By Philip Walker, MS

Three case studies outline the trainer’s contribution in a team treatment approach for complicated clients.

The Trainer’s Role in the Multidisciplinary Team
Let me introduce you to Robin, she is my personal trainer, my dietitian and my therapist!
s the popularity of personal training continues to escalate, so does the need for personal trainers to become adequately informed in a variety of health-related fields. Consequently, clients frequently approach their trainers with an assortment of complex diet, medical and psychological concerns. In addition, myriad health questions ranging from medical advice to relationship guidance often arise during training sessions. Thus assuming responsibility for their clients’ total well-being, trainers are constantly challenged with issues that may be outside their own professional boundaries. This leads to head-on confrontation of significant ethical dilemmas that may impact the quality of their professional reputations.

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Furthermore, it is becoming common practice for prospective clients to contact a personal trainer before consulting with additional health care professionals. It is then the trainer’s responsibility to decide whether the prospective client: I is medically sound to work out I has other contributing health factors that may require immediate attention I requires expert advice on a specific condition An effective tool to maintain high ethical principles without compromising patient care is to ally oneself with a network of diverse health care providers for a team treatment approach. The following article illustrates three fictional characters who initially requested the services of a personal trainer for a weight loss program–an erroneously perceived solution to their apparent health problems.

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NOVEMBER-DECEMBER 2001

Help! What Should I Do With Janet? Adult American women as a group tend to gain weight with age. Many women report that their weight gain is accompanied with an increase in abdominal fat (Simkin 2000) starting around menopause. Similarly, with a possible increase of mood disturbances (Mona 1998) such as depression, many women find the years surrounding menopause very daunting. Janet’s Profile I Janet is characteristic of a perimenopausal woman; complains of a gradual 18-pound weight gain over the past five years. I She has increased her dress size from a size eight to a size 12, and her favorite clothes are tight and unflattering. Despite a number of recent attempts to lose weight by restricting calories, her body fat continues to accumulate. Subsequently, she is self-conscious and distressed. As a successful retail manager she has spent most of her career in the fashion industry and she is very conscientious of her appearance and distraught that she “let herself get into such a state.” I With the exception of a few five- to eight-pound weight fluctuations during her college years, and two weeks of a banana diet to lose 10 pounds in her 30s, Janet considered herself one of the lucky few that never had a weight problem. She has been a consistent 118 pounds throughout her adult life. I Her job is very stressful. During long hours in the office she has a tendency to calm her nerves with “feel good” foods, adding that chocolate is a recurring favorite. I She experiences significant energy slumps. She attributes these to frequently missed meals because of meetings and deadlines. She regularly dines at local restaurants or fast food establishments on the way home from work. I She exercises by herself on occasion, but finds it difficult to sustain a program beyond a few weeks because she does not notice any results. I She understands the importance of regular exercise and is open to any suggestions. I Janet has not visited a physician for a number of years, but says she is in good health. I She does not take any medications and is avoiding hormone replacement therapy (HRT), which she postulates will add to her weight gain. I Apart from some sleeping problems, she has no ongoing physical pain or discomfort. I She is happily married to a businessman; however, she adds that he “travels too much.” I Janet has no children.

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She enjoys an active social life with moderate alcohol intake. Clearly, Janet has enjoyed a successful career, good health and a happy marriage. However, to witness her tears when the subject of body size was addressed verified that she was dejected about her weight gain. In addition, Janet’s previous dieting techniques and subsequent statements signifying that she wants to lose weight quickly and effectively indicate that her treatment will be more complex than first anticipated. Following in-depth dialogue, enough information exists to create a strategy for Janet. What would you do?

Synopsis First, Janet’s weight gain is not due exclusively to behavior; furthermore, her lack of knowledge in regards to the physiological changes during perimenopause is evident. Like many women, Janet tends to view menopause as a two- to fouryear transition. While the most intense physiological transition does last a few years, initial minor changes may occur more than a decade prior to “the change.” Studies demonstrate that the impact on body weight and fat cell distribution is greatest in the perimenopausal years. The common belief that a menopausal woman’s weight gain is largely due to HRT is contrary to most research findings (Seumeren 2000). Characteristically, what appears to influence weight gain is not the hormonal status, but a loss of muscle mass and the accompanying “1 to 2 percent per decade” decline in metabolic rate commencing in the mid-30s (Ryan 1995). Thus, calorie restriction–the prevalent practice of weight loss for menopausal women–depresses the metabolism even further, often resulting in confusion, frustration and failure. On the other hand, an effective exercise regime reverses the diet-induced reduction in metabolism and increases the declining muscle mass. Exercise has proven very effective for middle-aged women who want to control their weights (Ryan 1996). Studies also confirm that perimenopausal women who increase their physical activity during midlife had less weight gain and a reduced amount of fat accumulation (Owens 1992). Inactive women in their 50s tend to lose muscle strength, bone density and functional capacity at an accelerated rate. Studies demonstrate that during a woman’s menopausal years, physical exercise with an appropriate diet will delay weight gain, increase lean body mass and decrease total body fat mass. Additionally, exercise will assist in the protection of bone mass and may be associated with decreased risk of estrogen-dependent breast and endometrial carcinomas. A combination of exercise, a healthy diet and HRT will noticeably contribute to metabolic fitness and
IDEA PERSONAL TRAINER NOVEMBER-DECEMBER 2001

