Chapter 19 Lifestyle Modification and Behavioral Coaching:

• Figure 19.1 Stages of Change Model
• Know the stages of Change
• Be familiar with the initial session
• Effective Communication skills
• Goal setting- SMART Goals
• Cognitive Strategies
• Positive Self talk
• Exercise Imagery

States of Change

Stage 1: Precontemplation

• No intention of changing. Do not exercise and do not intend to start within 6 months. Education is best strategy with precontemplators. 

Stage 2: Contemplation

• Thinking about becoming more active in next 6 months. Listen to what contemplators need and support them any way that they can. Contemplators still need information. 

Stage 3: Preparation

• Exercise occasionally but are planning to begin exercising regularly next month. May have unrealistic expectations for the change they hope to achieve, oftentimes leads to high risk of disappointment and early dropout. 
• Help clients clarify realistic goals and expectations, help clients maintain their beliefs in the importance of exercise, discuss programs that work best for different clients, consider clients’ schedules, ask about previous successful experiences with exercise, avoid exercise that could lead to discomfort or injury, discuss building social support network.

Stage 4: Action

• Started exercise, but not yet maintained behavior for 6 months. Continue to provide them with education. Work with their clients to develop steps for overcoming any barriers or disruptions.

Stage 5: Maintenance

• Maintained change for 6 months or more. Still tempted to return to old habits. 

The Initial Session

• 20 seconds to make a good first impression. Body language. Initial session building relationship.
• Discuss health concerns.
• Clarify fitness goals. Verbalize goals. Set SMART goals, specific, measurable, attainable, realistic, and timely.
• Reviewing previous exercise experiences
• Finalizing program design. Have good sense of health concerns, fitness goals, and past positive and negative experiences.
• Help clients anticipate the process.

Importance of Effective Communication Skills

• Difference between success and failure in relationship between trainer and his or her client. 
• Nonverbal and verbal communication – posture, body language, verbal must be clear to be understood correctly.
• Active listening – genuine interest in client’s perspective and getting to know them. Pay attention, avoid distractions, look the speaker in the eye.
• Asking questions – ask open not close ended questions.
• Reflecting – Express the purported meaning of what you just heard. Make sure client is accurately understood.
• Summarizing – Draws all important points of conversation together and again allow clients to clarify either what they have said or how someone has interpreted what they have said.
• Affirmations show appreciation for clients and their strengths. Listen carefully to know what to affirm. Validate positive comments about their thoughts, plans, skills.
• Asking permission – ask permission to share information.

SMART Goals

• Specific – clearly defined in such a way anyone could understand what the intended outcome is. Detailed description of what is to be accomplished.
• Measureable – Quantifiable. Establish a way to access the progress toward each goal. If goal cannot be measured a client cannot manage it.
• Attainable – Right mix of goals that are challenging, but not extreme.
• Realistic – Repesent objective toward which an individual is both willing and able to work.
• Timely – Always have a specific date of completion. Realistic but not too distant in the future.

Cognitive Strategies

• Positive self-talk – Help clients become aware of their negative thought process. Help clients come up with list of positive thoughts they might use with regard to exercise. Train clients to notice negative thoughts, stop negative thoughts, and translate those into something positive.
• Exercise imagery – process created to produce internalized experiences to support or enhance exercise participation. Clients can imagine themselves approaching their activity with greater confidence. Visualize performing with greater relaxation and muscle control. Rehearse positive outcomes.

Chapter 18 Supplementation:

• Table 18.2 Dietary reference intake terminology
• Units of measure used on dietary supplement labels
• Adverse effects of excess for specific vitamins & minerals
• Be familiar with the ergogenic aids and dosage

Dietary Supplements

What are supplements

• Dietary Supplement – Substance that completes or makes an addition to daily dietary intake. 
  
• Defined by DSHEA as containing one or more of following: vitamin, mineral, herb, other botanical, amino acid, dietary substance to supplement diet, concentrate, metabolite, constitutent, or extract. Intended for ingestion in a tablet, capsule, powder, softgel, gelcap, or liquid form. Labeled as dietary supplement. Cannot be repesented for use as a conventional food or as a sole item of a meal or diet. Cannot include an article that is approved as a drug or biologic.

