Program Design And Implementation

68 Pages·2011·1.67 MB·English

Part V
Program Design and
Implementation
Chapter 12
Weight-management
Programming
Chapter 13
Exercise
Programming
Chapter 14
Nutritional
Programming
Chapter 15
Lifestyle
Modification and
Behavior Change
Chapter 16
Adherence to
Physical Activity and
Weight-loss Behaviors
Fabio Comana
Fabio Comana, M.A., M.S.,is an exercise physiologist, research
scientist, and spokesperson for the American Council on Exercise.
He also currently teaches courses in exercise science and nutrition
at the University of California, San Diego and San Diego State
University. Comana regularly presents and writes on many topics
related to exercise, fitness, and nutrition, and has authored or
co-authored more than three dozen articles and chapters in various
publications. He has master’s degrees in exercise physiology
and nutrition, and currently holds certifications from ACE, the
American College of Sports Medicine (ACSM), the National Strength
and Conditioning Association (NSCA), and the International
Society of Sports Nutrition (ISSN).
Chapter 12
Weight-management
Programming
In 2006, 72 million American dieters spent $55 billion in the IN THIS CHAPTER:
weight-loss market, and forecasts estimate that amount to reach
Introduction to
nearly $69 billion in 2010 (Marketdata Enterprises, Inc., 2007). Effective Weight Management
Components of an Effective Weight-
According to the Centers for Disease Control and Prevention (CDC), management Program
there has been a rising trend of Americans considered overweight
Prevalence of Obesity
and obese: from 65.7% and 30.6% in 2001–2002 to 66.3% and Population Statistics
Health Objectives
32.2% in 2003–2004, 68% and 33.8% in 2005–2006, and 68.3% and
Safe and Effective Weight Loss
33.9% in 2007–2008, respectively (Table 12-1).
An effective weight-management program involves a Understanding Behavioral Change
multidisciplinary team approach that includes a physician,
Transtheoretical Model of Change
registered dietitian, exercise physiologist, and behavioral (Stages of Behavioral Change)
Stages of Change
therapist. Through this team approach, the three critical areas—
Processes of Change
Decisional Balance
behavior and lifestyle modification, nutrition, and physical
Self-efficacy
activity—can be coordinated. While this approach is ideal, the cost
Tracking Progress and
of employing a team of healthcare experts, combined with the lack
Keeping Records
Participation and Activity Logs
of third-party reimbursement, creates potential barriers. Hence,
Emotional Association With Programming
overweight or obese clients may instead opt to seek the services of
Strategies for Overcoming Obstacles
competent allied health professionals who are experienced in all
Barriers to Participation
three disciplines and have an established referral network in place. Relapse Prevention
The success of a Lifestyle & Weight Management Coach (LWMC)
Summary
necessitates proven competencies in these areas and the ability to
address the individualized needs of clients. The science behind each
area is discussed earlier in this book, while the subsequent chapters
focus on programming guidelines and strategies.
CHAPTER 12 Weight-management Programming
Introduction to Effective ent’s decisional balance toward change
(Prochaska & Marcus, 1994)
Weight Management
• S elf-esteem, self-efficacy, and self-
efficacy-building strategies
Components of an Effective Weight-
• A cknowledgement of, and reframing of,
management Program
current attitudes, perceptions, appre-
LWMCs can expect to encounter obsta-
hensions, and belief systems
cles, either identified or reported by their
• V alue of cognitive techniques, such as
clients, during the early stage of their rela-
goal-setting
tionship. During the interview and informa-
• Rapport building and maintenance
tion-gathering stage, LWMCs may identify
• E ffective verbal and nonverbal commu-
internal and external barriers. Internal
nication, and good listening skills
barriers could be anxieties, ambivalence,
• Different personality styles (e.g.,
or defensive avoidance, such as rational-
technical, sociable, or assertive) and
izing a decision to delay starting a program.
appropriate communication styles
External barriers could be the inconvenience
(Griffin, 2006)
of the program, lack of time, or lack of sup-
• Support systems
port (Griffin, 2006).
