
dysfunctions mainly
characterized by insulin
resistance, impaired
glucose tolerance,
dyslipidemia, hypertension,
and central adiposity.
PREDIABETES:
A condition where blood
glucose is higher than it
should be, but not in the
diabetes range.
TYPE 2 DIABETES:
A long-term metabolic
disorder that is
characterized by high blood
sugar, insulin resistance,
and relative lack of insulin.
TYPE 1 DIABETES:
A chronic condition in which
the pancreas produces little
or no insulin.
GESTATIONAL
DIABETES:
A condition characterized
by an elevated level of
glucose in the blood
during pregnancy, typically
resolving after the birth.
HYPERGLYCEMIA:
Elevated blood glucose.
 ISSA | Certified Personal Trainer | 609
CHAPTER 16 | Chronic Conditions
Figure 16.2 Type 1 Diabetes
Type 2 Diabetes
Type 2 diabetes is a preventable condition caused by unhealthy lifestyle habits. In this
condition, cells do not respond normally to insulin, so the pancreas makes more to try and
signal the cells to work. The pancreas cannot keep up with the demand and begins to shut
down. This is known as insulin resistance.
 Figure 16.3 Type 2 Diabetes
Gestational Diabetes
This condition occurs in pregnant women who do not have diabetes. Roughly 2 to 10 percent
of pregnancies develop gestational diabetes. With all the physiological changes that happen
in a woman’s body during pregnancy, the body becomes insulin resistant, increasing the need
for insulin. Some cases may be controlled by diet, and others need insulin injections. In most
cases, it is resolved after the birth.
INSULIN RESISTANCE:
An impaired response
of the body to insulin,
increasing levels of blood
glucose.
NORMAL TYPE 1 DIABETES
 ISSA | Certified Personal Trainer | 610
Exercise is a proven, safe, and effective intervention to lower blood glucose. When muscles
contract during movement, cells can absorb glucose from the blood with or without insulin.
During and after physical activity, insulin sensitivity is increased, and muscle cells will use
available insulin to uptake glucose for energy. This is how exercise lowers blood glucose in
the short term and how it gradually lowers hemoglobin A1c (HbA1c) after a regular physical
activity program is implemented. The higher the glucose concentration in the blood, the higher
the level of HbA1c.
RISK FACTORS
There is a chance that blood glucose may become too low. Hypoglycemia can happen quickly
and needs to be treated immediately. Hypoglycemia can happen when there is too much
insulin in the body, when a client has waited too long without a meal or snack, if they haven’t
eaten enough, or if they’ve already exercised or engaged in some sort of physical activity.
Symptoms of low blood sugar are different for everyone but may include the following:
• Shakiness
• Nervousness or anxiety
• Sweating, chills, or clamminess
• Irritability or impatience
• Dizziness and difficulty concentrating
• Hunger or nausea
• Blurred vision
• Weakness or fatigue
• Anger
• Stubbornness or sadness
At the same time, there are many risk factors for developing diabetes or hyperglycemia.
Before prescribing a workout program, it is important to determine if any of the following are
true. If so, clients are at a higher risk of developing diabetes.
Being Overweight
Being overweight is a primary risk factor for prediabetes, type 2 diabetes, and gestational
diabetes. It is not a risk factor for type 1 diabetes. Diet and lifestyle choices don’t affect
type 1 diabetes because it is an autoimmune response (immune system attacking otherwise
healthy cells). Though, all other types of diabetes can develop from having excess bodyfat,
which is a direct result of nutrition and lifestyle choices. When a client’s bodyfat increases,
their body becomes more insulin resistant.
HEMOGLOBIN A1C
(HBA1C):
A minor component of
hemoglobin to which
glucose is bound.
HYPOGLYCEMIA:
The condition of lower-thannormal blood glucose.
 ISSA | Certified Personal Trainer | 611
CHAPTER 16 | Chronic Conditions
Age
Diabetes can develop at any age, but the risk of prediabetes increases after age 45. The risk
of developing type 2 diabetes also increases after age 45. Type 1 diabetes is more likely to
develop as a child, teen, or young adult, and gestational diabetes can occur at age 25. There
is evidence showing a strong relationship between age of onset and type 2 diabetes. This
research also shows that type 1 diabetes is most common in youth, accounting for more than
85 percent of all diabetes cases below the age of 20.
Family History
Family history is a strong indicator of the likelihood of developing diabetes. In most cases,
the risk of prediabetes increases when a client has a parent or sibling with type 2 diabetes.
Family medical history represents many genetic factors that can develop in the future. It is
important for clients to know if they are at risk and immediately make necessary changes to
their diet and lifestyle.
Physical Activity
Inactivity is a lifestyle choice that puts clients at a greater risk for prediabetes. Keeping
clients engaged in physical activity helps prevent unhealthy weight gain. Exercise promotes
effective use of insulin within muscle cells. This leads to the breakdown of sugar, which is
used as energy, limiting glucose buildup in the blood.
Gestational Diabetes
If a woman has diabetes during pregnancy or gives birth to a baby over nine pounds, she will
be at a higher risk for developing prediabetes. The child is also at a higher risk of developing
prediabetes. Women with polycystic ovary syndrome have a higher risk of prediabetes too.
