6. Discuss fat cell growth in both size and number.
During the first years of life, adolescence, pregnancy and sometimes in the morbidly obese, fat cells increase in number (hyperplasia), and remain the same throughout adulthood. A normal individual has 25-30 billion fat cells, whereas the obese individual can have up o 42-106 billion. The size of the fat cell can grow (hypertrophy) through any stage of life and is an average of 40% larger in the obese. Hypertrophy of fat cells is primarily responsible for obesity as triglycerides are stored when excess. The number of fat cells cannot be changed (except in the case of liposuction), yet can decrease in size during weight loss. It is beneficial to encourage a healthy diet and exercise during periods of growth to avoid hyperplasia in fat cells.

7. How are energy needs measured?
Energy is expressed in kilocalories, or the amount of heat needed to raise the temperature of 1 kg of water 1 degree Celsius. An individual’s energy needs are determined by the metabolic rate. The basal metabolic rate (BMR) is the energy required to sustain life, (ie: respiration, body temperature regulation, heart rate, absorption, and excretion of waste). BMR can vary according to age, gender, body size and body composition. Resting metabolic rate (RMR) is used to assess calorie needs because it is the energy required to maintain life at a relaxed, awake or reclined state. Indirect calorimetry is used to assess metabolic rate by oxygen utilization (for every liter of oxygen consumed per minute, 5 kcal is yielded). Energy needs also factor in physical activity and can exceed RMR by 10 times.

8. What role does genetics play in body weight? Role of environment?
Research by Mayer et al has shown that a child has a 40% probability in becoming obese if one parent is obese, and a 80% probability if both parents are obese, and only a 10% probability if neither parents are obese. This link could mean there is a genetic link, but is also a strong indicator of environmental influences. Bouchard et al performed a long term controlled study in overfeeding of identical twins and found a moderate (r = .55) in weight gain due to overfeeding in twins. The changes in body fat, fat mass, trunk fat and visceral fat were three times greater in the higher weight gainers. Bouchard’s work shows that genetics contributes some to a person’s ability to adapt to caloric excesses. It was determined that 25% of the variability among individuals in body weight and body fat is genetic, and 30% is environmental.

9. Explain how psychological factors can influence body weight.
For some individuals that are overweight or obese, food represents more than fuel to the body and can be perceived as a coping mechanism for stress, emotional distress and happiness. Food can falsely fill a void in an individual’s life and contribute to obesity. Some individuals are compulsive eaters and consuming excess food as a result of anxiety, insecurity, depression, loneliness, and tension. Compulsive eaters need to discover the underlying issue so that they may understand and change their behavior.

10. What are the principles of a weight loss program?
By combining well-balanced diet of no less than three meals per day and exercise, a healthy weight loss program can be achieved. Research has shown that exercise or diet alone as a weight loss tool is not as effective as diet and exercise combined (1997). Weight loss should be gradual and will decrease in rate over time (no more than 2 pounds per week) and the caloric deficit should not exceed 1000 kcal/day or a minimum of 1200 kcal/day. A deficit of 3500 kcal per week equals a loss of 1 pound of fat, and loss should not include lean body tissue. It is important for a client to be aware that a shorter, lighter person will have a slower weight loss than a taller, larger individual due to the greater RMR in the taller person, and men will lose weight faster than women for the same reason. A diet program or supplement that promotes quick weight loss should be avoided and psychological issues that may contribute to compulsive eating need to be identified and referred for the appropriate counseling.

11. Discuss effective techniques for implementing lifestyle changes and what are the predictors of success for a weight loss program?
Behavior modification is imperative for initiating any change in lifestyle for an individual. Establishing reinforcement for the new behavior, emphasizing self-efficacy and blending the new behavior with the lifestyle of that individual helps in the modification. Predictors of success in a weight loss program include: daily exercise, self-monitoring (ie: food diary, exercise log, body composition and fitness level monitoring), social support and stress management, and problem solving approach to life.

12. Briefly identify the stages of change (Prochaska 1994) and how an exercise professional can assist an individual at each stage.
Precontemplation: The person does not feel the behavior applies to them, it is not being considered. A fitness professional can create a positive relationship with this individual by being supportive and caring.
Contemplation: During the stage of considering the behavior, a professional can discuss how to move beyond past attempts at the behavior and address any "failures".
Preparation: During the point that the client is approaching readiness to undertake the behavior, a professional can organize a problem ladder and discuss solutions.
Action: Client is ready to perform the activity and needs the fitness professional to help set goals and specific, manageable steps to achieve the committed to goal.
Maintenance: The client is in need of a discussion of possible plateaus and how to manage lapses and relapses. Education will help to prevent the relapses and encouragement to allow the client to forgive themselves.

