Fred would benefit significantly from the exercise referral scheme as it is a psycho-social intervention and would therefore allow Fred to suggest his own personal goals with the practitioner. This is an imperative aspect of the programme as it provides a greater sense of accomplishment and control for the individual upon improvement. Also, it is easier for the client to continue independently once the intervention terminates.
Goal Setting
Personal goals set for Fred should be ‘SMARTER’:
S – Specific
Fred needs specific goals so that he has a target to aim for, he can take control of his lifestyle and so he can distinguish/eliminate what works well for him and what he enjoys.
M – Measurable
The client can measure body fat using bioelectrical impedance, this method is more efficient than using scales as lean body mass and excess body fat can be distinguished. Blood pressure can be measured using a blood pressure monitor showing whether the client is hypertensive (>140mmHg systolic and >90mmHg diastolic), normal (120-139 mmHg systolic and 80-89mmHg diastolic) or optimal (<120mmHg systolic and 80mmHg diastolic), (Durnstine and Moore, 2003). Weight loss can also be measured by measuring waist circumference.
A –Action/Acceptable
How Fred accomplishes the goal must be planned so that he can prepare himself thoroughly for the exercise session/lifestyle modification. Fred must decide his own goals so that he is entirely happy with the goal setting and doesn’t feel too pressurised or stressed.
R – Realistic
The goals must be realistic otherwise the intervention will be unsuccessful and not applicable once the intervention is complete. If unrealistic goals are set, this may result in a lower self-esteem of the client and possible withdrawal from the programme. Realistic modifications for Fred would be starting with a slight change to his lifestyle with exercise at a moderate intensity of 40% VO2 max. It would not be appropriate to use %HRR as the client is using beta blockers as medication to lower blood pressure and therefore the heart rate is artificially lower and would give an unreliable measurement. With regards to intensity it is required to use RPE or %VO2 so that Fred can self assess his work out and whether the exercise is too strenuous for him. A small decrease in body fat should be expected at completion of the six week programme.
T – Time Frame
It is desirable for short term goals to be accomplished by 6 weeks of the intervention however, any improvement is praised as individual differences result in varied durations of goal achievements.
E – Evaluate/Exciting
Evaluation of the scheme is imperative as it considers enjoyment of the regime and how well Fred has adapted to the modifications. The scheme must be kept exciting for the client in order to prevent stagnation and/or withdrawal from the programme. This can be achieved by varying exercise with respect to the activities undertook as well as surroundings (i.e. swimming pool, going for walks etc). It is also exciting for the client as it can help increase social circles and can meet people who are in a similar situation and can motivate and support one another. Providing awareness of foods so that the client can still enjoy the foods they like but in moderation or low fat alternatives can keep the client involved in the programme, as they don’t feel like they are making extreme sacrifices or changes and therefore their ‘new lifestyle’ still characterises familiarity and habitual pattern .
R – Review/Rewarding
Reviewing the intervention is essential as it monitors Fred’s improvements and progress so he can observe his development. The scheme is rewarding as it improves health status, overall well being, reduces risk of CAD and provides a sense of self accomplishment (Wormald et al, 2006 and Hillsdon et al, 2005).
Fred’s first short term goal is to introduce exercise into his lifestyle and aim to exercise twice a week.
S - Brisk walking at 40% VO2 max, 12 on RPE scale (see appendix 1)
M – Walk with a stopwatch or wrist watch and use pedometer for reviewing and evaluating.
A – Wear appropriate clothing and footwear for safety whilst exercising. Plan a walking route. Substitute getting the bus for walking whenever possible.
R – Fred can walk his dog regularly
T – 2 sets of 15minute bouts at least twice a week for 6 weeks
E – Evaluation can be carried out by a feeling of overall well being, weight loss, improved health status and/or ease in everyday activities. It can be kept exciting by varying the route taken for different surroundings, different gradients and different surfaces.
R - The exercise can be reviewed by number of steps taken per day via the pedometer to record improvements. Self assessments can also be used to review whether the exercise is too strenuous or not demanding enough via RPE and how the activity can be improved to suit the clients’ needs. It is rewarding as it allows a sense of accomplishment and improves health status.
Fred’s second short term goal is to cut down on fast food consumption.
S – Substitute fast food snacks for healthier alternatives and aim to lose 1lb per week
M – 500 Kcal deficit per day in energy intake. Measure weight loss via waist circumference or bio-electrical impedance as this distinguishes between lean body mass and body fat percentage.
A - Prepare food the previous evening to take to work and refer to food labels for nutritional value.
R – Instead of 3 large meals per day, introduce 5 smaller meals consisting of breakfast, 3 meals during breaks at work from driving the lorry and an evening meal.
T – 6 weeks
E – Overall well-being can be evaluated eg. Feeling less lethargic, weight loss and how well the modification is working with Fred and his lifestyle. Reducing fast food intake can still be kept exciting as it can be incorporated as a treat sporadically or consume low fat alternatives.
R – Food diaries are a useful method for reviewing dietary consumption throughout the six week intervention. Weight loss, improved health status and increased self perception are also good indicators of reviewing the programme and are also rewards.
Long term goals for Fred include:
-
Reducing overall risk of coronary artery disease (CAD) such as atherosclerosis, reducing systolic blood pressure to <130mmHg,
-
Reducing diastolic blood pressure to <85mmHg and
- Losing excess body fat (around 1lb per week). This could be achieved by increasing caloric deficit to 1,000 Kcal over a period of 6-9 months and increase physical activity to 45 minutes a day four/five times a week.
