I recently thought about why we exercise and what we choose to do first – and it isn’t generally strength training. Why is that? I believe it’s because we feel we CAN’T do something about becoming stronger unless we join a gym – and then we always seem to gravitate to cardio exclusively as if that is all we can do. We want to lose weight, feel better about ourselves, burn stored fat or just increase our energy level, but what if there was a better way?
For many exercise professionals, the goal of training and educating clients is to improve health, increase strength and performance, and improve fitness parameters. The concept of reducing injuries may not be high on their radar screens.
There are so many misconceptions and misinformation about nutrition. Everyone wants to believe they are eating to properly fuel their body and prevent disease. There is one clear path to learn how to separate fact from fiction when it comes to nutrition information. For some reason, many people prefer to follow the nutrition fads, instead of trying to understand how the body works.
It’s no secret that our bodies feel tight and stiffer if we don’t stretch, especially as we get older. If you invest most of your exercise time into strengthening your muscles or working on your cardio routine, it’s easy to forget about stretching.
Regaining weight after losing it on a diet is much more common than keeping the weight off. Often dieters gain back more than they lost, and it’s a common experience to have an even harder time losing weight the next time. “Weight cycling” is the term for these repeating episodes of intentional weight loss followed by unintentional regain, also often called “yo-yo dieting.”
Research reveals health dangers of weight cycling
In addition to making the next attempt at weight loss more difficult, repeated cycles of weight loss and gain have damaging effects on the body.
A study presented at the American Heart Association’s March 2019 Scientific Sessions reported that weight cycling was associated with poorer cardiovascular health parameters. Women were assigned a cardiovascular risk score based on 7 factors: smoking, diet, physical activity, BMI, blood pressure, cholesterol, and blood glucose. Women with a history of weight cycling were less likely to have a favorable BMI and less likely to have a favorable overall cardiovascular health score.1 Previous research also linked bouts of weight cycling to a greater risk of endometrial cancer.2 It is also worth noting that in the cardiovascular study, over 70% of the 485 women reported having a history of weight cycling (at least one instance of weight loss and regain), highlighting how common this issue is.1
One of the most important messages about weight loss is this: change your diet, lose the weight and keep your new, healthier way of eating forever.
Dump the Dieting Mentality
The human body responds to weight loss the same way it would respond to starvation – by conserving energy. The brain uses information about calorie intake and the body’s amount of stored energy to determine whether to release appetite-enhancing or appetite-suppressing hormones. One way the body adapts to weight loss is by altering the production of appetite-regulating hormones such as ghrelin and leptin, favoring weight regain by increasing appetite and promoting fat storage. Another way is by decreasing resting energy expenditure.1
These compensatory systems make going back to one’s old unhealthy diet even more weight gain-promoting. The highly palatable low nutrient foods, which stimulate cravings via the dopamine reward system, are even more dangerous for someone whose calorie expenditure has fallen. Also, when you lose weight, some loss of muscle is unavoidable, and strength exercise helps to limit muscle loss. However, when someone gains weight back after dieting, that weight is fat, potentially leaving the dieter with a greater body fat percentage than before.
Studies have linked weight cycling to a greater risk of diabetes, hypertension, gallbladder stones, and shorter telomere length.2-6 Shorter telomeres mean rapid aging. Weight cycling women were also found to have a greater waist circumference, and seem to gain more weight over time than “non-cyclers” who start off at the same BMI.7,8
The bottom line is that making changes to your diet to improve your health and your weight need to be permanent changes, not temporary.
Body fat is not just stored energy
Why is gaining back body fat harmful? Adipose (fat) tissue is more than a vessel for storing excess energy. In addition to storing fat, adipose tissue acts as an endocrine organ: it contains macrophages (a type of white blood cell) in addition to adipocytes; it produces and secretes compounds that affect the function of other types of cells. Obesity is accompanied by a systemic low-grade inflammation.9,10 Adipose releases compounds that can induce negative consequences such as insulin resistance, higher triglycerides, and reduced immune function, and even growth promoters that can increase risk of cancer. As fat tissue grows, more of these pro-inflammatory compounds are produced, leading to chronic inflammation, which increases the risk of cardiovascular disease, diabetes, and cancer.11
How to avoid weight cycling
The key to losing weight and keeping it off forever is changing your diet forever. Stay away from extreme fad diets; they are not sustainable long-term. About 80 percent of dieters are unable to keep 10 percent of their original body weight off for more than one year.12 Feeling deprived and going back to your old diet is almost inevitable. However, if you use high-nutrient foods to resolve toxic hunger and achieve greater meal satisfaction with a smaller number of calories, it will be much easier to stick with your new way of eating and prevent future weight regain.
