Chap. 19a Clients With Nutritional and Metabolic Concerns

1. Chap. 19a Clients With Nutritional and Metabolic Concerns NSCA’s Essentials

2. Nutritional and Metabolic Concerns • More technology, the need for less rigorous work and more food availability have led to increased health risks • Along with other societal changes, we have seen an increase in obesity, hyperlipidemia, diabetes and eating disorders

3. Nutritional and Metabolic Concerns • As personal trainer you are likely to encounter many types of clients who have these types of conditions related to nutrition • Obtaining medical clearance is the first and most important key with clients such as this • Referral to nutrition specialist or other healthcare professionals is extremely important as it is out of your scope of practice with these types of conditions…

4. Nutritional and Metabolic Concerns • You are not to diagnose or prescribe care for clients who have conditions that exceed your knowledge and experience level!

5. Nutritional and Metabolic Concerns • Overweight and Obesity • An epidemic is now occurring in adults and children • 32.2% of U.S. men and 35.5% of U.S. women are obese and 68.0% are overweight • These figures are expected to increase further in the future

6. Nutritional and Metabolic Concerns • Conditions of being overweight and obese raise the risk of morbidity (death) from: • Hypertension • Hyperlipidemia • Type 2 diabetes • Coronary Heart Disease (CHD) • Stroke • Osteoarthritis • Sleep Apnea

7. Nutritional and Metabolic Concerns • Definitions of Overweight and Obesity and Important Differences • Overweight: Body Mass Index (BMI) of 25-29.9 kg/m2 • Obesity: BMI of >30 kg/m2 • BMI usage is limited though to individuals who are muscular as it overestimates body fat due to muscle weighing more than fat • Also underestimates those with lean body mass loss (due to advanced age)

8. Nutritional and Metabolic Concerns • BMI calculated by: Weight (kg) divided by height squared (m2) BW (kg) / HT2 (m2) • BMI Calculated by: Using pounds and inches: • [weight (pounds) divided by height (inches squared)] x 703 • 1 foot = 12 inches (ex. 5 feet = 60 inches, 5 feet 2 = 62 inches) • Inches converted to meters: (inches x .0254) = meters • Pounds converts to kilograms: (lbs divided by 2.2) = kilograms

9. Nutritional and Metabolic Concerns • BMI classification chart • Underweight: < 18.5 • Normal: 18.5 – 24.9 • Overweight: 25.0 – 29.9 • Obesity: 30.0 – 34.9 (Class 1) • 35.0-39.9 (Class 2) • Extreme obesity: ≥ 40.0 (Class 3)

10. Nutritional and Metabolic Concerns • Let’s figure out a BMI Calculation! • A person who weighs 164 lbs and is 5 ft 8 inches tall • What would be this person’s BMI • [164 lbs ÷ 68²] x 703 = ___ • Would this person be considered overweight? Obese?

11. Nutritional and Metabolic Concerns • Important Differences between Overweight and Obese • Obese have significantly greater excess of weight than overweight people • Percentage of adipose tissue higher in obese than overweight as opposed to fat free tissue • Obese person have a larger positive energy balance (decrease in physical activity, increase in food consumption) over a longer period of time than overweight people • Obese individuals have a higher resting metabolic rate and expends more energy on activities than those who are overweight or normal weight.

12. Nutritional and Metabolic Concerns • Energy Balance = consuming as many calories as you expend • Positive Energy Balance = consuming more calories than you expend, increase in body weight • Negative Energy Balance = consuming less calories than are expended, decrease in body weight

13. Nutritional and Metabolic Concerns • The sedentary lifestyle is a huge predictor of overweight or obesity • Overweight: early intervention through increased exercise is important. Get to them before they become obese. Just increasing activity level could return them to normal weight without having to resort to cutting calories severely • Obese: strong emphasis on cutting calories and increasing physical activity

14. Nutritional and Metabolic Concerns • Obesity is an multi-factorial chronic disease involving: • Genetics • Environment • Social • Behavioral • Metabolic • Possibly ethnic influences • What are some issues with each of these factors that may contribute to obesity?

