Define the difference between overweight and obese: normal weight if they have a BMI from 18.5 to 24.9, overweight if they have a BMI from 25 to 29.9, obese if they have a BMI of from 30 to 39.9, and extreme obesity if their BMI is greater than or equal 40.
Understand the reasons for the growth of obesity domestically and internationally.
Technology and physical inactivity
Food accessibility and marketing
Understand statistically how this epidemic affects the adult and youth populations…individuals 20-29 years old and older than 70 have the lowest prevalence of being obese.
Adults: healthier people will live longer, and obese individuals are less likely to live past the age of 60.
women have a slightly higher prevalence of obesity at 36.3% compared with men at 35.5%
Youths: In addition to the health problems experienced by obese children, they tend to become obese adults.
individuals need to expend 2,000 kcal per week through activity in order to lose weight in comparison to the government’s minimal requirements that only aims to target 1,000 kcal per week to improve health
Body Mass Index, also known as Quetelet’s index
Metric Formula: BMI = Weight (kg) ÷ Height2 (m2)
89.1 ÷ (1.78m)2 = 28.1
Standard Formula: BMI = Weight (lbs.) x 703 ÷ Height (inches) ÷ Height (inches)
Some of the most common comorbidities found in obese individuals include:
Type 2 diabetes mellitus
…with approximately 25.6 million people suffering from it; it is estimated that nearly 90-95% of those cases are type 2 diabetes mellitus.
Insulin is a hormone produced by the pancreas that facilitates the uptake of glucose from the blood to various cells.
When a person has diabetes, one of two things is occurring in the body:
1) not enough insulin is being produced (production) by the pancreas, or
2) the glucose can’t be taken up (usage) by the tissues and used for energy.
Of these six components, abdominal obesity and insulin resistance (elevated fasting glucose) are thought to be the principal traits of metabolic syndrome as seen in a type 2 diabetic client.
The treatment for type 2 diabetes mellitus includes medication and exercise. Regular exercise works to improve daily glucose control and improve insulin sensitivity.
Physical activities can include any movements that involve the large muscle groups, such as walking, jogging, swimming, cycling, or stair-climbing.
The main goal for many patients should be to exercise at moderate to vigorous intensity (50% to 80% of VO2max) for 20 to 60 minutes per day, 3 to 7 days per week.
Exercise sessions should begin with a 5- to 10-minute warm-up and stretching of the muscles to be exercised, and conclude with a 5- to 10-minute cool-down period.
Resistance training should take a progressive approach, with patients starting with light weights (60-80% of 1 rep max), doing 2-3 sets of 8-12 repetitions, using all major muscle groups.
Individuals who have type 2 diabetes mellitus also are encouraged to increase physical activity throughout the day, and the use of step counters can serve as a way to set additional daily activity goals.
for patients who have peripheral neuropathy (nerve damage that often causes numbness in the hands and feet), diabetic retinopathy (damage to blood vessels of the eye), and nephropathy (kidney disease) should be avoiding extreme environments, proper foot care, avoiding the Valsalva maneuver (exhaling with a closed glottis), and paying special attention to hydration. All initial exercise sessions should be supervised if possible, the diabetic client should avoid exercising alone at any time, and those nearby should be informed of the possible complications of diabetes and exercise.
The term “heart disease” is a term often used to refer to a number of conditions involving a diseased heart, including myocardial infarction and coronary artery disease. A myocardial infarction is a heart attack, and coronary artery disease is caused by the narrowing of the vessels that supply blood and oxygen directly to the heart. This narrowing is usually caused by a condition called atherosclerosis, which occurs when cholesterol, in the form of plaque, builds up on the walls of the arteries. As the coronary arteries narrow, blood flow to the heart is reduced, which is myocardial ischemia, or it can stop, which is myocardial infarction. Any disruption of the blood flow to the heart can cause discomfort, including chest pain and shortness of breath.
If a client has heart disease, any exercise recommendation needs to be prescribed and monitored by the client’s physician. The health and fitness professional should not deviate from recommendations.
Hypertension is commonly referred to as high blood pressure.
Blood pressure readings are measured in millimeters of mercury (mm Hg) and are recorded as two numbers
The top number is systolic pressure: the pressure exerted on the arteries during ventricular contraction.
considered high if it is consistently greater than 140 mm Hg at rest.
The bottom number is diastolic pressure: the pressure exerted on the arterial walls during ventricular relaxation.
considered high if it is consistently greater than 90 mm Hg.
Prehypertension is when systolic blood pressure is between 130 and 139 mm Hg and/or diastolic blood pressure is between 80 and 89 mm Hg on multiple readings (Table 2.2).
anti-hypertensive medications such as beta blockers and diuretics disrupt the body’s ability to regulate body temperature during exercise. Additionally, beta blockers reduce the heart rate, which can adversely affect the percent of maximum heart rate at which clients should train. Alpha blockers, calcium channel blockers, and vasodilators may cause hypotension following exercise, making a cool-down very important
Acute bouts of resistance training will actually increase systolic and diastolic BP with only a small increase in heart rate, making exaggerated BP responses one concern about resistance exercise. A physician’s clearance is advisable before prescribing intense resistance training.
A stroke is similar to coronary heart disease except a cerebral artery becomes blocked and leads to a stroke. A stroke occurs when blood supply to part of the brain is blocked, or when a blood vessel in the brain bursts. Whichever part of the brain that does not receive adequate blood supply will suffer the damage.
Physician recommendations should always be followed.
obesity also places stress on the respiratory system. Carrying around excess fat leads to additional work that has to be done by the muscles just for activities of daily living and can interfere with breathing mechanics. Respiratory complications can range from shortness of breath with mild exertion to exercise induced asthma to obstructive sleep apnea.
Some mechanisms that may explain the relationship are that lung volume and tidal volume are reduced, which leads to airway narrowing along with an increase in inflammation affecting the ventilation-perfusion ratio…evidence is mounting that obesity occurs before asthma symptoms are present, and that weight loss results in improvements in symptoms
In sleep apnea, increased fat tissue and reduced lung volumes in people who are obese act together to cause airway closures during sleep…routinely do not get enough rest and suffer further from a host of issues associated with fatigue, in some cases including being unable to exercise.
According to the American Institute for Cancer Research, obesity either is or may be a cause of a number of cancers, and maintenance of a healthy weight throughout life may be one of the most important ways to protect against cancer.
Further, all forms of physical activity protect against some cancers. Unfortunately, weight gain, being overweight, and obesity also independently cause some cancers regardless of the level of physical activity.
Dyslipidemia is often referred to as high cholesterol, but it is actually a disorder of lipoprotein metabolism.
A lipoprotein is made up of lipid and protein. Dyslipidemia can be caused by an increase of total cholesterol, low-density lipoprotein (LDL) cholesterol, and in triglyceride concentrations, or a decrease in high-density lipoprotein (HDL) cholesterol concentration in the blood.
Exercise recommendations have varied considerably, and research has not yet determined the exact levels of physical activity that will maximally increase HDL, lower LDL and triglycerides, and slow or reverse atherosclerosis.
lifestyle modifications, such as losing weight and eating a healthy diet, can improve one’s lipid profile. Along with a healthy diet, losing as little as 5 to 10 pounds can help lower total cholesterol levels.
exercise and diet should be prescribed together
also called Syndrome X, is when several cardiovascular disease risk factors exist in combination. With these risks comes an increased chance of developing type 2 diabetes, cardiovascular disease, and stroke
Metabolic syndrome exists if a person has three or more of the following: abdominal obesity, dyslipidemia (high triglycerides, low HDL-C, or small LDL particles), elevated blood pressure, elevated fasting glucose, prothrombotic state (forming clots), or proinflammatory state (increased CRP levels) (25).
abdominal obesity and insulin resistance (elevated fasting glucose) are thought to be the principal traits of metabolic syndrome as seen in a type 2 diabetic client
Other factors associated with the syndrome are age, hormone imbalances, genetics, and physical inactivity.
the key to managing metabolic syndrome is lifestyle modification, with exercise and diet playing integral roles
Musculoskeletal issues can affect the body’s muscles, joints, tendons, and ligaments, and they can be quite debilitating. Common symptoms of musculoskeletal disorders include pain, weakness, stiffness, and decreased range of motion. Inflammation, which can cause pain, swelling, tenderness, and decreased function, may be one cause. One of the main causes of musculoskeletal issues is an injury, but problems also can be more chronic, stemming from being overweight, having poor posture, or repetitive movements. Common causes of musculoskeletal irritation are bruises, tendinitis, sprains, bursas, arthritis, and fibromyalgia. Another common problem that is experienced by many people is low-back pain caused by muscle imbalances.
Low-back pain (LBP) is the second-most common condition treated by primary care physicians today; cardiovascular issues are the first…the No. 1 cause of disability in the working population, and it is considered a global problem
Overweight and obese people, particularly those who have abdominal obesity, place an enormous amount of stress on the lowback muscles by pulling the lumbar spine “forward.”
Weight loss is often recommended for overweight and obese people who have musculoskeletal issues
Low impact physical activity may be an option for many in an effort to maintain low-back function.
Depression is related to obesity, but research has yet to determine whether obesity is a firm cause of depression or whether depression is a cause of obesity. Either way, with the prevalence of both conditions, it is not uncommon for them to occur at the same time
individuals who have abdominal obesity are more likely to have major or moderate-to-severe depressive symptoms
Although depression is a mental disorder that can be diagnosed only by a medical doctor, some of the common symptoms include feeling sad, guilty, or worthless; disturbances in appetite and sleep; low energy; and loss of interest in activities.
Calories are units of energy that are so small that even an apple provides tens of thousands of them.
scientists express energy in 1,000-calorie metric units known as kilocalories, or Calories
Technically, a kilocalorie is a unit of heat equal to the amount required to raise the temperature of 1 kg of water by 1˚ C at 1 atmosphere of pressure. This measurement is used by nutritionists to characterize the energy-producing potential in food. In other words, a kilocalorie (sometimes called a “nutritionist’s calorie”) is a unit of energy-producing potential equal to the amount of heat that is contained in food and released upon oxidation by the body. When talking about the energy value of food, kilocalories, or Calories, are commonly written as calories, with a lowercase “c.”
Like wood burning in the presence of oxygen, the body releases energy through metabolism. Metabolism is commonly defined as the entire range of biochemical processes that occur within any living organism. Metabolism consists both of anabolism (buildup) and catabolism (breakdown) of substances. Metabolic efficiency refers to the amount of energy an organism has to exert to perform a given amount of work. In a discussion of nutrition, the term “metabolism” often refers specifically to those processes that break down food, transform it to energy, and store the energy surplus. This text will use “metabolism” to refer to all chemical reactions that go on in living cells, and “energy metabolism” when referring specifically to the reactions of nutrient metabolism.
The study of thermodynamics and energy conservation is an examination of the relationships and conversions between heat, work, and other forms of energy.
The first law of thermodynamics (law of conservation of energy) states that the total amount of energy in any isolated system remains constant and cannot be recreated, although it may change forms.
In short, the first law of thermodynamics states that energy can change from one form to another but cannot be created or destroyed.
This fundamental principle of physics can be applied to biological systems in an effort to better understand the fundamentals of energy balance as they relate to weight control.
The regulation of energy homeostasis and body weight is controlled by numerous bioenergetic (metabolic) pathways and hormone (endocrine) control systems. The autonomic nervous system in conjunction with numerous endocrine hormones, most notably the thyroid hormone system, regulates energy expenditure. For example, thyroid hormones influence many metabolic functions throughout the body, including fat and carbohydrate metabolism, and growth. Thyroid hormones have a constant effect on energy expenditure and affect every cell in the body.
