Cardiovascular disease is still the number one cause of morbidity and mortality in the United States and much of this burden of disease can be linked to poor nutrition and a dramatic increase in sedentary lifestyles.

Personal Trainers have the opportunity to do more than just help people they train become more active. Physical activity should not be the only approach to encouraging a healthy and balanced lifestyle.
We need to be prepared to also help our clients implement lifestyle behavior changes related to stress, family history of coronary heart disease, obesity, smoking, high blood pressure and high cholesterol.

A look at what is being called metabolic syndrome will help you understand why, even though increasing physical activity levels is the overall best thing you can do for any client, there are other ways to guide them to a healthier lifestyle. Sometimes you may be able to help them make the changes yourself, and sometimes you will need to refer them to another health professional like a doctor or dietician for guidance. Either way, knowing how to help them, or when to turf them to someone who is more knowledgeable than yourself is important. So first lets get familiar with the syndrome and the clinical criteria that the doctor uses to diagnose it. Your goal is then to help your client understand and make the necessary changes, so that they don’t progress to cardiovascular disease and the almost certain heart attack heart that will be the end result. 

Cardiovascular disease is still the number one cause of morbidity and mortality in the United States and much of this burden of disease can be linked to poor nutrition and a dramatic increase in sedentary lifestyles, leading to overweight and obesity. This increase in weight leads to an increase in the incidence of type 2 diabetes, and blood pressure and cholesterol problems, which are all well-established cardiovascular disease risk factors. The National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III has updated the recommendations for the evaluation and management of adults dealing with high cholesterol, renewing its emphasis on the importance of lifestyle modifications for improving cardiovascular risk. The NCEP has coined the term “therapeutic lifestyle changes”(TLC) to reinforce both dietary intake and physical activity as crucial components of weight control and cardiovascular risk management.

As well as focusing attention on the LDL cholesterol (also called bad cholesterol) levels the NCEP also identified the metabolic syndrome as a secondary target of therapy. The importance of lifestyle modifications in the treatment and prevention of cardiovascular disease has heightened and caused growing awareness of this condition. The metabolic syndrome  (also called insulin resistance syndrome and syndrome X) is characterized by decreased tissue sensitivity to the action of insulin (pre-diabetes), resulting in a compensatory increase in insulin secretion. This metabolic disorder predisposes individuals to a cluster of abnormalities that can lead to such problems as type 2 diabetes, coronary heart disease, and stroke. According to Daniel Einhorn, MD, who is cochairman of the American College of Endocrinology (ACE) and the American Association of Clinical Endocrinologists (AACE) Insulin Resistance Syndrome Task Force and medical director of the Scripps Whittier Institute for Diabetes in La Jolla, California, the prevalence of the syndrome has increased 61% in the last decade. He says that it is crucial for medical professionals to identify patients at risk and follow these patients closely and counsel them about making lifestyle changes to lower the risk of type 2 diabetes and cardiovascular disease.

Using 1988-1994 data (NHANES III) the Centers for Disease Control and Prevention estimates that at least 47 million Americans have metabolic syndrome. And, in 2000, more than 97 million adults were considered obese, and more than half the population is now overweight. This epidemic is not likely to plateau because childhood obesity is also increasing at an alarming rate. The explosive increase in the prevalence of obesity observed in the past decade suggests the current rate of metabolic syndrome is now likely higher than that estimated by NHANES III.

Millions of Americans at risk for metabolic syndrome can sharply lower their chances of getting this disease by adopting a healthy lifestyle (stop smoking, low-fat diet, weight loss/maintenance and increased physical activity). Diet and exercise are the cornerstones of treatment in patients with metabolic syndrome. According to Robert Chilton, MD, (November/ December 2002 issue of Men’s Total Health Digest) without diet and exercise modifications, most patients will eventually fail and progress to type 2 diabetes within a decade and experience a heart attack about 10 years later.
Dr. Chilton recommends a diet reduced in saturated fats ((so who out there is surprised??!!).  However, Dr. Chilton says, any exercise is better than none, and a target of 30 minutes every other day is a reasonable level for most patients.