15. Nutritional and Metabolic Concerns • Fat Distribution • Two types • Android (apple shaped body): high fat distribution in trunk and abdominal area. Usually see in men • Gynoid (pear shaped body): high fat distribution in the hips and thighs. Usually see in women • Adominal fat is a direct and independent predictor of disease risk for type 2 diabetes, hypertension and CVD

16. Nutritional and Metabolic Concerns • Measuring Abdominal Fat • Positive correlation between abdominal fat and waist circumference measurement • Use waist circumference measurement (pg. 214)

17. Nutritional and Metabolic Concerns • Skinfold Measurements can be hard to do on persons who are obese • Caliper placement is difficult and requires a great deal of experience • Process can also be demeaning to client • However, if when possible, use these assessments during initial assessment and for follow up measurements • Demonstration of loss of inches can have more meaning

18. Nutritional and Metabolic Concerns • Assessing Abdominal Fat in Clients who are Overweight or Obese • Use waist circumference and BMI in lieu of or addition to skinfold • Conduct in a private setting, confidentiality of results • Be matter of fact yet sensitive, avoid uncomfortable humor • Allow client to conduct measurement him/herself if too embarrassed for you to do it, obviously give instruction on how to do it • Tell client before hand to wear thin clothing and allow them to keep all clothes on during measurement if they are uncomfortable • Look at cutoff for increased risk for type 2 diabetes, dyslipidemia, hypertension, and CVD in individuals with a BMI between 25 and 34.9: • Men > 40 inches (> 102 cm) • Women >35 inches (> 88 cm)

19. Nutritional and Metabolic Concerns • Controlling Cardiovascular Risks • Increase abdominal fat distribution moves an individual I the overweight or Class I obesity category to an even higher disease risk category (See table 19.1, pg. 490) • Trainers should emphasize controlling cardiovascular risks by working with clients to control risk factors that are controllable • Increasing physical activity along with cessation of things such as smoking and consuming a heart healthy diet with or without weight loss is a significant improvement in health

20. Nutritional and Metabolic Concerns • Benefits of Exercise in Weight Reduction • Exercise should be a vital component of a weight loss program for overweight clients • Obese clients, although exercise is essential, will have to work their way into exercise due to the higher amounts of fat not allowing them to do many movements…decrease in calories main goal at first • Exercise physically lower risks for CVD, increase energy expenditure, decrease abdominal fat, decrease insulin resistance, etc. • Psychologically exercise promotes increased sense of well-being, mood, body image and self-esteem

21. Nutritional and Metabolic Concerns • Lifestyle Change Program for Obesity • In terms of diet…refer, refer, refer! • Do not overstep scope of practice boundaries…you are not a nutritionist! • Referral to dietary professional is common for clients who are obese or who have other conditions (e.g. diabetes) • However, knowledge in the area is necessary to work with nutritionist who you’ve referred your client to

22. Nutritional and Metabolic Concerns • Lifestyle Change Program for Obesity • Recommendations for nutrition • Be sensitive to client’s cultural and ethnic background and food selection • Availability and cost of food • Meet recommended dietary allowances • Obese persons will have caloric restrictions of 500-1000 calories per day to facilitate a 1-2 lbs weight loss per week, this is to achieve a safe and progressive program • Women should consume diets containing no less than 1000-1200 calories per day • Men should consume diets containing no less than 1200-1600 calories per day • See lower calorie step diet for more information (pg. 496) • Important to stress long term weight loss not short term weight loss • Reducing bodyweight by 10% over six months is an appropriate goal; at this time, new goals can be set.

23. Nutritional and Metabolic Concerns • Physical Activity (overweight or obese) • Moderate levels • At least 30 minutes • Most (3-5) days per week

24. Nutritional and Metabolic Concerns • Physical Activity • Moderate levels of activity: defined as using around 150 calories a day, 1000 calories per week to facilitate weight loss • ACSM recommends a minimum of between 150 to 250 minutes per week of moderate intensity (40-60% VO2R or heart rate reserve) to vigorous intensity (50-75% VO2R or HRR) physical activity to prevent weight gain for individual that are overweight or obese. • Overweight and obese clients should progress to a level of physical activity of 250 to 300 minutes per week or 50 to 60 minutes per day five days a week to enhance long-term weight loss maintenance. • For weight loss, some individuals may need to progress to 60 to 90 minutes per day of moderate-to-vigorous-intensity physical activity. • Important to consider progression with obese clients • Initial activities will probably have to be low-intensity or increasing daily tasks (e.g. using stairs instead of elevator, take a walk after lunch, etc.)

25. Nutritional and Metabolic Concerns • Physical Activity • Well designed programs avoid the incidence of injury and make beginning exerciser feel comfortable • Start with lower demands and then move your client up slowly

26. Nutritional and Metabolic Concerns • Lifestyle Change Support • Various strategies to help clients adhere to physical activity and diet programs • Helps client identify obstacles from keeping them motivated • Use techniques such as self-monitoring, rewards, goal setting, stimulus control and dietary behavior changes

27. Nutritional and Metabolic Concerns • Self-Monitoring • Practice of client’s taking note of his/her activity and diet behaviors and recording them • Food and calorie intake • Bouts of exercise and activity • Moods when eating • Where food was eaten • Trainers can have clients fill out forms such as Activity Diary (pg. 499) • Self-monitoring helps the client become self-aware of the obstacles and challenges facing them and how to deal with them • What else can you self-monitor?