High concentrations of thyroid hormones tend to cause an increase in resting metabolic rate (RMR),
whereas lower-than-normal levels tend to cause a decrease in RMR.
Theoretically, a human body should maintain its weight if energy input (what a person eats and drinks) is equal to energy output (what a person expends).
To measure human metabolism, scientists use a variety of technologies and accompanying equations. The term basal metabolic rate (BMR) is used to describe the rate at which the body expends energy to maintain basic physiological survival.
The term resting metabolic rate is used as well, expressing the same concept but using slightly different measurement conditions.
BMR is measured while a person is awake but lying still after a restful sleep and an overnight fast.
RMR is slightly higher than BMR because the criteria for food intake and activity are not as strict.
The term resting energy expenditure (REE) is also commonly interchanged with RMR.
BMR makes up the majority of daily energy expenditure, with the other contributions coming from the thermic effect of food (TEF) and the thermic effect of physical activity (TEPA) at approximately 10%, and 15 to 30%, respectively.
TEF refers to an estimation of the energy required to digest, absorb, transport, metabolize, and store nutrients.
TEPA refers to an estimation of energy required to support physical work outside of BMR.
In a sedentary person, TEPA may account for less than half as much energy as BMR. An athlete, on the other hand, may have a TEPA equal to her BMR.
Generally, the more a person weighs, the more total energy he or she expends on BMR, but the amount of energy per kilogram of body weight may be lower.
For example, the BMR of an average healthy male weighing 73 kg may be 1,500 calories, and the BMR of a healthy 5.5 kg infant may be 300 calories. The total BMR of a child is clearly lower than an adult. However, the calories per kilogram for an infant is considerably higher.
Estimating Energy Needs
Basal Metabolic Rate (BMR)
With BMR representing as much as 75% of total energy needs, any estimation of energy requirement must try to accurately estimate BMR. The most common methods for estimating resting energy expenditure (REE)are published prediction equations…(Figure 3.1)…of these equations take into account individual weight, fat free mass (FFM), height, age, and/or sex.
For health and fitness professionals who will not be working with clients requiring clinical nutrition care, there is an easy estimate of REE that is derived from the Dietary Reference Intakes (9) using a reference male and female (1):
Men: slightly > 1 kcal/min (1.1-1.3 kcal/min)
Women: slightly < 1 kcal/min (0.8-1.0 kcal/min)
…estimating energy requirements is not always a straightforward task. Because an increase or decrease of body fat will result from an imbalance in the energy budget, sometimes it is the actual changes in an individual’s body weight over time that is the most convincing evidence that there is a surplus or a deficit.
For example, if a client is following a program with an estimated number of calories for weight loss and is gaining weight, the counselor can either determine that the allocation is incorrect or that the client has been eating more than the recommendation by tracking changes in weight or body fat.
Thermic Effect of Food (TEF) and Thermal Effect of Physical Activity (TEPA)
RMR, TEF, and TEPA all contribute to total energy needs. Although TEF is estimated to be approximately 10% of energy intake (for example, a person who eats 2,000 calories probably will expend 200 of them digesting, absorbing, and transporting those nutrients), it is rarely calculated into energy estimation equations. This is because the TEF varies with dietary content, as well as because the contribution of TEF to total energy expenditure is presumably smaller than the margin of error involved in estimating overall intake and output.
Once REE is estimated, an approximation of physical activity expenditure must be made, which usually requires the client’s self-report.
Even if the health and fitness professional is working with the client, there will be time spent in activity that the client will need to report.
Like with the estimations of REE, under and over estimation of physical activity will result in a miscalculated estimation of energy needs.
For example, if a client reports 5 hours per week of moderate- to high-intensity cardiovascular exercise, and in reality the client is accomplishing 1 or 2 hours per week of low- to moderate-intensity cardiovascular exercise, the resulting energy equation will be inaccurate.
See Table 3.1 for examples of energy expenditures for various activities.
Practitioners can either calculate the expenditure of calories based on the specific activity, or calculate REE and then use the well-established activity factors to estimate the additional energy a person would need to maintain a sedentary, low-active, active, or very active lifestyle (Table 3.2).
For example, once REE is calculated using any of the equations, the number would be multiplied by the activity factor (AF) to calculate total energy needs. Using the basic equation below for the reference female on the previous page, a 64 kg woman would have a REE range of 1,463 (64 kg x 0.8 cal x 24 hours) to 1,536 (64 kg x 1 cal x 24 hours). If she is low-active, the health and fitness professional would multiply 1,463 x 1.12 (AF) and 1,536 cal x 1.12 (AF) to get a range of 1,639 cal/day to 1,720 cal/day.
Once the client’s daily energy needs have been estimated, this information can be used to help the client gain, lose, or maintain weight as desired. In humans, for each 3,500 calories eaten in excess, a pound of body fat is stored. Conversely, a pound of fat is lost for each 3,500 calories expended beyond those consumed.
In humans, for each 3,500 calories eaten in excess, a pound of body fat is stored. Conversely, a pound of fat is lost for each 3,500 calories expended beyond those consumed.
According to the U.S. Dietary Guidelines, overweight and obese people should aim for a slow, steady weight loss by decreasing calorie intake while maintaining an adequate nutrient intake and increasing physical activity. Most experts agree that a safe and maintainable rate of weight loss is between 0.5 and 2 pounds per week, generated by a 250- to 500-calorie deficit per day below maintenance level.
Estimating Energy in Foods
Recall that the energy released from carbohydrates, fats, and proteins is measured in kilocalories…To estimate the gross energy contributions of foods…the energy values of foods are derived by bomb calorimeter.
Set Point Theory
Research demonstrates that most people participating in a weight loss program are successful at initially losing weight…regain it during the subsequent months or years. According to the set point theory, the body’s internal biochemical processes and regulatory control systems determine an individual’s natural body weight and fat percentage.
Deviations from this “set point” are resisted and minimized by these processes.
Accordingly, some individuals may have a naturally higher body weight (set point), making weight loss efforts difficult to sustain.
Clients often use the set point theory to explain reaching a plateau in weight loss that seems insurmountable. Several operative mechanisms to explain weight loss plateaus have been developed.
Energy gap: As people lose weight by energy restriction alone, their total energy expenditure decreases due to a lower energy cost of moving around a smaller body.
Hyperplastic obesity: The actual production of more fat cells as a result of obesity creates a tissue-type potential for regain. Fat cells are capable of increasing their size by twentyfold and their number by several thousandfold. In the case of extreme weight cycling, the more fat cells that are created (even if they shrink during weight loss), the greater the potential for regain.
Metabolic efficiency: Defined as an actual decrease in metabolism with a weight loss of as little as 10% that cannot be explained based on body composition alone.
Causes of Overweight and Obesity
Appetite and Satiety
Appetite refers to the sensations of hunger, satiation, and satiety that prompt a person to eat or not eat.
Hunger describes the sensations that promote food consumption, and it is a multidimensional attribute with metabolic, sensory, and cognitive facets.
Satiation follows the initiation and progression of a meal and causes hunger to subside.
Satiation is determined by both meal size and duration.
Eventually, feelings of satiation will contribute to the cessation of eating, and a period of abstinence from eating will begin.
Satiety refers to the sensations that determine this intermeal (between meals) period.
if the hormonally regulated “telecommunications system” between brain, gut, and circulating nutrients is not working properly, the regulation of energy intake may not be matched with physiological need, and that broken system can be inherited.
Other Genetic Influences
other genes encode for proteins that determine energy storage or expenditure, affecting on a cellular level the very “energy metabolism”
predisposition to movement and activity may be genetically programmed, making it genetically more challenging for some people to want to get up and move than others.
Fast food: high-energy-dense (calorie/gram), low-nutrient-dense (essential nutrients/calorie) food at cheap prices and convenient locations.
Supersizing and “value meals”: large sizes of food that people buy because they perceive them to be a good economic value.
Sugary beverages: rapidly growing sugar added beverage market, much of it promoted as “performance enhancing” or healthful in some way.
Decreased physical activity: escalators, elevators, automobiles, remote controls, and automated tools and recreation (computers, children’s games, television, etc.) all replace physical activity at home, in the workplace, and at play.
Media exposure — the average child sees 40,000 commercials on television each year, and many of them promote fast food, snack foods, and highly sugared foods.
Socioeconomic factors — low income and less education have been linked to higher rates of obesity.
Cognitive stimulation — low cognitive stimulation has shown to increase the risk of obesity in children, independent of socioeconomic factors, race, maternal marital status, or maternal BMI.
Family situation — the increase in single-parent or two-working-parent homes produces time constraints that make it harder for people to have healthy food at home for all family members.
Weight loss industry — prevalence of fad diets, weight loss “magic” products, and gimmicks.
Tracking the number of calories consumed is relatively uncomplicated (although somewhat monotonous) as food labels and online resources provide calories per serving. This information can be gathered and summed to determine the ‘calorie in’ side of the energy equation. But how do individuals estimate the number calories they are expending (calories out) without sophisticated equipment or body sensor devices?
Total daily energy expenditure (TDEE), is defined as the amount of energy (calories) spent, on average, in a typical day. TDEE is actually the sum total of three different energy components:
Resting metabolic rate (RMR): The amount of energy expended while at rest; represents the minimal amount of energy required to sustain vital bodily functions such as organ function, blood circulation, respiration, and temperature regulation. RMR typically accounts for approximately 70% of TDEE.
Thermic effect of food (TEF): The amount of energy expended above RMR as a result of the processing of food (digestion) for storage and use. TEF accounts for approximately 10% of TDEE.
Thermic effect of physical activity (TEPA): The amount of energy expended above RMR and TEF associated with all forms physical activity (exercise and nonexercise activity). Physical activity accounts for approximately 20% of TDEE.
Step Two: After estimating REE or RMR, determine the additional calories expended through the thermic effect of food and the thermic effect of physical activity.
As an example, let’s use these equations to calculate TDEE for Kathy, a relatively inactive 40-year old female who stands 5’4” (162.5 cm) and weighs 145 lbs. (65.9 Kg). She participates in approximately 30-minutes of light-to-moderate intensity activity two to three times per week, but works as a data software controller, a predominantly sedentary occupation.
Recent research on exercise and weight loss…shift towards innovative ideas that incorporate more movement and activity throughout the day, outside of planned exercise.
This strategy known as non-exercise activity thermogenesis (NEAT) is a phenomenon that represents one’s basic activities of daily living and includes fidgeting, standing, and moving around.
This strategy uses a behavioral approach of making individuals more mindful of their overall activity levels throughout the day, regardless of what they do for exercise, as exercise alone is often insufficient to promote effective weight loss, especially with new exercisers. With this strategy, we do not require detailed (and often unreliable) 3-day activity logs, but simply ask individuals to list their typical daily schedules from recall (e.g., Monday-Friday workday, average weekend). This is completed using a basic activity log (c). With this information, health and fitness professionals now have two implementable strategies:
Use this information to help individuals identify when they are excessively sedentary and should consider more physical activity (Table 1). This provides health and fitness professionals with chances to challenge clients to be more active via NEAT. Encourage simple, yet manageable tasks that build self-efficacy to strengthen a lasting commitment for change.
Another option is to develop a point system for activity. For example, allocate negative points for lying, reclining or seated activities, excluding sleep (i.e. -1 point) and award positive points for standing and higher-intensity activities (i.e. 1 point for standing, 2 points for light-intensity activities such as walking, 3 points for moderate-intensity activities such as light-jogging). Total the individual points attained within a day and identify areas in need of change and strategies to improve the overall score (ccc).