Ethnicity
Ethnicity is a risk factor for all types of diabetes. Black, Hispanic, American Indian, and Asian
American people are at a higher risk for prediabetes and type 2 diabetes. African American,
Hispanic and Latino American, American Indian, Alaska Native, Native Hawaiian, and Pacific
Islander ethnicities are at a high risk for gestational diabetes. The Caucasian ethnicity is one
of the only risk factors for type 1 diabetes.
POLYCYSTIC OVARY
SYNDROME:
A hormonal disorder
common among women of
reproductive age.
 ISSA | Certified Personal Trainer | 612
PROGRAM DESIGN
First, it is important to have a physician’s approval before moving forward. When meeting
with a new client for the first time, a personal trainer should ensure they have visited with a
diabetes educator. They must have a current record of blood sugar readings and know their
signs and symptoms. Knowing how to treat their hypoglycemia or hyperglycemia is important.
Low- to moderate-intensity activity is safe and effective for helping clients with prediabetes and
type 2 diabetes lower the risk of a cardiovascular disease event and developing other complications
associated with diabetes. Clients with existing retinopathy, neuropathy, or nephropathy may also
safely participate. However, vigorous activities such as high-impact exercise or heavy lifting should
be avoided as they may increase the risk for a cardiac event or other injuries.
Moderate- to high-intensity training has been shown to reduce the risk of death for clients with
diabetes regardless of their age, level of education, body mass index (BMI), blood pressure,
total cholesterol, or smoking status. Exercise has also demonstrated a protective effect for
clients at any level of BMI, blood pressure, cholesterol, or smoking. Although exercise is
generally advisable for clients with diabetes, there are some contraindications to be mindful of.
Clients with type 1 or type 2 diabetes, who also have advanced peripheral neuropathy or
proliferative retinopathy, should avoid vigorous aerobic activity and heavy lifting. Clients may
still engage in low- to moderate-intensity aerobic activity and light resistance training. At each
session, the personal trainer and client should discuss when the client last ate. A client’s
current blood glucose reading will reflect how long ago a client consumed food. Clients should
have necessary insulin or glucose pills available for additional support during exercise.
Some data suggests that by working with a trained health and fitness professional, clients
can reduce the risk of developing type 2 diabetes by 58 percent or up to 71 percent for clients
over 60 years of age. When developing a fitness program for this demographic, small and
sustainable lifestyle changes can be implemented. Clients should be educated on healthy
food choices and finding ways to manage stress. Motivation and encouragement help clients
as they face difficulties and setbacks. Clients shouldn’t be instructed to change too much
too soon. In addition, adequate sleep is essential. Finally, working with clients with diabetes
should be a collaborative effort with health care providers, family, and friends.
RETINOPATHY:
Disease of the retina that
results in impairment or
loss of vision.
PROLIFERATIVE
RETINOPATHY:
An overgrowth of blood
vessels around the retina.
NEUROPATHY:
Disease or dysfunction
of one or more peripheral
nerves, typically causing
numbness or weakness.
NEPHROPATHY:
Disease or damage of the
kidney.
ADVANCED
PERIPHERAL
NEUROPATHY:
A result of damage to
peripheral nerves that
often causes weakness,
numbness, and pain.
 ISSA | Certified Personal Trainer | 613
CHAPTER 16 | Chronic Conditions
SPECIAL CONSIDERATIONS
Any client with prediabetes, type 1 diabetes, or type 2 diabetes, with or without diagnosed
comorbidities, should be required to undergo specialized screening by their physician before
getting started with a physical fitness program.
In addition, an exercise stress test is recommended for all persons with type 2 diabetes who
have been diagnosed with one or more comorbidities, such as cardiovascular disease, eye
problems, nerve problems, and kidney problems. This includes clients who have greater-thannormal waist circumference, increased triglycerides, hypertension, advanced age (age 60 or
over), a history of smoking, and a family history of cardiovascular disease.
Monitoring blood glucose before and after exercise is necessary to prevent hypoglycemia,
hyperglycemia, and ketoacidosis which is an overproduction of ketones. This must be a
collaborative effort between the fitness professional and client.
Tracking this data helps the trainer and client become familiar with how the client’s blood
glucose responds to exercise. The trainer can then use this data to demonstrate the benefits
of physical activity to the client and track how the client’s body reacts to different activities.
In addition to monitoring clients’ blood glucose, foot care is important for clients with diabetes
as well. Peripheral neuropathy, a complication of diabetes, can reduce pain sensations in the
feet and mask injuries or issues. Clients should wear cotton socks and well-fitted athletic
shoes appropriate for the activity. After each exercise session, the client should check their
feet for sores, blisters, irritation, cuts, or other injuries.
Clients should also stay well hydrated during exercise and follow general nutritional guidance
to help with fat loss and heart health. Diabetes self-care requires much of the individual
and can become mentally and emotionally draining. Willpower is not enough for clients to
succeed. The personal trainer must be a source of inspiration, motivation, and education and
be encouraging, helping clients view setbacks as opportunities for growth and helping them
develop habits around self-care that are simple, enjoyable, and rewarding.
EXERCISE AND ARTHRITIS
Arthritis, inflammation of the joints, comes in several forms and impacts the lives of over 50 million
Americans. That number is expected to rise to almost 80 million people by 2040. The following
list includes a description of each form, signs and symptoms, and causes and risk factors, and
general guidelines are presented for creating safe fitness programs for this demographic.
