**3. Dyslipidemia**

Dyslipidemia is a derangement of lipids in the blood. It is further defined by the presence of elevated levels of total cholesterol or low-density lipoprotein (LDL-C), elevated levels of triglycerides (TG), or low levels of high-density lipoprotein (HDL-C). Among the causes of dyslipidemia, the most common cause is poor lifestyle choices which includes diet; however, genetic constitution plays a significant contributing role, and increased levels of cholesterol often cluster within familial groups [8]. Lifestyle modifications are the basis of treatment for dyslipidemia even for patients who may ultimately require medicines to manage their dyslipidemia. Exercise has its remarkable effects on dyslipidemia, although the effect is often minimal. Aerobic exercise training persistently reduces LDL-C by 3–6 mg/dL (0.17–0.33 mmol/L) but does not appear to have a consistent effect on HDL-C or TG blood levels [9]. The American College of Sports Medicine makes the following recommendations regarding exercise testing and training of individuals with dyslipidemia.


*1-RM, one repetition maximum; HRR, heart rate reserve; HRrest, resting heart rate; PNF, proprioceptive neuromuscular facilitation; RPE, rating of perceived exertion; VO2R, oxygen uptake reserve; VO2peak, peak oxygen uptake.*

#### **Table 2.** *FITT principle for Dyslipidaemia.*

#### **3.1 Exercise testing**

In general, an exercise test is not mandatory for asymptomatic patients prior to beginning an exercise training program at a light to moderate intensity. One should be meticulous when investigating people with dyslipidemia because undiagnosed CVD may be present. Special consideration should be given to the underlying prevalence of chronic diseases and health conditions (*e.g.*, Metabolic syndrome, obesity, hypertension) that may require modifications to standard exercise testing protocols and modalities.

#### **3.2 Exercise prescription**

An important difference in the FITT principle of Exercise Prescription for clients with dyslipidemia as compared to normal adults is that weight maintenance as per height and age should be highly emphasized. Further, aerobic exercise for the purpose of increasing energy expenditure (EE) for weight loss becomes the basis of the Exercise treatment, and the FITT recommendations (**Table 2**) are in line with the recommendations for healthy weight loss and maintenance of 250–300 min/wk. [11].

Resistance and flexibility exercises are adjuncts to an aerobic training program because these modes of exercise have less consistent beneficial effects in patients with dyslipidemia as compared to healthy adults [12]. Generally, flexibility training is recommended for usual health benefits only.

#### **4. Hypertension**

Hypertension is defined by the 7th Report of the Joint National Committee (JNC7) on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure as having a systolic blood pressure (SBP) ≥140 mm Hg at rest and/or a diastolic blood pressure (DBP) ≥90 mm Hg at rest, confirmed by at least two measures taken on two separate days, or consuming antihypertensive drug for the purpose of BP control [13]. Primary hypertension is responsible for 95% of all hypertensive cases and is a risk factor for CVD and premature mortality. The known factors responsible for primary hypertension include genetic constitution and lifestyle factors such as high-fat and high-salt diets and physical inactivity [14]. Secondary hypertension is responsible for the remaining 5%. The principal causes of secondary hypertension are diseases like chronic kidney disease (CKD), renal artery stenosis (RAS), pheochromocytoma, excessive aldosterone secretion, and sleep apnea [15]. The rate of switch from prehypertension to hypertension is related to age, initial BP, and comorbidities. Apparently, hypertension is not a feature of human aging but the result of poor lifestyle choices [16]. The ACSM recommends for Hypertensive clients:

#### **4.1 Exercise testing**

Hypertensive patients may have an extraordinary BP response to exercise, even if resting BP is under control [17]. Recommendations over exercise testing for hypertensive patients vary depending on their BP level and the presence of other CVD risk factors, target organ disease, or clinical CVD [18, 19]. For most asymptomatic hypertensive and prehypertensive individuals' adequate control of BP prior to engaging in light-to-moderate intensity exercise programs such as walking is sufficient with no need for evaluation by a physician or exercise testing [20]. Recommendations include the following: Hypertensive patients whose BP is not controlled (*i.e.*, resting SBP ≥140 mm Hg and/or DBP ≥90 mm Hg) should consult *Exercise Prescriptions for Co-Morbid Conditions DOI: http://dx.doi.org/10.5772/intechopen.98339*


*1-RM. One repetition maximum; HRR, heart rate reserve; PNF, proprioceptive neuromuscular facilitation; VO2R, oxygen uptake reserve.*