Case Studies
decreased cardiovascular risk (Gapard 2001).

Example of Treatment Team Professionals
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Strategy 1. Medical. Fear of weight gain is one of the main factors contributing to poor compliance with hormone therapy (Seumeren 2000). Therefore, strongly recommend that Janet arrange a consultation with a gynecologist to discuss her health status and become adequately informed regarding her midlife condition. Perhaps the gynecologist could assist Janet with her sleep deprivation and depleted energy levels. Once Janet signs a patient consent form, confer with her physician and get medical clearance to design an exercise program. 2. Education. Educate Janet on the various stages of menopause by suggesting a reading list including the following books: I Outsmarting the Midlife Fat Cell by Debra Waterhouse, MPH, RD, (New York: Hyperion, 1998) I Living Without Dieting by John Paul Foreyt and G. Ken Goodrick, (New York: Warner, 1992) 3. Exercise. Recommend a progressive exercise program that includes cardiovascular training, strength training and stretching with an accompanying comprehensive written fitness program. Also, suggest personal training services for two to three days a week to establish a strength training program and provide motivation. Furthermore, suggest that Janet exercise unaccompanied for two to three days per week to build self-reliance. The exercise frequency of up to five days per week is designed to give Janet the power to choose a regime with which she is comfortable and compliant. Discuss the specific program with Janet and help her choose activities that are comfortable, pleasurable and compatible with her lifestyle. In addition, increase the time spent with Janet if she becomes susceptible to
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Psychotherapist Physicians:
Gynecologist Pediatrician Internist Podiatrist Sports Medicine Specialist (often found in clinics) Allergist Cardiologist

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Dietitian Nutrition Therapist (for suspected eating disorders) Physical Therapist (often found in clinics) Sleeping Disorder Specialist (often found in clinics) Back Specialist (often found in clinics) Chiropractor

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Help! Tiffany’s Case Is Complicated! Female athletes who participate in sports that value thinness are under intense pressure to have a low percentage of body fat for performance. Clearly, Tiffany is no exception to this rule. The 17-year-old competitive figure skater not only is convinced that she is overweight for her sport, but her parents also continually pressure her into losing weight. Consequently, Tiffany reports that she has surreptitiously tried everything including laxatives, diuretics, smoking and chronic dieting to shed the 10-pound nemesis. As her only remaining option, Tiffany’s parents thought that a supplementary training program and a specialized low-calorie diet from an “expert” would be the solution. Tiffany’s Profile I She is an excellent skater who proudly declares that she began performing at seven years old; next year her goal is to compete in the nationals, the pinnacle of her athletic career. I Six days per week she trains for two hours at 4:30 AM and for three hours more in the evening. I She recently visited the Hard-Body Club, a local gym, for a body composition analysis. She was told that considering her height (5 feet, 4 inches) and weight (117 pounds), 18 percent body fat was high for an elite athlete; she could afford to lose as much as 12 pounds of body fat. I She acknowledges she has experienced menstrual cycle irregularities during the past six months, but didn’t give it much thought as many of her skating friends boasted of no menstrual periods. I The nutrition assessment reveals that Tiffany’s food intake is considerably lower than her body demands for her daily activity and training program. I She experiences excessive guilt for eating large portions late at night due

a relapse. Although Janet’s longterm exercise program takes precedence and basic nutrition tips are useful, a sound foundation in balanced nutrition is indispensable. Thus, recommend an initial meeting and ongoing nutritional support program with a registered dietitian during the early phases of treatment. 5. Recommended Referrals. Suggest that Janet see a gynecologist for medical issues, a professional trainer for ongoing support and a registered dietitian for nutrition counseling. While Janet is distressed about her weight gain, this is a healthy response indicating that she is aware of the problem. Simply because she had a few teary moments in the introductory session when describing her weight does not necessarily indicate that she needs a referral to a mental health professional. In cases such as these, provide clients with the education that will help them understand their specific situations and move them closer to a positive outcome.
4. Nutrition.

