The American College of Cardiology (ACC) and the American Heart Association (AHA), along with nine other organizations, recently released updated blood pressure guidelines.

What are the changes?

The 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults is the first major revision of the guidelines in more than a decade, replacing "Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure" (JNC 7), which published in 2003. Watch the AHA video regarding the update.

The 2017 update includes the following key changes:

• emphasizes the importance of structured exercise in the prevention and treatment of hypertension

• adjusts the category names and thresholds

• lowers the definition of high blood pressure from 140/90 mm Hg to 130/80 mm Hg

SBP, Systolic Blood Pressure; DBP, Diastolic Blood Pressure.

Why are the changes important?

According to 10th edition of ACSM's Guidelines for Exercise Testing and Prescription, hypertension appears to be the result of lifestyle factors such as diets high in salt and fat intake, excess body weight, and physical inactivity. Hypertension is the leading cause of cardiovascular disease and premature mortality.

The revised guidelines from the AHA mean an increase in the number of patients diagnosed with hypertension, up to 46% of adults in the United States.

However, nonpharmacological treatments, such as diet modifications and increased physical activity, are recommended for most adults who are classified as hypertensive under the new guidelines. The increased emphasis on the importance of structured exercise further reiterates the mission of one of ACSM's key initiatives, Exercise is Medicine®, and the many other spokes that circle this important message.

How does this affect ACSM members and is ACSM updating their resources to incorporate these changes?

ACSM's resources are in the process of being updated to reflect these important updates from the AHA. Check ACSM's social media channels, the ACSM Blog, the Certification Blog, and Certified eNews for additional information.

• All ACSM members: The ACSM Blog hosted guest authors Linda S. Pescatello, PhD, FACSM and Paul D. Thompson, MD, FACSM to provide their expert take on the impact of the revised AHA guidelines.

• Certified Professionals: Watch the Certification Blog and Certified News for guidance on how this change affects what you do. If you are not yet certified, the exams will reflect the updated guidelines no earlier than January 2019. 

• Clinicians: We encourage you to read the 2017 guidelines and related resources and advise your patients of how the revised guidelines affect them.

• General Public: If you're concerned about your blood pressure, see your doctor. They can discuss ways to prevent or manage hypertension with lifestyle changes such as adjusting the amount of salt and fat in your diet, losing weight, and increasing your physical activity level. The AHA site also has great resources such as understanding blood pressure readings, making lifestyle changes, adding physical activity, and many more.

Additionally, the senior editors and authors of our book resources have weighed in on the impact of these changes for recently published titles. The updates will be reflected in the ebooks and book updates page immediately.

For more information please contact the following:

• Media and press inquiries, please contact the ACSM Communications and Public Information Department: publicinfo@acsm.org

• For questions regarding publications and related content, please contact the ACSM Publications Department: achastain@acsm.org

• For certification or exam questions, please contact the ACSM Certification Department: certification@acsm.org

High blood pressure (hypertension) is redefined for the first time in 14 years by the American College of Cardiology and American Heart Association Task Force on Clinical Practice Guidelines. The new threshold for high blood pressure is 130or 80 mmHg versus the old standard of 140 or 90 mmHg, as was defined by the Joint National Committee Seven on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)¹. The change means 46 percent of adults in the United States now have hypertension, compared with 32 percent according to the old JNC 7 definition. Furthermore, the JNC 7 term prehypertension, defined as a resting systolic blood pressure from 120 to 139 mmHg or diastolic blood pressure from 80 to 89 mmHg, has been eliminated, and the new term elevated blood pressure, defined as resting systolic blood pressure from 120 to 129 mmHg and diastolic blood pressure < 80 mmHg, has been added. See the figure below for the new blood pressure classification scheme and other Highlights from the new 2017 Guideline for the Prevention, Treatment, Evaluation and Management of High Blood Pressure in Adults².

What do the new guidelines mean for your patients and clients with high blood pressure? 

According to Dr. Paul Thompson, Chief of Cardiology at Hartford Hospital, and 42^nd President of the American College of Sports Medicine,

If you had come into my office in the past in that 130-to-140 mmHg range, I might have left you alone, maybe told you to keep an eye on it, improve your diet or exercise more. Even though the new guidelines recommend not prescribing medications for most patients* until they reach 140/90 mmHg, I think many doctors will. Keep in mind these are guidelines, not rules, so it will be up to the doctor to decide. This is also a lifestyle alert. The lower hypertension definition gives people a better chance to address their high blood pressure with exercise, weight loss, better diet, less sodium, and moderate alcohol use.