A study by the Diabetes Prevention Program (DPP), which was discussed in the October 2002 issue of Type 2 Diabetes Digest, found that there was a reduction of 58% in progression to diabetes when moderate life style changes were made. These changes were directed towards getting people to lose 8-10 pounds and becoming more active, mainly by walking briskly for 150 minutes per week.

Other studies have been done by the DPP using a medication called metformin. It reduced the progression to diabetes by about 30%, but was not as effective as behavioral interventions and it didn’t work in all groups. The behavioral intervention, on the other hand worked across the board, regardless of age, body weight, or race and ethnicity. Another drug called acarbose has also been tested and found to reduce progression by about 33%. So, there are medications that can be beneficial, but nothing was as effective overall as the behavioral intervention used in the DPP. Consideration also needs to be given to the potential side effects of a medication used to prevent diabetes compared with lifestyle changes.

According to Frank Vinicor, MD, who is the director of the diabetes program at the US Centers for Disease Control and Prevention in Atlanta, the behavioral interventions used in these studies was quite intense and involved 16 interactions with individuals during the first year, with a whole series of very innovative and creative follow-up meetings. The interventions are being explored further to see if they can be made more practical, more feasible, and more economically possible. Another point is that, even within the DPP, a physician did not deliver most of the behavioral interventions. New recommendations from the CDC will call for involving trained nurses, dieticians, and other community health workers in the process.

Also according to Dr. Vincor, about 90% of people with diabetes receive their diabetes care from the primary care community and there is no reason to anticipate that things will be any different with pre-diabetes or metabolic syndrome. He believes the primary care community (internists and family practice physicians) will play a pivotal role in both the identification of people with pre-diabetes, as well as the initiation of therapy. And again he emphasizes, that does not mean that primary care doctors themselves have to do the counseling and behavioral intervention. Instead he anticipates they will make appropriate referrals to others in their communities.

As a fitness professional reading this, hopefully you are not asking yourself “so what?” but are instead seeing an opportunity to educate and motivate some of your current clients and to usie your knowledge to help attract future clients. The medical community is good at diagnosing this syndrome, but not necessarily equipped to provide patients with the tools to be successful with the lifestyle changes they recommend. There exists a wonderful opportunity to build a partnership with physicians in your area.

Most physicians will gladly refer patients to you for help with the all-important exercise and nutrition portion of the treatment program. In many cases, you have more knowledge in this area than the physician who has been trained in tertiary, not preventative, (i.e. most MD’s know very little about diet and exercise since they are not taught this in medical school) medicine.  Often times all that you will need to get a referral is for the doctor to be aware of your existence and to give them an easy way to get the patient to you.

A short introduction letter outlining your qualifications, and showing your desire to help people make lifestyle changes, is a good start. A personal visit to your primary care doctor and others in your area is even better. But, be prepared to take up just a few minutes of their time to introduce yourself, your idea, and leave your letter and cards.

Article Reviewed:
Simao, R., Farinatti, P.D.T.V., Polito, M.D., Major, A. S., Fleck, S.J. (2005). Influence of exercise order on the number of repetitions performed and perceived exertion during resistance exercise. Journal of Strength and Conditioning Research. Vol. 19(1), 152-156.

INTRODUCTION

Exercise training designs are based upon available research and applications of theoretical knowledge. Since many areas in exercise design have not been thoroughly studied, the value of many common exercise practices is often employed, but subject to debate. One such area is the well-accepted technique of performing large-muscle group exercises prior to small-muscle group exercises during resistance training. The rationale behind this training recommendation is two-fold. First, total force production for the entire workout is greater when large-muscle groups are exercised before small-muscle groups. Second, when small-muscle groups are exercised first, the force production of the following larger muscle groups is decreased. In theory, these tenets support ordering resistance exercise this way because it may result in the greatest overall strength gains. In practice, however, when large-muscle groups are always exercised before smaller-muscle groups, the smaller muscle groups may not become as well trained. If those smaller muscle groups are important in the program of the exercising individual, performance may instead suffer.

