These case studies will demonstrate how to apply different weight management strategies to a spectrum of widely divergent clients.
With more than half of U.S. adults now considered to be overweight and/or obese (Flegal et al. 1998), it’s no wonder fitness professionals are constantly asked questions about weight loss. Those of us who work with clients over an extended period of time have an opportunity to really facilitate change in people’s long-term health behaviors. Our clients rely on us, not only to instruct them about exercise programs, but also to impart general information about eating habits. Recommending specific nutrients is outside our scope of practice, but we can play an important role in helping clients make healthier lifestyle choices and become better informed about the dangers of fad diets and dietary supplements. We can also make referrals to local nutrition experts and work in conjunction with other health care professionals whenever necessary.
One way to help clients is to keep abreast of the current principles of weight management that apply to all clients to some degree. Another way is to develop a working knowledge of the different personality types you are likely to encounter in your fitness practice. Through a series of client case studies, this article will recommend different strategies to employ with different types of clients. These case studies represent broad categories; a single client is unlikely to possess all the attributes described in a case study. However, you can apply the strategies to any number of clients you work with during your career.
Fitness professionals working with clients who express a desire to lose weight should be familiar with the following basic principles:
Caloric Intake. No matter what type of food plan a client chooses, in order to lose weight it is essential to create a negative caloric balance, or a caloric deficit. To create such a deficit, the energy expended during basal metabolism and physical activity needs to exceed the calories taken in from food and beverages. While a caloric deficit can be accomplished by increasing physical activity levels, most people choose to alter their food intake. Generally, women need between 1,400 and 2,000 calories daily, while men require 1,600 to 2,000 calories a day; people with very active lifestyles have higher requirements.
Despite the proliferation of diets available today, most reputable health organizations, including the American Dietetic Association (ADA), American Heart Association and American Diabetes Association, continue to recommend a high-carbohydrate, low-fat diet (55% carbohydrate, 20% protein and 25% fat). The ADA also recommends no more than a 1- to 2-pound weight loss per week, to ensure that the loss comes from fat mass rather than lean body mass. To achieve a weight loss of 1 to 2 pounds per week, clients should take in 500 fewer calories each day, or 3,500 fewer calories each week, according to most nutrition experts.
To ensure that clients get the proper nutrients in the correct portion sizes, I highly recommend that your clients meet with a registered dietitian, who can help them calculate an individualized meal plan. Meal plans create the basic tools clients need to comply with a healthy weight loss program. Once a client’s meal plan is in place, you as the fitness professional can help affirm that plan, motivate the client and make the plan a reality.
Fad Diets. Although fad diets are more popular than ever, the truth is that most don’t work in the long term. To produce quick weight loss in the short term, most of these diets are extremely restrictive in terms of caloric intake and foods allowed, which makes the diets unsustainable for long periods. Also, the majority of fad diets come with claims that are too good to be true—for example, by simply drinking a certain product, you will shed pounds while you sleep. Yet, having seen their friends lose weight on a particular fad diet, your clients will undoubtedly pose questions, which you must be able to answer based on facts. For example, many clients want to know more about the high-protein, low-carbohydrate diets in vogue today. You need to be able to explain why it is possible to lose weight on these diets in the short term (the reason being that water weight is quickly lost when carbs are restricted), while also conveying the dangers of restrictive food plans and the value of a balanced diet. Encouraging your clients to follow a high-protein, low-carb diet—which many people advocate—can jeopardize your credibility as a health and fitness professional in the same way that recommending a popular but contraindicated exercise would. When you respond to questions about fad diets, your goal should be to discourage any food plan that creates a fear of food, sends mixed messages about what constitutes a healthy diet or is so restrictive that it leads to disordered behavior, such as binge eating.
Food Journals and Behavior Contracts. Studies show that keeping a food record can help clients reduce their caloric intake (Foreyt & Goodrick 1993). Clients in my own practice have found it very helpful to record food intake during the initial couple of weeks of a weight loss program. A food journal is one of the best tools you can employ to help clients observe their daily behaviors (e.g., mealtimes, choices of snacks, food eaten in restaurants) and the factors that trigger certain food desires. By using the food journal in conjunction with the Food Guide Pyramid, you can provide general guidelines on fat, protein and carbohydrates. An example of a food journal that has worked well for my clients is shown on page 40.