What do the new guidelines mean for you, the exercise professional?

The good news, as Dr. Thompson indicates, is the new guidelines are a lifestyle alert.  Indeed, they state, “Even though more people will be classified as having hypertension . . . nearly all of these new patients can treat their hypertension with lifestyle changes instead of medications . . . with the biggest impacts being changes to diet and exercise.”  In the report, physical activity was rated among the best nonpharmacologic interventions for the prevention and treatment of hypertension as it lowers blood pressure 5 to 8 mmHg among adults with hypertension³. The blood pressure lowering effects of exercise occur from lower to higher intensity, when exercise is continuous or accumulated in shorter bouts, and after both aerobic and resistance exercise.  Dr. Thompson also likes to emphasize to his patients that you do not have to “get in shape” to get the blood pressure benefits from exercise since blood pressure is lowered immediately following a single session of exercise for up to 24 hours. In other words, 30 minutes a day of exercise, might help keep the medicines away.  Nonetheless, the immediate blood pressure lowering effects of exercise, termed postexercise hypotension, were not addressed in thereport.    

The new guidelines recommend 90 to 150 minutes per week of moderate-to-vigorous intensity, aerobic and resistance exercise training which is a bit of a departure from the American College of Sports Medicine (ACSM) recommendations regarding intensity and modality^4,5.  However, since the publication of the ACSM position stand on exercise and hypertension over a decade ago, accumulating evidence indicates the importance of higher exercise intensity⁶, and dynamic resistance⁷ and concurrent (i.e., aerobic and resistance combined)⁸ exercise in addition to aerobic exercise to lower blood pressure among adults with hypertension. The ACSM is in the process of revising its 2004 position stand on exercise and hypertension as a systematic review and meta-analysis of this newer evidence. Stay tuned!

*Those with known cardiovascular disease, diabetes melllitus, or chronic kidney disease or an atherosclerotic cardiovascular disease risk score >10%, the new guideline recommends both lifestyle and pharmacological treatment for those with a systolic blood pressure >130 mmHg or diastolic blood pressure >80 mmHg.  If the atherosclerotic cardiovascular risk score is <10%, lifestyle modification is recommended for those in these blood pressure ranges.  For those with a systolic blood pressure >140 mmHg or diastolic blood pressure >90 mmHg, lifestyle and pharmacological treatment are recommended. Learn more here. 

References

1. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL,Jr, Jones DW, Materson BJ, Oparil S, Wright JT,Jr, Roccella EJ, Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. National Heart, Lung,and Blood Institute, National High Blood Pressure Education Program Coordinating Committee. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003; 42(6):1206-52.

2. The American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines released the 2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults [Hypertension, 2017].

3. Cornelissen,  VA, Smart,  NA. Exercise training for blood pressure: a systematic review and meta-analysis. J Am Heart Assoc. 2013b. 2(1):e004473

4. Pescatello LS, Franklin BA, Fagard R, Farquhar WB, Kelley GA, Ray CA, et al. American College of Sports Medicine position stand: Exercise and hypertension. Med Sci Sports Exerc. 2004;36:533-53.

5. ACSMs Guidelines for Exercise Testing and Prescription 10^thEdition.  Riebe, D (senior ed.) and Ehrman, JK, Liguori, G, and Magal, M (assoc. eds.).  Philadelphia, PA:  Wolters Kluwer Health, 2018.

6. Pescatello LS, MacDonald HV, Ash GI, Lamberti LM, Farquhar WB, Arena R, Johnson BT. Assessing the existing professional exercise recommendations for hypertension: A review and recommendations for future research priorities. Mayo Clin Proc [Internet]. 2015 Jun;90(6):801-12.

7. MacDonald,  HV, Johnson,  BT, Huedo-Medina,  TB, et al. Dynamic Resistance Training as Stand-Alone Antihypertensive Lifestyle Therapy: A Meta-Analysis. J Am Heart Assoc. 2016. 5(10):#pages#

8. Corso,  LM, Macdonald,  HV, Johnson,  BT, et al. Is Concurrent Training Efficacious Antihypertensive Therapy? A Meta-analysis. Med Sci Sports Exerc. 2016. 48(12):2398-2406

Linda Pescatello, PhD, FACSM, is a Distinguished Professor of Kinesiology at the University of Connecticut. Her research on topics including exercise and hypertension, physical activity interventions and exercise genomics (among other topics) has been widely published. She was the recipient of an ACSM Citation Award in 2011, and served as the Senior Editor for ACSM's Guidelines for Exercise Prescription and Testing, 9th edition. 