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Preparing to Assist Complicated Clients
1. Prepare an extensive questionnaire. 2. Consult other professionals for advice in areas in which you are not familiar. 3. Require parental consent for clients younger than 18. 4. Prepare a “release of confidential information” form for clients to sign so that you can confer with referring/referred professions. 5. If in doubt; refer out!

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to extreme hunger. Recently, Tiffany has noticed a decline in her academic functioning, which she attributes to sleep deprivation, depressed mood and impaired concentration. She thinks that most of her problems seem to coincide with the recent decline in the quality of her ice skating performance. Her parents think her “excessive weight” was the convening factor to her deteriorating performance. Thus, the parents encouraged her to participate in an effective weight loss program. What would you do?

Synopsis The nutritional intake of elite female athletes is a critical determinant of their athletic performance and is principally predicated by their training load and body mass. Nevertheless, immense pressure is placed on female ice skaters to not only be in peak condition to compete, but also to possess an aesthetically pleasing, feminine body shape. It is not uncommon for many female athletes to ingest less than their training needs (Hawley 1995). However, studies demonstrate that despite a high energy expenditure, nationally ranked female ice skaters have lower energy, carbohydrate, fat, dietary fiber and cholesterol

intake than the average American adolescent. Many ice skaters may actually be at risk of undernutrition (Ziegler 1999). Body fat in female athletes varies considerably, with some of the lowest measurements in long distance runners and body builders, and some of the highest measurements in swimmers and weight lifters (Vogel 1992). Fat distribution in women athletes is far more complex than in males, with additional and different sites for storage, and a larger amount of fat dispersed to the extremities and subcutaneous locations. Therefore, the more elaborate nature of female body fat reflects a different meaning to health and performance than it does for men. Consequently, it is commonly misconceived that the fitness-toleanness link that is associated with male athletes is also associated with female athletes. Implicit in the actions of Tiffany’s parents is the assumption that they can take her flawless performance record for granted and expect her to improve on the things that are not so perfect. Alternatively, Tiffany’s unique physique may actually be enhancing her capacity to skate well, and altering her intricate body structure may in fact impair her performance both physically and psychologically. Few maxims in performance sports are harder to follow than the simple admonition “if it’s not broke, don’t fix it.” Tiffany’s demanding training schedule coupled with her current restricted caloric intake and disordered eating patterns are clearly causing a loss of energy, as well as mental and physical complications. If a significant loss of body fat prevails, Tiffany’s menstrual cycle could cease and she would experience amenorrhea (i.e., the cessation of three consecutive menstrual cycles). Thus, the corresponding cessation of estrogen production may lead to brittle bones, possible stress fractures and eventually osteoporosis. In essence, if Tiffany continues to lose

weight she may be at risk for a condition known as the female athlete triad– a three-tiered disorder that affects active females. The female athlete triad normally commences with disordered eating (not consuming adequate calories), then elevates to menstrual cycle irregularities or amenorrhea and culminates with osteoporosis. Although a difficult disorder to recognize (Smith 1996), coaches and personal trainers are on the front line for detection of the female athlete triad and can play an integral role in its multidisciplinary management. In summary, red flags for this condition should not be overlooked.