Another helpful tool for clients on a weight management program is a weekly behavior contract. This type of contract helps focus clients on a limited number of specific goals each week so that clients don’t have to change their diet all at once. The contract should include clear and obtainable goals, along with the respective action(s) needed to attain them. For example, the first goal might be “I will eat breakfast every morning for the next week.” In this case, the associated action could be “I will eat a breakfast that contains one serving each of carbohydrates and protein, plus a small amount of fat, such as 1 cup of Quaker Oats cereal + milk + banana.” If you take the time to have clients fill out contracts and then review them together on a weekly basis, your clients will see results, which will encourage them to continue the process. An example of a behavior contract that I have used with my own clients is shown on page 41.
Supplements. Americans spend billions of dollars annually on weight loss products, such as dietary supplements (Colditz 1992). As with fad diets, you need to know about these products so you can educate your clientele regarding their efficacy and potential dangers. Under no circumstances should a fitness professional recommend or endorse dietary supplements. For one thing, doing so is out of the scope of practice for fitness professionals. Second, these products may contain harmful substances, such as ephedra, a bronchodilator commonly used in asthma medications. Since 1994, the U.S. Food and Drug Administration (FDA) has received hundreds of reports of ephedra-based supplements causing adverse events, such as dangerously high blood pressure, irregularities in heart rate, insomnia, tremors and headaches, seizures, strokes, heart attacks and even death. The events occurred in otherwise healthy adults who used ephedra (also known as ma huang) to control weight and boost energy. For more information on incidents involving ephedra, visit the FDA’s Web site, www.fda.gov/medwatch.
Body Composition. The ideal outcome of any weight loss attempt is to lose fat and spare muscle mass. The only way to document results is to take body composition measurements. Weighing in on a scale is inadequate as a sole way of recording progress, because the scale can only record pounds, not overall body composition. Also, a scale often measures shifts in water retention, which are ephemeral in nature and not reflective of changes in body fat. While the scale can be used in tandem with other measurement tools, some clients may resist being weighed weekly. They may also be discouraged by the small increases in weight that deconditioned people sometimes experience after starting an exercise program. (These changes are due to increases in muscle mass and glycogen stores.) Measuring body composition, on the other hand, can increase a client’s motivation and diet retention because you can document subtle improvements over time. I recommend taking body composition measurements every six weeks, which should provide ample time for clients to see changes. Using skin calipers and taking circumference measurements are typically the easiest, cheapest and most accurate ways to measure body composition, as long as these methods are performed correctly.
Portion, or Serving, Sizes. Among the main contributors to our escalating obesity epidemic are the supersized portions first served up by restaurants and now considered the standard for home cooking. Many clients (and fitness professionals, too) are confused as to what counts as a portion. It is best to refer these clients to the Food Guide Pyramid for facts and serving sizes. For example, many clients are surprised to learn that, for an adult, the recommended serving of meat in one meal is a mere 3 ounces. Most people are shocked when they see how small this amount actually is compared to the much larger servings they have grown (no pun intended) accustomed to eating. In fact, it is not unusual for clients to realize they regularly eat twice that amount of meat, since the typical restaurant serving is at least 6 ounces. You can help clients rethink their portion sizes by providing visual references for some common foods; for example, let clients know that 3 ounces of meat is similar in size to a deck of cards. (For more information on portion size, see “Less Is More” in the June 1999 issue of IDEA Health & Fitness Source.)
Understanding the principles of weight loss is one thing. Putting them into practice with actual clients is another story. For example, trying to help a 285-pound sedentary male executive who eats lunch out every day and dinner out at least four nights per week is quite different from working with a 30-year-old mother of two who regularly exercises, eats most meals at home and wants to lose a few pounds. Even though the basic training principles of weight management apply to both these cases, the focus of instruction will differ as you try to customize your approach.
After years of practice spent counseling a broad spectrum of individuals, I’ve come to think in terms of approaches that work best for different categories of clients. While every client is unique in his or her own right, I have noticed that certain types of personalities share many of the challenges associated with weight management. For the purposes of simplification, the following sections will describe how best to work with the four categories of clients I encounter most frequently: the executive; the soccer mom; the disordered eater; and the metabolically challenged client. Included for each category is a case study of a typical client, along with practical strategies that have worked well in my practice.