Supplementation Guidelines

 

Labels of Dietary Supplements

• Proteins, carbs, fats expressed in grams
• Vitamins, minerals, amino acids are expressed in milligram(mg) or microgram(mcg or ug)
• IUs are international units.

Vitamin and Mineral Supplements

• Vitamin A – high intake of retinol but not Beta carotene is associated with increased incidence of hip fracture in older women. Excess intake of retinol at conception and during early stages of pregnancy increases risk of birth defects.
• Increase in risk of lung cancer in smokers taking 20 to 30mg of beta crotene.
• Calcium should be at low levels or absent. Excess calcium consumed with other minerals can decrease absorption of some important trace minerals.
• B vitamins, niacin, folic acid.
• Deficiency of vitamins and minerals can cause mental and emotional problems. Iron deficiency has been shown to affect both physical and mental function adversely.
• Vitamin B12 deficiency, most commonly seen in elderly and those who avoid consuming animal foods. Mental and emotional changes caused by vitamin B12 deficiency are often mistaken for Altzheimers and dementia. Condition can be reversed if corrected early in deficiency state. If not, nerve damage and dementia symptoms can be irreversible. High dose oral supplementation, 200 to 2000 ug per day may be as effective as injections.

Ergogenic Aids

• Ergogenic means work generating. Something that enhances athletic performance. 
• Creatine – synthesized naturally in human body from amino acids methionine, glycine, and arginine. In resting skeletal muscle, about two thirds of creatine exists in a phosphorylated form that can rapidly regenerate ATP to maintain high-intensity muscular efforts for up to about 10 seconds.
• When creatine supplementation is combined with strength-training program, it has been shown to increase muscle mass, strength, and anaerobic performance. Typical dose begins with 5 to 7 days at 20g per day then followed by 2 to 5g a day to sustain maximal muscle creatine levels.
• Consuming creatine with carbs can enhance muscle uptake of creatine and potentially increase muscle levels above that achieved without concurrent carb consumption.
• Creatine plays an essential role in normal brain function.

Stimulants

• Caffeine – most widely used drug in the world. Acts as stimulant, primarily affects central nervous system, heart, and skeletal muscles.
• Ergogenic effects from caffeine, especially when tested on well-trained athletes performing endurance exercises(more than one hour) or high intensity short-duration exercise lasting about 5 minutes. Does not appear to be ergogenic effect on sprint type efforts lasting 90 seconds or less.
• Most effective ergogenic response observed when dose of caffeine is 3 to 6 mg per kg body weight, ingested 1 hour before exercise. For 155lb person this is 210 to 420mg of caffeine.

Chapter 17 Nutrition

• Know all Definitions throughout the chapter
• Table 17.4 Know all of the Essential Amino Acids
• Table 17.6 Recommended Protein Intake
• Daily recommendations for fiber
• Specific recommendations for endurance athletes
• Fatty acids
• Lipids in the body
• Daily recommendations and importance of water
• Table 17.11The effects of dehydration
• Be familiar with guidelines for altering body composition
• Risks of very low calorie diets
• Calorie count for proteins, carbohydrates, fats

Definition

• Nutrition – Process by which living organism assimilates food and uses it for growth and repair of tissues. 

Standards of Practice and Scope of Practice: Personal Trainers versus licensed Dieticians

• Should be familiar with concepts of nutrition. 
• Professional, legally qualified to practice in the field of nutrition is Registered Dietician(RD). RD is specialized in food and nutrition expert with extensive training.
• Practice of nutrition is governed by national credentialing programs and state licensing laws. 46 states have specific laws that explicitly define scope and practice for nutrition and dietetics professionals, and performing these duties without a license could be considered illegal.

Daily Energy Needs

• Calorie – amount of heat energy required to raise temp of 1 gram of water 1C. 
  
