Personal trainers have the opportunity to do more than just help people they train become more active. Physical activity should not be the only approach to encouraging a healthy and balanced lifestyle. We need to be prepared to also help our clients implement lifestyle behavior changes related to stress, family history of coronary heart disease, obesity, smoking, high blood pressure and high cholesterol.
A look at what is being called metabolic syndrome will help you understand why, even though increasing physical activity levels is the overall best thing you can do for clients, there are other ways to guide them to healthier lifestyles. Sometimes you may be able to help them make the changes yourself, and sometimes you will need to refer them to another health professional like a doctor or dietician for guidance. Either way, knowing how to help them or when to refer them to someone who is more knowledgeable is important. So first let’s get familiar with the syndrome and the clinical criteria that the doctor uses to diagnose it. Your goal is then to help your clients understand and make the necessary changes, so that they don’t progress to cardiovascular disease and the almost certain heart attack that will be the end result.
Cardiovascular disease is still the number one cause of morbidity and mortality in the United States, and much of this burden of disease can be linked to poor nutrition and a dramatic increase in sedentary lifestyles, leading to overweight and obesity. This increase in weight leads to an increase in the incidence of type 2 diabetes and blood pressure and cholesterol problems, which are all well established cardiovascular disease risk factors. The National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III has updated the recommendations for the evaluation and management of adults dealing with high cholesterol, renewing its emphasis on the importance of lifestyle modifications for improving cardiovascular risk. The NCEP has coined the term “therapeutic lifestyle changes” (TLC) to reinforce both dietary intake and physical activity as crucial components of weight control and cardiovascular risk management.
As well as focusing attention on the LDL or "bad" cholesterol levels, the NCEP also identified the metabolic syndrome as a secondary target of therapy. The importance of lifestyle modifications in the treatment and prevention of cardiovascular disease has heightened and caused growing awareness of this condition. The metabolic syndrome (also called insulin resistance syndrome and syndrome X) is characterized by decreased tissue sensitivity to the action of insulin (pre-diabetes), resulting in a compensatory increase in insulin secretion. This metabolic disorder predisposes individuals to a cluster of abnormalities that can lead to such problems as type 2 diabetes, coronary heart disease and stroke. According to Daniel Einhorn, MD, who is co-chairman of the American College of Endocrinology (ACE) and the American Association of Clinical Endocrinologists (AACE) Insulin Resistance Syndrome Task Force and medical director of the Scripps Whittier Institute for Diabetes in La Jolla, California, the prevalence of the syndrome has increased 61 percent in the last decade. He says it is crucial for medical professionals to identify patients at risk and follow these patients closely and counsel them about making lifestyle changes to lower the risk of type 2 diabetes and cardiovascular disease.
According to the NCEP, the criteria for metabolic syndrome includes at least three of the following five clinical factors:
||>40 in (>102 cm)
||>35 in (>88 cm)
|Fasting Triglyceride Level
|HDL Cholesterol Level
||>130/>85 mm Hg or taking antihypertensive medication
|Fasting Glucose Level
||>110 mg/dL or diabetes
*Source: Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Bethesda, Md: National Institutes of Health; 2001. NIH publication 01-3670.
Using 1988-1994 data (NHANES III), the Centers for Disease Control and Prevention estimates that at least 47 million Americans have metabolic syndrome. And in 2000, more than 97 million adults were considered obese, and more than half the population is now overweight. This epidemic is not likely to plateau because childhood obesity is also increasing at an alarming rate. The explosive increase in the prevalence of obesity observed in the past decade suggests the current rate of metabolic syndrome is now likely higher than that estimated by NHANES III.
Millions of Americans at risk for metabolic syndrome can sharply lower their chances of getting this disease by adopting a healthy lifestyle (stop smoking, low fat diet, weight loss/maintenance and increased physical activity). Diet and exercise are the cornerstones of treatment in patients with metabolic syndrome. According to Dr. Robert Chilton (November/December 2002 issue of Men’s Total Health Digest), without diet and exercise modifications, most patients will eventually fail and progress to type 2 diabetes within a decade and experience a heart attack about 10 years later. Dr. Chilton recommends a diet reduced in saturated fats (<7 percent), low in cholesterol (<200 mg/day), high in fiber (20-30gm/day) and reduced in simple sugars. Weight loss of only five to seven percent (less than 15 pounds) can make a big difference in health markers like cholesterol and blood pressure. A program that includes exercise daily reaching 85 percent of heart rate for age is reported to benefit the patient as well (who out there is surprised??!!). However, Dr. Chilton says, any exercise is better than none, and a target of 30 minutes every other day is a reasonable level for most patients.
A study by the Diabetes Prevention Program (DPP), which was discussed in the October 2002 issue of Type 2 Diabetes Digest, found that there was a reduction of 58 percent in progression to diabetes when moderate lifestyle changes were made. These changes were directed toward getting people to lose eight to 10 pounds and becoming more active, mainly by walking briskly for 150 minutes per week. Other studies have been done by the DPP using a medication called metformin. It reduced the progression to diabetes by about 30 percent but was not as effective as behavioral interventions, and it didn’t work in all groups. On the other hand, the behavioral intervention worked across the board, regardless of age, body weight or race and ethnicity. Another drug called acarbose has also been tested and found to reduce progression by about 33 percent. So, there are medications that can be beneficial, but nothing was as effective overall as the behavioral intervention used in the DPP. Consideration also needs to be given to the potential side effects of a medication used to prevent diabetes compared with lifestyle changes.
According to Frank Vinicor, MD, who is the director of the diabetes program at the US Centers for Disease Control and Prevention in Atlanta, the behavioral interventions used in these studies was quite intense and involved 16 interactions with individuals during the first year, with a whole series of very innovative and creative follow up meetings. The interventions are being explored further to see if they can be made more practical, more feasible and more economically possible. Another point is that, even within the DPP, a physician did not deliver most of the behavioral interventions. New recommendations from the CDC will call for involving trained nurses, dieticians and other community health workers in the process.
Also according to Dr. Vincor, about 90 percent of people with diabetes receive their diabetes care from the primary care community, and there is no reason to anticipate that things will be any different with pre-diabetes or metabolic syndrome. He believes the primary care community (internists and family practice physicians) will play a pivotal role in both the identification of people with pre-diabetes as well as the initiation of therapy. And again he emphasizes, that does not mean the primary care doctors themselves have to do the counseling and behavioral intervention. Instead, he anticipates they will make appropriate referrals to others in their communities.
As a fitness professional, hopefully you are not asking yourself “so what?” but are instead seeing an opportunity to educate and motivate some of your current clients and to use your knowledge to help attract future clients. The medical community is good at diagnosing this syndrome but not necessarily equipped to provide patients with the tools to be successful with the lifestyle changes they recommend. There exists a wonderful opportunity to build a partnership with physicians in your area. Most physicians will gladly refer patients to you for help with the all-important exercise and nutrition portion of the treatment program. In many cases, you have more knowledge in this area than the physician who has been trained in tertiary, not preventative medicine. (Most MDs know very little about diet and exercise since they are not taught this in medical school.) Often times, all you will need to get a referral is for the doctor to be aware of your existence and to give them an easy way to get the patient to you. A short introduction letter outlining your qualifications and showing your desire to help people make lifestyle changes is a good start. A personal visit to your primary care doctor and others in your area is even better. But be prepared to take up just a few minutes of their time to introduce yourself and your idea and leave your letter and cards.