• I nternal and external barriers and
While LWMCs have the best intentions
obstacle management
for their clients, they must act ethically
• A ppropriate cognitive, motor-skill, and
and responsibly to determine what is appro-
affective learning techniques
priate, given the client’s current stage
• M otivational strategies, including
of behavioral change. LWMCs must never
reinforcements, antecedents, rewards
assume that a meeting with a client means
(extrinsic to intrinsic), personal con-
that he or she has entered the prepara-
tracts, stimulus control, and self-talk
tion or action stage of behavioral change,
and is therefore ready to move forward. Exercise programming:
LWMCs must be skilled in identifying a cli- • Exercise science
ent’s current stage of change and have the • H ealth-risk assessments and risk
ability to implement or recommend the stratification
appropriate strategies. This is a critical first • R eferrals to appropriate professionals,
step toward facilitating a more permanent confidentiality, and SOAP note format
lifestyle change. Time and money invested • Exercise and testing contraindications
in a nutritional or activity/exercise program • P hysiological assessments and termina-
may be wasted if the client’s underlying tion criteria
psyche is not addressed first. The subse- • L imitations of assessments and the
quent chapters address individual program- interpretation of criterion-referenced or
ming components of lifestyle and behavioral norm-referenced data
modification, exercise, and nutrition. • Program design and implementation
In general, the design of effective • Environmental effects
weight-management programs for clients • R eevaluation and modification/
requires that LWMCs gain a working knowl- progression
edge of the following skill sets.
Nutritional programming:
Lifestyle and behavior modification: • N utrition (macronutrient and micro-
• R eadiness to change behavior and iden- nutrient function) and digestion
tification of current stage of change • N utritional assessments
• P rocesses of change (cognitive and/ • C aloric balance and weight-manage-
or behavioral) and the shifting of a cli- ment-program design
264 Lifestyle & Weight Management Coach Manual AMERICAN COUNCIL ON ExERCISE
Weight-management Programming CHAPTER 12
• D ietary guidelines, labels, and portions The increased incidence of obesity is attrib-
sizes uted to decreasing levels of activity and
• W eight-loss diets and supplements increasing access to, and consumption of,
• D ietary needs for special populations, food. Physical-activity statistics from the
women, and vegetarians Department of Health and Human Services
and the Centers for Disease Control and
Prevalence of Obesity Prevention in 2007 indicated that only 48.8%
of U.S. adults were achieving the recom-
mended physical-activity levels consistent
Population Statistics
with the U.S. Surgeon General’s report; 37.7%
The National Health and Nutrition
were insufficiently active (defined as more
Examination Survey (NHANES), which is
than 10 minutes total per week of moderate-
conducted every 10 years by the National
or vigorous-intensity lifestyle activities, but
Center for Health Statistics (NCHS) and the
less than the recommended level of activity);
CDC, assesses the health and nutritional
13.5% of adults were inactive (defined as less
status of adults and children in the United
than 10 minutes total per week of moder-
States. It is arguably the largest and lon-
ate- or vigorous-intensity lifestyle activities).
gest-running longitudinal health survey of
Likewise, the average consumption of calo-
the U.S. population and provides valuable
information on important health indica- ries in adults increased by 12%, or 300 kcal,
tors. The prevalence of overweight and between 1985 and 2000.
obesity has been tracked since 1971, and Being overweight or obese significantly
a rising trend is evident within the U.S. increases the risk of developing serious dis-
population (Table 12-1). In 2008, an esti- ease and health conditions, including the
mated 154 million adults were overweight following:
or obese; among women 20 years and older, • Hypertension
more than 97 million were overweight, and • Dyslipidemia
more than 49 million were obese. • Type 2 diabetes
According to the CDC, the average • Coronary heart disease
male weighed 166.3 pounds (75.5 kg) • Stroke
in 1960–1962, while the average female • Gallbladder disease
weighed 140.2 pounds (63.7 kg). By contrast, • Osteoarthritis
in 1999–2002, the average male weighed • Sleep apnea and respiratory problems
191.0 pounds (86.7 kg), while the average • Some cancers (endometrial, breast,
female weighed 164.3 pounds (74.6 kg). and colon)
Table 12-1
Age-adjusted Prevalence of Overweight and Obesity Among U.S Adults, Ages 20–74
NHANES II NHANES III NHANES NHANES NHANES NHANES NHANES
(1976–1980) (1988–1994) (1999–2000) (2001–2002) (2003–2004) (2005–2006) (2007–2008)
(n = 11,207) (n = 6,679) (n = 4,117) (n = 4,413) (n = 4,431) (n = 4,356) (n = 5,555)
Overweight or Obese 47.0% 56.0% 64.5% 65.7% 66.3% 68.0% 68.3%
(BMI >25.0)
Obese (BMI >30.0) 15.0% 22.9% 30.5% 30.6% 32.2% 33.8% 33.9%
* Age-adjusted by the direct method to the year 2000 U.S. Bureau of the Census estimates using the age groups 20–39, 40–59,
and 60 years and over.