13. What are the limitations to using the Metropolitan Life Insurance Company (1980) weight tables to assess a client’s body weight?
The values provided by the Met Life tables represent the weight and height of an individual with shoes and clothing, however when the values were determined, they were not standardized for shoes and clothes. The tables also provide individuals with an estimate of body weight that does not account for body composition differences. Also, the data was obtained from individuals who could afford life insurance and are predominantly from a young and middle-aged white population of men and women, therefore, cannot be inferred to other populations. When discussing weight loss with a client, assessing body composition and using the body composition technique to determine the appropriate weight will provide a more realistic goal with an appropriate level of body fat and fat free mass. The tables also may show an individual to be within appropriate range, yet with the assessment of body composition, may find a level of fatness that exceeds healthy levels. Aging can contribute to a greater increase in fat and decline in muscle mass that may appear to be within normal limits in body weight.

14. Discuss how an individual’s total energy expenditure is estimated. What factors are taken into account?
RMR is proportional to a person’s size and surface area, in that it will be larger in a person that is taller and larger, and is also affected by age, gender and amount of fat free mass. As we age, RMR decreases (2-5% during each decade after age 25), because the number of metabolically actively cells declines. Muscle mass affects RMR because muscles are more metabolically active than fat tissue. Women tend to have a lower RMR by 5-10% less than men possibly due to a greater relative fat content or smaller body surface area. A person’s RMR is 60-75% of the total needs, 10% is the thermic effect of food, 15-30% thermic effect of activity and +/- 10% adaptive thermogenesis. Activity can be estimated by using percentages designated for various activity levels. The contribution of activity can also be estimated by using a physical activity log and estimating total caloric expenditure.

15. How can you help your client lose body fat and not lean body mass?
To ensure that lean body mass is not being lost, a fitness professional can first use the body composition method to determine the healthy weight of the client. Dietary changes consisting of a high carbohydrate, low fat diet with adequate protein will help to spare protein and maintain glycogen stores. Daily exercise is also recommended, and research has shown improved maintenance of fat free mass in mildly obese males on a rapid weight loss diet (Pavlou 1985). The aerobic exercise helped to preserve FFM by increasing fat utilization. Exercise also helps to increase the levels of epinephrine and norepinephrine that promote fat mobilization.

16. What are the guidelines for an exercise prescription for weight loss?
An individual should be encouraged to choose an activity that he/she enjoys and preferably falls into the ACSM group I or II activities (most may require less skill than group III and provide a consistent intensity). The intensity is recommended at 60-70% of the VO2 max or heart rate range, for 30 minutes or longer, once or twice per day. The length of the program will vary according to the client’s goals.

17. Why is exercise necessary for a weight loss program if a caloric deficit can be created without it?
As stated earlier, exercise helps to alter the metabolic rate and preserve lean body mass during a caloric restriction. Exercise helps to create a negative energy balance without decreasing the calorie intake to an unrealistic level. Improvements in cardiorespiratory fitness also helps to allow an individual to expend calories at a faster rate than a less fit individual at a given exercise heart rate. As an individual increases cardiorespiratory fitness, the lactate threshold will be increased, thereby delaying the effects of lactate in the body (inhibits fatty acid metabolism). Improved fitness also promotes fatty acid utilization during submaximal activities for longer than the less fit. A person that is less fit will oxidize glucose at a lower intensity than the more fit. This means that the more fit individual will utilize fat during daily, moderately intense activities, such as vigorous house cleaning, car washing or playing with toddlers, rather than utilize carbohydrates like the less fit may need to.

18. Compare and contrast high versus low intensity for weight loss.
The decision to choose low or high intensity exercise for weight loss has become a controversial area of study. The higher the exercise intensity, the greater the energy expenditure, therefore, the greater the negative energy balance. However, if an individual decreases the intensity and increases the duration, a greater energy expenditure can be achieved. Other issues that fuel the debate include the beneficial effects of higher intensity on the heart muscle and alternatively, higher intensity exercise may be unrealistic for the obese client or non-exerciser. The client’s goals need to be strongly taken into account when determining exercise intensity.

19. Should an individual incorporate resistance training into a weight loss program?
Resistance training, or weight training is a beneficial component of a weight loss program. The advances in lean body mass can help to increase the client’s metabolic rate and preserve lean body mass during a calorie deficit. Marks et al (1995) observed the effects of aerobic and/or resistance training with a moderate calorie-restricted diet on moderately overweight women. The results showed that exercise in general (any combination of aerobic and/or resistance) helped to maintain lean body mass and promote weight loss. This evidence suggests that resistance training may be a beneficial exercise alone to promote weight reduction. However, the health benefits of a cardiorespiratory workout include a decrease in blood pressure, improved lipid profile and reduction in heart disease risk, among other disease risk reductions.

