HSC 316 Module 6 Exam

BEHAVIOR-CHANGE THEORIES AND WEIGHT MANAGEMENT 351

-The Transtheoretical Model and Stages of Change -The Health Belief Model -The Theory of Planned Behavior -Self-Efficacy -Self-Determination Theory and Motivation -Principle of Limited Self-Control

Positive Approaches for Changing Negative Health Behaviors 385

-Use of OARS Communication Skills -Tailoring Approach to Stage of Change -Applying the Principles of Self-Determination Theory -Building Self-Efficacy for Change

Problem-Solving 323

As clients record eating behavior, they may become aware of patterns related to eating. Some patterns may support desired behaviors, whereas others interfere with behavior-change plans.

Medical imaging techniques 333

Both magnetic resonance imaging (MRI) and computed tomography (CT) are used to assess body tissues and can be used to calculate body composition. MRIs and CT scans can also provide information on the location of adipose tissue stores. These techniques are used for research on body composition.

Let Clients Lead Behavior- Change Recommendations 360

Health and fitness professionals tend to get excited when clients can pinpoint situations that lead to overeating. This, after all, is the beginning of success. Once the problem is identified, solutions call out for attention. At this point, however, professionals must remember their open questions and reflective-listening skills to guide clients to devise solutions that are most likely to work in the context of clients' individual lives.

Air displacement 333

Instruments such as the Bod Pod estimate body composition from air displacement. The heavier people are for a given size, the denser they are. As with underwater weighing, higher density means less fat tissue. Individual variations in tissue density reduce the accuracy of body-composition predictions. Air-displacement equipment is most commonly found in research and academic settings.

Coping Planning: Preventing Relapse 363

Most people experience lapses during their behavior- change efforts. Lifestyle-modification programs for weight loss can be especially difficult to maintain long term, as they involve modification of many different behaviors and habits. Health and fitness professionals can encourage clients to accept the difficulty of this work and anticipate factors that may contribute to both success and relapse. Professionals should help clients understand that it is human to make mistakes and that self-forgiveness is the correct response, followed by renewed efforts to resume a healthy lifestyle. A lapse need not be interpreted as a relapse. Some variables that can influence risk of relapse include the following: • Flexible attitude: Lifelong behavior change re- quires a great deal of flexibility and adaptation. Flexibility helps people work around the road- blocks that inevitably arise to challenge plans and to make decent choices within the constraints of daily life. People must learn how to adapt accordingly to schedule interruptions and adjust food and exercise as best they can. Most important is the ability to recover from setbacks. Lapses in weight-control programs are universal: almost everyone has good days and bad days. • Coping planning for high-risk situations: Many clients can describe situations that tend to be especially difficult for them. Parties, vacations, holidays, visitors, eating out, and travel may present circumstances that disrupt the normal routine or present irresistible temptation. Health and fitness professionals can encourage clients to anticipate challenges and plan effective coping strategies. Eventually, these plans themselves become habits. • Negative emotional states and food cravings: Coping with stress and negative moods requires self-control energy, and spending energy on stress management depletes the self-control needed for behavior change. People with mood disorders such as depression and anxiety may have extra difficulty with behavior change if these changes increase feelings of stress. Clients should do what they can to manage stress and avoid negative emotional states. Cravings that arise when people are facing high-risk situations in a negative mood are difficult to resist . • Outcome expectancies: Outcome expectancies refer to what people think will happen if they engage in a given behavior. If a client thinks eating a big meal will make him feel better, he will be more likely to indulge. If a person thinks exercise will make her feel tired, she'll skip her workout if she is already stressed and tired. Health and fitness professionals can help clients. For example, people might be able to learn that a moderate workout helps them feel more energetic and less irritable. • Abstinence violation effect: The abstinence violation effect describes the behavior of people who resume a behavior that they are trying to avoid after a period of abstinence. People feel a loss of control and guilt when they violate a self- imposed rule, such as a rule about not overeating or a rule about following some sort of eating plan. Once they break their rule, they feel self- blame and a loss of control and reach for the behavior that they think will make them feel better, and they fall into relapse. • Close relationships: Friends and family can either sabotage or support clients' behavior-change efforts. People are more likely to be successful in their weight-management efforts if they can cultivate a helpful and supportive social network.

Maintenance 323

People are in the maintenance stage if they have stuck to their new eating behaviors for 6 months or more. The longer they sustain their new eating behaviors, the more likely it is they will continue. For any given individual, some behaviors may become habits that last for long periods of time (e.g., rarely eating breaded and fried foods). In contrast, some behaviors are more difficult to achieve every day (such as striving to eat five to nine servings of fruits and vegetables each day; while the striving may continue, the person may not reach this target every single day).

Intrapersonal Level 344

People's genetic predisposition strongly influences how they respond to their environment. An individual's behaviors in turn interact with genetic predisposition to influence feelings of hunger, food choices, and engagement in physical activity.