Dr. Paul Thompson, M.D., FACSM is the Chief of Cardiology at Hartford HealthCare Heart and Vascular Institute in Hartford, CT. His research in the area of heart disease and cardiac function have been widely published. He served as the 42nd President of the American College of Sports Medicine 1998-1999. 

Activity trackers (ATs) are once again at the top of the ACSM fitness trends (clocking in at #3 on the 2018 list). Why is this? With 80 percent of the US population failing to meet the recommended cardiorespiratory and resistance training guidelines, maybe people are looking for a different and/or more convenient way to motivate themselves toward a healthy lifestyle. 

It is hard to research ATs in this world of changing technology. We do not know if wearing ATs changes behavior over time (the research is mixed and not very robust) but we know the business of ATs is booming. It is expected that ATs will generate $53 billion in sales by 2019, and an estimated 75 million people will use an AT by 2021!

Has technology invaded the fitness world much the same way it has invaded many other aspects of our lives? The real question is: IS THIS HEALTHY AND DO THEY WORK TO SUSTAIN A LIFESTYLE CHANGE? Currently we do not have enough research to say one way or the other.

Two past HFJ articles on ATs by Segar (1) and Kiessling et al. (2) shed some insights on this dilemma. Segar, a motivation scientist at the University of Michigan, suggested ATs, although valuable tools, are only tools, and that something additional must be included to provide motivation (1). Segar believes ATs do not address behavior change sustainability. She suggests you must realize WHY you want to move BEFORE you start counting steps.

Kiessling et al. (2) initiated a Ready to Move (RTM) program combining activity tracker usage with health coaching (2). The health coaches were students enrolled in a course that taught motivational interviewing and behavioral intervention strategies. The students were encouraged to address clients’ core motivations for movement. Participants in this program did experience success in learning about the devices, and they stated that they enjoyed the freedom the device allowed for fitting movement into their day.

A research focus that includes behavioral components of the impact of ATs might help us to understand their effects. Technology continues to challenge us to look at new and different ways to accomplish goals. What we do know is that ATs (whether accurate or not) have intrigued us to count steps, self-motivate, and participate in social challenges with others to move more and sit less.

If this top ACSM trend is going to continue, our hope is that researchers focus on a behavioral/social perspective and research the impact of ATs on sustainable behavior change. For now, let us appreciate that ATs are here to stay whether we like them or not (and whether they are accurate or not). One thing is for sure; they cost less and are much easier to transport and move than weights and treadmills. In addition, they remind us that there is more to health and wellness than movement/exercise alone since they also track sleep, getting up regularly, and other health parameters.

1. Segar M. Activity trackers and motivational science. ACSMs Health Fit J. 2017; 21(4): 8-17.

2. Kiessling B, Kennedy-Armbruster C. Move more, sit less, be well. Behavioral aspect of activity trackers. ACSMs Health Fit J. 2016; 20(6): 26-31.

Carol Kennedy-Armbruster, Ph.D., FACSM, is a Senior Lecturer within the Department of Kinesiology at Indiana University, Bloomington. She has worked in both the private and university setting during her 30 years in the fitness/wellness industry as an educator and supervisor of fitness staff. She has taught/created academic courses on group leadership, personal training, and fitness management and produced books and DVD’s on group exercise, water exercise and functional exercise progressions. Shehas served on multiple editorial/review committees and advisory boards during hertenure as a member of ACSM. She has presented both nationally and internationally on various fitness/wellness topics and is certified as a Group Exercise Instructor & Health Fitness Specialist.

Do you or a client have a bucket list of races or events you have been wanting (and needing?) to check off? These events often take place in exotic locales that present challenging environmental obstacles. Bucket lists can be a great motivational tool, but excitement and anticipation can quickly turn into fear and dread when you realize the performance decrement associated with racing in environmental extremes.