Often, people who are struggling to lose weight have accompanying psychological issues to resolve that reach far outside the scope of the health and fitness professional.
Body Image Issues
Having an unfavorable view of one’s body often can be a significant factor in whether a person is willing to be out in public to exercise.
Behaviors associated with a poor body image are avoiding mirrors, avoiding physical activity because it is uncomfortable to move, avoiding social situations, and placing blame on others. Negative body image issues can even manifest in a more serious condition called body dysmorphic disorder, which is a preoccupation with an imagined physical defect or an exaggerated concern about a slight defect in appearance.
One model that examines self-esteem in the physical domain is the exercise and self-esteem model (Figure 4.1).
This model suggests that exercise behavior is associated with self-esteem through perceptions of self-efficacy, physical competence, and physical acceptance.
self-efficacy…is a measure of confidence that one can successfully exercise in a variety of adverse or challenging situations, influences physical competence perceptions, which in turn influence physical acceptance.
It is physical acceptance along with physical competence perceptions that then influence self-esteem.
The influence of physical acceptance on both exercise and self-esteem may be particularly important for women because women tend to have lower levels of physical acceptance compared with men.
Low Confidence and Self-Efficacy
Self-efficacy can be acquired, enhanced, or even reduced by mastery experiences, social modeling, social persuasion, or physical and emotional states. This means that as people get better at a skill such as exercise — as they see others do it, are encouraged to do it, and feel and see rewards from it — they will be more likely to continue with it.
Mastery experiences refer to past experiences with a particular situation.
Successful performances will cause self-efficacy to rise, and unsuccessful performances will cause a decrease in self-efficacy.
The relationship between past experience and self-efficacy is thought to be reciprocal, meaning past experiences influence self-efficacy, and self-efficacy influences future behavior. Social modeling is often described as vicarious experiences, in which someone else successfully models a skill. Social persuasion will most likely be verbal encouragement from a person who has credibility or status for the situation at hand.
Triggers to Eating: Stress and Depression
Disordered eating can include behaviors such as binging, purging, food restriction, prolonged fasting, and use of diet pills, diuretics, and laxatives. The spectrum of disordered eating behavior ranges from moderate restriction of food intake or occasional binging and purging to severe food restriction, as in anorexia nervosa, and regular binging and purging, as in bulimia nervosa.
Some of the physiologic problems with disordered eating that can affect an exerciser include dehydration, electrolyte disturbances, hypoglycemia, anemia, decreased muscle mass, and decreased fat mass (12, 13). These can result in a loss of strength and endurance, and can lead to an increased prevalence of injuries.
Physiological Complications of
When people are engaging in caloric restriction, there is also a loss of water that contributes to reduced body weight. Water is essential for thermoregulation, and a dehydrated person can overheat and fatigue more quickly, or suffer from hyperthermia.
Strategies for Working with Weight Loss Clients
One of the biggest challenges in the area of weight control is initiation of and adherence to a new lifestyle. It is important to always be a good listener and be empathetic.
Improved self-confidence and body image: With regular exercise, most people see positive physical changes.
Decreased daily and chronic stress: Exercise is one of the best ways to help deal with stress.
Enhanced mood: When done appropriately, exercise makes most people feel good. This often leads to elevation in mood. This may be due to the release of certain hormones or simply the distraction from daily stress.
Alleviate depression: Studies show that regular exercise is associated with a reduction in the symptoms of depression.
…ective communication is often the difference between success and failure for exercise leaders. Therefore, it is important to send effective verbal and nonverbal messages while training clients. Always consider the message you are sending based on the following nonverbal cues (18). The following are guidelines for sending effective verbal and nonverbal messages.
Physical appearance: Dress appropriately for the setting in which you are interacting with the client.
Posture: An erect posture conveys control and energy.
Touching: Some people are not comfortable with touching, so the health and fitness professional should always get permission first.
Engagement and good listening skill: Health and fitness professionals should talk to clients about their likes and dislikes, ask about daily challenges that interfere with progress, and get to know the names of spouses and children.
Facial expression: make eye contact and smile at clients.
Be complete and specific:
Be clear and consistent:
Focus on one thing at a time:
Reinforce with repetition:
Make the message appropriate to the client’s frame of reference:
Look for feedback that the message was accurately interpreted:
Motivating Clients to Exercise
Four Guidelines for Building Motivation
Because people’s motivations may change over time, the health and fitness professional should continue to monitor people’s motives for exercise participation even months after they begin (20).
Guideline 1: People are motivated by situations and personal traits
Guideline 2: People have multiple motives for involvement
Guideline 3: Change the environment to enhance motivation
Guideline 4: Personal trainers can influence motivation
Social support can come from
As a provider of social support, the health and fitness professional should
By helping someone establish a social support network, he or she will
Barriers to Exercise
One key to long-term exercise adherence is the ability to identify and overcome barriers to exercise. The following are common barriers to exercise and some tips on helping clients to overcome them.
Not enough time to exercise: If a client cannot find an extra 30 minutes in a day, then the client should try to walk for 5-10 minutes several times a day. Schedule exercise into the day, and keep it as a person would an important meeting. Making exercise a daily priority will help clients find the time. Also, clients should choose activities that they enjoy and that are convenient. Here are a few ways health and fitness professionals can get them over the time crunch.
If they have kids, ask them to set aside 30 minutes to play with them in the yard or in the house. A fun game of tag or catch can start the client on the road to exercise.
If they like a particular TV show at night, ask them to march in front of the TV and do sit-ups during commercials. This way they won’t miss their shows, and they can squeeze in some exercise.
Remind your client that if they have time for TV and their kids, then they have time to move.
Lack of energy: …fatigue is often self-induced through busy work schedules and daily stresses. Exercise can actually decrease stress and make clients feel more energized. If they are feeling sluggish, then they can take a brisk walk. This might be the jump-start that they need. Also, if clients are too tired after work, they should try to exercise in the morning before the day gets too hectic.
Family and friends don’t exercise: Clients should remind family and friends about the benefits of physical activity, that this is important, and they should invite them to exercise. Clients should find activities that they can do with other people, such as walking at lunch with coworkers or after work with neighbors. Remember that having someone to exercise with is not essential.
Boredom or lack of enjoyment: Clients should identify a variety of activities that they enjoy so that they have options. They should vary their routine by exercising at different times of day, or by walking in different locations, such as a park or a shopping mall.
Fogg Behavioral Model (FBM): human behavior is simply a product of three factors; motivation, ability and triggers, each containing individual sub-components.
asserts that desirable behaviors require
(a) one to be sufficiently motivated,
(b) have the ability to execute a desired behavior, and
(c) be appropriately triggered to perform the behavior. Furthermore, all three factors must occur at the same instant for the behavior(s) to occur.
ability is not simply a reflection of physical competence, but includes any variable that may impact the ability to complete a task or challenge (e.g., time, money, perseverance, etc.).
To increase levels of ability, the goal should be to simplify the desired behavior in terms of activity type, time commitment, cost, physical or cognitive effort required, etc. Simplicity is defined as a function of a person’s scarcest resource at the moment that he behavior is triggered.
health and fitness professionals should strive to identify their client’s scarcest resource (e.g., time, money, effort, etc.) and work to reduce those barriers to promote participation.
if the individual believes that 30-minutes is too fatiguing or challenging…resort to initial actions that are more enjoyed…e.g., walking the dog 2x / week at a leisurely pace for 15 minutes initially may prove effective to helping someone start to believe they can attain a 30-minute of running 4x / week).
Motivation: The takeaway message with motivation is to connect with those core values or emotions that hold importance and even relevance in a person’s life (i.e., impact heir life immediately or in the near future).
Take time to identify which behaviors are associated with pleasure, acceptance or hope (positive approach)
For example, if getting into shape so you can play with your kids is important, then use that as your motivator.
Triggers: can take on many forms; from a feeling, thought or physical sensation; reminder in your planner; to a friend or environmental signal.
Triggers must capture our conscious attention; they must connect with the desired behavior; and they must be timed to occur when both motivation and ability are high.
For example, a reminder in your phone to stop working in 30-minutes in order to run or play with your kids captures conscious attention.
if the trigger occurs at the time when the combination of ability and motivation are high, you are likely to perform the desired behavior.
If the trigger occurs at the time when both the combination of ability and motivation exceed the Behavior Activation Threshold (BAT), illustrated in Figure 1, then we are likely to perform the desired behavior.
BAT is defined as the minimal level of ability and motivation needed to activate a behavioral response.
Spark triggers: They inspire and motivate people to action, and are used best with individuals demonstrating low motivation levels.
An email alert on your phone is perhaps a classic example of a spark trigger to perform an action (i.e., check emails).
When trying to motivate yourself to stop working and play with your kids or complete that 30-minute run, find strong triggers that motivate such as your kids calling you,
a running partner asking you whether you’re ready to go,
reading an inspirational quote, or even receiving a supportive email.
Facilitator triggers: They are best used with individuals demonstrating high levels of motivation, but struggling more with ability (low ability). The intent is to trigger the desired behavior by helping the individual believe the task is simple and easy to complete.
For example, if you feel that 30-minutes of running is too challenging, a trigger to build ability may be to divide the run session into three, separate 10-minute segments that can each be completed with some other activity in between.
Signal triggers: These function best when you have high levels of both motivation and ability, and the trigger simply serves as a reminder to you.
For example, your alarm going off to remind you to meet your best friend for happy hour down the street from your office.
we should subscribe to the ‘ready-willing-able’ mentality as our guide to assess the motivation (importance) and ability of an individual for change:
Readiness reflects commitment for change (i.e., to be motivated to put forth the necessary effort).
Willingness reflects their desire to change and should examine an individual’s ambivalence and resistance to changing behavior. Ability reflects the individual’s belief that they can complete the desired behaviors.
Application of the Model: In helping individuals change behavior, it is helpful to identify whether they are trying to change behavior just once or for indefinite periods of time. Attempting a change just once is a perfect stepping stone to more sustained behavioral change. Consider the various changes an individual may strive to accomplish:
Adopt a new or familiar behavior just once (e.g., get a medical exam).
Increase the intensity or duration of a behavior just once (e.g., extend your workout by 30 minutes today).
Reduce an undesirable behavior just once (e.g., eat less bread at dinner this evening).
Stop an undesirable behavior just once (e.g., skip dessert this evening).
Adopt a new or familiar behavior for a period of time or indefinitely (e.g., standing more at your workstation).
Increase the intensity or duration of a behavior for a period of time or indefinitely (e.g., become more mindful of the snacks you eat at night).
Reduce an undesirable behavior for a period of time or indefinitely (e.g., eat less cookies and potato chips).
Stop an undesirable behavior for a period of time or indefinitely (e.g., stop smoking).
Additional Areas of Specialization:
Fundamental concepts of health and lifestyle coaching.
Developing rapport with individuals.
Communication (verbal, non-verbal) and questioning skills.
Identifying and profiling a personality style.
Transtheoretical or Stages of Change Behavioral model and applications.
Operant conditioning; and social and individual factors that influence behavior.
Extrinsic and intrinsic motivation.
Relapse prevention; overcoming barriers.
Fundamentals of Health and Lifestyle Coaching
if you can impact their life positively for 100 – 115 hours a week (coaching) rather than being limited to just three to five hours a week (personal training), you will hold greater value (relevance, importance).