Lifestyle Recommendations for Increasing Daily Energy Expenditure 342

The best strategy for increasing daily energy expenditure is to include a good amount of physical activity into one's day. Recommendations for increasing daily energy expenditure include the following. Exercise All types of physical activity require muscle contraction, which in turn requires energy. Exercise mode should match a person's fitness level and preferences. Those new to exercise should start slowly and build gradually. Activity recommendations should be safe and not cause injury. Consider interval training People who like high-intensity exercise and are in pretty good shape might try interval training, which allows one to exercise at very high intensities for short periods of time. These high-intensity periods are interspersed with bouts of lower-intensity work. High-intensity exercise requires a longer recovery, which means people burn a few extra calories during the post-exercise period. People new to exercise should build some strength and endurance before attempting interval training. People who don't really enjoy working out may still appreciate interval training because it requires less time than lower-intensity exercise. Strength train regularly Regular resistance training has many beneficial health and fitness effects, such as strengthening muscles, joints, and bones. It can also increase muscle mass somewhat, depending on a person's age, sex, and hor- monal profile. More muscle mass means people burn a few more calories per hour even when resting. And, of course, people burn even more calories during strength-training workouts.Get more daily activity People increase daily energy expenditure when they take advantage of opportunities to be active throughout the day. They burn more calories taking the stairs than riding the elevator. People can try to walk to do their errands when possible, play with their kids, or take longer walks with their dogs. Screen time should be limited, since it can actually cause metabolic rate to drop below normal resting level (depending on what is viewed). Consume protein with meals It takes more calories to digest protein, and a high protein intake may also reduce hunger. People should replace high-carbohydrate, empty-calorie foods with proteins such as eggs, beans, soy products, fish, nonfat dairy products, and lean meats. People with kidney problems should only increase protein intake after checking with their physicians. Get adequate sleep One might think that since people burn more calories awake than asleep, getting less sleep would help someone lose weight. However, shorter sleep duration is associated with higher levels of ghrelin, feelings of hunger, and greater incidence of obesity. Daytime fatigue can also reduce daily energy expenditure. Avoid very-restrictive dieting People trying to lose weight are often frustrated by the fact that as they diet, metabolic rate slows and weight loss stalls. Limiting calorie intake too severely can depress resting metabolic rate, a reaction known as the "starvation response." The body goes into energy-conservation mode to cope with a food shortage. Although one must decrease food intake to lose weight, experts usually recommend decreasing intake by only about 250 calories per day, if one's diet is fairly healthy to begin with, and consuming at least 1,200 to 1,600 calories daily. Enjoy flavorful food and smaller portions Delicious food pleases the appetite, so people are satisfied with less. Smaller portion sizes and high-fiber foods also help limit calorie intake. People who enjoy spicy foods may find that these decrease hunger and slightly increase resting metabolic rate.

reward pathway 373

The term reward pathway refers to the anatomic locations and biochemical events that make up the mind-body's experience of pleasure. To understand the basics of reward pathways, readers will need to re- call the information presented in Chapter 2 about the nervous system, including its structure and function. The role and behavior of neurotransmitters are especially important, as they influence the nature of the thoughts, memories, and emotions produced in the brain. The areas of the brain activated also determine the nature of the mind-body experience that occurs.

Disordered Eating and Eating Disorders 397

These disorders are generally variations on the themes of restricting, bingeing, and purging

alcohol dehydrogenase. 390

Women's stomachs produce lower amounts of a key enzyme responsible for breaking down alcohol, alcohol dehydrogenase

Metabolism 341

refers to the entire collection of biochemical processes that occur in the body, many of which require energy. Most bodily functions require energy, from digesting food to contracting the muscles needed to walk down stairs.

Nutrient density 307

refers to the nutritive value per calorie of a given food. If one food has a higher nutrient density than another, it means it has more nutrition per calorie.

Body-composition tests can be helpful in several situations, including the following 335

• An apparently lean person is gaining a little scale weight but appears to be getting more muscular, not fatter. Body-composition tests might assure lean or muscular people that they are not fat. • A person has a normal BMI but lacks muscle size and strength. Such people may fall into the category of normal-weight obesity, which is associated with the same health risks as obesity. A body-composition test might help motivate these individuals to improve eating and exercise behaviors. • An athlete is attempting to reach a specific weight category or weight minimum. Such athletes may find body-composition tests helpful to see if their weight goal is realistic. • An individual has a high BMI but appears fairly muscular. A body-composition test can help re- assure such people that they are not overly fat and should not focus on losing weight, unless other obesity-associated health risks indicate that some weight loss would be beneficial.

Some of the antioxidants that health and fitness professionals (and clients) may be familiar with include: 305

• Anthocyanins: found in red and purple fruits such as eggplant, blueberries, and raspberries • Astaxanthin: found in red algae and animals who eat red algae, including salmon and some shellfish • Carotenoids: found in yellow and orange fruits and vegetables, such as carrots, cantaloupe, and winter squashes • Lutein: found in spinach and red peppers • Lycopene: found in red tomatoes and water- melon • Zeaxanthin: found in corn

Tobacco Use 390

• Cardiovascular Disease • Cancer • Chronic Respiratory Disease

Many factors influence how a student's body weight will respond to college life including: 350