One example of such environmental extremes are races held at elevation (Western States 100, Leadville 100, UTMB, etc.). Indeed, endurance performance at altitude is compromised. This is due to several physiologic factors including decreases in oxygen saturation and plasma volume, and increased cardiovascular challenges. For this reason, best practice suggest at least 14 days of exposure to moderate altitude (5,000 to 8,000 feet) is necessary to acclimate to hypoxia¹. Outside of a fortunate few people, 14 days at altitude represents limitations as far as time (goodbye vacation days!), geography (anyone live near Whitney Portal?), or finances (who wants to cash in their Roth IRA?).

However, there are new lines of evidence that demonstrate exposure that culminates in adaptation to one environmental extreme can improve performance in a different environmental extreme. This phenomenon has been labeled cross-tolerance and is primarily attributed to changes at the cellular level. For example, a male cyclist improved 28 seconds over 16 km time trial at 14,271 feet after 10 days of heat acclimation compared to the time trial before the heat acclimation process². You see, the adaptations that are associated with exercise in the heat resulted in better performance at altitude (i.e., cross-tolerance). Similarly, heat acclimated subjects improved performance to a comparable degree as hypoxic-acclimated subjects during a 16 km cycling time trial at 14 percent fraction of inspired oxygen (similar to ~9,000 feet)³. Two important conclusions can be drawn from these data: 1) heat acclimation improves endurance performance in hypoxia and 2) endurance performance at elevation is improved after heat acclimation to the same degree as acclimation to hypoxia. This means that exercising in a hot environment could prepare you for exercising in hypoxia (and prepare you to a similar degree as training in hypoxia).

Heat acclimation is a relatively easy process that takes about 7 to 10 days. Each exercise session should be about 90 minutes in a hot environment. However, should you find yourself needing to become heat acclimated in the dead of winter, there's still hope. Simply conclude each exercise bout with a soak in hot water (~40°C). Researchers showed that training in 18°C followed by a 40-minute soak in hot water led to classic markers of heat acclimation (lower exercising core temperature, earlier onset of sweating, etc.)⁴. The best part, however, was that after 6 days of soaking after each training bout, 5 km run time improved almost 5 percent compared to the group that didn't sit in hot water (that's taking off almost one minute for a 19:00 5k!).

Heat acclimation will last as long as one is exposed to exercise in a hot environment (or hot water baths). Once this exposure ends there is about 1 week until acclimation starts to lessen, and after about 3 weeks, 75 percent of the benefits are lost5. With exercise in the heat it's important to use caution and monitor for signs of heat illness (headache, nausea, dizziness, etc.). Start exercising in the heat slowly and begin to add time as you feel more comfortable with this new stressor.

So quit putting off that dream race because of fears that racing at altitude will bring you to your knees. Don't stress that time, finances, or geography may limit your ability to acclimate to elevation. Rather, leverage the cross-tolerance phenomenon and get heat acclimated to perform better at elevation.

References
1. Schuler B, Thomsen JJ, Gassmann M, Lundby C. Timing the arrival at 2340 m altitude for aerobic performance. Scand J Med Sci Sports. 2007; 17(5): 588-94.
2. White AC, Salgado RM, Astorino TA, et al. The effect of 10 days of heat acclimation on exercise performance in acute hypobaric hypoxia (4350 m). Temperature. 2016; 3(1): 176-85.
3. Lee BJ, Miller A, James RS, Thake CD. Cross acclimation between heat and hypoxia: heat acclimation improves cellular tolerance and exercise performance in acute normobaric hypoxia. Front Physiol. 2016; 7: 78.
4. Zurawlew MJ, Walsh NP, Fortes MB, Potter C. Post-exercise hot water immersion induces heat acclimation and improves endurance exercise performance in the heat. Scand J Med Sci Sports. 2016; 26(7): 745-54.
5. Pandolf KB. Time course of heat acclimation and its decay. Int J Sports Med. 1998; 19: S157-S60.

It is hard to believe that this month (November) marks 10 years since the Exercise is Medicine® (EIM) initiative was created during my tenure as president of the American College of Sports Medicine. It is exciting to look back and reflect on how far this initiative has come and where it can go in the future. As a family medicine physician, I have observed first-hand the harmful effect that a sedentary lifestyle can have on my patients. And, as an ACSM member, I became keenly aware of the vast scientific evidence base being assembled that has clearly demonstrated the health benefits of being physically active. It was obvious to me that, if such compelling evidence had been developed around a pill or surgical procedure, every doctor around the world would want to prescribe it to their patients — in fact, it would be malpractice not to do so! 