A recent study published in the American Journal of Lifestyle Medicine analyzed and reported weight loss results provided by 75 obese patients who had switched to a Nutritiarian diet. The average weight loss was 55 pounds after three years, which means they kept the weight off long-term. Compare these results to most weight loss intervention studies, which report average losses of only 6-13 pounds maintained after two years.13 One reason for the remarkable effects on permanent weight reduction with a Nutritarian diet is that the users are more fully educated regarding the long-term health and longevity benefits and it is adopted not merely for its weight loss benefits. Additionally, it has been demonstrated that this nutrient dense, plant-rich diet can suppress appetite and resolve food cravings and food addictions.14
My book The End of Dieting explains exactly how to break out of the cycle of physical and emotional addiction and overeating – how to keep the weight off permanently.
Originally printed on DrFuhrman.com. Reprinted with permission.
Joel Fuhrman, M.D. is a board-certified family physician, six-time New York Times bestselling author and internationally recognized expert on nutrition and natural healing, who specializes in preventing and reversing disease through nutritional methods. Dr. Fuhrman coined the term “Nutritarian” to describe his longevity-promoting, nutrient dense, plant-rich eating style.
For over 25 years, Dr. Fuhrman has shown that it is possible to achieve sustainable weight loss and reverse heart disease, diabetes and many other illnesses using smart nutrition. In his medical practice, and through his books and PBS television specials, he continues to bring this life-saving message to hundreds of thousands of people around the world.
- Byun SS, Bello NA, Liao M, Makarem N, Aggarwal B: Weight Cycling is Associated With Poorer Cardiovascular Health Assessed Using AHA’s Life’s Simple 7 in a Diverse Sample of Women Encompassing Different Life Stages. In American Heart Association’s Epidemiology and Prevention Lifestyle and Cardiometabolic Health Scientific Sessions 2019.
- Welti LM, Beavers DP, Caan BJ, Sangi-Haghpeykar H, Vitolins MZ, Beavers KM. Weight Fluctuation and Cancer Risk in Postmenopausal Women: The Women’s Health Initiative. Cancer Epidemiol Biomarkers Prev 2017, 26:779-786.
- Greenway FL. Physiological adaptations to weight loss and factors favouring weight regain. Int J Obes (Lond) 2015, 39:1188-1196.
- Delahanty LM, Pan Q, Jablonski KA, et al. Effects of weight loss, weight cycling, and weight loss maintenance on diabetes incidence and change in cardiometabolic traits in the Diabetes Prevention Program. Diabetes Care 2014, 37:2738-2745.
- Guagnano MT, Ballone E, Pace-Palitti V, et al. Risk factors for hypertension in obese women. The role of weight cycling. Eur J Clin Nutr 2000, 54:356-360.
- Tsai CJ, Leitzmann MF, Willett WC, Giovannucci EL. Weight cycling and risk of gallstone disease in men. Arch Intern Med 2006, 166:2369-2374.
- Syngal S, Coakley EH, Willett WC, et al. Long-term weight patterns and risk for cholecystectomy in women. Ann Intern Med 1999, 130:471-477.
- Mehta T, Smith DL, Jr., Muhammad J, Casazza K. Impact of weight cycling on risk of morbidity and mortality. Obes Rev 2014, 15:870-881.
- Field AE, Manson JE, Taylor CB, et al. Association of weight change, weight control practices, and weight cycling among women in the Nurses’ Health Study II. Int J Obes Relat Metab Disord 2004, 28:1134-1142.
- Strychar I, Lavoie ME, Messier L, et al. Anthropometric, metabolic, psychosocial, and dietary characteristics of overweight/obese postmenopausal women with a history of weight cycling: a MONET (Montreal Ottawa New Emerging Team) study. J Am Diet Assoc 2009, 109:718-724.
- Coelho M, Oliveira T, Fernandes R. Biochemistry of adipose tissue: an endocrine organ. Arch Med Sci 2013, 9:191-200.