As the field of personal training merges with wellness, our menu deliverable services continue to expand to include a more multi-faceted approach that includes the multiple dimensions of wellness (e.g., behavioral, intellectual, emotional, social), which in essence resembles coaching. However, unlike training that traditionally adopts a more directive approach (i.e., leading, instructing, guiding), health and lifestyle coaching is more client-centered and founded on a principle of a non-directive approach.
a good coach can wear many caps, but is essentially a facilitator, support-system, role model (mentor), motivator, educator, leader, advisor and counselor, and exhibits the following traits:
Great rapport-building skills.
Active listeners (doing more listening than talking.
Facilitate ideas and opportunities for change.
Help clients find their own solutions (competency) and ask permission to direct or lead rather than assuming they can take it (6).
Offer support (relatedness) to help individuals continue developing and achieve their specific personal or professional results or goals (self-actualization) (7).
Always offer or present choices to individuals and enable autonomy (empowering clients with the right and ability to choose)
The next step is to ensure that people exercise regularly and that discussion begins by understanding adherence. Adherence means conforming faithfully to a standard of behavior that has been set as a part of a negotiated agreement. The most agreed upon definition of exercise adherence includes maintenance of an exercise program for at least six months.
many people find it easier to begin an exercise program than to stick with it because 50 percent drop out before the first six months
STRATEGIES FOR ENHANCING ADHERENCE
Reinforcement approaches can include positive rewards for attendance and participation, and feedback on participants’ progress in their exercise program.
Cognitive/behavioral approaches assume that internal events have an important role in behavior changes. One cognitive/behavior approach to help keep people motivated and on track is goal setting.
Decision-making approaches include making people more aware of the potential benefits and costs of an exercise program.
The social support approach is important in determining an individual’s attitude about other people’s involvement in their exercise program. Social and family networks may work as an influence on physical activity, depending on the needs of the individual.
Intrinsic approaches work to empower the individual to think about the positive aspects of physical activity from an internal perspective, and this includes focusing on the experience itself rather than trying to obtain an external goal or reward. Research has revealed that focus on the process as opposed to the outcome is related to adherence, and it’s important that individuals engage in purposeful and meaningful physical activity, as they define it.
Quantifying numbers is time-consuming and difficult to log, calculate, and follow (for both clients and Health and Fitness Professionals), and also prone to error. As such, it may be more productive to shift your approach to changing dietary behaviors away from a quantitative method and towards a more qualitative approach (i.e., making healthier selections and controlling portion sizes).
Savvy Health and Fitness Professionals tackle portion-size challenges by equating standard serving sizes with common household items (e.g., computer mouse, tennis ball) or various hand positions (e.g., cupped palm, clenched fist). However, they still struggle with the complexity of coaching for healthier food selections.
Nuval® is a new nutritional scoring system aimed at simplifying the decision-making process on healthier foods – visit www.nuval.com for more information. Developed by an independent panel of nutrition and medical experts, this system generates a single numerical score on a 1-100 scale to rank a food’s quality (higher scores reflect better nutrition). The scoring algorithm considers 30-plus nutrients in the food—both good and bad— and condenses overall nutrient quality into a single number (9). This simplified approach allows individuals to move towards making healthier choices by seeking comparable foods with higher scores than what they already eat.
Weightwatchers® is one of the more successful commercial dietary programs available to the public. Part of their success is attributed to their PointsPlus® system and “four pillars approach” that promote accountability and behavioral change. Through their point system, consumers increase awareness of healthy and unhealthy foods. Their system however, is not without its challenges given the need to understand (a) portion sizes, and (b) the advanced point system for foods eaten and totals allowed. Consider adopting your own points system, but utilize a simplified approach. First, educate your clients or patients on standardized portion sizes for the 100 foods they consume most frequently. Then, using this list of foods, devise a food checklist that:
Earns positive points per serving for healthy foods (whole grains; fruits / vegetables – raw, frozen; very lean / lean meats – baked, grilled; dairy – low / nonfat)
Earns negative points per serving for unhealthy foods (refined starches; fats; sweets; salty snacks; fruits/vegetables – canned in syrup, deep fried; medium / high-fat meats – fried, etc.; dairy – whole)
Evidence demonstrates that gradual weight loss is more likely to be maintained than rapid losses…The National Institutes of Health Obesity Education Initiative details a reasonable timeline for weight loss as a 10% reduction in body weight over 6 months of therapy.
For…BMI’s in the range of 27 to 35, a decrease of 300 to 500 kilocalories a day will result in weight losses of about .5 to 1lb a week and a 10% weight loss in 6 months.
…BMI’s greater than or equal to 35, deficits of as much as 500 to 1,000 kilocalories a day will lead to weight losses of about 1 to 2lb a week and a 10% weight loss in 6 months.
a weight loss program should include the following:
The prevention of weight gain or stopping weight gain in an individual who has been seeing a steady increase in weight.
Varying degrees of improvements in physical and emotional health.
Small, maintainable weight loss or more extensive weight loss achieved through modified eating and exercise behaviors.
Improvements in eating, exercise, and other behaviors.
Questions like, “Will you tell me about your priorities around weight loss?” or “Would you describe to me what a successful weight loss program would look like to you?” can often elicit more valuable information from the client than “What do you want to weigh?” or “How much would you like to lose?”…Important components of motivational interviewing are the following:
The client-centered practice of and investigating ambivalence about behavioral change.
Examining discrepancies between the individual’s current behavior (nonhealth supportive) and core values or personal goals (health enhancing), and embracing that discrepancy rather than trying to reconcile it.
The employment of change-talk (the individual’s own reasons and arguments for change).
Recall that carbohydrate, protein, and fat are the energy-yielding (calorie-providing) nutrients. To lose weight, these need to be modified to create an energy deficit. Although macronutrient manipulation programs (e.g., low-carbohydrate or low-fat diets) are extensively debated in the scientific and popular literature, there is not a consensus that one specific macronutrient ratio will produce a significantly greater weight loss over another.
Carbohydrates, Hormonal Homeostasis, and Weight Control
Although continued attention on the role of carbohydrates and insulin in weight gain is warranted, the suggestion that any one macronutrient category (or subcategory) is responsible for obesity, independent of energy surplus, is not yet supported by research.
Evidence indisputably supports limiting carbohydrates in the insulin-resistant or prediabetic individual. However, the exclusive assignment of blame for weight gain to this macronutrient is not yet supported by research. That said, the importance of the quality of carbohydrates is considerable, and that will be discussed in a later section, “Nutrient Density.”
Vitamins and minerals are micronutrients that, compared with macronutrients, are needed in very small amounts by the body. Where macronutrient requirements are measured in grams (g), micronutrients are usually measured in milligrams (mg) and micrograms (mcg). The healthiest choices of macronutrient-rich foods generally will deliver the right amount of micronutrients. On the other hand, those food choices that are less healthy do not provide the body with as many essential vitamins and minerals.
Many vitamins facilitate the release of energy from carbohydrate, protein, and fat…they help to “unlock” the energy from the macronutrients during energy metabolism, they do not provide energy (they do not contain calories).
Minerals, also important to a host of physiological processes, are further subdivided into two categories: major and trace.
Nutrient Reference Values and Guidelines
The Dietary Reference Intakes (DRI) are nutrient reference values each with a specific use in defining recommended dietary intake levels for individual nutrients.
Almost two decades ago, the DRI replaced the Recommended Dietary Allowance (RDA) in the United States and the Recommended Nutrient Intake (RNI) in Canada.
Of particular interest to the fitness professional is a set of values within the DRI called Acceptable Macronutrient Distribution Ranges (AMDR). The AMDR are the healthy ranges of intake for carbohydrate, protein, and fat.
Recommendations of specific micronutrients are outside the scope of practice of fitness professionals. However, recommending nutrient-rich foods is an excellent way for fitness professionals to help clients meet their micronutrient needs.
The Marriage of Macros and Micros: Nutrient Density
Nutrition scientists determine nutrient density by calculating: essential nutrition/kilocalorie, or EN/kcal. For example:
Helping clients choose the most nutrient-dense and the least energy-dense foods can be crucial in supporting their weight loss efforts.
Nutrition Education Tools and Solutions
MyPlate (Figure 6.1), can be used to improve dietary quality and support weight loss. MyPlate is the current nutrition guide published by the U.S. Department of Agriculture (USDA), depicting a place setting with a plate and glass divided into five food groups.
MyPlate can assist with improving most clients’ nutrition in that it is 50% fruits and vegetables, which are very nutrient-dense and less energy-dense than other foods. The limitations on grains and protein to 25% each in many cases also will decrease the total daily calories because these two categories are more energy-dense (kcal/g of food) than fruits or vegetables. Perhaps of greatest value is that the plate represents a visual with which everyone is familiar and can relate to at meal and snack times. They can picture their plate (vs. a pyramid) and easily determine if it matches the MyPlate scheme and proportions.
Unfortunately, cheap food is very often not nutritious food, and it often comes in sizes that are far larger than the average person needs.
Food models can be used to help clients visualize what is considered an average or typical portion. Household items also can be used to illustrate portion size. For example:
four dice or two dominos equal 1 oz cheese
a deck of cards equals 3 oz poultry
a checkbook equals a 3 oz filet of fish
a golf ball equals 2 tbsp peanut butter.
Fitness professionals can devote a segment of a training session to reviewing these portions with their clients.
Nutrition Facts Panel
The Nutrition Facts panel, which appears on almost all packaged foods, is an excellent resource for serving size information and calories, as well as nutrient content.
For people trying to lose weight, the three most helpful sections of the food label are right at the top: serving size, servings per container, and calories per serving.
The next two sections of the Nutrition Facts panel list the nutrient contents of the food. The column on the right is known as the Percent Daily Value, or % DV. These values are not recommended intakes. They are reference points to help consumers better understand their overall daily dietary needs, and how a particular food fits in. The Percent Daily Value is based on a 2,000-calorie diet.
Clients should be counseled to try to achieve the Dietary Reference Intake for fiber, 25 g for women and 38 g for men, and use the label to choose high-fiber( more than 5 g/serving) foods. The data provided on the food label for fat content includes: total fat, saturated fat, trans fats, and cholesterol. In brief, total fat should be kept to 35% or less of total calories contributed from fat and equal to or less than 10% from saturated fat (derived primarily from animal fats). Current guidelines for dietary cholesterol suggest less than 300 mg/day (18). For sodium, the National Heart, Lung and Blood Institute’s recommendation for avoiding or lowering high blood pressure is 1,500 to 2,300 mg/day (25).
if people eat large volumes of foods with lower energy density, they will feel satisfied and eat less. According to her research, people tend to eat the same weight, or amount, of food each day… Because some foods (e.g., fruits and vegetables) are less energy dense than others, filling the plate with more of those means eating fewer calories without actually eating less food. Low-energy-dense foods, which are low in calories but high in volume, water, and fiber, help people feel full, which in turn helps them eat less and achieve their weight loss goal.
The “volume approach” is all about getting more food and more nutrients but fewer calories. The success of eating high volumes of food with lower energy density lies with its focus on satiety, the feeling of fullness. Rolls demonstrates that people feel full because of the amount of food they eat — not because of the number of calories or the grams of fat, protein, or carbohydrates. In fact, some people new to this type of eating actually feel like they are eating more, not less, although their total energy (kcal) intake is lower than it was before. The volume approach, which incorporates the principles of nutrient density and energy density, can be combined with MyPlate for a comprehensive, actionable, and evidenced-based weight loss program.
By accessing online menus with nutrition information (a legal requirement for any chain with 20 or more establishments as of 2010), better choices can be highlighted for the client who frequently eats away from home…increasing dependence on food prepared outside the home parallels the rise in obesity.
Undress everything — ask for no mayonnaise, sauce, dressing, etc.