• College environment: Students who leave home to go to college must adapt to a new environment. Life on a college campus is often marked by erratic schedules and regular opportunities to party. Some students adapt fairly quickly and establish a new routine that supports their ability to make the most of the academic and social challenges. Others have more difficulty settling in. Changes in weight usually reflect the lifestyle that a student develops. Some colleges do more than others to nurture healthy habits, but in the end it is usually up to the individual student to be sure he or she develops a healthy lifestyle. • Activity level: Unless the student is an athlete or attends exercise classes, college life is a fairly sedentary one. Although students tend to walk from place to place, they also spend much of their time studying, reading, and writing—all sedentary activities. Students who do not sign up for an activity class of some sort, join a sports team, or participate regularly in campus recreation activities may get little exercise. This lack of activity contributes to weight gain and also to feelings of stress. • Stress: Many students encounter emotional challenges during the college years. First-year students are especially likely to feel homesick and lonely, missing family and friends back home. The stress of difficult classes, roommate issues, and other problems that normally arise in life can make the college years even more challenging. Feelings of stress often cause changes in appetite and eating behavior. Food is familiar and can serve as a stand-in for missing family. • Fatigue: Fatigue increases hunger, as higher ghrelin levels drive people to overeat. Students are notorious for skipping sleep and pulling all-nighters to complete assignments. Of course, a lack of time management and study skills, coupled with procrastination, are often the real culprits of sleep deprivation . • Knowledge-based work: Knowledge-based work increases feelings of hunger and can drive excessive snacking. The boredom sometimes associated with completing homework assignments can also lead to snack attacks. • Dieting: Ironically, students who try to lose weight by severely restricting food intake may end up gaining weight. Diets are often followed by periods of overeating as the dieter gives in to hunger and food cravings. Unfortunately, dieting behavior and more-serious disordered eating behaviors are very com- mon on college campuses. • Social eating: Most college social events involve food, from dining hall meals to campus parties. People are more likely to overeat in social settings, especially in all-you-can-eat dining halls where dessert is served at every meal. Parties encourage excess alcohol consumption and snacking

Brown adipose tissue 337

(BAT) is a special type of fat that contains a higher density of capillaries and mitochondria than white fat. Brown fat cells generate heat and help mammals maintain body temperature in cool environments without shivering.

thermic effect of food 341

(TEF) refers to the energy required for the processes of digestion and absorption. The term "thermic" refers to energy expenditure. This word is used because all of the body's energy expenditure processes generate heat; by measuring heat (calories), scientists can calculate energy use. Why does eating take energy? Energy is required to chew food, contract the muscles of the gastrointestinal (GI) system, produce digestive enzymes and fluids, and absorb nutrients from the digestive system into the lymphatic system or bloodstream. TEF expends about 10% to 15% of people's daily caloric requirements.

incomplete proteins 301

(proteins lacking one or more essential amino acids) usually results in an adequate intake of protein (. The U.S. Department of Agriculture recommends 0.8 grams of protein per kilogram of body weight (or 0.36 g/lb). People who are significantly overweight (in the form of excess body fat) should base their protein intake calculations on a weight that would be healthier for them.

Social and Environmental Factors: People's social and built environments exert strong effects on their behavior, including risks of developing substance use and addiction disorders. A few of the more-powerful variables influencing risk include the following. 379

-Access to Substance or Behavior: Access to a substance or behavior is obviously a prerequisite for development of substance use and addiction disorders. People tend to develop disorders for substances and behaviors more common in their environment, including in their social circles. Access may take the form of a substance being available, such as prescription drugs being sold by one's friends. -Childhood Family and Home Environment: Children are strongly influenced by their early home environment and their family members. Early environment shapes social norms and children's attitudes toward sub- stances and behaviors. -Social Norms: Social norms regarding substance use and behavior exert a strong impact on an individual's perceptions. Social norms influence which substances an individual may decide to use and how use occurs. Similarly, social norms provide a context for behaviors that may become problematic, such as interpersonal dependence (being overly dependent on another person), gambling, work, and so forth. Peer group norms are especially strong. -Socioeconomic Status and Social Environment: Socioeconomic status and social environment contribute strongly to people's stress levels, physical and emotional health, and risk of substance abuse. Stressors such as poverty and discrimination limit people's access to re- sources and behaviors that enhance likelihood of success in many life arenas, especially career and financial success. Sociologists have observed that stressors tend to proliferate: those with more challenges tend to continue to find themselves in challenging situations, while people who have the resources and abilities to cope effectively with stress tend to master challenges -Adverse Childhood Events: An abusive home environment and other adverse child- hood events are associated with increased risk for the development of addiction. Studies suggest that such exposures may cause mood and anxiety disorders, which in turn increase risk for substance abuse and addiction because people seek to improve mood and reduce anxiety

Disordered Eating and Eating Disorders 397

-Anorexia nervosa (AN) is an eating disorder marked by an intense fear of gaining weight or becoming fat and severe food restriction leading to an abnormally low body weight. -Binge eating disorder (BED) is characterized by recurrent episodes of eating very large volumes of food, while feeling a lack of control over one's ability to stop eating. -Bulimia nervosa (BM) perform binge eating along with harmful compensatory behaviors to prevent weight gain, including self-induced vomiting; misuse of laxatives, diuretics, and other drugs; fasting; or excessive exercise. -Mortality rates: about 4% to 5%

Executive Cognitive Functions 383

-Another difference is that executive cognitive functions are more likely to be a problem, and therefore the therapeutic target, for behavior-change programs involving negative health behaviors and addiction. This is be- cause lower levels of executive cognitive function (ECF) are associated with addiction -Executive cognitive functions include abilities that are critical for behavior change, including planning, organizing, problem-solving, and regulating one's behavior and emotions. Executive cognitive functions are essential for making the decision to change behaviors and to sustain one's motivation for change.