Most highly successful professionals are perfectionists with type A personalities. They tend to be goal oriented and like to see quick results. Time is always an issue for these clients, considering that many of them work more than 60 hours a week. Executives typically travel frequently for both leisure and business, sometimes as much as four or five days each week. They are highly educated and usually know the basics of good nutrition, such as why baking foods is preferable to frying them. Some executives skip breakfast, have lunch meetings and entertain colleagues for working dinners, which often include alcohol. Their professional and personal lives can be highly stressful, and most have assistants at work and/or home. The majority of these clients are computer literate and prefer to communicate via e-mail.
- Executives are highly motivated by results, so show them the numbers. Measure body composition at baseline and then record measurements every six weeks; weigh clients on a weekly or bimonthly basis. Just knowing they are going to be weighed can often be a huge motivator to reduce overall food intake. However, don’t overemphasize weight differences at the cost of safety. Make sure these clients understand that a safe and effective weight loss is 1 to 2 pounds per week. Female clients may retain water weight during their menstrual cycles, so education is essential when weighing or taking measurements. Take measurements in private rather than in a public area.
- Communicate via e-mail. Because executives are time sensitive and frequently on the road, e-mail is often their preferred mode of communication. You can use e-mail messages to help set weekly goals, keep food journals and stay in close contact, even if you can’t meet in person one week.
- If financially feasible, put clients in touch with a reputable local private chef who can provide nutritious, well-balanced daily meals. This arrangement is especially effective for bachelors and professional athletes.
- Refer executives to a registered dietitian in your area for nutritional counseling and meal planning. You can find a dietitian via the ADA Web site, www.eatright.org. But meet this person before referring clients.
- Provide your Internet-savvy clients a list of reputable nutrition Web sites, such as www.cyberdiet.com, www.eatright.org and www.webmd.com. However, caution clients that much of the information posted on some sites is questionable in nature.
- Set both short- and long-term weight loss and exercise goals. Have your executive clients use the behavior contract on page 41 to focus on specific goals, such as “I will eat breakfast every day this week.”
Case Study: John is an affluent 51-year-old male who owns his own business. He is 5'10" and weighs 285 pounds. He eats lunch out every workday and often entertains clients at business dinners. For lunch, he frequents the fast-food restaurants near his office. He and his wife host dinners at home nearly every weekend, and John travels at least once per month. He has tried many diets, including liquid diets. John works with one of our trainers three days per week and decided to see me for nutrition counseling. This is the first time he has attempted to lose weight by combining exercise and basic nutrition changes.
After consulting with John, I devised a meal plan that focused on appropriate serving sizes and on healthy menu choices in restaurants. I see John twice a month and weigh him each time; his trainer takes body composition measurements every six weeks. John finds it very motivating to see his weight and measurements change. To maintain his food plan, he keeps a food journal and e-mails it to me before we meet. At each meeting, we discuss issues that arise in real time, such as the challenges of an upcoming heavy travel schedule and ways to avoid temptations during the holidays. Since I began working with John three months ago, he has lost 25 pounds.
Soccer mom is a term that has come to apply to all mothers trying to juggle the responsibilities of a family—whether that family plays soccer or not! These busy women typically are the glue that holds everything together; in trying to please everyone, they may allow their own needs to get lost in the shuffle. They tend to be highly educated and to have had a career prior to becoming mothers. While they may continue to work full-time or part-time after giving birth to their children, the transition to motherhood can be challenging for them. Time is almost always an issue for these clients, as they race to take their children to various activities (hence the term soccer moms) in between volunteering, entertaining and performing household chores and errands. They have little time for themselves, especially when it comes to carving out a good time to exercise or even to plan a nutritious meal. Many skip breakfast because they are too busy feeding their children and getting them off to school. Those who hold a job in addition to tending to their family often run errands at lunchtime. By the time they rush home after work, they are usually ravenous and need to quickly get dinner on the table for the kids. In addition to skipping meals, many snack all day long, which does not satiate them but only leaves them hungrier
- Set weekly exercise and behavior goals for your soccer mom clients. Because they have so much to do for everyone else, do whatever you can to simplify what they need to do for themselves. Use behavior contracts to remind these clients of their goals. An example of a weekly goal would be “I will sit down and eat lunch three times this week and include a protein at each meal.” The good news is that, as clients, soccer moms are usually compliant, as they want to please you in the same way they please their family members.
- Provide these clients with quick, easy recipes for nutritious meals that will appeal to the whole family. If the moms themselves are computer shy, tell them to enlist the aid of their kids in accessing Web sites that provide recipes. Sites include www.cyberdiet.com, www.cookinglight.com and www .campbells.com.