Choose single- or child-sized options instead of supersized and “value” meals.
Choose baked or grilled options when available (e.g., baked potato instead of fries, and grilled chicken instead of breaded cutlets).
Pizza can be a good option. Opt for vegetable toppings, and limit sausage, pepperoni, extra-cheese, and deep-dish options. Order a side salad instead of a second slice.
Mexican/Southwest chains can offer healthy items, but remind clients to minimize cheese, sour cream, and tortilla chips. Good choices include plain, small burritos, grilled chicken or seafood soft tacos, or fajitas with salsa and lettuce. Avoid taco salads in taco shell “bowls,” which can have as many as 850 calories.
Salads also can be healthy choices, and many fast food chains are offering them as entrée options, but fitness professionals should educate clients about dressings and toppings. One well-known chain offers a bacon ranch salad that has more calories than its biggest burger.
Sandwich shops can offer healthy fare. Good choices include whole wheat bread instead of large rolls, lots of vegetable toppings, and mustard. Limit cheese, mayo, and other dressings/sauces.
Order an appetizer portion of a favorite entrée, or select an entrée from the appetizer menu.
Although permanent lifestyle change is the ultimate goal of a behavior modification program for weight loss, this will be more achievable for some than others. Meal replacements (MRs) may be a useful tool for some people who are unable to alter their eating habits enough to maintain a lower weight. Meal replacements also require a change in eating, but the change is relatively straightforward, involving only one daily meal in most formats. This routine provides a constant that can reduce daily energy intake to support weight loss and prevent weight regain.
MRs generally are used to replace one or two meals a day and allow freedom of choice for the remaining allotted foods/calories. Meal replacements support the following:
Accurate calorie counts
Supplementation and Weight Loss
Dietary supplements have two possible functions in weight management:
They can provide nutrients for diets that are restricted in calories and thereby may be deficient in essential nutrients.
…it may be difficult to achieve RDA levels for certain nutrients — in particular iron, calcium, and vitamin B6 — on these hypocaloric diets. The lower the diet is in calories, the greater the probability that there will be a deficiency in some nutrients. To protect against shortages, a weight loss client can do the following:
Add several servings of foods rich in the specific nutrient (e.g., low-fat dairy for the provision of calcium).
Add commercially prepared meal replacement products that are relatively high in nutrients for the calories they provide (e.g., a meal replacement bar fortified with iron).
Take a single-nutrient supplement and/or a multivitamin/mineral supplement.
Some are alleged to augment weight loss by diminishing hunger or increasing metabolic rate.
to stimulate or enhance weight loss (as opposed to correct a deficiency).
there are safety concerns with some dietary supplement ingredients concerning nutrient-nutrient interactions, nutrient-medication interactions (especially with many drugs taken by people for conditions secondary to obesity like hypertension and diabetes), and contraindications for people who have particular health conditions (known or unknown). There are also significant risks of contamination, which historically have resulted in conditions including kidney failure, liver failure, and carcinogenicity.
“psychological reactance,” a phenomenon defining behavioral responses that occur when regulations (i.e., diet) threaten or eliminate specific behavioral freedoms (1). In other words, this reactance occurs when a person feels that their choices or freedoms have been limited or removed. In the diet scenario, undesirable behaviors (e.g., eating comfort foods, chips, cookies) become more appealing because the fear of losing choices or freedom motivates a person to recapture that threatened parameter.
Researchers for the National Weight Control Registry (NWCR) have measured long-term weight loss success (defined as losing 10% or more of initial weight) and demonstrated great success when proper strategies are implemented. This rate only drops to 25 – 27% over a period of at least five years, thus demonstrating that long-term weight loss maintenance is achievable.
Being More Mindful
Mindless nibbles may negate all weight loss exercise efforts, or on the bright side, offer an alternative or additional strategy to target weight loss. Many Americans stop eating when they are full, whereas in leaner cultures, people tend to stop eating when they are no longer hungry.
Stages of Competency
A simple guideline is to reduce portion sizes by 20% as generally, people do not notice this reduction…reductions greater than 30% increase conscious awareness of deprivation and may trigger a psychological reactance effect.
Pace the Clock
After eating, the presence of food in the stomach and gastrointestinal (GI) track and the entry of food into the blood, trigger neural and hormonal responses that turn off the sensation of hunger. Leptin— a hormone from adipose cells—is released under the influence of the parasympathetic system (active during digestion) and by elevated insulin levels (responding to the presence or anticipation of food). This hormone binds to neuropeptide Y, a known appetite stimulant (increases food intake and storage of fat) and deactivates it to inhibit hunger. The hormone cholecystokinin (CCK), released from the intestinal cells, initiates digestion by secreting digestive enzymes. It is stimulated by the presence of food in the stomach and also functions to slow down digestion (to ensure efficient digestion and absorption) and suppress further eating.
…it may take approximately 20 minutes after initiating eating for these signals to take effect, which raises the question as to how much damage we can do with food in 20 minutes.
Build Volume for Fewer Calories
Strategize food preparation, food delivery, and eating order to focus upon building volume as a means to control caloric density (e.g., substituting fruits and vegetable snacks for candy; sequencing delivery of side veggies or lean salads before bread). Be careful however with substitutions to avoid the perception that one is being deprived of specific foods (e.g., comfort foods that are sweet, fatty, or salty).
Aim to introduce more food incorporating the cheapest and most calorically-inexpensive ingredients possible, namely air and water*. For example, by taking a portion of food (e.g., half pound burger) and substituting some of the calorically dense ingredients (e.g., meat) with less calorically-dense ingredients (e.g., lettuce, tomatoes), that person will achieve comparable levels of fullness with fewer calories.
In Sight Equals In Mind
America has a clean plate mentality (if we see it, we had better eat it) and this is an issue of concern.
…research also tells us that sometimes what we see can raise our levels of consciousness or awareness as to how much we are eating (becoming mindful) and may help reduce mindless eating…we need to be more vigilant about our “clean-plate” mentality, sometimes visibly seeing what we plan to eat or have eaten may give us reason to pause and be more mindful.
Out of Sight Equals Out of Mind
Generally, when buying in bulk, we tend to eat more from these larger containers initially (i.e., in the first seven days). Then as we grow tired of the food, the containers become castaways in the refrigerator, freezer, or pantry.
Removing visible foods decreases temptations for mindless snacking (seeing, smelling, or thinking). If snacks are going to be left in plain sight, aim to make them nutritious and healthy.
If buying in bulk, immediately repackage larger containers into smaller, opaque containers and store all but one container out of sight – this helps curb subconscious eating. Even a small strategy, such as placing a lid on a container or covering it with foil or plastic wrap, will curb mindless munching.
Don’t Deprive Foods (Comfort Foods): Control Them
People seek out comfort foods when they: Feel happy (86% of the time). Feel the need to celebrate or reward themselves (74% of the time). Feel bored (52% of the time). Feel depressed (39% of the time). Feel lonely (39% of the time).
Once clients become mindfully aware of their triggers, the next step is to strategize distractions, taking into consideration that thoughts and emotions are generally fleeting (short-lived). An effective distraction therefore is one that satisfies the thought or emotion while simultaneously reducing the likelihood of eating (e.g., calling a friend to vent or leaving a voicemail, expressing thoughts in a journal, playing with a pet, doing an activity). This distraction need not be complicated as its intention is simply to distract a short-lived desire. However, a key to distractions is to recognize that if the desire still persists after the activity (i.e., a few minutes), then the individual should be allowed a small mindful indulgence.
Essentially, you are not eliminating choices, but instead are giving the client the power to choose from several options, while concurrently making them aware of the consequence of each choice…a 100 kcal snack is equivalent to a 23-minute walk or standing for 52 minutes.
controlling the number of food choices we have, we may subconsciously develop a perception of less enjoyment from the food and may actually eat less…When there is more food–or when we think there is more food–we tend to think that eating more is appropriate, a concept that is called “sensory-specific satiety“.
Excess post-exercise oxygen consumption (EPOC): The state in which the body’s metabolism is elevated after exercise.
Dieting: alone can certainly result in weight loss, but it is safe to estimate that for every pound (0.45 kg) lost, 69% of the weight loss will originate from fat, while the remaining 31% will originate from lean mass
Dieting coupled with cardio: can also help clients lose weight; but again, for every pound lost, assume 78% will originate from fat and 22% from lean mass
Resistance training: on the other hand, is an effective method not only to lose weight but also to preserve lean mass. With this modality, the loss of lean mass for every pound is only 3%, with the remaining 97% originating from fat
General Overview to Weight Loss Training Methodologies
…it is important to recognize that exercise alone generally is insufficient for successful weight loss for most people, especially new exercisers.
Is Exercise Sufficient for Weight Loss?
…it is evident that exercise calories for new exercisers barely exceed 10% of intake, proving to be grossly inadequate to make any significant impact upon weight loss. Therefore, it would be a mistake to focus exclusively upon exercise as the primary means to enhance caloric expenditure for weight loss, when the focus should shift to reflect a more global approach of all calories expended throughout the day.
The benefits of exercise for weight loss tend to rely heavily upon the notion of building lean mass to burn more calories and boosting metabolism after exercise.
Non-Exercise Activity Thermogenesis (NEAT)
…non-exercise activity thermogenesis (NEAT), a phenomenon that represents one’s basic activities of daily living and includes fidgeting, standing, and moving around. It appears to be equally important as exercise in burning calories, losing weight, and reducing the risks of mortality.
The implications of this research are groundbreaking, providing evidence of a need to not limit weight loss strategies to the few hours a week of exercise, but to include strategies for the remaining 100-115 waking hours. For example, the health and fitness professional should explore opportunities with clients to increase NEAT during bathroom and water or coffee breaks (walking to bathrooms further away) or with company meetings (walking meetings).
Rationale for Exercise as it Relates to Weight Loss
…a comprehensive weight loss program should include both resistance and cardio training in order to burn calories while simultaneously preserving or building lean mass.
Resistance Training Programming Options
Total Body Training
…the use of compound exercises where several joints and muscle groups are trained simultaneously in one exercise. These exercises typically involve the use of both the upper and lower extremities.
Research also demonstrates that multi-joint exercises can increase testosterone and growth hormone levels (to enhance muscle growth potential) when compared with most joint-isolation exercises.
This form of training includes many exercises that mimic activities of daily living (ADLs) more closely than isolation-type exercises, thus becoming more functional in nature.
…should be performed early within a training resistance training session when muscles are not fatigued and concentration levels are high.
…emphasizes an eccentric lengthening action (loading phase) that precedes a very brief transition (amortization phase) and explosive, concentric shortening action (unloading phase) to harness the muscles elastic energy (recoil), much like a rubber band.
Implemented as a modification to traditional powertype training for performance that involves integrated, higher-intensity, lower-volume, explosive exercises, power training for health and fitness involves integrated, lower-intensity, higher-volume, explosive training aimed at targeting the larger type II muscle fibers to increase caloric burn.
This form of training has become very popular among women who are seeking to tone and shape yet express reservations about overly bulking up…
…carefully selected resistance exercises arranged sequentially, each having a short recovery between the exercises (stations).
One primary objective behind circuits is to incorporate both cardiorespiratory and resistance training into a single bout.
