NSCA CPT Chapter 19 – Clients With Nutritional and Metabolic Concerns

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Chapter Objectives:

• Discuss the scope of practice for personal trainers that work with people with nutritional and metabolic concerns.
• Talk about the appropriate prescription of exercise and the design of programs for people that are obese, overweight, or have hyperlipidemia, eating disorders, or even diabetes.
• Discuss the general guidelines for the nutrition of people with nutritional and metabolic concerns.
• Explain lifestyle change strategies that may increase the health statuses of people with nutrition and metabolic concerns.

Overweight and Obesity

These two conditions have become a global epidemic in today’s world. In the US, about 68% of all adults are overweight in the population. And this may increase further as studies now show that childhood obesity has multiplied by four in the last four decades.

The condition of being overweight raises the risk of morbidity from all of the issues within this chapter.

Definitions of Overweight and Obesity and Important Differences

We use the BMI scores to classify people in certain weight classes. An overweight person has a BMI of 25 – 29.9 kg/m2. When someone’s BMI is over 30, they are considered to be obese.

BMI has its limitations with more muscular people (it will overestimate their body fat), and with people with advanced age that lose their muscle mass (it will underestimate the body fat they have). So, it’s fair to say that it is best used for more average individuals who fall in the middle.

BMI is calculated as someone’s weight in kilograms divided by their height in meters squared.

The Classifications are:

• Underweight = <18.5
• Normal = 18.5 – 24.9
• Overweight = 25 – 29.9
• Obesity one = 30 – 34.9
• Obesity two = 35 – 39.9
• Extreme Obesity or Obesity three = > 40

Obese people have more excess weight, mostly fat, than people who are overweight. Essentially, obese people have greater ft stores without any added muscle mass.

People who are obese are likely to have had a larger positive energy balance than overweight people over a long period of time. This can be decreased physical activity and also increased food intake. 

People who are obese have a higher resting metabolic rate and use more energy than overweight or normal weight people.

Overweight clients may benefit best from simply doing more physical activity and changing their diets in a minor way. Obese people should concentrate on reducing their caloric intake and increasing physical activity.

Causes and Correlates of Overweight and Obesity

The biggest reason for obesity is a positive energy balance is the increased accessibility to calorie-rich foods and a sedentary lifestyle. The Surgeon general reports that “body weight is a combination of genetic, metabolic, behavioral, environmental, cultural, and socioeconomic influences.”

Tv viewing is directly related to becoming overweight as a child. In fact, for every additional hour of television, the likelihood of being overweight increases by 20 – 30%. High internet use is like television time, and thus it also increases the likelihood of being overweight.

Fat Distribution

Gynoid obesity – this is seen as a pear-shaped body and is present when someone has most of the fat in their hips and thighs.

Android obesity – this is an apple-shaped body that is present when someone holds most of their fat in their trunk and abdominal area.

Fat in the abdominal area has also been an independent predictor for type 2 diabetes, hypertension, and cardiovascular disease.

Measuring Abdominal Fat

There is a positive correlation between abdominal fat content and waist circumference measurements. 

It is tough to obtain skinfold measurements on clients who are obese, in addition to the process itself being demeaning due to the size of the skinfolds.

For the assessment of abdominal fat in overweight and obese clients:

• Use waist circumference and BMI measures instead of using skinfold measures. 
• Test privately and let the client know that no one besides them will ever see the results.
• Avoid humor, and do the test firmly, but also be a little sensitive.
• If they are too embarrassed to have their waist measured by someone, let the client measure their own waist after instructing them on how to do so.
• Let the client know before the day of testing that they should be wearing thin clothing and let them keep their clothes on if they are uncomfortable about removing their clothes. The measure will be less accurate, but it will still provide a starting point and hopefully, the client will avoid embarrassment.
• These few cutoffs show increased risks for CVD, hypertension, type II diabetes, and dyslipidemia in people that have a BMI between 25 and 34.9 kg/m2: Men: >40 inches (>102 cm) Women: >35 inches (>88 cm) 

Controlling Cardiovascular Risk Factors

Trainers who are working with overweight clients should emphasize cardiovascular risk factors, just like they do weight loss.