PURPOSE

The purpose of this study was to examine the effect of exercise order on the number of repetitions performed and ratings of perceived exertion (RPE) in a resistance training session composed of five upper body exercises.
The hypothesis was that, regardless of the exercise order of the particular program, muscle groups exercised later in the exercise session would be more greatly fatigued than the muscle groups performed earlier in the session.

METHODS

The study design utilized a counterbalanced crossover research protocol. In essence, using random assignment, this study plan requires each subject to complete all of the treatment sequences. For example, in this investigation eighteen male and female participants (14 male, 4 female; average age = 20 yr), who had at least 6 months of resistance training experience, performed 2 exercise sessions 48 hours apart. Each volunteer was randomly assigned to a particular exercise session to follow, and then completed the second exercise session 48 hours later. Each exercise session consisted of the exact same exercises, but in a different order.  

Sequence “A” worked large-muscle groups before small-muscle groups (free-weight bench press, machine lat pull-down, seated machine shoulder press, standing free-weight biceps curl with a straight bar, and seated machine triceps extension). Sequence “B” reversed the exercise order, working smaller-muscle groups first (seated machine triceps extension, standing free-weight biceps curl with a straight bar, seated machine shoulder press, machine lat pull-down, and free-weight bench press). All exercises in both sequences were performed for 3 sets to volitional fatigue using a pre-determined 10 repetition maximum (10RM) weight. Sets of exercises in both the sequences were separated by timed 2-minute passive rest periods.

All testing and training was completed on Life FitnessTM equipment and free weights. This 10RM weight determination was made 48 hours prior to the two exercise sessions following standardized procedures. Thus the 10RM testing established the training weight for the performance of the 5 upper body exercises during sequences “A” and “B”. After the 10RM of one exercise was reached, no shorter than 10 minutes were allowed before the next exercise 10RM was attempted. During the training sequences, no pause was allowed between the eccentric and concentric phase of each repetition. Also, the warm-up before training sessions “A” and “B” consisted of performing 12 repetitions of the first exercise in the sequence at a weight of 40% of the 10RM.

RESULTS

There were no significant differences in the number of repetitions performed between the first and second sets for all exercises between sequences “A” and “B”. There were also no differences between the two sequences in the third set, except for the bicep curl (significantly fewer in sequence “A”). Thus, the exercise order DID NOT significantly affect the number of repetitions performed with the five upper body exercises. However, when repetitions per set “within” each sequence was evaluated, there were clear trends for decreased performance for exercises performed later in the protocol, particularly in the third set of the exercise. Thus within sequence “A” and “B”, most subjects were unable to perform as many repetitions on the third set with most of the five upper body exercises. There was no difference in RPE scores.

DISCUSSION

Regardless of whether a large-muscle to small-muscle group or small-muscle to large-muscle group sequence is employed, with multiple-set exercise schemes, sets preformed later in the sequence show the most decreased performance (as measured by repetitions performed). Muscle fatigue causes a decrease in repetitions in the final set of a 3-set (multiple-set) upper body training regime, regardless of order. This research suggests that although many fitness professionals develop exercise programs that focus on large muscle groups earlier in the session, this technique may be too blindly followed with upper body training programs.
In this study, no single muscle group was a primary mover in 2 successive exercises of the five upper body exercises in sequences “A” and “B”. Thus, these sequences represented common training protocols employed by many personal trainers and strength and conditioning professionals.

PRACTICAL APPLICATION

This study recommends looking at the particular functional objective of each client and tailoring the upper body exercise sequence to best meet this end. In short, exercise the most important muscle groups early in the training program regardless of whether it is a large muscle group or small muscle group. This will allow the client to target the muscle groups that will help to achieve his or her goals more quickly. Instead of viewing an exercise program in traditional terms of the greatest overall strength gains, our clients are better served by looking at which muscles and muscle-groups are most important to their goals, and then designing programs to achieve these objectives. In addition, for variety in upper body training exercise plans, this study suggests the large-muscle to small-muscle group and small-muscle to large-muscle group exercise designs are viable options to incorporate.