“cardio circuit” commonly used with overweight individuals who are less experienced with resistance training yet have the need to incorporate this form of training into the regimen while simultaneously attempting to increase their caloric expenditure during exercise. This format also uses multiple stations in sequence, but it emphasizes more cardiorespiratory training over resistance training. This may include a 30-second jumping jack station, a 3-min moderate-intensity treadmill walk/ run and a 30-second step-up station, followed by a body weight squat station.
blended routine, which provides a slight twist to traditional circuit training. Unlike circuits that typically offer alternating resistance stations, blended routines involve alternating longer bouts of resistance and cardio exercise. For example, one may complete a 5- or 10-min anaerobic resistance training circuit, then complete a 5- or 10-min aerobic cardio bout (treadmill running), then repeat the entire process. The rising popularity of this method stems from saved time and convenience. In an era in which people have limited time, the ability to complete a blended workout that overloads multiple systems simultaneously (aerobic and anaerobic pathways, cardiopulmonary, musculoskeletal) is certainly beneficial. This type of routine also allows one to push the shorter exercise bouts slightly harder than normal, increasing caloric burn, while still enjoying the overall experience.
Metabolic Resistance Training (MRT)
…an all-encompassing generic term to define any workout that involves high work rate-type activities (high repetition counts) coupled with little to no recovery intervals.
The primary goal with MRT is to impose greater physiological stress upon the body in order to elicit larger neuroendocrine responses that result in faster biological adaptations (i.e., muscle growth). Additionally, these workouts aim to increase caloric expenditure and EPOCs. Although highly popular, they are extremely diverse and can include multiple variations of training (e.g., Crossfit™, Met-Rx 180™)…the programs involve a high volume of integrated exercises with little recovery.
As fatigue increases, so does the risk of injury associated with poor form during these repetitive movements.
Variations in MRT training are too numerous to list, but some examples include the following:
Building volume by performing integrated movements in all three planes.
Completing high-volume sets of an exercise while taking needed breaks in between by simply changing the exercise, and continuing to work and not stopping (e.g., while performing push-ups, taking the necessary breaks as a plank or mountain climber until the set is complete).
A giant set that progressively expands from an isolated, limited range of movement exercise toward an integrated movement.
General Cardiorespiratory Training Guidelines
FITTE stands for frequency, intensity, time, type, and enjoyment.
Obese individuals, given their poor tolerance for both intensity and duration, should exercise at least five times per week, and up to seven times a week until they can sustain the recommended durations and intensities of exercise for healthy adults.
This threshold occurs at a lower intensity for deconditioned individuals than it does for more conditioned individuals. For most adults, this minimal threshold occurs at approximately 40% of VO2 Reserve (VO2 R) or heart rate reserve (HRR)…logistical limitations to measuring oxygen consumption has generated greater reliance upon simpler methods, such as…the talk test..
Overweight and obese individuals are encouraged to participate in moderate- to vigorous-intensity activity at 40-60 % of VO2 R or HRR, progressing gradually to 50-75% of VO2 R or HRR. Because most individuals have no means to correlate this intensity into practical terms, the use of RPEs (ratings of perceived exertion) and the talk test are suitable methods to gauge intensity.
If opting to simplify subjective scoring (recommended strategy) to a modified 0-10 scaling system to reflect percentage of effort (i.e., 5 of 10 = 50% of maximal effort, 7 of 10 = 70% of maximal effort), then this intensity should coincide with about 45-60% of maximal effort.
For an individual who has a maximal heart rate of 200/ min and a resting heart rate of 70/min, the heart rate reserve is 130/min (200-70/min). Fifty percent of heart rate reserve or maximal effort equals 65/ min (130 ÷ 2) plus resting heart rate equals 135/min, close to an RPE of 13.
The talk test is identified as the intensity where continuous talking is challenging but not difficult, and where depth of breathing and mouth breathing are noticeable, but breath rate has not increased significantly.
NASM has reclassified the relative intensity of exercise in six incremental stages, from “very light” to “maximal effort,” with a corresponding oxygen uptake reserve or heart rate reserve and rating of perceived exertion at each progressive level (Table 7.3).
Duration defines the amount of time spent performing the physical activity, but it also can be expressed as the number of calories expended or the quantity of exercise completed (e.g., 2 miles, 5,000 steps).
ACSM guidelines seek to promote general health and fitness, and recommend participation by overweight and obese individuals in at least 30-60 min per day to total 150 minutes per week of moderate-intensity exercise. This should progress to 50-60 min per day to total 250-300 min per week of moderate-intensity exercise, 150 min per week of vigorous exercise, or some combination of both to enhance long-term weight control.
The quantity of activity or exercise performed each day can be accomplished through one continuous bout, or intermittently throughout the day in bouts lasting a minimum of 10 min each to accumulate the minimum duration for the day. A minimum of 2,000 kcal per week is needed to promote weight loss.
…any type of activity that involves a sustained increase in heart rate using large muscle groups. Types of cardiorespiratory exercise include walking/jogging on a treadmill, and using a stair-climber or a stationary bike. It is important to change the type of exercise used from time to time to create a new stress for the client to adapt to (particularly if the client has hit a weight loss plateau) as well as to decrease the risk of boredom.
Cardiorespiratory Training Programming Options
…traditional cardio (running, cycling), through group aquatic exercise, or even with circuit training, and include the following:
Steady State (SS) Training
involves bouts of sustained, steady state or fixed-intensity aerobic exercise that varies in intensity from low to moderate to more vigorous levels…the repetitive nature and longer duration that sometimes makes SS exercise boring, diminishing its overall enjoyment.
Aerobic Interval Training (AIT)
…alternate between moderate- to high-intensity exercise work intervals with a recovery interval…varying lower-intensity recovery periods (e.g., walking, light jogging).
…very high-intensity bouts of work, it is aerobic interval training (AIT) or fitness interval training (FIT) that recently has become more popular.
This format also tends to be more engaging than SS due to the alternating nature of the work-recovery bouts, making it an appropriate mode of training for deconditioned and overweight individuals…AIT training is an effective modality to use.
Anaerobic Interval (ANI) Training
…also known as high-intensity interval training (hiit), involves shorter, intense bouts of exercise ranging from 15-90 seconds, interspersed with specific active or passive bouts of recovery. Passive recovery implies little to no movement, whereas active recovery implies light activity.
The length of the work and recovery bouts can vary between 6 seconds to 4 min (24).
More recently, supramaximal interval training bouts, such as Tabata-type training, have become popular. Individuals perform very short bouts of extremely high intensity exercise at workloads greater than 100% VO2max followed by shorter recovery periods. Although this form of training may appear to increase caloric expenditure due to high intensities, they ordinarily do not because the total amount of work performed is very small.
Obviously, this form of training is inappropriate for most individuals, but as mentioned previously, many practitioners are implementing modified versions of this program to train the general population.
This format involves using various modalities of cardio exercise within one session (e.g., running, elliptical, bicycling). A primary objective is to introduce variety and avoid boredom, a strategy suitable for novice exercisers who fail to enjoy longer exercise bouts.
Stepwise or Pyramid Training
This format involves incremental increases and/ or decreases in exercise intensity within the aerobic spectrum of training.
This enables the practitioner to progressively raise the exercise challenge by incrementally adding or removing physiological overload.
This format is effective with all exercisers seeking a gradual method to improve their overall fitness level or perhaps break the monotony of SS exercise, as long as the incremental changes remain relatively straightforward and simple.
A traditional stepwise format initiates with a warm-up phase, then incrementally progresses to one or more levels of increasing intensities during the conditioning phase before entering the cool-down phase. For example, a cardio session may begin at 4 mph (6.4 km/hr), then increase to 5 mph (8 km/hr) and then 6 mph (9.6 km/hr) before entering the cool-down phase.
A standard pyramid includes equal increases and decreases in intensity in one cardio session. This format involves a warm-up phase, a conditioning phase with multiple incremental increases and decreases in intensity, and a cool-down phase. For example, a session may begin with a 4 mph warm-up, progress incrementally through 5 mph, 6 mph, and 7 mph, then gradually decrease back down to 6 mph and 5 mph before terminating with a cool-down phase.
A skewed pyramid occurs where the incremental increases and decreases are not equal. For example, after a 4 mph warm-up, the session may increase to 5 mph, 6 mph, and 7 mph intervals, but then drop back to a 5 mph interval before transitioning into the cool-down phase.
The benefits of stepwise and pyramid programs include opportunities to impose greater challenges upon the energy pathways because each level places unique demands upon the systems. Furthermore, this format may also closely mimic the demands of certain ADLs, thus better preparing the body for those activities.
Mixed-Tempo, Undulating, or Fartlek Training
“Fartlek,” a Swedish word for “speed play,” is a format of training introduced to the United States more than 70 years ago and involves a combination of alternating running speeds over flat and hilly terrains. Much like pyramid training, it involves incremental changes in exercise intensity, but it does so through a blend of continuous (aerobic) and interval (anaerobic) intervals.
…the idea behind this format is that the participant has the freedom to choose alterations in intensity and durations based upon individual needs and desires Fartlek training is ideal for general conditioning, off-season athlete training, and athletes participating in sports involving both continuous- and interval-bouts (e.g., soccer, rugby).
Split Routine Training
This format involves splitting cardio sessions into multiple sessions rather than completing all cardio in one session. For example, a 40-min cardio workout could be divided into two 20-min runs completed separately. Although this format may offer some conveniences, it also may provide the exerciser with the opportunity to perform the total volume of work at higher intensities.
Furthermore, it offers a second EPOC. As discussed previously, although EPOCs generally are considered small for new exercisers, the caloric sum of two smaller EPOCs usually exceeds a single EPOC, and every calorie counts.
Initial programs should progress at a rate of about 10%, or 5 to 10 min of total weekly training volume per week, every 1 to 2 weeks.
…one method of measuring volume is to multiply frequency by duration. Thus, a person exercising three times a week for 20 min would participate in a total volume of 60 min. Thus, a 10% weekly total volume progression would equal 66 min and 72-73 min during the next two consecutive weeks.
Frequency of training is typically the next most appropriate variable to progress, followed lastly by intensity, but the sequence needs to be evaluated on a case-by-case basis.
This phase therefore offers the perfect entry point for deconditioned or overweight/ obese individuals who usually present with many of the above-mentioned traits.
…exercises may need to regress to a more corrective modality for the severely deconditioned individual or begin in more stable environments before any challenge of instability can be introduced.
…improve posture, balance, core function, flexibility, and movement efficiency.
Strength Level: Phase 2: Strength Endurance
This hybrid stage is the first of three strength phases in which increased loads are placed upon the musculoskeletal system, increasing the body’s metabolic demands while also enhancing stabilization endurance.
…this phase is additionally important to the overweight or obese individual because increasing lean mass will boost resting metabolism to facilitate weight loss.
Essentially, this phase can be described as the transitional stage from volume-based training erformed predominantly in unstable environments to load-based training performed predominantly in stable environments. This bridging stage implements a superset format, sequencing a stable, strength-type exercise with a proprioceptively challenging, stabilization-type exercise (volume) requiring a similar biomechanical motion.
For example, a dumbbell bench press (stable) may be followed by a single-leg cable press (unstable).
Strength Level: Phase 3: Hypertrophy
…optional to weight loss clients, but it should always be considered for individuals who need or desire more lean mass or for those seeking to accelerate fat loss.
Strength Level: Phase 4: Maximal Strength
This phase may hold the least relevance to the overweight or obese client, unless it is deemed necessary for any life or occupational tasks, or ultimately for some sport they may endeavor to pursue. may not be best suited for an individual attempting to lose weight.
Power Level: Phase 5: Power
This training phase also uses a superset format, sequencing a more traditional strength-type exercise, followed by a whole-body, explosive movement requiring a similar biomechanical motion. For example, a barbell squat may be followed by squat jumps.
…one must possess optimal levels of stability and strength before advancing into this phase of training.