• Calorie – Unit expression of energy equal to 1,000 calories. Amount of heat energy required to raise 1 KG or liter of water 1C or kilocalorie.
• Kilocalorie – equal to 1,000 calories, raise 1kg of water 1 degree C.
• Estimated total energy expenditure(TEE) is defined as amount of energy(calories) spent, on average, in a typical day. TEE the sum of three different energy components:
• Resting metabolic rate(RMR) 70% of TEE., Thermic effect of food(TEF) amount of energy expended above RMR as a result of processing of food, TEF typically accounts for 6-10% of TEE. Energy expended during physical activity – Approx 20% of TEE.

Resting metabolic rate

• Accounts for 70% of total daily energy expenditure in sedentary person. Affected by wide variety of factors including age, sex, genetics, hormonal changes, body size, body comp.
• 27 million Americans have thyroid related disorders.
• Cardiovascular meds can reduce RMR from 4 to 12%. Chemo can reduce RMR from 6 to 11%. Long term use of growth hormone increases RMR by 12%. Thyroid meds and hypothyroidism can increase RMR by 17%.
• Thermic effect of food – Process of digestion requires energy, increase in energy expenditure after meal is called thermic effect of food (TEF) 6-10% of total energy expenditure.

Estimating Total Daily Energy Expenditure

• Weight(lbs) x 10 = RMR
• RMR x activity factor = TEE
• Even most commonly used formulas can have up to 20% variance in over or understimating resting metabolism and total energy expenditure.

Protein

• Protein – Amino acids linked by peptide bonds. Build and repair body tissues and structures. Involved in synthesis of hormones, enzymes, and other regulatory peptides.
  

Structure of Protein

• Made up of amino acids linked together by peptide bonds. Body uses approx 20 amino acids to build its many different proteins. Arranging amino acids in different sequences yields the body’s myriad of proteins.
• Two general classes of amino acids: essential and nonessential.
• Essential amino acids cannot be manufactured in the body – therefore must be obtained from food supply or some other exogenous source.
• Nonessential – body can manufacture them from dietary nitrogen and fragments of carbs and fat.
• Arginine and histidine are semiessential amino acids.

 

Digestion, Absorption, and Utilization

• Proteins must be broken down into constitutent amino acids before body can use them or repair tissue or as energy substrate. Fate of amino acids after digestion depends on body’s homeostatic needs, which can range from tissue replacement or tissue addition to need for energy.
• Proteins encounter HCL in stomach which uncoils(denatures) protein so that digestive enzymes can begin dismantling peptide bonds. The enzyme pepsin begins to cleave protein strand into smaller polypeptides(strands of several amino acids) and single amino acids.
• As protein fragments leave stomach and enter small intestine, pancreatic and intestinal proteases(protein enzymes) continue to dismantle the protein fragments.
• Resulting dipeptides, tripeptides, and single amino acids are then absorbed through the intestinal wall into enterocytes and released into the blood supply to the liver.
• Once in bloodstream, free-form amino acids have several possible fates: they can be used for protein synthesis(building and repairing tissues or structures), immediate energy, or potential energy(fat storage).
• Amino acids are first deaminated(stripped of amine group), allowing remaining carbon skeleton to be used for production of glucose or ketones to be used for energy. Removed amine group produces ammonia, which is converted to urea in the liver and excreted as urine by the kidneys.
• If intake exceeds need for synthesis, then proteins are deaminated, carbon fragments stored as fat.

Protein in Foods

• If food supplies all essential amino acids in appropriate ratios it is called complete protein. If food source is low or lacking in one or more essential amino acids it is called incomplete protein. 
• Biologic value (BV) measure frequently used when discussing protein sources, BV is measure of protein quality, how well it satisfies body’s essential amino acid needs.
• Protein source with higher score provides amino acid profile that is more closely related to needs of the human body.
• Major sources of complete proteins are animal sources, dairy and meats. Sources of incomplete protein include grains, legumes, nuts, seeds, and other vegetables.