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All of the other risk factors are just as important as the weight factor.

Benefits of Exercise in a Weight Reduction Program:

Increases energy expenditure 

Reduces heart disease risk more than just losing weight does alone

It might reduce the individual’s body fat and prevent muscle mass decreases that often happen when someone loses weight.

It might lessen the amount of abdominal fat 

Decreases the resistance to insulin

It might comply better with the recommended diet and reduce caloric intake.

It might not stop the decline in RMR that is often associated with Low calorie diets, but it may minimize the decrease that happens.

Improved mood and general well-being 

Improved body image 

Increased self-esteem and self-efficacy 

Serves as a coping strategy

Lifestyle Change Program for Obesity

The most successful programs for weight management are those that modify the diet, increase physical activity, and change lifestyle patterns. 

Diet Modification and the Low-Calorie Diet

Overweight and obese clients must be referred to dietitians to evaluate their diets properly.

Most of the weight loss for obese people is through the restriction of calorie intake alone.

Clients can spare more lean body tissue when they take in a low-calorie diet, as opposed to a very low-calorie diet where you lose more lean body tissue.

Low-Calorie Diet

Calories – 500 – 1000 cal reduction from typical intake.

Total Fat – 30% or fewer calories

Saturated fatty acids – 8 – 10% of total calories

Monounsaturated fatty acids – up to 15% 

Polyunsaturated fatty acids – up to 10% 

Cholesterol – < 300mg

Protein – ~15% total calories

Carbohydrates – 55% or more total calories

Sodium – Not more than 100 mmol

Calcium – 1 – 1.5 thousand mg

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Fiber – 20  – 30 g

Physical Activity

Moderate activity for a minimum of 30 minutes on most days of the week is recommended for people who are obese or overweight.

Lifestyle Change Support

Techniques of self-monitoring, rewards, goal setting, stimulus control, and dietary behavior changes may potentially help clients to see their progress and make real, long term changes.

Exercise Concerns of Clients Who Are Overweight or Obese

Heat Intolerance

Due to added fat and insulation from it, it is harder for obese and overweight individuals to thermoregulate compared to normal-weight individuals.

Movement Restriction and Limited Mobility

Modification may be required due to the added difficulty of the limited range of motion from excess fat mass.

Weight Bearing Stress

The added weight puts more force on joints and musculature, which is a concern, especially for people with osteoarthritis or musculoskeletal injuries.

Posture Problems and Low Back Pain

There is added stress from abdominal fat mass on the spine and then partnered with less strength in the abdominal wall muscles.

Balance Concerns

Excess weight can affect balance, and obesity may cause many people to not participate in sports. Thus, they would have less developed coordination.

Hyperpnea and Dyspnea

This is both uncomfortable and a source of anxiety for obese people when they are exercising. 

Hyperpnea is an increased breathing rate, and dyspnea is labored or difficulty breathing.

Exercise Prescription and Program Design for Clients Who Are Overweight or Obese

Aerobic Conditioning

Recommended to be 30 minutes each day for most of the days of the week.

5 or more days per week will maximize caloric expenditure.

The goal should be 300 minutes per week.

These may include moderate or vigorous intensities.

It is possible to achieve this with the intermittent exercise of 10 minutes at a time.

Resistance Training

This should be 2 – 3 days per week and be on nonconsecutive days.

It should start with at least 1 set and progress to 2 – 4 sets with 10- 15 reps.

All of the major muscle groups should be trained.

The load should gradually increase.

Flexibility Training 

This should occur 2 – 3 days per week. 

4 or more reps should be done per muscle group.

Static stretches need to be held for 15 – 60 seconds.