Psychological Factors: Many of the psychological factors associated with addiction risk have biological components, such as those described previously, and interact with other risk factors. 379

-Attention Deficit Disorders: Addiction is marked by repeatedly using substances or performing behaviors despite the knowledge and experience of negative consequences. The prefrontal cortical areas of the brain are responsible for the executive functions that inhibit impulsive behavior, attend to tasks, plan, and think about consequences. Attention deficit disorders often indicate lower levels of executive function and higher levels of impulsivity. -Mood Disorders and Post-Traumatic Stress Disorder: People with mood disorders such as anxiety and depression are more likely to develop substance-use disorders than people without mood disorders, although it is not easy to always know which came first: the substance use or the mood disorder. Nevertheless, it is well documented that people with anxiety and other disorders some- times use substances to reduce emotional distress, a practice known as self-medication -Less-Effective Coping Skills: When people have better resources and abilities to cope with stress, they appear to be less likely to turn to sub- stances for self-medication or to addictive behaviors for solace. Studies suggest that adolescents and adults can identify factors and situations that increase their risk of substance use and apply cognitive behavior therapy to learn better ways to cope with risky situations -Hopelessness: Hopelessness is often accompanied by feelings of helplessness and an external locus of control. Hopelessness generally restricts a person's feeling of choice and control, so that individuals perceive themselves as having fewer response options when facing a challenge. In addition, feelings of depression often accompany hopeless- ness, perhaps mediating the link between helplessness and external locus of control with negative health out- comes. Feelings of hopelessness lead to low self-efficacy and low drive to persist in coping with difficulties.

Understanding Addiction to Tobacco Products 392

-Despite knowledge of the health risks of using tobacco products, about 20% of people in the United States are smokers. While smoking rates have declined since the 1960s, this rate of decline has slowed considerably in recent years. In the United States, about 1000 people younger than 18 and 1800 people 18 years old and over become smokers each day -Nicotine addiction develops very readily, so users quickly become physically dependent on tobacco. In addition, habits of use reinforce behavioral dependency. Users turn to tobacco products for stress relief, relaxation, or simply because it is a habit that accompanies homework, talking on the phone, taking a break, or spending time with friend

Issues That May Motivate Eating Behavior Change

-Food allergies or intolerances • Type 1 or type 2 diabetes • Pregnancy • Pregnancy-related problems, such as gestational diabetes • Heart disease or artery disease • Digestive system problems, such as irritable bowel syndrome, ulcers, chronic constipation • Osteoporosis and/or sarcopenia—clients wanting to build muscle and bone and slow the age-related loss of both • Cancer • Obesity • Weight loss • Weight gain

Biological Factors: Biological factors include genetic heritage and physiological characteristics that interact with potentially addictive substances and behaviors. 378

-Genetic Predisposition: A family history of addiction increases an individual's risk for developing an addiction. Studies in identical and fraternal twins suggest that genetics may account for about 40% to 60% of variation in risk for addiction . Some research indicates that genetic inheritance influences the number and type of dopamine receptors on neurons -Psychophysical Response to Substance or Behavior: People who experience improvement in mood, positive emotions, or euphoria in response to using a substance or performing a behavior will be more likely to want to repeat the experience than someone who has no response or a negative reaction. -Adolescent Age: During adolescence, various areas of the brain mature at different rates. Of special concern is the observation that the limbic system, home of the reward pathway, develops earlier than the prefrontal reasoning and planning areas. Such differences may help explain the higher levels of risky behaviors observed in many adolescents: the potential to have fun overrides ideas about reasonable action and inhibition of risky impulses. Of course, biological age interacts with family and other environmental factors to influence the development of negative health behaviors. -Early Exposure to Addictive Substances: Early exposure to addictive substances can occur in utero or early in a person's life. Developing fetuses, children, and adolescents are more vulnerable than adults to the effect of many substances.

Waist Circumference 334

-Many health and fitness professionals now use waist circumference in addition to BMI to assess body fat- ness. Although waist circumference does not provide an estimate of body composition, it does provide information about torso mass. Excess fat stored in the abdominal region, especially inside the torso around body organs such as the liver and pancreas, exerts the greatest negative impact on health. -Waist circumferences over 35 inches (88 cm) in women and 40 inches (102 cm) in men are associated with increased health risks, such as type 2 diabetes and hypertension.

Some of the most-useful behavior-change skills for clients changing eating behaviors include: 322

-Self-Monitoring -Problem-Solving -Coping Planning -Stress Management -Cognitive Restructuring

Elisabeth Kübler-Ross (P.416)

-whose book On Death and Dying brought the grieving process to the attention of both the medical community and the public (Kübler- Ross, 1969). Kübler-Ross worked with terminally ill patients and their families. She believed that grieving people go through the following five stages: • Denial: Initially, people can't believe they are ill or that a loved one is terminally ill. • Anger: People wonder why life is unfair and why the tragedy is happening to them, and they experience feelings of anger. • Bargaining: People facing tragedy may then try to make a deal with a divine power, promising to take certain actions if they are allowed more time. • Depression: Sad feelings develop as grief sets in. • Acceptance: People eventually accept their circumstances when they realize change is not possible.