The leaky gut syndrome is the name given to a very common health disorder in which the basic organic defect (lesion) is an intestinal lining which is more permeable (porous) than normal. The abnormally large spaces present between the cells of the gut wall allow the entry of toxic material into the bloodstream that would, in healthier circumstances, be repelled and eliminated.

The gut becomes leaky in the sense that bacteria, fungi, parasites and their toxins, undigested protein, fat and waste normally not absorbed into the bloodstream in the healthy state, pass through a damaged, hyperpermeable, porous or “leaky” gut. This can be verified by special gut permeability urine tests, microscopic examination of the lining of the intestinal wall as well as the bloodstream with phase contrast or darkfield microscopy of living whole blood.

Why is The Leaky Gut Syndrome Important? The leaky gut syndrome is almost always associated with autoimmune disease and reversing autoimmune disease depends on healing the lining of the gastrointestinal tract. Any other treatment is just symptom suppression.

An autoimmune disease is defined as one in which the immune system makes antibodies against its own tissues. Diseases in this category include lupus, alopecia areata, rheumatoid arthritis, polymyalgia rheumatica, multiple sclerosis, fibromyalgia, chronic fatigue syndrome, Sjogren’s syndrome, vitiligo, thyroiditis, vasculitis, Crohn’s disease, ulcerative colitis, urticaria (hives), diabetes and Raynaud’s disease.

Physicians are increasingly recognizing the importance of the gastrointestinal tract in the development of allergic or autoimmune disease. Understanding the leaky gut phenomenon not only helps us see why allergies and autoimmune diseases develop but also helps us with safe and effective therapies to bring the body back into balance.

Due to the enlarged spaces between the cells of the gut wall, larger than usual protein molecules are absorbed before they have a chance to be completely broken down as occurs when the intestinal lining is intact. The immune system starts making antibodies against these larger molecules because it recognizes them as foreign, invading substances.

The immune system starts treating them as if they had to be destroyed. Antibodies are made against these proteins derived from previously harmless foods. Human tissues have antigenic sites very similar to those on foods, bacteria, parasites, candida or fungi. The antibodies created by the leaky gut phenomenon against these antigens can get into various tissues and trigger an inflammatory reaction when the corresponding food is consumed or the microbe is encountered.

Autoantibodies are thus created and inflammation becomes chronic. If this inflammation occurs in a joint, autoimmune arthritis (rheumatoid arthritis) develops. If it occurs in the brain, myalgic encephalomyelitis (a.k.a. chronic fatigue syndrome) may be the result. If it occurs in the blood vessels, vasculitis (inflammation of the blood vessels) is the resulting autoimmune problem. If the antibodies end up attacking the lining of the gut itself, the result may be colitis or Crohn’s disease.

If it occurs in the lungs, asthma is triggered on a delayed basis every time the individual consumes the food which triggered the production of the antibodies in the first place.
It is easy to see that practically any organ or body tissue can become affected by food allergies created by the leaky gut. Symptoms, especially those seen in conditions such as chronic fatigue syndrome, can be multiple and severely debilitating.

The inflammation that causes the leaky gut syndrome also damages the protective coating of antibodies of the IgA family normally present in a healthy gut. Since IgA helps us ward off infections, with leaky gut problems we become less resistant to viruses, bacteria, parasites and candida. These microbes are then able to invade the bloodstream and colonize almost any body tissue or organ. When this occurs in the gums, periodontal disease results.

If it happens in the jaw, tooth extraction or root canals might be necessary to cure the infection. In addition to the creation of food allergies by the leaky gut, the bloodstream is invaded by bacteria, fungi and parasites that, in the healthy state, would not penetrate the protective barrier of the gut.

