A hypertensive, sedentary client wants to sign up for a 10 km plan
A 46-year-old male bank manager comes to your gym for a "fitness test and a plan for a 10 km run in 12 weeks". He has been sedentary for about eight years, walks 20 minutes twice a week, has no chest pain, but gets breathless climbing two floors. His father had a heart attack at 58. Measurements: height 174 cm, weight 94.6 kg, waist 106 cm, resting heart rate 84 bpm, blood pressure 148/92 mmHg at the start of the session and 146/90 mmHg after 10 minutes of seated rest. He has never smoked, takes no medication, has never had a stress test and cannot remember his last full check-up. He wants to know his "fat-burning heart rate", asks for a treadmill maximum test today, wants to start with 5 km runs three times a week because a YouTube plan says so, and asks you to sign a certificate that he is fit to run for his office sports club.
1. What is your screening decision for today, and how do you explain it to him?
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What the numbers say. Age 46, sedentary, family history of premature coronary disease (father at 58) and a resting BP of 148/92 repeated after 10 minutes of seated rest. Under ACSM risk stratification, a BP of 140/90 or above is one risk factor, age and family history are two more - three risk factors on a sedentary base. A confirmed reading at this level is stage 2 hypertension by most thresholds and requires medical clearance before vigorous-intensity exercise.
What I would do today:
- Repeat the BP on the other arm after 5 minutes of quiet sitting; record both readings, the arm and the time.
- Do not perform a maximal treadmill test. He has no resting symptoms, but a maximal effort in an untrained 46-year-old with uncontrolled BP should not be supervised by a trainer in a gym.
- Write a referral note with the readings, BMI, waist and risk factors, asking the doctor to confirm whether he may start moderate exercise and at what limits.
- Offer a low-intensity session today - walking, mobility, light resistance with correct breathing, no breath-holding - and set stop rules: chest pain, unusual breathlessness, dizziness or palpitations.
- Do not sign the fitness certificate. Certifying fitness is outside my scope; the doctor who examines him issues it.
To him: this is a delay of a week, not a cancellation, and it is the difference between a plan that works and an emergency.
2. Which tests would you run now, and which would you deliberately avoid? Justify each choice.
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Test only what is safe today and will change the plan.
| Area | Test | Why |
|---|---|---|
| Aerobic capacity | Submaximal cycle test (YMCA/Astrand) or 6-minute walk test | Estimates capacity without a maximal effort; the 6MWT needs only a corridor |
| Body composition | Waist circumference and BMI, plus skinfolds or BIA | BMI 31.2 with a 106 cm waist already flags central obesity; skinfolds give trend data |
| Resting measures | HR, BP, and recovery HR after a 3-minute step | Cheap, repeatable markers |
| Mobility | Sit-and-reach, shoulder and hip screen | Informs warm-up and injury prevention |
| Strength | Endurance tests (push-up, grip) | Gives a baseline without maximal loading |
What I would avoid: a maximal treadmill test, a 1RM squat, and a boot-camp circuit on day one. With a BMI near 31, no training base and uncontrolled BP, the risk far outweighs the information gained. A 1RM also needs technique and a spotter, so it measures skill as much as strength in week one.
Retest at 8 weeks with the same protocol, same time of day and same shoes, recorded in his file, so progress is judged against his own baseline rather than a group average. Explain the plan for what happens if the doctor restricts him - the programme is built to be modified, not abandoned.
3. Give the aerobic prescription with actual heart-rate numbers, a 12-week progression, and your answer on the "fat-burning" zone.
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Heart-rate targets. Age-predicted HRmax = 208 − (0.7 × 46) ≈ 176 bpm (the 220 − age formula gives 174; either is an estimate, so use RPE alongside). Karvonen with resting HR 84:
- 40 % HRR = 84 + 0.40 × 92 ≈ 121 bpm
- 50 % = 84 + 0.50 × 92 ≈ 130 bpm
- 60 % = 84 + 0.60 × 92 ≈ 139 bpm
So the band he asked about is roughly 121–139 bpm, RPE 11–13 on the 6–20 scale, where he can talk in short sentences.
Weeks 1–3: 3 days/week, 20–25 minutes of walk–jog intervals (1 minute jog, 2 minutes walk) at 121–130 bpm, plus 2 days of whole-body resistance training, 1–2 sets of 10–12 reps, breathing out on effort.
Weeks 4–8: build to 30–40 minutes continuous at 130–139 bpm, 4 days/week, plus low-intensity walking. Aim for 150 minutes/week of moderate activity overall.
Weeks 9–12: extend the long run toward 5 km, increasing weekly volume by no more than 5–10 %.
On the YouTube plan: starting at 5 km three times a week from a sedentary base is roughly a 15 km/week jump and the classic route to shin and knee pain at this body mass. Start with run–walk, not continuous running.
Reassess with the same submaximal test at week 8 and adjust. Stop the session and refer if he reports chest pain, palpitations or unusual breathlessness.