Diet Recommendations From the American Heart Association for the Prevention of Cardiovascular Disease 304

1. Consume an overall healthy diet. 2. Try to maintain or reach a healthy body weight by balancing calorie intake with physical activity. 3. Consume a diet rich in vegetables and fruits. 4. Consume a diet rich in whole-grain, high- fiber foods. 5. Eat fish, especially oily fish such as salmon and mackerel, two or more times a week. 6. Limit consumption of saturated fats to less than 7% of total daily calories. 7. Limit consumption of trans fats to less than 1% of total daily calories. 8. Limit consumption of cholesterol to less than 300 mg/day. 9. Minimize intake of beverages and foods with added sugars. 1 10. Limit consumption of salt. 11. If alcohol is consumed, use in moderation.

Substance-Use Disorder—Definition and Diagnostic Criteria The American Psychiatric Association defines substance-use disorder as "a maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 2 (or more) of the following, occurring within a 12-month period": 377

1. Repeated substance use that results in a failure to fulfill major obligations, such as poor work performance or neglect of children. 2. Repeated hazardous use of the substance, such as driving under the influence of the substance. 3. Continued use of the substance despite the fact that it is causing social or interpersonal problems and even though the user acknowledges that these problems are the result of use. 4. Development of tolerance: needing more of the substance to produce the desired effect or experiencing less effect for a given dose. 5. Withdrawal symptoms. 6. Substance is taken in larger amounts or for longer periods than intended. 7. Efforts to reduce or eliminate use are unsuccessful. 8. A lot of time is spent procuring or using the substance or recovering from substance use. 9. Involvement in important activities is given up or reduced as a result of substance use. 10. Craving or a strong need to use the substance.

Essential Fat 336

A certain amount of body fat, called essential body fat, is required for even the leanest person. Fat is a component of bone marrow, nerves, the spinal cord, brain, and many other internal organs. Cell membranes are com- posed largely of fat. Pads of fat help cushion vital organs. Essential fat contributes about 3% to 5% of body mass.

hedonic hotspots 374

A great deal of neuroscience research is exploring areas of the brain, such as the VTA and nucleus accumbens, that serve as hedonic hotspots, groups of neurons that when stimulated help produce sensations of pleasure. (Hedonic means relating to or characterized by pleasure.) Hedonic hotspots appear to exist in many areas of the brain. Hedonic hotspots are especially sensitive to specific types of neurotransmitters or chemicals.

probiotics 299

A high-fiber diet may promote colon health by providing an environment in- side the GI tract that favors the growth of beneficial bacteria.

Alcohol 388

Alcohol use is embedded in many cultures and perceived as socially normal by a majority of North Americans. About 70% of U.S. adults drink alcohol, at least occasionally, and most do so in a responsible fashion. How- ever, 25% of U.S. adults report having alcohol-related problems or have behaviors that put them at risk for developing problems. This translates into a very large number of people for whom alcohol poses a problem

Weight Control and Obesity Prevention: Energy Balance Requires Physical Activity 343

Although the big picture of weight control and obesity is complex and filled with many interacting variables, the bottom line is very simple, as stated at the beginning of this chapter. To reduce body fat stores and prevent obesity, people must eat less and exercise more.

Preventive Cognitive Behavior Therapy 381

An interesting group of researchers has used targeted cognitive behavior therapy (CBT) interventions in adolescents. The London-based group has developed CBT sessions that target specific vulnerabilities that make adolescents prone to substance use. These interventions have been tested in several studies.

Diagnostic Criteria for Eating Disorders 398

Anorexia Nervosa Severe restriction of food intake that causes significantly low body weight, that is, below the minimum of what would be expected for the person's age, sex, and health Intense fear of gaining weight or becoming fat, or practicing harmful weight-control behaviors even though significantly underweight Disturbance in the experience of one's body shape or weight or lack of acceptance that one's low weight is having serious negative health effects Binge Eating Disorder Recurrent episodes of binge eating characterized by eating abnormally large volumes of food in a discrete time period and experiencing a lack of control over food consumption Binge eating episodes are characterized by three or more of the following: • Eating more rapidly than normal • Eating until uncomfortably full • Binge eating in the absence of physical hunger • Eating alone because of embarrassment about eating behavior • Feeling depressed, guilty, or disgusted with oneself after binge eating • Distress regarding binge eating behavior • Binge eating occurs at least once a week for 3 months Bulimia Nervosa Recurrent binge eating, as described previously, with a feeling that one lacks control over eating behavior Regular inappropriate compensatory behavior performed to prevent weight gain, such as self- induced vomiting; misuse of laxatives, diuretics, or other drugs; fasting; or excessive exercise Binge eating and compensatory behaviors occur at least once a week for 3 months Self-evaluation is overly influenced by one's perceptions of one's body weight and shape Eating Disorder Not Otherwise Specified (EDNOS) EDNOS is diagnosed when symptoms of eating disorders are present but do not meet the full diagnostic criteria of any specific category.