COMORBIDITIES:
The simultaneous presence
of two chronic diseases or
conditions in a person.
EXERCISE STRESS
TEST:
An assessment that
usually involves walking
on a treadmill or riding a
stationary bike while heart
rhythm, blood pressure, and
breathing are monitored.
KETOACIDOSIS:
An increase in blood acidity
caused by excess ketones
in the bloodstream
KETONES:
By-products of the
breakdown of fatty acids.
 ISSA | Certified Personal Trainer | 614
Table 16.3 Arthritis Conditions
CONDITION DESCRIPTION
Osteoarthritis
A degenerative joint disease caused by wear and tear of the joints. The
hands, hips, and knees are most typically affected by osteoarthritis,
causing loss of strength, reduced flexibility, reduced proprioception, and
joint pain. Over 30 million US adults have this condition, 68 percent of
whom are over 65 years old.
Rheumatoid
arthritis (RA)
An autoimmune and inflammatory disease that most commonly affects
the hands, wrists, and elbows. About 1 percent of Americans have this
condition; two-thirds are women.
Fibromyalgia
(FM)
A condition that causes pain all over the body, sleep problems,
fatigue, and emotional and mental distress. Clients with this
condition have abnormal pain perception processing, a side effect of
the condition, which causes them to be much more sensitive to pain.
Gout
An inflammatory arthritis that affects one joint of the body at a time—
typically the big toe. This condition comes and goes unpredictably.
When the disease is active, it is called a flare, and when it is dormant,
it is called a remission.
Osteoarthritis
In this condition, the cartilage within a joint breaks down, causing friction between bones and
worsening over time. Friction within the joint causes pain or aching, stiffness, reduced range
of motion, and swelling. In some cases, osteoarthritis reduces function and causes disability.
TEST TIP!
The prefix “osteo” refers to bone. This helps to make it clear that osteoarthritis
is a breakdown and inflammation of the bone within a joint.
Rheumatoid Arthritis
With RA, the lining of the joint becomes inflamed, causing damage to joint tissue. This can
cause long-lasting pain, poor balance, and deformities in the joints. As this condition is an
autoimmune response, pain and aching, stiffness, tenderness, and swelling occur in more
than one joint and on both sides of the body, whereas osteoarthritis may only present in one
joint, unilaterally. Clients with RA may lose weight, suffer from fevers, fatigue, and weakness.
Fibromyalgia
Clients diagnosed with FM will experience the disease differently. Pain and stiffness all
over the body, fatigue, depression and anxiety, sleep problems, headaches (migraines),
and problems with thinking, memory, and concentration are common. Some clients may
REMISSION:
A significant reduction in
symptoms and signs of
rheumatoid arthritis.
OSTEOARTHRITIS:
Degeneration of joint
cartilage and the underlying
bone.
RHEUMATOID
ARTHRITIS (RA):
A chronic progressive
disease causing
inflammation in the joints.
FIBROMYALGIA (FM):
A chronic disorder
characterized by widespread
musculoskeletal pain,
fatigue, and tenderness in
localized areas.
ABNORMAL PAIN
PERCEPTION
PROCESSING:
An increase in the
subjective interpretation of
discomfort due to abnormal
sensory processing in the
central nervous system.
GOUT:
A disease in which
defective metabolism of
uric acid causes arthritis.
FLARE:
A sudden surge in
rheumatoid arthritis
inflammation.
 ISSA | Certified Personal Trainer | 615
CHAPTER 16 | Chronic Conditions
experience numbness or tingling in the hands and feet and pain in the face or jaw, as well as
digestive problems such as pain, bloating, constipation, or irritable bowel syndrome.
Additional complications include more hospitalizations, reduced quality of life, and high rates
of depression and death from suicide and injuries. The exact causes of fibromyalgia are not
known, but theories include genetics, infections, physical or emotional trauma, and stress.
Gout
Though gout usually only occurs in one joint at a time—the big toe, lesser toe joints, ankle,
or knee—it is intensely painful and accompanied by swelling, redness, and heat. This occurs
due to hyperuricemia, or too much uric acid in the body. Uric acid crystals build up in the
joints, fluids, and tissues.
All joints are required for movement, which is why arthritis pain and stiffness can be perceived
as a barrier to physical activity. Many clients with arthritis will avoid leisure activities they
once enjoyed and may miss work due to pain or immobility. The resultant inactivity causes
muscle atrophy and weakness, leading to further reductions in activity and muscle wasting.
Although science does not support the notion, many people (some physicians included) still
believe that intensive weight-bearing exercise causes undue stress on the joints, increasing
disease activity and causing further joint damage. Still, others believe that physical activity,
such as playing elite sports, causes arthritis and should be avoided. However, studies
observing the joints of arthritis sufferers found similar degeneration in the joints of former
athletes and the general population.
The key to success for clients with arthritis is a well-designed fitness program that addresses
the specific needs and goals of the client. Though it will take between six and eight weeks for
joints to get used to a new level of activity, the long-term benefits of exercise can help clients.