20. Your friend complains of excess abdominal fat and is doing crunches daily in hopes of losing the fat. How will you explain to her that this is not the most effective approach?
According to Carns et al, spot reduction exercises do not appear to be more effective than whole body aerobic activities in reducing body fat in specific areas. Research has shown that exercises that target certain areas, such as cycling using more lower body, does not promote greater losses in the legs and does help to reduce body fat in other areas as well. Fat utilization is not preferential and varies according to a biologically selected body fat distribution. Some areas may be more difficult to lose fat from due to the higher lipoprotein lipase activity (promotes lipid storage), such as in the hips or thighs of women. If we were able to "spot reduce" fat, runners may have very lean lower bodies with a higher fat upper body, or obese people that talked a lot could have very lean faces.

21. What are the guidelines for an exercise prescription for weight gain?
In order to gain weight, in the form of lean body mass, it is important to incorporate a resistance training program. The intensity should be 70-75% of 1-RM or 10-12-RM. For the beginner, begin with three sets, and 5 to 6 for the experienced lifter. It is preferable to do 1 to 2 exercises per muscle group, or 3 to 4 for the experienced lifter. The duration of the program will be 60 minutes or longer, 3 days per week, or 5 to 6 for the advanced lifter.

22. What is multi-mode training and how can it assist in weight loss?
Multi-mode training is a program that incorporates more than one type of exercise, such as kick boxing alternating with spinning classes within a week. Multi-mode training can be within a week, within a session with a varying in sequence or modes, or can vary weekly. It can be more fun for the client and help to avoid overtraining and injury by using different muscle groups. It is optimal for the development of all components of fitness. For weight loss, it helps to increase the energy expenditure by increasing the potential to do more work.

23. What is interval training and what are the benefits?
Interval training is a system of conditioning that consists of repeated periods of work interspersed with relief. In short, it is a variation of intensity throughout a workout. It was first introduced by Gershler, a German coach and doctor in 1930 in order to perform greater volumes of work by breaking up the workout into intense bouts of exercise between a rest/recovery session. The benefits include an advanced development of aerobic and "anaerobic" energy systems, enhanced capacity for fat and carbohydrate utilization, greater volume of work performed, ability to be designed for multi-level abilities and it is a precise method for stress stimulus.

24. What is the prevalence of obesity and anorexia nervosa in the United States?
Obesity has been rising steadily over the past 15 years in this country. Approximately one in every three adults is overweight and one in every four children is overweight (1994). Anorexia nervosa is thought to afflict 1% of the female population and has been seen in men as well, especially wrestlers or body builders.

25. With all of the diet plans and diet programs available in the United States, why are the statistics regarding weight not better?
Many individuals try each diet plan offered in a supplement, pill, program or frozen food, but only 50% of individuals asked about their efforts to lose weight incorporated both diet and exercise into their program. Many of the programs available pursue unrealistically low calorie levels, food elimination, fasting, and little to no lifestyle modification, never mind exercise. A meta-analysis of 493 studies in 1997 showed that diet and exercise combined showed superior, longer lasting results with a maintenance of FFM. Those that pursued diet only may have lost weight, but showed a 24% decline in FFM. This may lower metabolic rate further thereby increasing weight gain when the program is completed and leave the individual worse off than prior to the program. Reasons for weight gain also need to be investigated further to determine the underlying cause if it is a psychological link.

26. What are the health implications of obesity?
Obese individuals have an increased risk for cardiovascular disease, hyperlipidemia, hypertension, diabetes mellitus, obstructive pulmonary disease, sleep apnea, reproductive difficulties for women, osteoarthritis and some cancers. The prevalence of hypercholesterolemia is 2.9 times greater, hypertension is 2.1 times greater and Type II diabetes is 2.9 times greater than the nonoverweight population. Obesity also carries social stigma, financial implications, emotional distress and prejudice.

27. What are the exercise principles for weight management?
Lack of activity is the greatest suspect in the cause for obesity, rather than overeating, therefore for fat loss, aerobic activity is recommended daily. Resistance training will help to maintain FFM, can increase energy expenditure and help create a negative energy balance. To increase calorie expenditure, avoid using labor saving devices around the house and at work. Low intensity, longer duration exercise is more effective than high-intensity, short duration exercise for maximizing total energy expenditure. The RMR remains elevated 30 minutes or longer after vigorous exercise and as the fitness level increases, calorie expenditure is faster for a given heart rate. It is important to remember that exercise does not increase appetite and that passive exercise devices are unsubstantiated. Spot exercising is also not effective for losing fat.

28. Your client complains that she is exercising two times a week without an alterations in body composition. What is your explanation for her?
Although some is better than none, research has shown that two days of exercise is not effective enough to alter body composition. Significant alterations can be seen in 3 to 4 days, with 4 showing the best results.

29. A friend asks, "what is the best exercise for me to maximize fat loss?" You answer:
The best exercise mode is one that utilizes large muscle groups and is one that you enjoy. In a study comparing cycling, running and walking, the results showed reductions in body fat, but none shined greater.