These microbes and their toxins, if present in large enough amounts, can overwhelm the liver’s ability to detoxify.
This results in symptoms such as confusion, memory loss, brain fog or facial swelling when the individual is exposed to a perfume or to cigarette smoke that he or she had no adverse reactions to prior to the development of the leaky gut syndrome. Leaky gut syndrome also creates a long list of mineral deficiencies because the various carrier proteins present in the gastrointestinal tract that are needed to transport minerals from the intestine to the blood are damaged by the inflammation process. For example, magnesium deficiency (low red blood cell magnesium) is quite a common finding in conditions like fibromyalgia despite a high magnesium intake through the diet and supplementation.

If the carrier protein for magnesium is damaged, magnesium deficiency develops as a result of malabsorption. Muscle pain and spasms can occur as a result. Similarly, zinc deficiency due to malabsorption can result in hair loss or baldness as occurs in alopecia areata. Copper deficiency can occur in an identical way leading to high blood cholesterol levels and osteoarthritis.

Further, bone problems develop as a result of the malabsorption of calcium, boron, silicon and manganese.
The Causes The leaky gut syndrome is basically caused by inflammation of the gut lining. This inflammation is usually brought about by the following:

Antibiotics because they lead to the overgrowth of abnormal flora in the gastrointestinal tract (bacteria, parasites, candida, fungi) · Alcohol and caffeine (strong gut irritants)
· Foods and beverages contaminated by parasites like giardia lamblia, cryptosporidium, blastocystis hominis and others
· Foods and beverages contaminated by bacteria like helicobacter pylori, klebsiella, · citrobacter, pseudomonas and others
· Chemicals in fermented and processed food (dyes, preservatives, peroxidized fats)
· Enzyme deficiencies (e.g. celiac disease, lactase deficiency causing lactose intolerance)
· NSAIDS (non-steroidal anti-inflammatory drugs) like ASA, ibuprofen, indomethacin,
· Prescription corticosteroids (e.g. prednisone)
· High refined carbohydrate diet (e.g. candy bars, cookies, cake, soft drinks, white  bread)

Prescription hormones like the birth control pill Mold and fungal mycotoxins in stored grains, fruit and refined carbohydrates. The leaky gut syndrome can cause the malabsorption of many important micronutrients.

The inflammatory process causes swelling (edema) and the presence of many noxious chemicals all of which can block the absorption of vitamins and essential amino acids. A leaky gut does not absorb nutrients properly. Bloating, gas and cramps occur as do a long list of vitamin and mineral deficiencies. Eventually, systemic complaints like fatigue, headaches, memory loss, poor concentration or irritability develop. Prescription broad spectrum antibiotics, especially when taken for extended periods of time, wipe out all the gut friendly bacteria that provide protection against fungi and amoebic (parasitic) infections, help the body break down complex foods and synthesize vitamins like B12 and biotin.

Since this friendly bowel flora is killed off, the body now has no local defence against the parasites or fungi that are normally held in check. This then causes an inflammatory reaction leading to the leaky gut syndrome. Food allergies quickly develop and these may trigger the signs and symptoms of arthritis, eczema, migraines, asthma or other forms of immune dysfunction. Other common symptoms of this bowel flora imbalance and leaky gut syndrome are bloating and gas after meals and alternating constipation with diarrhea.

This set of symptoms is usually labelled as IBS (irritable bowel syndrome) or spastic bowel disease and treated symptomatically by general practitioners and gastroenterologists with antispasmodic drugs, tranquilizers or different types of soluble (psyllium) and insoluble (bran) fiber.

The Leaky Gut and IBS The mainstream thinking on IBS is that it is caused by stress. Irritable bowel syndrome is the number one reason for general practitioner referrals to specialists. In well over 80% of the cases, tests like the intestinal permeability test (a special urine test involving the determination of absorption rates of two sugars called lactulose and mannitol), CDSA or livecell darkfield microscopy reveal the presence of an overgrowth of fungi, parasites or pathogenic bacteria.