RISK FACTORS
Prior to describing exercise program design, it is important to understand the many risk
factors associated with arthritis. Some risk factors, such as obesity and overuse, can play a
critical role in day-to-day exercise prescription.
Age
The chance of developing rheumatoid arthritis and osteoarthritis increases with age. The
highest onset for rheumatoid arthritis is around age 60 while most cases of fibromyalgia are
diagnosed by middle adulthood. Aging causes bones to become less dense or more fragile.
This changes the composition of bone and cartilage.
HYPERURICEMIA:
An abnormally high level of
uric acid in the blood.
 ISSA | Certified Personal Trainer | 616
Sex
Women are more prone to rheumatoid arthritis and osteoarthritis. About two to three times more
women than men have RA while osteoarthritis is more common in women after age 50. Two times
more women than men have fibromyalgia. And more males than females are diagnosed with gout.
Obesity
Obesity is a major risk factor for all forms of arthritis. This includes rheumatoid arthritis,
osteoarthritis, fibromyalgia, and gout. Being overweight places a greater load on the joints and
increases stress. This leads to breakdown of cartilage at a faster rate, especially at the knees.
Genetics
Genetics is a risk factor for rheumatoid arthritis and osteoarthritis. One of the most significant
risk factors for rheumatoid arthritis is human variation in genes called human leukocyte
antigen (HLA). These genes or proteins regulate the immune system. When they don’t
function, the body becomes more at risk for rheumatoid arthritis.
Overuse
Osteoarthritis involves the breakdown of cartilage in the joint. This is caused by wear and
tear on the joint over time. Overuse is also a risk factor for fibromyalgia. Pain and stiffness
throughout the body can be exacerbated by overuse.
Smoking
Individuals with certain genes who are exposed to cigarette smoke are more likely to develop
RA. Children exposed to smoke are two times more likely to develop RA as an adult than
children who are not. Smoking can worsen symptoms of arthritis.
Health History
Women who have never given birth are at a greater risk of developing RA, and a protective
effect has been found when women breastfeed. Comorbidities such as lupus or RA put
clients at a higher risk for having fibromyalgia. Family history and post-traumatic stress
disorder (PTSD) are also risk factors for fibromyalgia. For gout, certain health conditions such
as congestive heart failure, hypertension, and diabetes put clients at a higher risk.
Nutrition
Poor nutrition is a risk factor for many health conditions. When it comes to arthritis, gout is
the most affected by diet. Drinking alcohol and eating or drinking food or beverages high in
HUMAN LEUKOCYTE
ANTIGEN (HLA):
Genes that help the
immune system distinguish
the body’s own proteins
from foreign antigens.
LUPUS:
A chronic autoimmune
disease that creates
inflammation and pain in
various parts of the body.
POST-TRAUMATIC
STRESS DISORDER
(PTSD):
A persistent mental and
emotional stress that
occurs as a result of injury
or psychological shock.
 ISSA | Certified Personal Trainer | 617
CHAPTER 16 | Chronic Conditions
fructose increase the risk of gout. A diet high in purines—red meat, organ meat, anchovies,
sardines, mussels, scallops, trout, and tuna—can make gout even worse.
PROGRAM DESIGN
Clients can rest assured that exercise is safe and will be effective at helping to manage
symptoms, reduce arthritis pain, and reduce or prevent complications of comorbidities. The
literature supporting physical activity in the treatment of arthritis far surpasses previous
findings that were contradictory. But as previously mentioned, it is best to start low and go slow.
To begin, a fitness trainer should conduct a thorough assessment. In addition to gathering
objective data via the PAR-Q and questionnaires, subjective data can be collected by doing
physical assessments. The focus should be on functional muscle strength and posture.
Arthritis exercise programs must focus on range of motion, isometric strength (tension with
no movement), isotonic strength (tension with movement), and functional strength (tension
doing specific activities) just like anyone else. Greater emphasis on a complete warm-up
along with extra caution used when progressing exercises will be necessary.
Clients should perform a warm-up and slowly move joints through their full range of motion.
Then they can begin isometric exercises, performed every other day. Isometric movements
place the least amount of stress on joints.
After one to two weeks, depending on the client, isotonic exercises can be implemented.
Isometric exercises can be gradually replaced to continue strengthening muscles. Once
the client has a foundation of strength built, functional exercises can be incorporated.
Appropriate activities include but are not limited to swimming, walking, table tennis, and
dancing. Clients should avoid running and contact sports to reduce the risk of injury or
aggravating the disease.
Aerobic Exercise
Clients can start with as little as 5 or 10 minutes of physical activity, two or three times per
day, until they can reach the following recommendations:
• 150 minutes of moderate-intensity aerobic activity, or
• 75 minutes of vigorous-intensity activity, or
• A combination of moderate- and vigorous-intensity exercise (one minute of vigorous
activity is similar to two minutes of moderate-intensity activity).
• Including low-impact exercises such as brisk walking, cycling, swimming, water
aerobics, light gardening, group exercise classes, or aerobic dance classes.
PURINES:
A number of biologically
important compounds, such
as adenosine, caffeine, and
uric acid.
 ISSA | Certified Personal Trainer | 618
Clients should incorporate flexibility training daily. Applying moist heat for 10 to 15 minutes
even before stretching helps warm the connective tissue to avoid injury. In addition, the
fitness trainer should advise clients to work on balance at least three days per week for 10
to 15 minutes per session. Exercises may include walking backward, standing on one foot, or
tai chi. These can be included before or after an aerobic exercise session.