Cardio Programming: Stage Training
This introductory stage aims to develop a solid cardiorespiratory foundation by building aerobic efficiency…this stage of cardio training also helps clients meet the muscular endurance demands of training in the stabilization phase…
A simplified approach using the talk test is suggested. Clients should exercise at intensities no higher than that level at which they perceive continuous talking for 10-20 seconds to first become “challenging”
…intensity of 40-59% of VO2R…(or) staying within 65-75% of MHR or RPE of 12-13 on the Borg 6-20 interval-ratio scale…
…clients build exercise volume, first through duration followed by frequency…
The overall goal is to gradually increase exercise duration…
This stage introduces interval training, uses aerobic interval training as the primary mode.
A more feasible option is to use the talk test where intensities range between the point at which continuous talking is “challenging” to the point at which it first becomes “difficult.”
…76-85% MHR, or RPE values between 14 and 16 on the Borg 6-20 interval-ratio scale.
Using the talk test during this stage is certainly a viable option and represents intensities where any form of talking is “difficult to impossible.”
…86-95% MHR, or RPE values between 17 and 19 on the Borg 6-20 interval-ratio scale.
…requires significant recovery time to adequately recover the anaerobic energy pathways.
Unless clients can tolerate very short recovery intervals and complete their workouts successfully, weight loss clients usually are suited better to Stage I and Stage II training.
Stage III training is variable, perhaps requiring 2 to 3 months or longer, but clients should always earn the right to progress to this stage…
The physiology behind a plateau can be explained by the first law of thermodynamics. Energy cannot be created or destroyed, only transferred from one form to another. The human body is constantly striving to be in energy balance, and a plateau represents this balance. In simple terms, the calories taken in match the body’s daily expenditure.
The common contributors to a weight loss plateau are the following:
Physiological adaptations to the prescribed physical activity program
…when a new client starts getting regular exercise, the body will initially expend more calories during exercise. This is due to the body’s inefficiency to meet the demands of the working muscles, but this inflated rate of caloric expenditure will gradually decrease as the body becomes somewhat accustomed to regular exercise.
A true weight loss plateau should not be confused with continued changes in body composition.
…plateaus can be avoided if measurements are taken in regular increments and program adjustments are made accordingly.
Noncompliance to the prescribed program — both nutrition and exercise components
…whether intentional or unintentional. This can be in the form of underreporting caloric intake or overreporting physical activity.
…task becomes even more difficult when meals are not prepared in the home.
Without a physiologic measure of intensity, such as monitoring heart rate during exercise, it is difficult to determine how many calories are being expended. Heart rate monitors, accelerometers, and other body-monitoring devices have become readily available and mostly affordable, and they have proved to be valuable tools for avoiding and overcoming a plateau.
The key to helping clients overcome plateaus is to always keep in mind that a weight loss plateau results from calorie intake equaling calorie expenditure.
Simple changes tend to be most effective, including reducing portions of the foods the client normally consumes, and incorporating lifestyle activity into a daily routine, such as short walks, house chores, taking stairs, standing or pacing during commercials, and overall less time spent being sedentary.
Strategies in Avoiding and Breaking Plateaus
Re-assess daily caloric need: As a client loses weight/body fat, daily caloric need is decreased. If a person is “smaller,” he needs fewer calories throughout the day than the individual did as a “bigger” person. If a client is losing too much lean body mass, an intermittent caloric reduction instead of daily caloric restriction may help to maintain lean mass, which will help keep metabolism high.
Have client measure and write down every bite of food and drink consumed: Sometimes the amount of food and drink consumed is difficult to estimate, and the only way to determine daily intake is to assess exactly what is being consumed. The only way to do this is to measure and/or weigh all food items and write it down at the time of consumption. The simple act of keeping a food log enhances weight loss and weight loss maintenance. This act of recording food intake creates greater awareness of what is consumed and can be used to the client’s advantage to work through a plateau.
Have the client take 1 week off of training (only if a lapse in training has not occurred during the past 10-12 weeks): If the body has grown accustomed to a vigorous and regular exercise routine, a few days off may be in order to let the body “decondition” slightly. When vigorous exercise is reintroduced after a few days, the body will respond with additional calories burned for the same amount of work done just a week earlier. This time off also may provide the client with a chance to fully recover. Overall fatigue may have affected intensity if there were no other breaks in the routine, and a client may return feeling rested and energized.
Implement significant changes to exercise routine, including cardiorespiratory and resistance training components: Increase the overall intensity of the exercise routine. This can be accomplished by introducing a different mode of cardiorespiratory training, having a client take a group exercise class, implementing interval or circuit training, increasing resistance used during strength training, or increasing overall training volume (sets and reps). This is also a good time to try new activities that require a new skill, which could additionally challenge the neuromuscular system.
Move more: Have a client wear a pedometer or accelerometer and increase daily steps to at least 10,000 steps/day. The health and fitness professional should encourage clients to walk whenever possible, including parking farther away, walking on a lunch break, walking before and/or after work, not sitting for more than 30 minutes at a time during the workday, and taking stairs instead of elevators.
Increase water intake: Research shows that increasing water intake, especially around a meal, can reduce overall caloric intake, aiding in achieving a caloric deficit.
Reassess long- and short-term goals and make adjustments: …refocus on original goals or make changes so that written goals reflect current objectives, including a specific plan on how to achieve those goals and an accountability plan.
Increase social support: A solid social support system will also help with accountability while working through a plateau.
Encourage a Self-Monitoring System
Deciding which variables to monitor and how to monitor should come with client input. Some suggestions are diet, exercise, and self-weighing, or a combination of the three. Recent data suggests that electronic monitoring may be more beneficial than keeping a paper log for weight loss clients. However, either method can be effective, making a client’s preference key (15, 16).
Pharmacology and Dietary Supplements for Weight Loss
Dieters should cease supplementation once the weight goal is reached or when they have their daily routines under control to continue making progress without the supplements. Finally, supplements can interact with prescription drugs. Therefore, clients should work with their physicians to determine the most beneficial route to maximize results toward long-term weight loss.
Today the term “low-carb diet” is often thought of as synonymous with the Atkins diet, named after cardiologist Dr. Robert Atkins. Also known as just “Atkins,” the diet restricts carbohydrate consumption by eliminating most carbohydrates (rice, bread, pasta) and replacing them with meats, poultry, eggs, and dairy products.
In most formats, the carbohydrate-modified (low-carbohydrate/high-protein) diet is a ketogenic diet, which induces a state of ketosis through severe limitation of dietary carbohydrates. Ketosis occurs in metabolism when the liver converts fat into fatty acids, and ketones (the byproduct of incomplete fat metabolism) reach high levels in the blood.
Scientists suggest that several mechanisms may be responsible for the weight loss seen with low-carbohydrate diets:
The severe restriction of carbohydrate depletes glycogen (stored carbohydrate) supply, leading to excretion of bound water.
The ketogenic nature of the diet may suppress appetite, leading to reduced caloric intake.
The high protein content of low-carbohydrate diets may provide greater hormonally mediated satiety, thereby reducing spontaneous food intake.
The self-selection from limited food choices may lead to a decrease in caloric intake.
…found that weight loss while using low-carbohydrate diets was principally associated with decreased caloric intake and increased diet duration, but not with reduced carbohydrate content.
The acceptable macronutrient distributions range (AMDR) is 45 to 65% of total calories from carbohydrates. According to science supporting the AMDR, anyone eating an adequate energy provision for weight loss from nutrient-dense foods, with 45% to 65% of total calories from carbohydrates, will fall inside of the recommendation.
Carbohydrates, Weight Gain, and Insulin
Related to the high-protein/low-carbohydrate diet phenomenon is the discussion of insulin and weight gain, with the premise being that carbohydrates stimulate insulin release, and insulin stores fat. Therefore, eating carbohydrates makes you fat.
“The More You Cut Calories, the More Weight You’ll Lose”
An energy deficit must be created for weight loss to occur. However, health and fitness professionals should caution their clients against going too low. Most nutrition experts do not recommend an energy intake any lower than 1,000 to 1,200 calories, and even that may be too low for an active or heavier person.
Very low-calorie diets (VLCDs) should be followed only under the supervision of a medical professional. A VLCD is a medically supervised diet that uses specially prepared formulas to stimulate rapid weight loss for obese patients. Patients on a VLCD will consume these formulas, usually liquid shakes or bars, for several weeks or months in place of solid foods.
Health and fitness professionals should provide guidelines for estimating daily calorie needs when counseling clients on the dangers of restricting calories below recommended levels. Some of the risks of following an overly restrictive diet include the following:
Increased risk of malnutrition.
Poor energy and inability to complete the essential fitness program.
A behavioral “pendulum” swing — an inability to reintroduce “forbidden foods” in a moderate manner.
Many patients on a VLCD for 4 to 16 weeks report minor side effects, such as fatigue, constipation, nausea, or diarrhea. The most common serious side effect is gallstone formation. People who are obese, especially women, are at a higher risk of getting gallstones, which are more common during rapid weight loss.
“Certain Foods (Grapefruit, Celery, Cabbage Soup) Can Burn Fat and Make You Lose Weight”
These programs, often called “negative-calorie diets,” suggest that somehow certain foods create a negative energy balance. Although there is a metabolic cost of digesting, absorbing, and transporting nutrients (called the thermal effect of food — TEF), experts do not consider it significant to weight loss. Negative-calorie diets are often very low calorie diets in disguise…most of these diets are limited to a small number of foods and do not provide adequate macro- or micronutrients.
“Low-Fat or Fat-Free Means ‘Healthy’ or ‘No Calories’”
…the premise has again taken hold with the low-carb/no-carb craze. The two share the same fallacy that if a product is fat-free or low-carb, it is somehow healthy, calorie-reduced, or even alorie-free. The inverse is often true because fat-free and low-carb products often contain large amounts of added sugar, protein, and/or fat.
“Skipping Meals is a Good Way to Lose Weight”
Skipping meals, or fasting altogether, is ultimately counterproductive and can adversely affect health.
“Eating at Night Causes Weight Gain”
Studies show that the most difficult time of day for people to resist overeating is during the evening and nighttime hours (17). Resulting weight gain, however, occurs not because the foods were eaten at night, but due to overconsumption of calories beyond one’s needs. Similarly, avoidance of nighttime eating often results in lower calorie intake, and thus, weight loss..
“Being Vegetarian is an Excellent Way to Lose Weight.”
Plant-based diets tend to be low in fat, and high in fiber and phytochemicals. If a vegetarian diet provides a calorie deficit, weight loss will occur.
“You Can’t Lose Weight or be Healthy if You Eat Red Meat.”
Eating lean red meat in small amounts can be part of a healthy weight loss plan. Red meat, pork, chicken, and fish contain some cholesterol and saturated fat (the least healthy kind of fat), but they also contain essential nutrients such as protein, iron, and zinc.
It is equally important to educate clients about portion size. One serving of meat is approximately 3 oz cooked — about the size of a deck of cards. The amount of meat individuals choose to eat should be based on their total calorie allotment for weight loss.
“If You Exercise, You Can Eat Whatever You Want.”
Experts recommend a combination of prudent eating with manageable exercise to produce lasting weight loss success. This discussion might also present an excellent opportunity for health and fitness professionals to discuss nutrient density and the effect of nutrient choices on exercise performance.
“More Protein Means More Muscle and More Fat Loss.”
The body needs the correct amount of protein, carbohydrates, and fat to grow, maintain, and repair itself, including the growth of lean body mass. Amino acids, the component blocks of proteins, are used as building material for the body. Whether “building” a hormone, antibody, enzyme, or bicep muscle, the body relies on its reserve of amino acids to build proteins as needed.