Perceptions of Social Control and Reactance Theory 384

Another difference between negative and positive health behavior-change programs is that many negative health behaviors have an associated stigma, and people who en- gage in these behaviors may feel a sense of shame. They may be embarrassed about their inability to control their smoking, gambling, eating, or other negative behavior. Feelings of embarrassment and shame may motivate people to hide negative behaviors, deny or downplay their importance, or avoid dealing with problems associated with them. People in a close relationship with a person who has negative health behaviors often seek to motivate that person to change. I

leptin 344

Another important chemical messenger is the hormone leptin. Leptin is manufactured in several places, including fat cells. Leptin levels help inform the body (including the brain) about total fat stores. It helps regulate other physiological functions as well, including reproduction and glucose metabolism. In general, higher leptin levels are associated with less hunger, although this relationship appears to be disrupted in people who are obese.

adiponectin. 337

Another interesting messenger affected by adipose stores is adiponectin. Higher levels of body fat have been associated with lower levels of adiponectin. Adiponectin helps insulin do its job of getting sugar from the bloodstream into cells where it can be stored or burned for energy. This observation may help explain the insulin resistance that often develops with obesity. Adiponectin also helps regulate the metabolism of lipids. Adiponectin appears to have an anti-inflammatory effect on the cells that line the artery walls.

Anthropometric measures 334

Anthropometry means "the measurement of human beings" and refers to measures that describe physical characteristics. The anthropometric measures used for estimating body composition include circumferences and skinfold thicknesses. Circumference in this context refers to the distance around a particular body part, such as the waist, hips, and upper arm. Circumferences are usually taken with a tape measure and then entered into an equation to predict body fat. Skinfold thickness is the thickness of the skin and layer of subcutaneous fat as it is pulled away from the under- lying muscle. Skinfold thickness is measured with calipers at several standard anatomic sites. These measurements are then entered into prediction equations to predict body composition. Circumference and skinfold measures are most accurate when taken by an experienced test administrator. Even then, body-fat predictions based on these measures are often inaccurate, because the equations that are used are based on population averages and may not apply to a given individual. Some health and fitness professionals use circumferences and skinfolds as "stand-alone" measures. When taken over time, they can show changes in and of themselves, without predicting body composition from them. For example, if a person is losing fat, waist circumference may decrease. Anthropometric measures are the least- expensive but also the least-accurate means of estimating body composition.

The Transtheoretical Model and Stages of Change 351

Applying the Stages of Change Model to weight management programs can be somewhat tricky, because it requires addressing several different behaviors simultaneously. Some changes come more easily than others, and people may be ready to change some behaviors but not others. For example, a client might al- ready be entering the action stage in terms of reducing foods with added sugars but have doubts about his or her ability to stick to an exercise program. This scenario is common for people with a history of obesity. They may have avoided exercise because physical activity was embarrassing or difficult for them but may have had plenty of practice dieting. When working with clients who are trying to lose weight, health and fitness professionals may want to assess stage of change for diet and exercise separately and use appropriate intervention strategies according to readiness to change. Is the Stages of Change Model helpful for people trying to lose weight? Research suggests that taking a stages of change approach can be moderately helpful compared with a "usual care" approach, according to one meta- analysis

subcutaneous fat 337

Approximately a third of a person's body fat is stored under the skin. These fat stores are called subcutaneous fat. Some subcutaneous fat is helpful for insulation, which keeps heat within the body in cold weather. People who have observed (or remember being part of) a pool or lake full of children will recall the thinner ones having less tolerance for staying in cool water, whereas their heavier friends were comfortable for longer periods of time. On the other hand, people with extra sub- cutaneous fat lose heat less quickly in hot environments and are at greater risk of heat illness, especially during high-intensity and prolonged physical activity. Subcutaneous fat improves the appearance of the face, help- ing to support the skin. The faces of very thin people usually look older in later life than their heavier peers

Self-Efficacy 352

Asking people about self-efficacy in terms of physical activity and dietary change can guide health and fitness professionals' expectations and recommendations. Like readiness to change, self-efficacy is behavior specific. Open questions and mindful listening usually allow health and fitness professionals to guide conversations to questions of self-efficacy for exercise behaviors, as well as eating behaviors. Weight-management program behavior expectations should match clients' levels of self efficacy. As clients are successful in following behavior change recommendations, hopefully self-efficacy will grow stronger.

Self-Determination Theory and Processes of Change for Contemplators 319

Autonomous motivation is essential for eating behavior change. Unfortunately, many clients may begin changing eating behaviors because they feel pushed or bullied into change by health-care providers, friends, family, or society at large. Internal conflict over changing eating behavior can lead to a great deal of negative emotion, stress, and ultimately failure, as anger, hunger, or exhaustion win out over good intentions. Health and fitness professionals should remember the three basic needs that underlie motivation: autonomy, competence, and connection.