Negative Energy Balance

• During negative energy balance amino acids are used to assist in energy production, a term called gluconeogenesis. Depleted glycogen increases gluconeogenesis. Supported by released of amino acids from structural proteins to maintain glucose homeostasis. 

Protein’s Effect on Satiety

• More satiating than fat or carbs. Studies indicate protein has direct effect on satiety. 

Protein Intake Recommendations

• Recommended Daily Allowance(RDA) for protein is 0.8 g/kg/day. 10 to 35% of total caloric intake. 
• High protein diet defined as higher than 35%. Risk factor for heart disease and some types of cancer.

 

Carbohydrates

• Carbohydrates – Neutral compounds of carbon, hydrogen, and oxygen(such as sugars, starches, and celluloses), which makes up a large portion of animal foods. 
  
• Sugars(simple), starches(complex), and fiber. Monosaccharide is single unit of sugar, many of which are connected to make starches. Monosaccharides include glucose, fructose, and galactose.
• Disaccharides(two sugar units) include sucrose(or common sugar), latose(or milk sugar), and maltose.
• Polysaccharides are long chains of monosaccharide units linked together and found in foods that contain starch and fiber. Called complex carbohydrates and include starch found in plants, seed, and roots.
• Dietary fiber is part of plant that cannot be digested by human gut enzymes and passes through small intestine and colon.

Digestion, Absorption, and Utilization

• Simple sugars are very easily digested. Double sugars such as table sugar require some digestive action but are not nearly as complex as starches. Starches require prolonged enzymatic action to be broken down into simple sugars.
• Rate at which ingested carbs raise blood sugar and its accompanying effect on insulin release is referred to as the glycemic index(GI).
• Mixed meals or protein, carbs, and fat can alter the glycemic effect of single foods.
• All carbs are eventually converted into simple sugars such as glucose or fructose.

Role of Fiber in Health

• Higher fiber intake is associated with lower incidence of heart disease and certain types of cancer. 
• Insoluble fiber does not absorb or dissolve in water. It passes through the digestive tract close to its original form. Insoluble fiber offers many benefits to intestinal health, including a reduction in the risk and occurrence of colorectal cancer, hemmrrhoids, and constipation.

Carbs and Performance

• As duration of activity increases, available glucose and glycogen diminish. Increasing reliance on fat as fuel source. 

Carbohydrate Intake Performance

• 6 and 10g/kg/day of carbs is recommended. 45 to 65% of total caloric intake. Complex carbs constitute majority of calories.
• Before exercise consume high carb meal 2 to 4 hours. Glycogen stores are lowered by as much as 80% in the mornings.
• Endurance athletes consume between 30 and 60g of carbs every hour to maintain blood glucose levels.
• One hour of intense cycling was improved by 12% with consumption of 53 ounces of water containing 79g of carbs.
• Timing of carbs important for maximizing recovery, recommended consuming 1.5g per KG of carbs within 30 mins of completing exercise to maximize glycogen replenishment. Delaying intake by even 2 hours can decrease total muscle glycogen synthesis by 66%. PWO environment hasten glycogen repletion as a result of increased blood flow to muscles and increased sensitivity of cells to effects of insulin.

Lipids

• Lipids – Group of compounds that includes triglycerides(fats and oils), phospholipids, and sterols.
  

Fatty Acids

• Saturated or unsaturated. Unsaturated classified as monounsaturated or polyunsaturated.
• Polyunsaturated provide important essential fatty acids(fats that cannot be manufactured by the body but are essential for proper health and functioning).

Function of Lipids

• Lipids(or fats) are most concentrated source of energy in the diet. One gram of fat yields approximately 9 calories when oxidized.
• Fats act as carries for fat-soluble vitamins A, D, E, and K. Vitamin D aids in absorption of calcium. Fats are also important for conversion of carotene to vitamin A.
• Fats are involved in: cellular membrane structure and function, precursors to hormones, cellular signals, regulation and excretion of nutrients in cells, surrounding protecting and holding in place organs, insulating body from environmental temp changes, prolonging digestive process by slowing stomach’s secretion of HCL, longer lasting feeling of satiety, initiating release of hormone cholecystokinin(CCK) which contributes to satiety.