“Females Get ‘Bulky’ by Lifting Weights”
…the data suggests that women can use conventional resistance training and gain strength on a similar percentage basis to men without developing “bulky” muscles.
“You Have to Exercise at a Low Intensity, or You Won’t Burn Fat.”
…there is still some confusion over the relationship of cardiorespiratory training intensity to fat expenditure.
During exercise of low intensity, there is a higher percent contribution from fat as a fuel source (Table 9.1). However, this is offset by the higher energy expenditure during high-intensity exercise.
…the percent contribution from fat is higher with the low-intensity exercise (60%) than in the highintensity exercise (40%), the total caloric expenditure (as well as the contribution from fat calories) is greater in high-intensity exercise. Partly to blame is the cardiovascular equipment in fitness facilities that is erroneously labeled “fat-burning zone.” High-intensity exercise of the same duration as low-intensity exercise results in more total calories and fat calories burned, making weight loss more likely.
“Sugar Makes You Fat.”
Health and fitness professionals’ message to their clients should be “Reduce junk food intake (soda, cookies, chips, candy), and increase daily physical activity to improve health and promote weight loss.” Their message should not be “Don’t eat sugar; it will make you fat.” For optimal health and body composition, added sugars should be limited to no more than 10% of total daily calories.
“Starvation Mode Prevents Weight Loss”
…drastically reducing calories…often leads to low energy levels, forcing a reduction in daily physical activity, mood swings, and possible malnutrition and micronutrient deficiencies…also leads to increased hunger, which may result in binge eating behavior that sabotages the individual’s weight loss efforts.
It is difficult to lose weight, and individuals failing to do so can easily misinterpret themselves as having a slow or damaged metabolism. The fact is that severely limiting calories will cause a person’s metabolism to adjust slightly, but not enough to prevent fat loss.
After completing this section, the health and fitness professional will be able to:
Sequence requirements for the first client session, including assessments, goal-setting, expectations, and recommendations.
Sequence requirements for a second client session, including reviews and rationales.
Implement a long-term plan for weight loss clients to reach body composition goals.
Prepare for client compliance challenges and strategies for resolution.
Introduction to the First Three Sessions with a Weight Loss Client
This module will outline the flow of the first three personal training sessions for clients who have the goal of weight loss.
Clients who want to lose less than 20 lb are referred to as “moderate” goal clients. Clients who want to lose more than 20 lb are considered “extreme” goal clients.
…start off on the right foot with a welcome e-mail or reminder phone call a couple of days before the first session. This should confirm with them the day, date, and time of the appointment, along with a short list of anything the clients should bring and a description of attire for them to wear.
Assessments: Special Considerations
When performing objective assessments on clients who have extreme weight loss goals, there are some considerations to help the client feel comfortable. Use private or semi-private locations to work with these clients, especially if they are new to working out in a gym or health club.
Food Intake Evaluation: Before heading to the workout floor, complete an assessment of the client’s eating habits. Teach clients the importance of and how to effectively journal their food. Provide them with shopping tips and ideas on how to enlist social support. While collecting subjective and objective data and reviewing their current nutritional habits, begin to get to know the client.
It is the health and fitness professional’s responsibility to temper quality conversation time with the client and move from assessment to assessment with alacrity.
Clarifying Fitness Goals: Experts agree that it is safe and reasonable to lose 0.5 to 2 lb per week. Clients who have an extreme weight loss goal may be able to exceed this general guideline. However, more drastic changes to lifestyle will need to be applied, and clients’ ability to maintain that lifestyle may be difficult. This will need to be communicated to clients who are looking for large fat-loss results in short periods of time.
Tracking success in the process can be very motivating for clients.
For example, if a client states that she wants to “feel better,” the fitness professional can prompt her to describe that feeling in detail. What does feeling better mean to her? Create a 1-10 scale so she can gauge how she feels now, and set a goal for how she wants to feel in the future. Then chart or track how she feels on a daily basis, before or after exercise, or during exercise training sessions. This will allow her to track her progress for this subjective goal.
Organizing Workout Sessions
Warm-Up: Cardio: NASM provides an effective, proven, and flexible approach to programming for weight loss strategies. That being said, the client’s experience is more important than following an evidence-based template. For clients who may seem self-conscious or uncomfortable, fitness professionals may choose to shape their exercise sessions differently than NASM suggests. This is completely appropriate.
Core Training: Core training will help to prevent injury and increase clients’ capacity to perform more challenging exercises.
Balance Training: Waiting to introduce one to two balance training exercises during the second session can allow a health and fitness professional to cover all of the content outlined in this module.
Plyometric, and Speed, Agility, and Quickness Training: Plyometric training, and speed, agility, and quickness training do not need to be inserted into the program during the first three sessions.
Resistance Training: During the first session, the health and fitness professional can teach them two to five resistance training exercises. A total-body exercise, back exercise, and chest exercise are recommended to be taught in that order to maximize learning and caloric expenditure.
By the end of the second session, the client should have been taught five to eight exercises. The fitness professional should be careful not to overwhelm them with too many exercises because clients may have trouble recalling how to perform them.
Integrated Cardio Training
Simply having clients spend a minute or two at a time performing rhythmic exercises, such as walking on a treadmill (Figure 10.14) or using training (battle) ropes (Figure 10.15), intermittently throughout their workout can be an efficient way to keep them engaged and sway their perception about the value of having a health and fitness professional work with them. Remember to teach clients about the importance of a proper cool-down, and walk them through it for at least the first session. Be sure to teach clients how to use more than one style of cardiorespiratory equipment because gyms tend to get busy during peak hours, and clients may not be able to get to their favorite piece of equipment. After the third session, clients should be able to warm up, work out, and cool down on their own and have basic understanding of their nutrition strategies for weight loss. Tables 10.3, 10.4, and 10.5 provide recommendations for structuring a client’s first three exercise sessions.
Troubleshooting Challenges for Weight Loss Clients
Missed Sessions: To mitigate the chance of a client missing a session, remember to confirm all appointments with a phone call, text, or e-mail, whichever form of communication the client prefers. If a client misses a session or scheduled independent workout, the fitness professional should make sure to follow up with the client ASAP. If a client is more than 15 min late for an appointment, the trainer should try to reach the client to determine whether everything is okay and where the client is. The fitness professional may be able to get the client to make the session a little late or reschedule for another time. An employer will have rules around “no shows,” but it is the health and fitness professional’s responsibility to support the client with consistent communication to help prevent that from happening. If a client misses a session, the fitness professional should find out why and reengage the client around a goal. Draw the client’s attention to short-term/proximal goals, and encourage the client to complete some of these tasks to keep the positive momentum.
Late Arrivals: Trainers should talk with clients about the importance of punctuality and how this can help them maintain progress towards their goals. If this becomes a chronic issue, then revisit the client’s goals and commitment level that they expressed during the first session. One strategy to make up for some lost time is to integrate cardio into the session. Using traditional cardio equipment, calisthenics, SAQ training, or games can be fun way to make up time and chew up some calories during the session.
Nutrition Compliance: It is impossible to out-exercise a poor diet.
Find out why the client is failing. Does the client have support at home? Does the client need easier ideas for preparing foods? Does the client know how to shop? Is the client drinking too much alcohol? If the fitness professional can pinpoint where a client is falling down, he or she can help to generate a collaborative plan to help the client succeed.
Some clients struggle with the exercise portion of their program. They may dislike an aspect of their program such as cardio or resistance training, so they do not participate in the program like they should. If this is the case, work with the client to identify barriers and strategize a way around them. For example, suggest group exercise classes or recreational sports, or have them find a workout buddy. The social component of a weight loss plan can be quite powerful.
Relapse: It is important for clients to know that if they momentarily break from their nutrition and exercise plan and regain some weight, they can get back on track. Remember to revisit proximal and distal goals so clients don’t feel overwhelmed. By focusing on actions and short-term goals, such as completing workouts or preparing a certain number of meals per day at home, clients can experience success almost instantaneously.
Sore Muscles: …the health and fitness professional can use this opportunity to rehash the importance of flexibility training, nutrition, hydration, sleep, and a proper cool-down.
To help clients move beyond their soreness, some recommendations include a bath with Epsom salts added to the water, a hot tub, or even a massage to reduce discomfort.
Extreme Hunger: The health and fitness professional may want to begin by helping clients identify what is triggering their hunger and gauge this feeling. Is it true hunger, or is it an urge triggered by a commercial or social situation? Is the hunger being triggered by a stressful event or time of the day? The health and fitness professional should have clients journal their hunger, how intense it is, and what could have possibly triggered it. Clients also may need to review their food intake. They may not be eating enough calories (severe caloric restriction) in an attempt to rush to their weight loss goal. Review the importance of balanced meals and the health dangers of very lowcalorie diets. Fat and protein provide higher levels of satiety. The fitness professional should make sure that clients are consuming an adequate amount of each with every meal or snack. Review the frequency of their meals and when they are experiencing hunger. It’s possible that their water intake is too low as well. One of the signs of dehydration is hunger.
Chewing sugar-free gum is another trick to help quell hunger pangs. An activity that has double the benefits is to have clients complete a short bout of exercise or activity, such as taking a brisk walk, climbing some stairs, or even jogging in place, to help the feeling pass. Deep/ diaphragmatic breathing or meditation can reduce stress levels similar to exercise. Stress may stimulate hunger. By learning to control stress, clients have learned a powerful tool to control hunger
clients will pay too much attention to the scale. Health and fitness professionals need to focus on the results of all of the objective data (weight, circumference measurements, body composition, etc.) in order to truly shape the results clients are experiencing.
Many clients will actually develop additional lean body mass while they are losing fat mass. If only scale weight is monitored, it may appear that clients are not progressing toward their goals.
Education is the tool of the trainer here. Keep clients locked in on proximal short-term goals, and do not remeasure too frequently. Wait at least 3-4 weeks between each “weigh in” to allow for the client’s hard work to show on the scale.
In the short term, ask clients about some of the implicit benefits of their hard work. How are their energy levels? How is their sleep? How do their clothes fit? Is their strength, flexibility, or endurance improving?
Eating Out, Holidays, and Special Events:
it’s possible for clients to enjoy a meal out and stay on target to reach their weight loss goals. It will require some planning and good decision-making. If clients are going to eat out, then they can adjust their caloric intake for the day. If they will be having a calorie-dense lunch or dinner, then they can have lower-calorie meals throughout the day. They can also schedule a snack or a small meal before they go out to help control their hunger. The health and fitness professional should coach clients to drink plenty of water or low-calorie beverages to keep them full during social events or parties. The fitness professional can remind clients of the importance of using a smaller plate to help control portion sizes, and making smart choices whenever possible. It’s okay to have sweets or a heavier food as long as the portions are reasonable.
There may be times when healthier food is not an option, or a client would like to splurge, and that is okay from time to time. The trainer just shouldn’t let clients get off track. Make sure they are back in the gym the next day. Going over their recommended caloric intake by 1,000 calories on Friday can be overcome. But if that leads to a downward spiral lasting the entire weekend, it will be much tougher for the clients to right the ship.
Use the Tools: An excellent resource for finding a registered dietitian who is geographically close to the member is the Academy of Nutrition and Dietetics’ “Find a Registered Dietitian” referral service at www.eatright.org/iframe /findrd.aspx. At this website, clients can input their ZIP code and select a location range (1- to 100-mile radius) to find conveniently located nutrition professionals.
Eating Disorders: Often health and fitness professionals will refer the person to a licensed/registered dietitian or nutritionist, and then the dietitian must refer to a psychiatric professional to assume diagnostic responsibility.