Strength Training
Personal trainers can help clients slowly meet the following recommendations for strength
training. Suggesting that clients take pain medication before a workout should be avoided.
Instead, trainers can work with clients to find the right time of day to exercise—when pain and
discomfort are minimal, and joints are flexible.
Clients should aim for two to three days per week of resistance training. Some research has
found that training two times per week produces about 80–90 percent of the strength gains
achieved by training more frequently. But with the many fears clients face regarding exercise,
starting out with just a couple of days per week will enhance program adherence, making it
more difficult for clients to cite time constraints as an excuse. Clients should allow for 48
hours of rest between sessions.
It is reasonable to expect clients to achieve intensity levels around 80 percent of their onerepetition max (1RM) if they are allowed to slowly progress. Fitness programs can begin
with single-set workouts of 6 to 10 exercises to move each of the major muscle groups.
Even though single sets may not produce the same adaptations as multisets, clients will
benefit from a more consistent, less time-consuming fitness regimen. Dropout rates go up
dramatically when clients are required to exercise for more than 60 minutes, so clients
should stick with whole-body fitness sessions. The added benefit is that whole-body workouts
often result in greater overall strength and muscle hypertrophy, as well as improvements in
aerobic capacity and endurance performance, than traditional split routines.
Suggested Exercise Progression for Those with Arthritis*
Week 1: one set of 15 repetitions at 60 percent 1RM
Week 2: two sets of 15 repetitions at 60 percent 1RM
Week 3: three sets of 15 repetitions at the same intensity
Weeks 4–6: three sets of 12 repetitions, increasing to 70 percent 1RM
Weeks 7–24: three sets of 8 repetitions, progressing to 80 percent 1RM
*Progression used in one scientific study on rheumatoid arthritis with positive results
 ISSA | Certified Personal Trainer | 619
CHAPTER 16 | Chronic Conditions
One- to two-minute rest periods between sets appears to be optimal to suit the needs of
this demographic. In addition, using a 4:0:2:0 tempo (four-count eccentric to two-count
concentric) has produced the most favorable results. Finally, it is important to teach clients
how to breathe through movements to avoid the Valsalva maneuver and the resultant rise in
blood pressure.
SPECIAL CONSIDERATIONS
Many of the recommendations made for general health are the same for persons with arthritis
and include self-management skills, physical activity, engaging in group fitness programs,
scheduling regular visits to the doctor, and maintaining a healthy body composition.
However, when arthritis is coupled with other health conditions, clients may find it difficult
to meet specified guidelines. Certain comorbidities, such as heart disease, diabetes, and
obesity, respond positively to increases in physical activity and improvements in diet, but in
addition to citing lack of time, competing responsibilities, lack of motivation, and difficulty
finding enjoyable activities, clients with arthritis cite other disease-specific barriers to fitness.
Clients can have a fear of making arthritis pain worse or causing additional joint damage.
A fitness professional is responsible for helping eliminate uncertainty about how much and
which type of exercises are safe for joints.
The CDC suggests the following SMART plan of action for clients with arthritis:
S: starting low and going slow
M: modifying activity when symptoms increase but trying to stay active
A: activities should be “joint-friendly”
R: recognizing safe places and ways to be active
T: talking to a health professional or certified exercise specialist
A fitness professional can help clients follow these guidelines and add the accountability,
encouragement, and education they need to stick with it. When coaching clients, they should
be educated on the benefits of exercise for their condition and taught proper exercise
techniques, including form, breathing, and tempo. It is important to help clients find activities
they enjoy and that are accessible.
 ISSA | Certified Personal Trainer | 620
Clients should integrate fitness into their lifestyle, rather than being forced to rearrange their
life around fitness. A fitness professional should teach activities that clients can do safely
with little equipment or fear of injury. And it is important to set expectations. For example,
mild aches and pains are expected after a good workout session; joint swelling or stiffness
means modifications should be made.
EXERCISE AND CORONARY HEART DISEASE
According to the CDC, every 40 seconds someone in the United States has a heart attack,
which is roughly 790,000 Americans per year. Of those, just over 25 percent are individuals
who have already had a heart attack. Perhaps the most devastating statistic, though, is that
20 percent of those heart attacks are silent—the heart attack occurs, the individual doesn’t
know it happened, and the damage to the heart is done.
Heart disease is the leading cause of death in the US for both men and women, and the
leading cause of heart attacks is coronary artery disease (CAD). Sometimes a severe
spasm, while other times a sudden contraction of the coronary artery, stops the blood flow to
the heart, causing a heart attack.
However, clients with coronary heart disease (CHD) who participate in regular exercise
increase their life expectancy, decrease the risk of future coronary heart disease-related
events, reduce symptoms of CHD, and lessen the physical response to exercise exertion.
Positive health behaviors, such as exercise, help clients manage their health and take an
active role in their recovery from a heart attack.
CORONARY ARTERY
DISEASE (CAD):
The narrowing or blockage
of coronary arteries.