The one-celled parasite, blastocystis hominis and different species of candida are the most common microbes seen in IBS. The only stress associated with IBS is that which is generated by infection and the leaky gut syndrome. If allowed to persist without the correct treatment, IBS can progress into more serious disorders like the candidiasis syndrome, multiple chemical sensitivities, chronic fatigue syndrome, many autoimmune diseases and even cancer. If treated medically, IBS is rarely cured.

To treat it correctly, natural treatments work best and must include the removal of the cause, improvement of gastrointestinal function and healing the lining of the gut. How to Reverse Leaky Gut Syndrome Band-aid treatments with corticosteroids, prescription antibiotics and immuno suppressive drugs may be temporarily life-saving for acute episodes of pain, bleeding or severe inflammation as occurs in lupus or colitis. In the long run, however, none of these treatments do anything to heal the leaky gut problem.

To reverse the leaky gut syndrome the diet must be completely changed to one which is as hypoallergenic as possible. Sugar, white flour products, all gluten-containing grains (especially wheat, barley, oats and rye), milk and dairy products, high fat foods, caffeine products, alcohol and hidden food allergies determined by testing must all be eliminated for long periods of time (several years in the most severe cases).

Treatment might also include the use of natural antibiotics (echinacea, colloidal silver, garlic), antiparasitics (cloves, wormwood, black walnut) and antifungals (taheebo, caprylic acid, grapefruit seed extract) depending on the type of infection which shows up on objective tests. It is rare that victims require prescription drugs for these infections and they should be discouraged.

The drugs are usually expensive, have unpleasant side effects and are best reserved for life-threatening conditions. Leaky gut syndrome patients can help themselves by chewing their food more thoroughly, following the basic rules of food combining, eating frequent small meals rather than three large ones and taking more time with their meals.

Gastrointestinal function can be improved with a juice fast or a hypoallergenic diet and supplements like lactobacillus acidophilus and bifidus as well as FOS (fructooligosaccharides) derived from Jerusalem artichoke, chicory, the dahlia plant or burdock root.

Beneficial Supplements for Leaky Gut Syndrome

Natural digestive enzymes - from plant (e,g, bromelain, papain) or pancreatic animal tissues (porcine, bovine, lamb) and aloe vera juice with a high MPS concentration (good brands are International Aloe, Earthnet and Royal) stomach acidity enhancing supplements - betaine and pepsin, glutamic acid, stomach bitters, apple cider vinegar amino acids - L-glutamine, N-acetyl-glucosamine (NAG) essential fatty acids - milled flax, flax seed oil, evening primrose oil, borage oil, olive oil, fish oils, black currant seed oil soluble fiber - psyllium seed husks and powder, apple or citrus pectin, the rice derived gamma oryzanol, antioxidants - carotenoids, B complex, vitamin C, E, zinc, selenium, germanium, Coenzyme Q10, bioflavonoids, especially quercetin, catechin, hesperidin, rutin and proanthocyanidins (pycnogenols, grape seed extract, pine bark extract, bilberry) herbs and plant extracts - kudzu, various high chlorophyll containing green drinks like spirulina, chlorella and blue green algae, burdock, slippery elm, Turkish rhubarb, sheep sorrel, licorice root, ginger root, goldenseal, bismuth and bentonite. Combination Green Foods - two excellent products are Green Life (Bioquest) and Greens Plus (Supplements Plus) Due to the increasing recognition of chronic fatigue syndrome, the leaky gut syndrome and multiple chemical sensitivity, a number of supplement companies have been marketing powdered hypoallergenic formulations containing most of the nutrients mentioned above in one convenient package. Some brand names include Ultrabalance ®, UltraClear Sustain ®, UltraClear Plus ®, Pro-Cleanse ®, Pro-Support ® and ActiClear ®.

The products are only available through natural health care practitioners like chiropractors, nutritional doctors and naturopaths. If you suspect you may be suffering from leaky gut syndrome, the most important thing to do is get yourself tested by a natural health care practitioner. A personalized natural program of diet and supplements can then be instituted to help you reverse this debilitating condition.

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