Risk Stratification and Assessment in a Client With Type 2 Diabetes
A 58-year-old man (5 ft 8 in, 214 lb, BMI 32.5) wants to start training. He has type 2 diabetes diagnosed 6 years ago (A1c 7.8%, fasting glucose 155 mg/dL), hypertension (resting BP 142/88 on lisinopril), and a father who had an MI at 56. He takes metformin and lisinopril. He walks 10 minutes twice weekly, denies chest pain, but reports occasional numbness in both feet. Resting HR 82, no known retinopathy. He wants to 'get stronger and lose 25 lb' and asks if he can start with heavy dumbbell training and interval sprints.
1. Determine his risk category and clearance needs, and identify which findings change your exercise recommendations.
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Known type 2 diabetes plus multiple risk factors (age >45, family history, hypertension, obesity, sedentary lifestyle) places him in a high-risk category. He needs medical clearance before starting an exercise program, especially before vigorous training. His resting BP of 142/88 should be reviewed by his physician. The foot numbness suggests possible peripheral neuropathy, so daily foot inspection, proper footwear, and balance work matter. A1c 7.8% means glucose monitoring around sessions. Heavy dumbbell training and sprints are inappropriate initially because of BP response, Valsalva, and possible silent ischemia; start moderate-intensity aerobic and low-to-moderate resistance work after clearance.
2. Which fitness assessments would you perform now, which would you defer, and why?
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Now: resting BP and HR, waist circumference and BMI, a submax aerobic test such as a 6-minute walk or YMCA cycle test, sit-to-stand, push-up test, flexibility, and a foot sensation/inspection screen. Defer: 1RM testing, sprint or interval testing, and maximal treadmill testing until medical clearance is obtained and BP is controlled. Rationale: submax tests give a baseline with lower risk; maximal tests require clearance and may provoke BP or glucose events.
3. Using his resting HR of 82, calculate a moderate-intensity target HR range with the Karvonen method (40-59% HRR) using age-predicted HRmax, and explain how you would monitor intensity given his medications.
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HRmax = 220 - 58 = 162. HRR = 162 - 82 = 80. 40% = 82 + 0.40(80) = 114. 59% = 82 + 0.59(80) = 129. Target range = 114-129 bpm. Because lisinopril can affect BP and his HR response may be altered, use RPE 11-13 and the talk test alongside HR. Stop for chest pain, dizziness, or unusual dyspnea. Monitor glucose before and after exercise; if glucose is <100 mg/dL, eat carbohydrate first.