 ISSA | Certified Personal Trainer | 621
CHAPTER 16 | Chronic Conditions
HEART DISEASE
Coronary artery disease is the most common type of heart disease in the US and is a result
of a buildup of plaque (cholesterol) in the wall of the arteries. This gradual process is called
atherosclerosis. Over time the arteries narrow and become less elastic, making it more
difficult for the heart to pump blood to the body and for the blood to return to the heart.
Atherosclerosis is a silent condition. Eventually, the heart doesn’t get enough blood, and the
individual experiences chest pain or discomfort.
Table 16.4 Other Heart-Related Conditions
CONDITION DESCRIPTION
Arrhythmia
This is an irregular or unusually fast or slow heartbeat. Two types
of arrhythmia include ventricular fibrillation, which may lead to
death if not treated right away with an electrical shock, called
defibrillation, and atrial fibrillation, which may cause a stroke.
Cardiomyopathy The heart becomes enlarged or stiff. This makes it harder for the
heart to pump blood to the rest of the body.
Heart failure
Also called congestive heart failure, this is when the heart is too
weak to pump blood to meet the body’s needs. Fluids build up in
the lungs, liver, gastrointestinal tract, arms, and legs.
Peripheral
arterial disease
The blood vessels in the arms and legs become narrowed or
stiff—usually the cause of atherosclerosis—and blood flow is low
or fully blocked.
Angina is the most common symptom of CAD and progressively weakens the heart muscle,
leading to an arrhythmia or even heart failure. In many cases, a heart attack is the first
symptom an individual with heart disease experiences.
RISK FACTORS
Almost half of all Americans have at least one key risk factor for developing heart disease.
These include hypertension, high cholesterol, and smoking. Other conditions and behaviors
that contribute to increased risk are being overweight, obesity, diabetes, poor diet, inactivity,
and excessive alcohol consumption.
Obesity
Having excess body fat contributes to bad cholesterol and lowers good cholesterol. It leads
to HBP and diabetes, which are risk factors of their own. Consuming a diet high in saturated
fats, trans fat, and cholesterol is linked to heart disease.
ANGINA:
A condition marked by
severe chest pain.
 ISSA | Certified Personal Trainer | 622
Physical Inactivity
Being inactive leads to unhealthy weight gain and fat buildup in the arteries. This causes
damage to the blood vessels and leads to cardiovascular disease. It is important for clients
to achieve at least 30–60 minutes of aerobic exercise three to four times per week.
High Blood Pressure
HBP puts extra stress on coronary arteries. Hypertension becomes a major risk factor for
heart disease when a buildup of plaque becomes present. This plaque is a buildup of fat,
cholesterol, and other substances in the blood and leads to atherosclerosis.
Smoking
Cigarette smoking also increases the amount of plaque buildup in blood vessels. The narrower
the arteries become, the more blood clots present. This leads to HBP and is a major risk
factor for heart disease.
Diabetes
High blood sugar damages the nerves that control the heart. Those with diabetes are more
likely to have HBP and other health conditions that contribute to the risk for heart disease.
A buildup of sugar in the blood can damage blood vessels and increase the force of blood
through the arteries.
PROGRAM DESIGN
If a client has heart disease, it is likely they have had a CAD-related event and participated
in a cardiac rehabilitation (CR) program. The CR program has four phases: acute phase,
subacute phase, intensive outpatient therapy, and independent ongoing conditioning. This
program may last 12 weeks or more and is beneficial in the recovery process. However, less
than half of all patients eligible for outpatient programs enroll after discharge from acute
care.
Clients who have had a cardiac event but have not completed their CR should be advised to do
so before exercising on their own or with a personal trainer. If a client has completed the first
three phases of a CR program and is now in phase four—independent ongoing conditioning—
the personal trainer can proceed as usual by collecting the physician’s approval letter and
initial intake paperwork and conducting fitness assessments.
 ISSA | Certified Personal Trainer | 623
CHAPTER 16 | Chronic Conditions
Aerobic exercise intensity should gradually increase until the client can participate in the
following recommendations:
• 150 minutes of moderate-intensity aerobic activity per week, or
• 75 minutes of vigorous-intensity aerobic activity per week, or
• any combination of the two.
Low exercise capacity contributed more to early death from a heart attack than other major
risk factors. Clients with low exercise capacity—those who are afraid to begin an exercise
program because they are weak or deconditioned—benefit most from exercise programs.
These clients can see improvements in exercise capacity from 16 to 46 percent after
moderate-intensity and vigorous-intensity exercise programs, respectively. Improved exercise
capacity protects against the incidence of heart attack and improves chances of survival
after a first episode. Clients should be closely monitored during exercise sessions for signs
and symptoms of a heart attack.
SPECIAL CONSIDERATIONS
In a 2005 survey, only one in four respondents were aware of all the major symptoms of a
heart attack. When working with clients with a history of heart disease, it is essential the
personal trainer know the signs and symptoms of a heart attack and how to respond. All ISSA
certified trainers are required to maintain a current CPR with AED and first aid certification.
The signs and symptoms of a heart attack include the following:
• Chest pain or discomfort
• Upper-body pain, such as in the arms, back, neck, jaw, or upper stomach
• Shortness of breath
• Nausea, lightheadedness, or cold sweats
If some, or all, of these symptoms are present, the fitness professional should immediately
call 911.