Bioelectrical impedance analysis (BIA) 334

BIA tests are based on the fact that fat tissue conducts electricity more slowly than nonfat tissue, which contains quite a bit of water. BIA equipment sends a weak electrical current through the body. The speed of the current reflects relative fatness. BIA measures assume a constant body water content for various tissues, so anything that alters hydration status or causes water retention will affect BIA body-composition estimates. Dehydration, premenstrual water retention, elevated muscle glycogen levels, and food in the stomach can interfere with the accuracy of BIA body-composition estimates. BIA equipment is found in many health and fitness facilities. Because equipment is quite portable and easy to use, BIA is often the technology of choice at health fairs.

Behavior-Change Skills 358

Basic behavior-change skills are the foundation of successful weight management. One of the first steps in creating weight-management recommendations is to try to figure out the causes of the extra weight. Clients often have some ideas about this.

Use of OARS Communication Skills 385

Because clients with negative health behaviors may quickly become defensive when others criticize them, professionals must be especially good listeners and try to engage clients in supportive, helpful ways. Client resistance is one of the greatest barriers to success in cognitive behavioral-change programs for addiction. Behavior-change theories such as the Health Belief Model and the Theory of Planned Behavior can provide professionals with important variables to ad- dress in discussions to help motivate a decision to change.

Self-Determination Theory and Motivation 353

Because societal and cultural forces can create great shame and low self-esteem for overweight people, many clients embark upon weight-management pro- grams with mixed feelings and unrealistic ideas about what weight loss will help them achieve in life. For some, concepts of body size and personal body image have become tightly interwoven with feelings of self-worth and explanations for their present circumstances. Too often, weight becomes the reason for everything: problems in relationships, unrewarding work, financial difficulties, or global unhappiness.

Self-Monitoring: A Lifestyle Reality Check 360

Behavior change for weight management begins with a look at a client's current lifestyle. Clients might begin by recording everything they eat for at least 3 days. They may wish to record foods and also the factors that influenced decisions to eat and food choices. Clients should also keep track of physical activity, including daily activities such as walking, taking the stairs, and doing housework and yard work. Self-monitoring helps both clients and professionals assess which behaviors need to be changed. In some cases, self-monitoring helps people realize that they are eating more than they thought, such as nibbling as they cook dinner or snacking as they watch television. Self-monitoring acts as a kind of a mirror so people get a good look at their behavior.

Settings for Behavior-Change Programs 382

Behavior-change efforts can occur in a variety of set- tings. The most-intensive forms of behavior-change treatment are more likely to be seen for negative health behaviors such as drug or alcohol addiction and eating disorders. When a negative health behavior has become a health problem, such as a substance-use disorder, treatment is likely to be more aggressive.

thermic effect of exercise 341

By far, the most-significant effect on metabolic rate is achieved with exercise. The thermic effect of exercise (TEE) refers to the calories used during exercise. During moderately vigorous physical activity, metabolic rate increases by a factor of 10 or more, burning hundreds of extra calories. The more vigorous the exercise, the more calories expended. After vigorous activity, metabolic rate remains elevated for the time it takes for the body to return to resting level

Lifestyle Support for Changing Negative Health Behaviors 388

Can developing positive health behaviors help people overcome bad habits? Anecdotal reports suggest that good nutrition and regular physical activity can help bolster resolve for change. However, research evidence is fairly sparse. Researchers propose that exercise in particular can help people coping with addictions and negative health behaviors for the following reasons • Physical activity activates CNS reward pathways, so it could potentially serve as a source of pleasurable experience to replace the negative behavior. • Regular physical activity is associated with improvement in symptoms of anxiety and depression, which motivate negative health behaviors for many people. • Regular physical activity decreases stress reactivity and may offer a positive way to cope with feelings of stress. • Physical activity venues may offer opportunities for social support. Exercise classes, community activities, walking groups, dance classes, and other group exercise programs bring people together. They generally provide environments lower in use of substances such as tobacco and alcohol. • Sticking to a program of regular physical activity may help build people's self-efficacy for self- control and behavior change.

Principle of Limited Self-Control 353

Clients seeking weight control often say, "If only I had more willpower." It takes effort to change one's lifestyle, exercise regularly, and change one's eating habits. Previous chapters have discussed the implications of limited self-control for the design of behavior-change recommendations. Because weight-management pro- grams often include a great deal of change, minimizing the need for self-control is especially important. Lifestyle-change recommendations should try to incorporate the following suggestions: • Keep changes as simple as possible. • Structure changes in ways that they can quickly become habits. • Help clients develop practices to reduce and cope with stress, since stress depletes self-control energy. • Recognize that self-control tends to decline throughout the day

Stress Management and Healthy Lifestyle 360

Dietary change should be seen as one part of a healthy lifestyle that supports emotional health and feelings of well-being. Health and fitness professionals should educate clients about the importance of adequate sleep and stress management. Regular physical activity should be the cornerstone of every weight-management program.

Dual-energy x-ray absorptiometry 333

Dual-energy x-ray absorptiometry (DEXA) technology uses two x-ray energies to measure bone density and body composition. It is becoming common for older clients at risk for developing osteoporosis to receive DEXA scans to evaluate and monitor changes in bone density. DEXA technology is used to assess body composition primarily in research settings.

irisin 337

During exercise, a myokine dubbed irisin (named after the Greek messenger goddess Iris) is produced. Irisin moves from the muscle to the bloodstream and appears to communicate with white adipose tissue, "telling" it to develop into BAT, especially in the visceral area. Increasing irisin levels in the blood of mice results in an increase in energy expenditure, with no changes in physical activity level or food intake.