Strategy If the trainer chooses to succumb to Tiffany’s wishes to increase fitness training and reduce caloric intake, serious health problems may result, as well as the deterioration of her performance. Alternatively, the prevention of Tiffany’s disordered eating practice does not necessitate the specific expertise of a personal trainer. Tiffany requires a deemphasis on low body fat percentage, medical assessment, psychological evaluation and a healthy nutrition education program. The following recommendations are suggested to Tiffany and her parents: 1. Cease all physical activity immediately. 2. Consult with her pediatrician or sports medicine physician for a thorough medical examination. 3. Schedule an appointment with her gynecologist to address her menstrual problems. 4. Consult with a psychotherapist to address possible mental health issues. 5. Organize nutrition counseling with a nutrition therapist. The aforementioned recommendations would be written in a formal report. Tiffany and her parents likely will deny the existence of her serious medical problem and threaten to move on to
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Case Studies
another professional looking for a more “favorable” solution. Nonetheless, the trainer must stand by his recommendations based on all of the information amassed about her situation. Despite these recommendations, and because of this denial and the immense pressure she is under to perform well, Tiffany probably will soon be running on a treadmill at the nearby Hard-Bodies gym with a complicit trainer by her side! (a common complication of obesity) showed a reading of 162/98 mm Hg. I Norman’s primary complaints are painful knee joints, low-back discomfort, shortness of breath when climbing the stairs and sleep problems. I He alleges that his weight has caught up with him and has finally prompted him into action. I He does not conceal that he dislikes exercise. For example, he has attempted working out with trainers before and each time he abandoned the treatment because of his aversion to exercise. He blames his cancellation record on the fact that he loathes going to a gym where a young, fit trainer counts his sit-ups. However, he is prepared for a fresh start and suggests paying for a trainer five days a week. Although he has a history of exercise noncompliance, this willingness to invest money in helping himself shows motivation. I Clearly, Norman is an interesting man. He is intelligent, well traveled, honest and a good businessman. A well-planned treatment strategy is critical to his lasting success. What would you do? on the individual’s overall health, risk factors, degree of obesity, motivation to lose weight and environmental/ lifestyle conditions. The most beneficial behavioral modification for an obese person with risk factors is somewhat nebulous. The relative benefits of weight loss versus cardiovascular exercise on cardiac risk factors associated with obesity are still debatable (Katzel 1997). Exercise itself has proven beneficial to overweight persons even though it may not make them lean (Blair 1993), and physical activity is associated with a significant reduction in diabetes risk (Hu 2001). However, most studies do agree that a combination of both cardiovascular exercise and a mild hypocaloric diet significantly contributes to weight loss and reduces a number of health risks (Dengel 1998).

Help! Norman’s Case Is Very Challenging! Norman sold his successful telecommunications businesses 10 years ago when his wife died of cancer, and he has since led a somewhat reclusive existence. He lives in a large five-bedroom house and spends most of his day at the computer “working the market.” He squanders his evenings with the TV remote and a number of black Russians (vodka and kahlua). With the exception of a few casual female relationships, he has no close friends and no nearby family members. Norman’s Profile I Norman, 56, is naturally a large man, at 6 feet, 2 inches, weighing 420 pounds. I Norman scheduled an appointment under the orders of his primary physician; however, the referral was made 10 pounds and eight months ago. It is very obvious that Norman has reluctantly sought out weight loss services because his declining condition has begun to take a physical toll. I He experienced an excessive weight gain 10 years ago, shortly after his wife passed away. I He has never attempted to lose weight and calculated that his natural weight for most of his life was approximately 280 pounds. I His last visit to his physician revealed that he had an unfavorable blood cholesterol level and adult-onset diabetes. A check of his blood pressure
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Synopsis Obesity is a serious illness that can lead to many medical complications. No magic bullet exists for the very difficult, but medically important task of weight loss. Unfortunately, because of the nature of the condition and the longterm process essential to treating it effectively, it is rare that physicians care solely for obesity. However, they do treat the complications of obesity (i.e., hypertension, diabetes, cancer, degenerative arthritis and elevated cholesterol) and rely on a treatment team of behavior modification specialists, such as personal trainers, mental health specialists and dietitians, to focus on lifestyle changes and ultimately weight reduction. As a result, the method of treatment and the professionals involved largely depend

Strategy Norman’s ultimate goal is to make a lifelong commitment to achieving reasonable lifestyle changes. Thus, an evaluation should be the first step in Norman’s therapeutic plan. Before personal training commences, insist that Norman undergo a full physical assessment; his physician’s written clearance is needed before supervised physical activity can be undertaken. Document the meeting with Norman and forward a report to his primary physician and other professionals that may participate in his health care treatment. Recommendations for the Personal Trainer Prior to commencing an exercise program: I Insist that Norman undergo a full physical assessment prior to any physical activity and attend regular physician appointments. I Schedule sessions with a registered dietitian and work in conjunction with the dietitian on Norman’s case. I Respectfully remind the primary

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7 Techniques to Building a Treatment Team
1. Write letters of appreciation and intent to referral sources. 2. Complete client status form and send to recommended referral. 3. Ask to assist on a treatment team. 4. Communicate regularly with your client’s health care professionals. 5. Arrange meetings with potential referral sources. 6. Maintain client charts with regular entries and updates. 7. Specialize in specific health-related fields.

Philip Walker, MS, is the managing partner of the Walker Wellness Clinic in Dallas, a comprehensive eating disorder treatment center incorporating psychotherapy, nutrition therapy and exercise prescription. He has earned eight sport coaching qualifications and was the former fitness management consultant for the Cooper Clinic. Walker is a frequent lecturer on the topics of sport coaching, eating disorders, childhood obesity and weight management.