28. Nutritional and Metabolic Concerns • Rewards • Can be used to encourage or motivate clients to stay the course • An effective reward is something that is desirable to the client • Also to acknowledge attainment of meeting specific goals • Can be big or small goals, tangible or intangible • Be careful though because overuse of rewards creates a dependency on them for success • What are some types of rewards you could use?

29. Nutritional and Metabolic Concerns • Goal Setting • Important for trainers to work with clients in setting goals for them • Goals provide a direction and a source of motivation • Adhere to S.M.A.R.T goal format • Can also be used in conjunction with self-monitoring and rewards • Activity and Exercise contract on page 501

30. Nutritional and Metabolic Concerns • Stimulus Control • Identifying social or environmental cues that seem to trigger undesired eating patterns or non-participation in physical activity • Examples • Always eating popcorn and drinking soda at a movie when you are not hungry • Over eat a buffets • Have rich desserts when out with a particular friend • What else could be social or environmental triggers?

31. Nutritional and Metabolic Concerns • Food Consumption Behavior Changes • Slow down eating speed (fast eating does not allow the body to signal satiety before end of meal) • Use smaller plates to make portion size look bigger • Schedule meals in smaller increments to not overeat because you don’t eat during the day • Find what works best for client

32. Nutritional and Metabolic Concerns • Exercise Concerns of Clients Who Are Overweight or Obese • Heat Tolerance • Increase insulation issues due to excess fat • Encourage clients to wear cotton clothes, preferably shorts and t-shirt in moderate and hot temps. • Be careful though of embarrassment with shorts and t-shirt with clients (long sleeve shirt and light weight track pants) • On hot days consider different methods of exercise (aquatic, lower intensity exercise, etc.) • Trainers must ensure that the client drinks enough water before, during, and after exercise.

33. Nutritional and Metabolic Concerns • Movement Restriction and Limited Mobility • Movement limited due to excess fat • Modifying various exercises may be necessary • Figure 19.2 – 19.4 (pg. 502-503) • Assisted stretching devices may be of help (using a towel or a partner)

34. Nutritional and Metabolic Concerns • Weight Bearing Stress • Excessive weight bearing on joints is concern for people who are obese or overweight • High impact training may further increase discomfort and pain • Shoot for low-impact activities • Pool • Walking • Jogging • Avoid single limb exercises for long periods of time (alternate if doing this) • Swimming, shallow-water walking, deep-water running

35. Nutritional and Metabolic Concerns • Posture Problems • Stress of abdominal fat mass on spine can cause posture problems • Can have problems such as lordosis lower spine, kyphosis of upper spine, etc. • Lots of muscular imbalances due to excess fat • Include a variety of strengthening exercises for abdominal muscles and back muscles (due to the hip flexor dominance aggravating abdominal weakness) • Include flexibility training • Chronic back pain clients should be referred to health care provider to be checked out • Strengthen upper back musculature, stretch chest muscles

36. Nutritional and Metabolic Concerns • Balance Concerns • Due to little experience in movement from excess fat, clients may have poor balance • Lack of balance also related to lack of strength • Balance training is a must! • What kind of balance training activities could you do with overweight or obese clients?

37. Nutritional and Metabolic Concerns • Hyperpnea and Dyspnea • Increased respiratory rate and labored breathing • Although expected with exercise…it can be extremely uncomfortable with these types of clients so be careful to provide appropriate intensity • Use RPE scale to evaluate proper intensity levels with this population of clients • Modified interval training, especially at the beginning of an exercise program, is highly recommended, as the rest intervals (active or inactive) will allow clients to bring their breathing into better control.

38. Nutritional and Metabolic Concerns • Exercise Prescription and Program Design for Clients Who Are Overweight or Obese • Aerobic Conditioning • ≥ 5 days/wk • 30 min. minimum (150 min./week) • Goal of 40-60 min. (300 min./week) • Moderate (40-60%) to vigorous (50-75%) of VO²R or HRR • Resistance Training • 2-3 days/wk, non-consecutive days • 1 or more sets, progressing to 2-4 sets, 10-15 reps • Exercises for each major muscle group (8-10 exercise) • Gradual load increase • Flexibility Training • 2 or 3 days per week • Hold static stretches for 15-60 seconds • ≥ 4 reps per muscle group

39. Nutritional and Metabolic Concerns • Program Modifications and Motivational Strategies for Clients Who Are Obese • Avoid being judgmental about your client! • Get client to focus on lifestyle change as opposed to measuring success by pounds • Modify exercise training methods to provide safe and effective programming • Use progression-start with daily living, move to low intensity and so on • Use interval training with unfit individuals • Establish a regular workout schedule • Incorporate lifestyle change strategies (e.g. goal setting, rewards, etc.) • Promote the increase of everyday activities to burn extra calories