- Take a cooking class with these clients. Since they are usually the family meal planners, help them increase their cooking repertoire of tasty, healthful options.
- Find “healthy gourmet” to-go options for especially busy nights. Every city has small outlets that sell specialty meals that are ready to heat up at home. Moms will appreciate the break from cooking and planning. They will also feel less guilty knowing they didn’t resort to an unhealthy fast-food meal like pizza. Do remind them, though, that not all gourmet foods are healthy; warn against high-fat temptations.
- Ensure compliance with exercise routines by having these clients record their daily activities. If they get too busy taking care of everyone else, they may neglect their exercise program and stop losing weight. We use exercise adherence charts to document how much clients have exercised in a given week.
- Food journals also help with compliance. Again, these clients are naturally compliant, so a food journal is a great tool—especially since they know you will be checking their progress on a weekly basis.
Case Study: Ellen is a 42-year-old mother of two young boys, both of whom do play soccer. At 5'2" and 164 pounds, she wants to lose at least 30 pounds. She has a master’s degree in business but gave up her career to have kids. She doesn’t like to cook, which is exacerbated by the fact that her kids and husband are picky eaters. Ellen has tried numerous diets in the past to no avail. One thing she did notice, though, was how motivating it was to be weighed on a weekly basis.
I train both Ellen and her husband three days per week. Ellen also jogs occasionally on her own. She and I have met separately to discuss her nutrition goals and customize a meal plan for her to follow. I gave her a few vegetable recipes and even helped her cook a few meals to try out on her family. She began to keep a food journal, which has helped her remember to eat regularly during the day. Seeing exactly what she was eating during the day (her weakness was potato chips!) was a real eye opener for Ellen. After maintaining the food journal for a week or two, she cut down on snacking and worked hard to plan more balanced meals. Although she has lost about 15 pounds to date, she is having a problem losing the last 15 pounds. Her hectic schedule still gets in the way of regular daily exercise and proper nutrition. In fact, I plan on reassessing her meal plan and will ask her to go back to keeping a daily food journal. I am also trying to find a cooking class we can attend together so she knows I am willing to go the extra mile with her.
More and more often, fitness professionals are encountering clients with disordered eating patterns. Disordered eating differs from the more serious eating disorders in that it is episodic, not chronic, in nature. While disordered eating can lead to transient weight fluctuations, it rarely causes the kind of major medical complications that result from eating disorders. Disordered eating can be difficult to diagnose because the symptoms are more subtle than those associated with eating disorders. However, clients with a pattern of disordered eating often overexercise to reach their weight loss goals.
These individuals tend to be extremist in how they regard food: they typically think of different foods as being either “good” or “bad.” Most are highly motivated perfectionists who are fat phobic and restrict their daily caloric intake. Compared to other clients, they may want to lose only 5 to 10 pounds, but they will be quite adamant about achieving their goal at any cost. Ironically, clients with disordered eating patterns are often highly educated and pride themselves on their knowledge of sound nutrition practices. They diet frequently and are usually preoccupied with food, body weight and body image. One thing is certain: Unless these clients set more realistic weight loss goals and change their behavior, they will never be satisfied.
- Help these clients separate fact from fiction. While they may think they have all the answers, educate them about the benefits of long-term healthy eating and lifestyle behavior. Steer them to reputable sources of information, such as www.cyberdiet.com,www.eatright.org and www.webmd.com.
- Work on redefining their goals. Clients who have an unhealthy relationship with food need to understand the importance of balance in life. They also need to learn that no foods are good or bad. But be careful not to overstep your scope of practice, as it is inappropriate for fitness professionals to counsel clients. However, it is appropriate to refer any client you think has a food phobia or other psychological issue to a licensed psychologist or therapist in your area.
Case Study: Jackie is a 32-year-old advertising executive who is 5'7" and weighs 138 pounds. She exercises every day and during the workweek is very restrictive about caloric intake. Yet she smokes and during weekends allows herself to indulge in wine and rich food. She is married without children but is thinking about becoming pregnant. When we met, Jackie’s goals were to lose approximately 5 pounds and get healthy.