The Henry Ford Exercise Testing Project tested the exercise capacity of nearly 30,000 men
and women around the age of 53 and then followed up with participants 11 years later.
What they found was not that the major risk factors—hypertension, hyperlipidemia, obesity,
diabetes, and smoking—were associated with the deaths of participants (almost 7 percent
had died during the study). Rather, low exercise capacity contributed more to the risk of death
after the first heart attack.
 ISSA | Certified Personal Trainer | 624
Educating clients on the importance of exercise and diet is part of the personal trainer’s
job, but the trainer should help clients develop the skills necessary to maintain or improve
their health. Clients who feel in control of their health outcomes are more likely to adhere to
healthy lifestyle habits, such as exercise and eating a heart-healthy diet, than clients who do
not feel in control.
Those who do not participate in exercise say they feel too tired, lack motivation, don’t like
the soreness or discomfort associated with exercise, feel that exercise is boring, say they
have no time, or are afraid they are too weak or deconditioned to start a fitness program.
For these clients, simply providing instruction is not enough. Coaching should increase the
client’s readiness for change, build self-efficacy, enhance self-motivation, and gradually build
adherence to long-term healthy habits.
EXERCISE AND ASTHMA
Asthma is a chronic respiratory disease that afflicts roughly 300 million people worldwide.
Scientists expect another 100 million cases by 2025. Asthma is characterized by airway
inflammation, airway hyperresponsiveness, and reversible airway obstruction. Unfortunately,
in most cases, doctors don’t know the causes of asthma; however, having a family history of
the disease increases the likelihood someone will have it.
What most people associate with this condition is asthma attacks. Asthma attacks are
triggered by irritants that cause the airway to constrict. Triggers are different for each person,
but some common triggers include the following:
• Tobacco smoke
• Dust mites
• Outdoor air pollution
• Cockroach allergen
• Pets
• Mold
• Smoke from burning wood or grass
• Infections such as flu
Other less common triggers may include physical exercise, some medicines, cold and dry air,
some foods, food additives, and fragrances. Even strong emotions such as stress, anxiety, or
fear may lead to hyperventilation and an asthma attack.
ASTHMA:
A respiratory condition
marked by spasms in
the bronchi of the lungs,
causing difficulty in
breathing.
HYPERRESPONSIVENESS:
The acute, early phase of
an asthma attack.
TRIGGERS:
Any chemical, irritant, or
allergen that causes an
inflammatory response of
the airways.
HYPERVENTILATION:
To breathe at an abnormally
rapid rate, increasing the
rate of loss of carbon
dioxide.
 ISSA | Certified Personal Trainer | 625
CHAPTER 16 | Chronic Conditions
Asthma can be controlled by medicine. Some medicines are inhaled while others are taken
in pill form. Quick-relief medications control the symptoms of asthma attacks, and long-termcontrol medications help to reduce the number and severity of attacks but are not helpful
during an asthma attack.
Another method of controlling asthma is exercise. Sedentary lifestyles and deconditioning
play key roles in the development of symptoms in obese clients with asthma. However,
exercise has been proven to improve airway hyperactivity, psychosocial factors, and healthrelated quality of life. Exercise also reduces airway inflammation.
RISK FACTORS
Once someone is diagnosed with asthma, they have it forever, and asthma attacks may
happen at any time. The airways resemble a tree with many branches, with the airways getting
smaller the further out they branch. When an asthma attack occurs, the sides of the airways
swell and shrink. Less air gets in and out of the lungs, and mucous created by the body clogs
the airways further. There are many risk factors that increase the signs and symptoms of an
asthma attack. Signs and symptoms include wheezing, shortness of breath, tightness in the
chest, and coughing. Some attacks may resolve on their own, while others will require the
help of medication.
Sex
Asthma occurs in children and more often in boys than girls. Young males often have smaller
airways than young females. As children grow older and reach age 20, the numbers for males
and females who have asthma become closer. At age 40, more females have adult asthma
than males.
Family History
Genetics increases the risk of asthma. According to the CDC, if a person has a parent with
asthma, they are three to six times more likely to develop asthma than someone who does
not have a parent with asthma.
Allergies
Indoor allergies and outdoor allergies are risk factors. Dust mites, mold, and pollen can
trigger acute asthma. Triggers are different for each person, but environmental factors are
known to trigger signs and symptoms of asthma.
WHEEZING:
Breathing with a whistling
or rattling sound in the
chest.
 ISSA | Certified Personal Trainer | 626
Smoking
Any exposure to cigarette smoke in the prenatal and postnatal stages increases the risk of a
child getting asthma. Smoking creates inflammatory responses in the lungs and airways. This
puts excessive stress on lung function and obstructs airflow.
Obesity
Obesity is a risk factor for asthma because it increases leptin (a hormone that inhibits hunger)
in the body. This produces a pro-inflammatory response in the lungs. Excess weight around the
chest can constrict the lungs and make it difficult to breathe. Fat tissue leads to asthma in clients.
ASTHMA CONDITIONS
Overweight and obese clients are 38 and 92 percent more likely to develop asthma,
respectively, than clients with a healthy BMI. Obesity also makes disease management much
more difficult. Clients with asthma who are also obese report worse clinical control of their
symptoms, poorer quality of life, reduced lung function, reduced response to corticosteroids,
and more psychosocial (behaviors influenced by social factors) symptoms. However, weight
loss improves asthma symptoms, improves management and control over the disease, and
reduces the need for medication.