Eating Disorders

Disordered Eating

This is a further eating restriction that usually happens following a diet. This could be with the use of more extreme measures to lose weight, like diuretics, diet pills, vomiting, food faddism, fasting, the use of saunas, laxatives and enemas, 

Anorexia Nervosa

This is shown by extreme weight loss. Someone with this disorder has a fear of gaining weight or becoming fat, although they are already underweight, have a distorted body image, and possibly amenorrhea. People with anorexia restrict their food while excessively exercising.

Bulimia Nervosa

This disorder consists of episodes of binge eating that reoccur frequently and are followed by food purging.

Female Athlete Triad

Three disorders together can result in this female athlete triad. These are disordered eating, amenorrhea, and osteoporosis. The word athlete is included as this is the group in which it was first discovered.

Exercise Prescription and Program Design for Clients Recovering From an Eating Disorder

Clearance needs to be received from physicians to return to their exercise program.

When continuing a program, the trainer will need to reassess the client.

The program should deemphasize weight loss and instead emphasize low energy demand exercise.

Hyperlipidemia

This is the general term for elevated lipid levels in the blood, like cholesterol, triglycerides, and lipoproteins.

Possible Causes of Hyperlipidemia

Higher levels of LDL cholesterol have been a major cause of this.

Raised triglyceride levels are also a concern for this problem.

Therapeutic Lifestyle Change Diet

The consumption of an antiatherogenic diet being emphasized and used is important for lifestyle changes in HDL levels.

TLC Physical Activity: Exercise Prescription and Program Design For Clients With Hyperlipidemia

Aerobic conditioning is placed as a very important part of a therapeutic lifestyle change.

5 or more days per week will maximize the caloric expenditure.

30 – 60 minutes per day is the recommendation.

The eventual goal to shoot for is 50 – 60 minutes per day.

40 – 75% of HRR intensity.

TLC Weight Loss

Weight loss, along with a diet program and exercise, will bring larger decreases in LDLs, increases in HDLs, and reduce overall cholesterol.

Metabolic Syndrome

Someone with three or more of these criteria would be defined as having metabolic syndrome:

• Abdominal obesity: waist circumference > 102 cm in men and  > 88 cm in women 
• Hypertriglyceridemia: ≥ 150 mg/dl 
• Reduced HDL-cholesterol: <40 mg/dl in men and <50 mg/dl in women 
• Elevated blood pressure: ≥130/85 mmHg 
• Elevated fasting glucose: ≥110 mg/dl 

Diabetes Mellitus

These are metabolic diseases that have high blood glucose levels.

Some signs and symptoms include increased urination frequency, thirst, appetite, and general weakness.

Type of Diabetes

Type I diabetes is known as insulin dependent diabetes mellitus. It is associated with pancreatic beta cell destruction by autoimmune processes and leads to an insulin deficiency. This is the diabetes people are usually born with.

Type II diabetes is also known as non-insulin dependent diabetes mellitus. It is shown with insulin resistance in peripheral tissues and an insulin secretion deficit of the pancreatic beta cells. 90% of people with diabetes have this type and it is typically developed later in life from the lack of taking care of the body through exercise and eating.

Gestational diabetes mellitus is a condition where glucose levels are raised, and other symptoms appear when pregnant in women not previously diagnosed with diabetes. Not caused by lack of insulin but by insulin resistance.

Exercise Prescription and Program Design for Clients With Diabetes Mellitus

Glycemic Control

Aerobic Conditioning

3 – 7 days per week are recommended at 20 – 60 minutes per session or 150 minutes weekly. The eventual goal is to reach 300 minutes in a week.

Exercise should be at 50 – 80% of HRR.

Resistance Training

This should be 2 – 3 nonconsecutive days in a week and needs to be 2 – 3 sets of 8 – 12 reps.

It should include 8 – 10 multijoint exercises for all the body’s major muscles.

Flexibility Training

2  or 3 days per week and greater than or equal to 4 reps per muscle group.

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