During my initial consultation with Jackie, it became clear she had many misconceptions about food, was extremely fat phobic and had a poor body image. I also realized her diet was quite restrictive in terms of both calories and the types of foods she would eat. We went over her calorie needs and broke these down into recommended quantities (in grams) of protein, fat and carbohydrate. She was shocked to learn her daily requirements for calories, fat and protein. To address her needs, we started adding foods to her diet—gradually, to ensure compliance. For example, we first added a portion of meat to her lunches and progressed slowly from there. As I continued to work with Jackie, I gave her many articles to read that reaffirmed some of the nutrition and exercise principles I was introducing. Despite the fact that she was eating more food, her weight stayed neutral, so she became convinced she could eat more and not gain weight. After working with me for almost a year, Jackie no longer fears food, has stopped smoking and is now ready to start a family.
At one time or another, all of us have probably come in contact with a client who exercises regularly, eats soundly but cannot seem to lose weight. Many clients of this type are genetically predisposed to obesity (i.e., one of their parents is overweight) or to an associated health condition, such as diabetes or a thyroid problem. Despite their best efforts, they may never achieve their weight loss goals. To stay motivated and on the right path, these clients need to be rewarded and encouraged in different ways from other clients. Remember, the reasons people become overweight and obese are still not fully understood, and more research needs to be done.
- When you work with a metabolically challenged client, identify and document any health conditions that may contribute to the client’s inability to lose weight. Be sure to take a thorough medical history and if necessary consult with the client’s physician to understand the underlying medical conditions and any medications that may have implications for weight loss. For example, two side effects of some hormone replacement therapies that females may take during menopause are weight gain and increased appetite. Clients need your support to understand that their inability to lose weight when taking these kinds of medications is beyond their control. If you are unsure about a medication and its side effects, consult a medical professional (physician or pharmacist) or consult the Web site www.webmd.com.
- Refer clients with suspected or confirmed metabolic challenges to a dietitian in your area for a specialized assessment and meal plan.
- Most clients in this category need to increase their physical activity program to five or six days per week. Having cleared a plan with the client’s physician, set short-term goals for upping the exercise routine. Then be sure to document and emphasize any weight loss that results.
- Behavior contracts are especially effective with these clients. In addition to short- and long-term exercise goals, have clients set small, viable nutrition goals each week.
Case Study: Julie is 50 years old, stands 5'6" tall and weighs 180 pounds. A mother of two girls, she takes Synthroid® to correct a thyroid deficiency and hormone replacement therapy to make menopause more manageable. She works part-time and works out consistently three to five days per week. Julie tends to skip breakfast, but she eats a salad for lunch, an afternoon snack and a well-balanced dinner.
After meeting with me and discussing her problem areas, we formulated a customized meal plan. I focused on minimizing her food portions, which resulted in a lower intake of calories per day. Because Julie tended to consume most of her calories in the evening, I also emphasized the importance of eating small meals regularly throughout the day. To address Julie’s body image problems, I showed her pictures of larger-sized models who were quite attractive. We both agreed she would try whenever possible to increase her exercise routine by working out one more day each week.
After a month on the meal plan, Julie was disappointed at not having lost any weight, but she felt determined to keep up her efforts. After another month had elapsed without any weight change, I suggested she consult a physician to ensure that her thyroid medication was set at the proper dose. Once her doctor had ruled out changes to her medications, Julie and I continued to meet weekly, focusing on portion control and meal scheduling. During this period, I consistently assured her she was doing all she could by complying with her meal and exercise plan. I also explained—as did her physician—that some people cannot lose weight, owing to medical conditions and maintenance medications. Ultimately, we mutually agreed to discontinue our sessions, although she continues to work out with a personal trainer. This case is a good example of the small percentage of clients who exercise regularly and eat a healthy diet but still cannot achieve their weight loss goals. The important take-home message here is that sometimes your biggest role is simply to motivate and educate clients.
Perhaps the case studies and categories in this article resemble in some way a few of your own clients who struggle with weight loss. It’s important for us as fitness professionals to realize that weight loss is really a journey with numerous peaks and valleys along the way. It is essential to stick with our clients—especially during those valleys—by finding ways to keep them motivated. One thing I have learned in my own role as a fitness professional and registered dietitian is that, in order to help clients realize and sustain weight loss, I periodically have to revisit some of the basic training guidelines covered in this article. I also have to keep in mind that my clients’ successes and failures are not my successes and failures. So try not to take it personally if, despite your best efforts, clients do not achieve their weight loss goals. Instead, continue to work your magic in tandem with other health professionals, such as dietitians, to collectively try to assist people who really need your help.