- Strohacker K, Carpenter KC, McFarlin BK. Consequences of Weight Cycling: An Increase in Disease Risk? Int J Exerc Sci 2009, 2:191-201.
- Strohacker K, McFarlin BK. Influence of obesity, physical inactivity, and weight cycling on chronic inflammation. Front Biosci (Elite Ed) 2010, 2:98-104.
- Wing RR, Phelan S. Long-term weight loss maintenance. Am J Clin Nutr 2005, 82:222S-225S.
- Franz MJ, VanWormer JJ, Crain AL, et al. Weight-loss outcomes: a systematic review and meta-analysis of weight-loss clinical trials with a minimum 1-year follow-up. J Am Diet Assoc 2007, 107:1755-1767.
- Fuhrman J, Sarter B, Glaser D, Acocella S. Changing perceptions of hunger on a high nutrient density diet. Nutr J 2010, 9:51.
Pain is an elusive concept. Sometimes chronic pain or discomfort occurs in muscles and joints without having injured the area where they’re feeling the pain and discomfort. Why? Why do some people who have structural damage to a muscle or joint (as shown by MRI or other test) have no pain in the damaged area, but . . .
Women’s health concerns are much more complex than men’s and with the help of physical therapy (also called physiotherapy in many parts of the world), many of these issues can easily be remedied or addressed. There are main factors that greatly differentiate men from women. Of these, it is important to highlight three: menstruation, pregnancy and lactation. These bodily changes in a woman are mostly influenced by hormonal fluctuations and can also be a reason for mood swings and differences in behavior.
Most of us accept stress as a necessary evil that is a part of the American lifestyle. But living under stress day in and day out can lead to heart disease. According to the American Psychological Association, prolonged stress can contribute to high blood pressure and circulatory problems, and if stress makes you angry and irritable, you are more likely to have heart disease or even a heart attack.
Your passion is to help people maintain or regain optimal health and fitness. Under current law and standards, you are only permitted to work with clients who are already fit and healthy or have been released for independent exercise and have passed your health screening questionnaire. But those are not the people you yearn to work with. The clients you seek must have authorization or approval from a medical provider before you can proceed.
How often have you met with a potential new client, asked them to get clearance from their doctor and then never seen them again? Or, a client develops a new pain or problem and you refer them for consultation and that ends the relationship. Another frequent scenario: Your client has followed through with your request only to be referred by their primary care provider for a cardiac treadmill test, but your concern about their low back pain or shoulder dysfunction was not addressed. Success as a medical fitness professional is dependent upon working relationships with medical professionals. In order to establish those relationships, the aspiring medical fitness trainer needs better understanding of the medical system. What follows are a few insights into the medical system that medical fitness professionals need to understand.
Recognize how busy the medical practitioner might be
“Estimates suggest that a primary care physician would spend 21.7 hours per day to provide all recommended acute, chronic, and preventive care for a panel of 2,500 patients.”1[i]. Today, the average primary care provider is responsible for roughly 2,300 patients, so not quite 21.7 hours of work/day, but more than any individual can possibly provide.
In order to cope with the workload, doctors must rely on their support staff to help whenever possible. Do not be alarmed or offended if your inquiries are met by a nurse or medical assistant. Most providers simply do not have the time to meet with you for introduction or discussion. On the flip side, most doctors would love to have effective, safe and reliable resources for their patients who need to lose weight, get fit, manage diabetes, recover from surgery or cancer treatment etc. They need you.
Understand the current reimbursement rules
In most cases providers cannot bill for services unless the patient is in the room with them. Therefore, time spent talking on the telephone, responding to emails, or filling-out forms is usually unreimbursed time. This means that your client will probably need to actually make an appointment to be assessed and cleared for exercising with you. To streamline the process, send a letter with your client introducing yourself and what you do. Include a form stating your concerns and your proposed training plan. Design the form to be easy to read, with a simple agree or disagree that can be checked or circled and space for the provider’s signature. You might also want to leave room for comments and questions. If you have received a response from a provider, you should consider sending intermittent progress reports updating the provider about your mutual client/patient.
Be familiar with HIPAA
The Health Insurance Portability and Accountability Act (HIPAA) was enacted in 1996 to protect an individual’s medical confidentiality, particularly when changing jobs which at that time meant changing health insurance providers. Unfortunately, the law is complicated and places multiple restrictions on who members of a medical team can talk to about a patient’s medical condition.