#### **Table 3.**

*FITT principle for hypertensive patients.*

a doctor prior to starting an exercise program to determine if an exercise test is needed. Individuals with stage 2 hypertension (SBP ≥160 mm Hg or DBP ≥100 mm Hg) or with target organ disease (*e.g.*, left ventricular hypertrophy, retinopathy) must not begin exercise regimens, including exercise testing, prior to due evaluation and adequate BP management by a physician. Intensive evaluations may vary depending on results of the exercise test and the lifestyle vital signs of the individual. Exercise testing is performed for the specific purpose of designing the Exercise Prescription, it is always recommended that individuals take their usual antihypertensive medications as recommended [20]. Individuals on β-blocker therapy are likely to have an sub-optimal HR response to exercise and reduced maximal exercise capacity. People on diuresis may experience hypokalemia and other dyselectrolytemia, cardiac dysrhythmias, or potentially a false-positive exercise test.

#### **4.2 Exercise prescription**

Aerobic exercise of adequate intensity, duration, and volume that promotes an increased exercise capacity leads to reductions in resting SBP and DBP of 5–7 mm Hg and decrease in exercise SBP at suboptimal workloads in hypertensive patients [21]. Decrease in cardiac wall thickness and left ventricular mass in hypertensive patients who participate in persistent aerobic exercise training [22] and a lower left ventricular mass in prehypertensive patients and a moderate-to-high physical fitness status have also been reported [23]. Emphasis is laid on aerobic activities; however, these may be augmented with moderate intensity resistance training (**Table 3**). Some evidence exists that resistance exercise alone can lower BP, although the evidence is inconsistent. Flexibility exercise should be performed after a considerable warm-up or during the cool-down period following the guidelines for healthy adults.

## **5. Metabolic syndrome**

A consensus definition of Metsyn [10] includes hyperglycemia (or current blood glucose medication use), elevated BP (or current hypertension medication use), dyslipidemia (or current lipid-lowering medication use), and national or regional cut points for central adiposity based on waist circumference; however, differences in specific value within these criteria remain. It is further agreed that an individual is categorized as having Metsyn when he or she displays at least three of the defining risk factors.

#### **5.1 Exercise testing**

Metsyn *per se* does not require an exercise test prior to beginning a low-tomoderate intensity exercise program. If an exercise test is performed, the general recommendations can be adhered to, with particular consideration for dyslipidemia, hypertension, or hyperglycemia when present. Because many patients with the Metsyn are either overweight or obese, exercise testing recommendations specific to those individuals should be followed [24]. The lower potential for exercise in overweight or obese individuals' stresses upon to start with low initial workload (*i.e.*, 2–3 metabolic equivalents [METs]) and then make step up approach per testing stage (0.5–1.0 MET). Presence of increased BP warrants protocols for assessing BP before and during exercise testing [25].

#### **5.2 Exercise prescription/special considerations**

The FITT principle of Exercise prescriptions in Metsyn is usually in line with the recommendations for healthy population regarding diverse array of exercises. Similarly, the min amount of PA to improve health/fitness outcomes is in line with the public health recommendations of 150 min/week or 30 mins of moderate intensity PA on most days of the week [26]. However, due to the aggravated CVD and DM risk factors, along with the likely presence of chronic diseases and health conditions that accompany Metsyn, the following Exercise Prescription considerations are recommended: When developing the Ex Rx for Metsyn, focus is to be given to each risk factor present, with the most conservative criteria used to set initial workloads. Gradually and as tolerated, longer duration and higher intensities may be required to achieve substantial health and fitness outcomes. To reduce the impact of the Metsyn, risk factors for CVD and DM, initial exercise training should be performed at a moderate intensity (*i.e.*, 40–59% O2R or HRR) totaling a min of 150 min/wk. or 30 min/d most days of the week to allow for optimal health/fitness improvements. When appropriate, progress to a more vigorous intensity (*i.e.*, ≥60% O2R or HRR). Reduction of body weight, an important target in Metsyn [27]; therefore, gradually increasing PA levels to approximately 250–300 min/week or 50–60 min on 5d/ wk. may be necessary when appropriate. Daily and weekly amounts of PA may be accumulated in multiple shorter bouts (≥10 min in duration) and can include various forms of moderate intensity lifestyle PAs. For some individuals, progression to 60–90 min/d of PA may be mandatory to promote or maintain weight loss. Resistance and aerobic training together, can produce greater decreases in Metsyn prevalence as compared to aerobic training alone. Reported participation in ≥2 d/wk. of muscle strengthening activity reduces the risk of acquiring dyslipidemia, IFG, prehypertension, and increased waist circumference, all part of the Metabolic syndrome [28].