Source: National Center for Health Statistics, Centers for Disease Control and Prevention
AMERICAN COUNCIL ON ExERCISE Lifestyle & Weight Management Coach Manual 265
CHAPTER 12 Weight-management Programming
The Centers for Disease Control and tion to health insurance grew more than
Prevention had previously reported that 143%, with employees paying $1,094 more
obesity is responsible for more than 356,000 in annual premiums for family coverage
deaths a year, a number that has increased (Smith et al., 2006).
by 33% over the past decade and may soon
Health Objectives
overtake tobacco as the leading prevent-
Given the rising obesity and inactivity
able cause of death among Americans. More
levels and correlating higher healthcare costs,
recently, a study based on a nationally rep-
being proactive in weight-management is
resentative sample of U.S. adults estimated
critical. These issues are also being addressed
that approximately 112,000 deaths are asso-
at a federal level, which could affect corpora-
ciated with obesity each year in the United
tions and consumers working with LWMCs.
States (Mokdad et al., 2004; 2005). There are
The mission of the Center for Nutrition
two main reasons for the difference in the
Policy and Promotion, an entity within the
estimated number of obesity deaths—newer
U.S. Department of Agriculture (USDA), is
data and different methods of analyzing the
to improve the nutrition and well-being of
data. Because obesity has many different
Americans. In support of these objectives,
effects on numerous diseases, doctors have
the center offers several core resources,
difficulty reliably identifying obesity-related
including the following:
deaths based on death certificates. Scientists
• Dietary Guidelines for Americans
are now using more complex modeling tech-
• My Pyramid Food Guidance System
niques to estimate deaths related to obesity.
• Healthy Eating Index
Regardless, obesity shortens the average
• U.S. Food Plans
lifespan of an adult by four to nine months,
• Nutrient Content of the U.S. Food Supply
and in a child, the lifespan may be cut by
• Expenditures on Children by Families
two to five years, given the current childhood
The USDA Dietary Guidelines are pub-
obesity rates.
lished every five years by the USDA (see
Obesity-attributable medical expenditures
page 160). The guidelines provide educa-
have been estimated to be $117 billion in
tional material on good dietary habits to
the U.S. (Finkelstein, Fiebelkorn, & Wang,
2003). In 2002, the cost difference between promote healthy living and reduce the risk
treating a normal-weight person and an for developing major chronic diseases for all
obese individual was $1,244, up from $272 Americans (from age two to aging adults).
in 1987. In general, the annual medical costs In 1979, the U.S. Surgeon General estab-
for overweight and obese individuals (under lished national health objectives that served
the age of 65 years) is 14.5% and 36–37.4% as the basis for the development of state and
higher compared to normal-weight individu- community health plans (U.S. Department
als, respectively (Segel, 2006). Weight loss of Health and Human Services, 2000). The
can reduce lifetime medical costs by $2,200 objectives were developed through a broad
to $5,300 per person. consultation process, derived from current
In the corporate world, the impact can be scientific knowledge, and designed to mea-
significant. The hospital inpatient utilization sure programs over time. Healthy People, the
rate for workers with unhealthy weights was statement of these national health objectives,
143% higher than for normal-weight workers. is designed to identify the most significant
In March of 2005, the annual premium for an preventable threats to health, and to estab-
employee averaged $6,281. lish a national consensus of how to reduce
Since 2000, employment-based health them. The current version, Healthy People
insurance premiums have risen 73% (The 2010, contains 467 objectives in 28 focus
Henry J. Kaiser Family Foundation, 2005). areas (U.S. Department of Health and Human
Meanwhile, the average employee contribu- Services, 2000). Under focus area number 19,
266 Lifestyle & Weight Management Coach Manual AMERICAN COUNCIL ON ExERCISE
Weight-management Programming CHAPTER 12
entitled “Overweight and Obesity,” specific voluntary, and point-of-sale nutrition-
objectives include the following: information campaign for consumers
• O bjective 19-1: Increase the proportion • Therapeutics: Revising FDA guidance
of healthy-weight adults to at least 60% for developing obesity drugs and
• O bjective 19-2: Reduce the proportion of addressing challenges and gaps in
obese adults to less than 15% knowledge about existing drug thera-
The National Institutes of Health (NIH) in pies for treating obesity
2005 developed a strategic plan for obesity • Research: Supporting others and col-
research, earmarking a budget of $440.3 mil- laborating (with others, such as the
lion. The NIH recognizes the multifaceted NIH) on obesity-related research
variables that affect obesity. Its plan to fight
obesity is organized into four major themes
Safe and Effective
related to obesity prevention and treatment:
• Lifestyle modification Weight Loss
• P harmacologic, surgical, or other medical
approaches Lifestyle changes, including modifica-
• T he link between obesity and associated tions of food intake and physical activ-
health conditions ity to establish a daily negative caloric
• C rosscutting research topics, including balance, remain the hallmarks of effective
health disparities and technology programming. It can be difficult to accurately
The Food and Drug Administration’s estimate weight-loss rates for clients given
(FDA) Obesity Working Group released the numerous factors influencing weight
its final report in 2004 (U.S. FDA, 2004). loss. Additionally, using weight-loss rate
The group’s long- and short-term propos- is not recommended for long-term weight
als are based on the scientific knowledge management, because of the potential lean
that weight control is primarily a function body mass gain that accompanies overload
of caloric balance. Consequently, the FDA with resistance training. Instead, it is best to
focuses on calorie counting in its obe- focus the client’s attention on the perceived
sity campaign. The FDA’s ongoing actions benefits of accomplishing various program-
include the following: related goals, such as changes in body shape
• Labeling: Enhancing food labels to and image, and self-efficacy.