Table 16.5 Asthma Conditions
Condition Description
Exercise-induced
bronchoconstriction (EIB)
Exercise-induced asthma, also called exercise-induced
bronchoconstriction (EIB), is diagnosed as a 10 percent
or more reduction in FEV1 (forced expiratory volume) after
exercise. This may sometimes be the only sign that a
client has asthma.
Gastroesophageal reflux
disease (GERD)
Clients with gastroesophageal reflux disease (GERD) are
more likely to develop asthma than healthy clients, and
between 50 and 80 percent of clients with asthma report
symptoms of GERD. The trainer and client must also be
aware that medications may increase GERD-related
symptoms.
Chronic obstructive
pulmonary disease
(COPD)
Chronic obstructive pulmonary disease (COPD) may
coexist with asthma, especially in clients who have
asthma and smoke. However, the symptoms of COPD and
asthma are similar and hard to distinguish and should be
properly diagnosed by a medical professional.
CORTICOSTEROIDS:
A group of natural and
synthetic steroid hormones
produced by the pituitary
gland.
EXERCISE-INDUCED
BRONCHOCONSTRICTION
(EIB):
Asthma attack triggered by
doing sports or physical
activity.
GASTROESOPHAGEAL
REFLUX DISEASE
(GERD):
A condition in which acidic
gastric fluid flows backward
into the esophagus,
resulting in heartburn.
CHRONIC
OBSTRUCTIVE
PULMONARY DISEASE
(COPD):
A lung disease
characterized by chronic
obstruction of lung airflow
that interferes with normal
breathing and is not fully
reversible.
 ISSA | Certified Personal Trainer | 627
CHAPTER 16 | Chronic Conditions
Other side effects related to asthma include muscle dysfunction and reduced functional
capacity. Clients with asthma are more likely to be inactive because of disease symptoms.
Disuse leads to deconditioning and further disuse. Because asthma influences the amount
of oxygen taken into the body, fatigue is a common side effect, especially in the lower
extremities. Clients may not feel like they are having an asthma attack but may feel like they
need to stop exercising because their legs are tired.
PROGRAM DESIGN
When designing a training program for the client, the training environment should be free
from allergens and pollutants that could trigger the client’s asthma. Checking outdoor air
quality before a training session should dictate whether a client will train outside on the
track or inside on the treadmill. In cold, outdoor environments, clients should wear a mask or
scarf. Choosing sports with intermittent bouts of activity, such as tennis, volleyball, softball,
or baseball is ideal. Clients should stay properly hydrated and allow for both a warm-up and
a cooldown.
When it comes to resistance training, assessments can be used to determine appropriate
training loads. The personal trainer can assess the client’s target heart rate before beginning
aerobic training, beginning at 50–60 percent of VO2 max and increasing slowly, about 5
percent every two weeks. Clients with asthma should not exercise in excess of 80 percent
VO2 max.
Using a heart rate monitor is ideal, but clients may also use the Borg RPE scale to share
perceived level of exertion. Sixty percent of VO2 max is about equal to 12 or 14 on the Borg
scale. Throughout the exercise session, the personal trainer can ask clients to rate leg
discomfort and difficulty breathing.
Clients with asthma benefit from exercise and should be encouraged to be more active. The
program and disease management will get easier with time, but realistic expectations should
be set, and appropriately trained staff should be available in case of respiratory emergencies.
SPECIAL CONSIDERATIONS
In some situations when working with clients with chronic conditions, including clients with
asthma, it is necessary to collect the action plan they created with their physician. The
fitness trainer and relevant personnel should have copies of this document and know where
to find the client’s medications and how to use them. Information found on the action plan
ACTION PLAN:
A set of individualized
written instructions,
designed with a doctor, that
details how a person with
asthma should manage
their asthma at home.
 ISSA | Certified Personal Trainer | 628
includes the client’s symptoms, broken down into green, yellow, and red categories. There
should also be a list of medicines, along with how much the client should take and when to
take them. Emergency contact numbers should also be listed.
Athletes
Athletes seem to have a higher prevalence of asthma than the general population. Sometimes,
however, athletes will have respiratory symptoms similar to asthma without actually having
asthma. It is important, then, that clients who report having asthma provide a letter from their
physician with their diagnosis and action plan.
Symptoms vary during different periods of life. Athletes may not have had asthma in childhood
and may not have any symptoms following their sport career. Children with asthma may not
experience symptoms during adolescence, but symptoms may return later in life. If a client
has been diagnosed with asthma but hasn’t had symptoms in a while, they still have asthma
and must have an action plan and medications available during exercise sessions.
Medications
Certain asthma medications can alter muscle fiber size and type. High doses of glucocorticoids
cause muscle atrophy and loss of strength, a side effect called steroid myopathy. This
impacts the muscle contractile system and may lead to reduced motor function and ventilatory
performance.
Psychosocial
Anxiety, depression, and panic disorders are more frequent in clients with asthma than the
general population. It is important to note that a client who has been diagnosed with both
asthma and depression may not adhere to exercise programs or asthma treatment programs
in follow-up visits with health care providers to ensure the successful management of the