To me, it made perfect sense back in 2007 to use my pulpit as ACSM president to work toward making physical activity assessment and exercise prescription a standard part of the disease prevention and treatment paradigm for all patients. Along with that, I felt we needed to work toward merging the fitness industry with the health care industry so that physicians could refer inactive patients to a fitness professional and perhaps avoid increasingly costly pills and procedures. 

The first five years of EIM mainly involved getting the word out, building infrastructure and establishing collaborations (see SMB, May 17, 2011). During the last several years, there have been a variety of efforts to move EIM forward in an increasingly complex and changing health care landscape, including education, partnerships, outreach and policy work. 

Some key highlights include:

1. Building an EIM global health network, including seven regional centers that coordinate EIM partnerships in some 43 countries around the world. These are linked by a robust website designed to enhance communication and collaboration across this network;

2. Establishment of the World Congress on Exercise is Medicine as a central component of the ACSM annual meeting. The congress provides an annual dynamic forum for scientists, clinicians, health policy specialists and others to share the latest information on research and build collaborations across the country and around the world;

3. Growth of a vibrant EIM on Campus network that now includes 164 college and university campuses around the world and is still growing;

4. Development of a global EIM CME course to teach health care providers how to assess, counsel and refer patients for physical activity prescription to treat and prevent chronic disease;

5. Creation of an EIM Credential to qualify all NCCA-certified fitness professionals to receive and work with patients referred from health care providers;

6. Successful piloting of the EIM Solution model — linking clinical care/Physical Activity Vital Sign (PAVS) to community networks — at the Greenville Health System and the Greenville YMCA;

7. EIM partnerships with various health care associations and fitness organizations that have helped drive important programs to improve physical activity; specific partnerships include the Surgeon General’s Call to Action on Walking, the Every Body Walk! Collaborative and the Prescription for Activity Task Force.

On this 10th anniversary of EIM, the ACSM Board of Trustees has begun a process entitled “EIM Re-imagined,” the goal of which is to redefine EIM priorities to help guide its program efforts in the coming years. Key areas for advancement will include further establishing the use of the PAVS as a standard of care around the world. That standard encompasses identification of all inactive patients, counseling them and, perhaps, referring them to a qualified fitness professional as part of the EIM Solution. Working to establish collaborations with the health club and fitness industries is the third component of the EIM Solution. It requires redefining the role of fitness professionals and the clubs where they deliver exercise services — enabling them to provide patients with therapeutic exercise to prevent and/or treat chronic disease. Along with this should come reimbursement for services and recognition of the vital role the fitness industry can play in improving global health. We also want to expand the reach of EIM On Campus so that no student will leave a college campus less fit than when they entered and without a lifetime plan for their personal fitness. Further, there are plans for advocacy initiatives to increase funding support available for physical activity research; this initiative should emphasize funding for interventional studies to compare use of physical activity interventions in place of pills and procedures, as well as studies focused on clinically relevant behavior change and on sustaining lifelong physical activity habits. 

Finally, the ACSM Board of Trustees has established an EIM governance board to guide and work closely with our new vice president of EIM, Robyn Stuhr, M.A., ACSM-RCEP. Robyn is a longtime member of ACSM who brings more than 30 years of clinical and leadership experience in health care, including sports medicine, health promotion, business and occupational health, and cardiac rehabilitation. She is positioned to be the perfect addition to the EIM team that will help achieve the lofty goals set for the next 10 years. We hope that all ACSM members will look for their niche in the EIM program and contribute to its advancement at your local, state, national and international levels. 

For more information and to get involved with Exercise is Medicine, contact us at EIM@acsm.org.

Robert E. Sallis, M.D., FACSM, served as the 51st President of ACSM and chairs the Exercise is Medicine^® Advisory Board. He originated the EIM concept and has been its leading advocate from the beginning. Dr. Sallis earned an M.D. from Texas A&M University and completed his residency in family medicine at Kaiser Permanente Medical Center in Fontana, California. He has continued his medical career with Kaiser and now co-directs their sports medicine fellowship training program. Dr. Sallis is the founding editor-in-chief of ACSM's Current Sports Medicine Reports journal. Exercise Is Medicine® was launched in partnership with the American Medical Association and continues to grow as a global health initiative.