display the calorie count more promi- Modest and realistic expectations include
nently, and implementing more mean- achieving an initial 5 to 10% reduction in
ingful serving sizes body weight, as this range is consistent with
• Enforcement agencies: Collaborating improved overall health benefits, increased
with the Federal Trade Commission self-efficacy, and improved adherence
(FTC) to increase enforcement against [American College of Sports Medicine (ACSM),
weight-loss products that have false or 2010]. Always follow a prudent plan with a
misleading claims, and products that weight-loss goal that is consistent with the
declare inaccurate serving sizes most current dietary guidelines, unless cli-
• Educational partnerships: Working ents are medically supervised by a licensed
cooperatively with other government physician or registered dietitian. The 2005
agencies, nonprofits, industry, and USDA Dietary Guidelines and the 2010 ACSM
academia to educate Americans on the guidelines recommend a weekly weight loss
dangers of obesity and the importance of 0.5 to 1.0 kg (1.1 to 2.2 pounds) per week,
of leading healthier lives through bet- which necessitates a negative caloric balance
ter nutrition of 3,850 to 7,700 kcal weekly, or 550 to 1,100
• Restaurants: Encouraging the restau- kcal daily. A more conservative approach of
rant industry to launch a nationwide, 0.5 to 1.0 pounds (0.23 to 0.45 kg) per week,
AMERICAN COUNCIL ON ExERCISE Lifestyle & Weight Management Coach Manual 267
CHAPTER 12 Weight-management Programming
necessitating a negative caloric balance of 2005). Weight losses of only 5 to 10% may
1,750 to 3,500 kcal weekly, or 250 to 500 kcal greatly diminish any health concerns associ-
daily, may be more suitable for some clients. ated with being overweight, but even smaller
Ultimately, the weight-loss goal must be safe, losses can make a difference. Weights above
satisfy the needs and desires of the client, the ranges shown in Table 12-2 are considered
and include the following considerations: less healthy for most people. The greater the
• Age margin of difference between actual body
• T arget weight (or amount of weight and the healthy weight range for
weight to be lost) height, the higher the risk of weight-related
• Current physical-activity level health disorders.
• Medical concerns A more useful estimate of quantifying a
• History of dieting healthy weight in relation to height can be
• Emotional and psychological state obtained by calculating a height-normalized
Individuals do not need to lose weight if weight index. The body mass index (BMI)
their weight is within the healthy range rep- is the most commonly used indicator (Table
resented in Table 12-2, if they have gained 12–3). While the BMI has limited applications
less than 10 pounds since reaching their for athletes, seniors, and children, research
adult height, or are otherwise healthy (USDA, points to a strong relationship between BMI
and mortality rates. In a research study fol-
Table 12-2
lowing 1 million adults for 14 years, the
Healthy Weight Ranges for Men and Women lowest BMI-mortality rates were BMI scores
between 23.5 and 24.9 for men and 23.0 and
Height Weight (pounds) Weight (kg)
23.4 for women.