Digestion, Absorption, and Utilization

• Fat becomes emulsified in intestine so that pancreatic enzymes can break triglycerides down into two fatty acids and a monoglyceride. These are absorbed through intestinal walls into blood.
• In intestinal wall they are reassembled into triglycerides that are then released into the lympth in the form of lipoprotein called chylomicron. Chylomicrons from the lymph move to the blood. Triglyceride content of chylomicron is removed by action of the enzyme lipoprotein lipase (LPL), and the released fatty acids are taken up by the tissues. Throughout the day triglycerides are constantly cycled in and out of tissues, including muscles, organs, and adipose.

Recommendations

• 20 to 35% of total calories from fat. 
• Dietary fats stimulate release of CCK, hormone that signals satiety. Fat slow digestion of foods and thus nutrient content in the bloodstream.
• Medium chain triglycerides are more rapidly absorbed, they do not require incorporation into chylomicrons for transport but can enter systemic circulation directly providing readily avaialble, concentrated source of energy. MCT could benefit endurance performance by suppling exogenous energy source in addition to carbohydrates during exercise and increase plasma free acids(FFA), sparing muscle glycogen.

Water

• Sedentary men and women should consume 3L (13 cups) and 2.2L(9 cups) of water per day. Those in fat loss programs should drink additional 8 ounces of water for every 25 pounds they carry above their ideal weight. Water intake should be increased if individual is exercising briskly or residing in a hot climate.
• 60% of adult human body by weight.
• Benefits of consuming adequate water: endocrine gland function improves, fluid retention is alleviated, liver functions improve, natural thirst returns, metabolic functions improve, nutrients are distributed throughout body, body-temperature regulation improves, blood volume is maintained.
• Fluid loss of 2% of body weight will adversely affect circulatory functions and decrease performance levels. Thirst alone is poor indicator of how much water is needed.
• Athletes consistently consume inadequate fluid volume, managing to replace only 50% of sweat losses. Do not being practice session or endurance comp until body is at or slightly above standard weight.
• Drink 1.75 to 2.75 cups 2 hours before exercise. Drink 6 to 12 ounces of fluid every 15 to 20 minutes. Fluids should be cold because of more rapid gastric emptying.
• If exercise exceeds 60 mins use sports drink(containing up to 8% carbohydrate).
• When exercising for less than 60 minutes, water is experts’ choice for fluid replacement
• Ingest 16 to 24 ounces of fluid for every pound of body weight lost after an exercise bout, especially if rapid rehydration is necessary, as in twice-a-day training.

 

Altering Body Composition

Basic nutritional guidelines for altering body composition for fat loss

• Small decreases in food and beverage calories and increase physical activity.
• Distribute protein, carbs, and fat throughout day.
• Consume less than 10% of cals from saturated fat.
• Choose whole grains and fiber rich fruits and veggies over refined grains and simple sugars.
• Limit alcohol.
• Schedule no fewer than four and as many as six meals a day.
• Avoid empty calories and highly processed foods.
• Drink plenty of water(minimum 9 to 13 cups a day)
• Have clients weigh and measure food at least 1 week. Make them more aware of caloric values and serving sizes.

For lean body mass gain

• 4-6 meals a day. Spread protein intake throughout day.
• Post workout window of opportunity, ingestion of proteina nd carbs within 90 mins of a workout will increase recovery and protein synthesis, maximizing gains.
• Do not neglect importance of carbs and fat.

Risks of Starvation(low cal) Diets

• Nutrition experts do not recommend energy intake lower than 1,200 calories. 
• Increased risk of malnutrition, poor energy and inability to complete essential fitness program, behavioral pendulum swing, minor side effects as fatigue, constipation, nausea, diarrhea. Gallstone formation.

Chapter 16 Chronic Health Conditions and Physical or Functional Limitations:

For this chapter, read through the text and highlight the training guidelines and have a general idea on how to design a program for the special populations mentioned in this particular chapter.  Don’t worry too much about the acute variables (reps, sets, tempo, etc.) but rather on contraindications and more appropriate techniques for these populations.