Program Design
Each exercise session would include a five minute warm up before exercising and a five minute cool down after exercising.
Week one and two of the six week exercise programme - circuit training
Week three and four of the six week exercise programme – Circuit training
Week five and six of the six week exercise programme – Circuit Training
It was calculated using predicted maximum oxygen uptake that Fred should exercise at an intensity of between 4.2 and 5.2 METS and is suggested by Durnstine and Moore, (2003) that exercise intensity should be between 50% and 85% of VO2peak carried out 4-7days a week for 20-60mins per session. However, as Fred is currently leading a sedentary lifestyle it would be unrealistic to start his prescription with extensive, vigorous exercise. Therefore it is suggested to Fred that he starts with light exercise twice a week to ease him into the regime and then progress.
Cardiovascular exercise is prescribed for Fred mainly due to the desired loss of excess body fat and the fact that he gets out of breath quickly when playing with his children. When this loss is achieved there should be a consequent decrease in systolic and diastolic blood pressure (reducing the risk of stroke), insulin resistance will be reduced and an increased production of HDL cholesterol. According to the Department of Health (2004) CHD related mortality is also reduced by 50% when individuals become more active (Moore, Murphy and Raisanen, 2006). The goals anticipated from cardiovascular activity include increasing VO2max, increasing ventilatory threshold, increasing caloric expenditure and lowering systolic and diastolic blood pressure.
Durstine and Moore, (2003) explain that endurance training elicits an average reduction of 10mmHg in both systolic and diastolic blood pressure in individuals with stage 1 or 2 hypertension. This applies to Fred as he is at stage 1 hypertension falling in the category of between 140-159mmHg systolic and 90-99mmHg diastolic. Suggestions for activity for Fred to partake in could consist of playing football with the children, cycling, brisk walking, jogging or swimming etc.
Flexibility exercises can improve range of motion (ROM) in joints for the client. When clients have led a sedentary lifestyle, joints can stiffen and decrease range of motion. Therefore, by exercising these problem areas, joints and muscles can become supple and more flexible allowing Fred to increase mobility (Zakas, 2006). ROM exercises can easily be incorporated into his lifestyle via rotating ankles, neck and wrists etc. For example, Fred could rotate his neck or rotate his ankles during breaks from driving his lorry at work. The sit and reach test or yoga are also beneficial with regards to flexibility and yoga can help reduce levels of stress. Fred could also use the sit and reach test as a measure to monitor his progress with regards to flexibility (Barbosa, 2002).
Muscular strength exercises are beneficial for Fred as it helps maintain lean body mass, it is recommended that he uses a low resistance with more reps and short resting breaks. This is suggested by Rose (2007) as Fred is not looking to gain muscle bulk, merely to gain lean body mass.
Modifications Fred could make to his lifestyle could include walking his dog for 20-30 minutes per day, this could be unitary, interval or included in cross training with activities such as weights or swimming. It would be recommended to Fred to exercise in intervals as he will fatigue fairly quickly due to the beta blockers.
Fred could substitute picking up food from fast food outlets either with healthier alternatives, snack on foods such as fruit or consume five small meals per day instead of three large meals as this would also stabilise regular blood glucose levels throughout the day and prevent hypoglycaemia. As Fred likes to watch the children play football, he could incorporate flexibility exercises into this by warming up whilst encouraging the children to do so also. Once Fred has transitioned from preparation to action in the behavioural change model (Breckon, 2008), it is then essential for maintenance of the regime to be achieved. Relapse can occur and is fairly common during weight loss programmes and can have negative effects with regards to motivation for the individual.
Safety Precautions
Safety precautions must be administered to ensure that the client is performing physical activity in a safe environment with minimal hazards. It is imperative that the client warms up before exercise and cools down after exercise, this is so heart rate can stabilise progressively without a sudden change. Warm ups/cool downs also ensure muscle suppleness before exercise to reduce risk of injury.
Food and hydration are also safety aspects that the client must be made aware of and considered so that the client does not dehydrate or doesn’t exercise soon after a substantial meal. As Fred has type 2 diabetes, he should measure his blood sugar level before and after exercise, carry dextrose tablets, snacks and/or a bottle of juice in case his blood sugar level drops too low and drink plenty of fluids to help prevent dehydration.
Clients must obey the correct technique for the exercise and stick to their agreed intensity, duration and progression applied to them.
Exercise equipment should be checked so that the clients do not use faulty equipment or exercise with incorrect resistance etc.
Suitable clothing and footwear should be worn at all times by the participant when partaking in exercise or physical activity, this is to reduce risk of injury.
Finally, it is strongly recommended to the client that they stop exercising if they feel any discomfort, pain or fatigue etc and as Fred is taking medication, it is essential that he stops exercising if he experiences respiratory problems, dizziness, feels light headed or fatigue which are all side effects of beta-blockers.
In conclusion, it is recommended that Fred modifies his lifestyle starting with introducing light exercise. From monitoring his progress via self assessments, food diaries and measurements such as heart rate, RPE, blood pressure and weight loss Fred can progress by gradually increasing intensity, duration and frequency of the activities in order to achieve the long term goal of losing weight and reducing risk of disease.
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APPENDIX 3 – Blood Pressure Chart
Information = Applies to Fred