4'10" (1.47 m) 91–119 41.4–54.1
4'11" (1.50 m) 94–124 42.7–56.4
Understanding
5'0" (1.52 m) 97–128 44.1–58.2
5'1" (1.55 m) 101–132 45.9–60.0 Behavioral Change
5'2" (1.57 m) 104–137 47.2–62.2
People make choices and decisions based
5'3" (1.60 m) 107–141 48.6–64.1
on how they feel and think (Figure
5'4" (1.62 m) 111–146 50.5–66.4
12-1). Everyone’s belief system is based
5'5" (1.65 m) 114–150 51.8–68.2 on past and present experiences. These belief
5'6" (1.67 m) 118–155 53.6–70.5 systems drive people’s thought processes and
feelings, and the decisions and choices they
5'7" (1.70m) 121–160 55.0–72.7
make. To influence desired behaviors, LWMCs
5'8" (1.73 m) 125–164 56.8–74.5
must work with clients to help them think
5'9" (1.75 m) 129–169 58.6–76.8
about ways to achieve desirable behaviors and
5'10" (1.77 m) 132–174 60.0–79.1
talk to them about their feelings about those
5'11" (1.80 m) 136–179 61.8–81.4 desired behaviors. LWMCs may successfully
6'0" (1.83 m) 140–184 63.6–83.6 alter unfounded belief systems to influence
6'1" (1.85 m) 144–189 65.5–85.9 decisions and choices. Additionally, these
experiences should be engaging, positive, and
6'2" (1.87 m) 148–195 67.3–88.6
memorable, and build self-efficacy to empow-
6'3" (1.90 m) 152–200 69.1–90.1
er clients to want to stop unhealthy behav-
6'4" (1.93 m) 156–205 70.9–93.2
iors, while also enhancing their confidence in
6'5" (1.95 m) 160–211 72.7–95.9 their abilities to initiate change.
6'6" (1.98 m ) 164–216 74.5–98.2 Using a weight-management example to
illustrate this point, imagine a client with
Source: United States Department of Agriculture (2005). USDA Dietary
Guidelines for Americans. www.health.gov/dietaryguidelines. an estimated caloric intake of 2,000 kcal,
268 Lifestyle & Weight Management Coach Manual AMERICAN COUNCIL ON ExERCISE
Weight-management Programming CHAPTER 12
Table 12-3
Body Mass Index
19 20 21 22 23 24 25 26 27 28 29 30 35 40
Height (inches) Weight (pounds)
58 91 95 100 105 110 115 119 124 129 134 138 143 167 191
59 94 99 104 109 114 119 124 128 133 138 143 148 173 198
60 97 102 107 112 118 123 128 133 138 143 148 153 179 204
61 100 106 111 116 121 127 132 137 143 148 153 158 185 211
62 104 109 115 120 125 131 136 142 147 153 158 164 191 218
63 107 113 118 124 130 135 141 146 152 158 163 169 197 225
64 110 116 122 128 134 140 145 151 157 163 169 174 203 233
65 114 120 126 132 138 144 150 156 162 168 174 180 210 240
66 117 124 130 136 142 148 155 161 167 173 179 185 216 247
67 121 127 134 140 147 153 159 166 172 178 185 191 223 255
68 125 131 138 144 151 158 164 171 177 184 190 197 230 263
69 128 135 142 149 155 162 169 176 182 189 196 203 237 270
70 132 139 146 153 160 167 174 181 188 195 202 209 243 278
71 136 143 150 157 165 172 179 186 193 200 207 215 250 286
72 140 147 155 162 169 177 184 191 199 206 213 221 258 294
73 144 151 159 166 174 182 189 197 204 212 219 227 265 303
74 148 155 163 171 179 187 194 202 210 218 225 233 272 311
75 152 160 168 176 184 192 200 208 216 224 232 240 279 319
76 156 164 172 180 189 197 205 213 221 230 238 246 287 328
Note: Find your client’s height in the far left column and move across the row to the weight that is closest to the client’s weight. His or her body mass index will be at the top of that column.
Figure 12-1
}
Influences on
decisions and
choices
}
Subconscious
Conscious
who would like to lose 1 pound (0.45 kg) per clients tend to be deconditioned and are bet-
week. Long-term weight-loss success typi- ter suited to walking or performing walk-jog
cally involves modest caloric reductions of 10 intervals for exercise that burns between 5 and
to 15% initially, although some studies do 9 kcal per minute (for a 165-pound or 75-kg
demonstrate long-term success with initial individual). To expend 200 kcal, the individual
caloric reductions of 20 to 25%. Using a mod- needs to participate in 23 minutes of jog-
est reduction of 300 kcal of intake leaves a ging or 40 minutes of walking. Considering
balance of 200 kcal that must be expended via that only 46% of the U.S adult population
physical activity and exercise. Most overweight meets minimum recommendations of the
AMERICAN COUNCIL ON ExERCISE Lifestyle & Weight Management Coach Manual 269