As an unlicensed party, the fitness professional is not privy to “protected health information” (PHI) without direct written consent from the patient (your client). Due to these restrictions, the medical providers cannot fill-out or respond to your request for information or clearance without your client’s “written” consent. If the client takes the form and returns it to you, this action implies they have agreed to share the information. If you send the form directly to the provider, that permission has not been granted unless the client has signed a HIPAA release form allowing the doctor to share personal health information with you personally.
The aforementioned are a few reasons why you may have perceived a wall or barrier between you and medical providers. One solution is to ask your client if you might accompany him or her to the appointment to obtain medical clearance or guidance. That way the medical provider would have a specified time and be reimbursed for addressing your concerns. You would be communicating directly with the medical provider and not support staff, and it would be easiest for the client/patient. It is also a way to introduce yourself to the medical provider and initiate a working relationship. Although you will probably not be compensated, it may be well worth your time in the long run.
Once you have made it into the office with your client, now what?
Know your details
Because there are so many different avenues to becoming certified as a personal trainer, there can be large differences in the knowledge base and competence of one trainer compared to another. The aspiring medical fitness professional must have a thorough understanding of the pathophysiology of the conditions they will be working with in order to communicate effectively with medical providers. In addition, you need skill and experience in the programs you design and utilize with your clients. Be able to back up your training plans with published research.
Recognize that a medical fitness professional has a fund of knowledge that the medical provider does not have
Exercise science is not covered in medical school curricula. Medical school is about illness and disease not health and fitness. Generally speaking, the average MD knows very little about exercise science. Most do not know about the effects of eccentric versus concentric loading, how to train for endurance versus strength, what to do to improve stability, balance and core strength. Fitness professionals are not inferior to medical professionals; you have a different knowledge base. Recognize and believe that you have something to offer. You may not know all of the anatomy and biochemistry that the doctor does, but you have a basic understanding of your client’s condition and you know the potential benefits of your interventions. Share this information with the medical providers.
Stay within your scope of practice
Because personal trainers and medical fitness professionals are not licensed by any governmental or legal agency, and because laws vary from state to state, there is no clear definition of the skills and competencies of a medical fitness professional. Working outside of your scope of practice can lead to civil and even criminal penalties[ii]. Therefore, for the time being, if you want to work with clients struggling to manage chronic illnesses, recover fully from injuries or surgeries, etc., you need to work under the wing of medical professionals who have prescriptive authority – those professionals in the medical field licensed to diagnose problems and prescribe treatment.
Dr Robert Butler MD, founder of the National Institute on Aging once said: “If exercise could be packaged in a pill, it would be the single most widely prescribed and beneficial medicine in the nation.” There are pockets here and there in the US where medical providers and fitness professionals work together. In many cases there is a visionary medical provider at the helm of an interdisciplinary team. In other cases, fitness professionals have worked hard to become part of a medical delivery model.[iii] The more medical fitness professionals that can take the leap and align themselves with medical providers, the more people will be helped.
This article was featured in MedFit Professional Magazine Winter 2020 issue. Subscribe to MedFit Professional Magazine to read more great content like this!
Dr. Mary Hoagland-Scher,MD is a board-certified family physician who practiced medicine for 30 years. When she entered medical school, her goal was to help people stay healthy. As the focus of western medicine shifted away from health to disease management with a strong emphasis on pharmaceutical and or surgical intervention, she became uneasy with her role and decided to discard her prescription pad and learn new tools. Now as a NASM Certified Personal Trainer she is working to shrink the gap between fitness and medicine.
- [i] Estimating a Reasonable Patient Panel Size for Primary Care Physicians With Team-Based Task Delegation Justin Altschuler, MD, David Margolius, MD, Thomas Bodenheimer, MD⇓ and Kevin Grumbach, MD Ann Fam Med September/October 2012 vol. 10 no. 5 39
- [ii] For an excellent discussion of this issue, see: Abbott, Anthony Ed.D, FACSM, FNSCA. Scope of Practice, ASCM Health and Fitness Journal ,Sept/Oct 2018, Vol 22 Issue 5 pp 51-55
- [iii] Watch MedFit TV webinar by David Rachal III, “Exercise Prescription: Integrating Services with Medical Professionals and Insurance Providers”