Age Considerations

• Children and adolescents should get 1 hr or more of physical activity daily.

Physiologic Differences between Children and Adults

• Children do not exhibit plateau in oxygenuptake, peak oxygen uptake is more appropriate.
• Children less efficient, tend to exercise at higher percentage of peak oxygen uptake during submaximal exercise.
• Do not produce sufficient levels of glycolytic enzymes to sustain bouts of high-intensity exercise.

Resistance Training for Youth

• Resistance training is both safe and effective in children and adolescents.
• Untrained children can improve strength by 30 to 40% in 8 weeks.

Seniors

• Older adults with and without other chronic health conditions can and do respond to exercise much in the same manner as apparently healthy younger adults.
• Walking is one of most fundamental functional activities affected with degenerative aging.
• Musculoskeletal loss not entirely related to aging.
• Complete PAR-Q. Assessments.
• Progression should be slow, well monitored, based on postural control. Exercises should be progressed if possible toward free sitting or standing. If client cannot tolerate SMR perform slow rhythmic active or dynamic stretches.

Obesity

• Flexibility exercises should be performed from standing or seated position, using standing hip flexor stretch rather than kneeling hip flexor stretch, standing hamstring stretch, wall calf stretch.
• Core and balance training important for obese individuals.
• May find it difficult to use machines, dumbbells, cables, exercise tubing work quite well.

Diabetes

• Most important goal is glucose control. Exercise improves insulin sensitivity. Positive effect on prevention of type 2 diabetes.
• Take care to prevent blisters and foot microtrauma that could result in foot infection.
• Daily exercise recommended. Flexibility exercises recommended.
• Follow exercise guideline for obese adults. Lower impact exercise modalities.

Hypertension

• Low to moderately intense exercise just as effective as high intensity activity in reducing blood pressure.
• Important to monitor body position of clients with hypertension at all times. Body position can have dramatic effect on blood pressure response before, during, and after exercise in clients with hypertension.
• Avoid heavy lifting and valsalva maneuvers. Do not let client overgrip weights or clench fists. Modify tempo to avoid extended isometric and concentric muscle action. Perform exercises in standing or seated position. Allow client to stand up slowly to avoid possible dizziness. Progress client slowly.

Coronary Heart Disease

• Monitor pulse to stay below safe upper limit of exercise. 
• Clients may have other diseases to consider as well, such as diabetes, hypertension, peripheral vascular disease, or obesity
• Modify tempo to avoid extended isometric and concentric muscle action
• Avoid heavy lifting and Valsalva maneuvers
• Do not let client overgrip weights
• Perform exercises in standing or seated position
• Progress slowly

Osteoperosis

• Progress should be slow, well monitored, based on postural control
• Exercises should be progressed if possible toward free sitting(no support) or standing
• Focus exercises on hips, thighs, back, and arms
• Avoid excessive spinal loading on squat and leg press
• Make sure client is breathing in normal manner and avoid holding breath in Valsalva maneuver

Arthritis

• Avoid heavy lifting and high reps
• Stay in pain-free ranges of motion
• Only use SMR if tolerated by client
• May be need to start out only with 5 mins of exercise and progressively increase

Cancer

• Avoid heavy lifting in initial stages of training
• Allow for adequate rest intervals and progress client slowly
• Only use SMR if tolerated, avoid SMR for clients undergoing chemo or radiation
• May be need to start out with only 5 mins of exercise and progressively increase

Exercise and Pregnancy

• Avoid exercises in prone or supine position after 12 weeks
• Avoid SMR on varicose veins and areas of swelling
• Plyometric training not advised in second and third trimesters

Chronic Lung Disease

• Upper body exercises cause increased dyspnea and must be monitored
• Allow for sufficient rest between sets

Intermittent Claudication/Peripheral Arterial Disease

• Allow for sufficient rest
• Workout may start with 5-10 mins of activity
• Progress slowly
• Treadmill walking preferred.
• Primary limiting factor is leg pain.