Organizational Level 315

Eating behavior is influenced by organizations in which people spend time. For example, members of a church congregation may gather for coffee hour after a service. Clubs often have snacks at meetings. Children are guided in food selection at school by the meals avail- able there. Workplaces may have meals served at certain meetings or cafeterias from which employees choose foods.

Interpersonal Level 315

Eating is often social behavior and is shaped by family members and peer groups. Family shopping, cooking, and eating patterns may determine food availability for family members not involved in food preparation. Peer groups usually evolve certain behaviors that include food: college student friends may order late-night pizza for a study break. Coworkers may share dessert every day at lunch. Friends may gather for drinks after work. Family members may enjoy a snack together as they watch their favorite TV shows in the evening.

social control 384

Efforts to motivate other people to change their behavior are known as social control. Social control can be positive or negative. Positive social control offers help and strives to generate positive emotions and feelings of support. Negative social control is more likely to take the form of criticism and judgment and to generate negative emotions. Studies suggest that positive social control is more likely to lead to behavior change

Emotional Eating 362

Emotional eating is so common that it is sometimes considered well within the range of normal behavior (Behavior Change in Action 10-1). Problems arise when emotional eating becomes excessive and interferes with a person's lifestyle and health. For emotional eaters, the drive to eat is often associated with unpleasant feelings such as boredom, loneliness, depression, anxiety, anger, or fatigue. Eating provides comfort and solace, numbing the pain and "feeding the hungry heart." In extreme cases, people can become addicted to binge eating, and it's not so much that eating feels good as that not eating feels bad. Binge eaters have an eating disorder that causes them to consume large quantities of food and have no sense of control over their eating behavior.

• Employer (P.294)

Employers may set limits on how much nutrition advice health and fitness professionals can give. Professionals should understand these policies and get answers to their questions. Some employers may restrict certain practices, even though the professional may feel qualified to provide these services. Sometimes this is because of state regulations. Individual states govern the licensure of nutrition professionals. Some states, such as Ohio and Florida, mandate that only licensed professionals, such as registered dietitians (R.D.s), may provide nutrition advice for monetary gain. Employers may be worried about a variety of liability issues if employees give nutrition information.

secondary exercise addiction 399

Excessive exercise often occurs as part of a larger constellation of disordered-eating behaviors. In this case, it is known as secondary exercise addiction.

primary exercise addiction 399

Exercise addiction that occurs without other symptoms of eating disorders

sex-specific fat 336

Females have an additional category of essential fat: sex-specific fat, found in the breasts, hips, and thighs. Sex-specific fat explains why the leanest of females is fatter than the leanest of males. A great deal of energy is required to run the menstrual cycle and to grow and nurse a baby; hence the extra energy stores. Sex-specific fat stores contribute about 5% to 9% of body mass in females.

Societal and Cultural Level 315

Food and eating are integral parts of society and culture. While families transmit many social and cultural traditions, these traditions are shaped by the larger forces of the society and cultures themselves. Religious traditions may prohibit or recommend certain foods and the manner in which they are consumed. Public policy shapes legislation that promotes certain agricultural practices, supporting certain farming methods and discouraging others, and influencing the price of food. Public policy shapes governmental recommendations, school lunch programs, and nutrition-education curricula in public schools. Government and private efforts may create food-donation programs for low-income residents.

complete proteins. 301

Foods that contain all nine essential amino acids are called complete proteins. These foods include eggs, dairy products, animal flesh (chicken, fish, beef, etc.), animal organs (liver, kidneys, etc.), soybeans, and a few other plant foods.

Genetics 344

For centuries, scientists have observed enormous individual variation in body types, body composition, and the factors that contribute to energy balance. During the past three decades, studies of twins have led to the conclusion that genetic variation explains 40% to 75% of the variation in BMI among people. Research in 5,092 twin pairs 8 to 11 years old found that genetics explained 77% of variation in waist circumference. Researchers believe that a genetic predisposition to obesity allows an "obesogenic environment" to enable expression of obesity through long-term positive energy balance. For some individuals and ethnic groups, genetic predisposition for obesity is especially strong. Their "thrifty" genes allow them to capture every calorie that they consume and efficiently store energy, primarily as fat, against future lean times. Unfortunately, in an environment where food is plentiful, these thrifty genes trans- late almost automatically into obesity.

Behavioral Therapies for Changing Negative Health Behaviors 387

For clients who have made the decision to change, the most-successful strategies for changing negative health behaviors incorporate principles of behavior learning theory and cognitive behavioral approaches. • Coping skills training: Coping skills training teaches cognitive and behavioral skills to improve individuals' abilities to cope with situations in which the negative health behavior is likely to occur. People learn new responses to the stimuli that provoke the negative behaviors. • Cognitive behavioral therapy: CBT helps individuals become aware of thought and behavior patterns that promote the negative health behavior. People learn to use new ways of thinking and responding to high-risk situations. CBT typically addresses immediate behavior change as well as long-term relapse prevention. • Contingency management therapies: Contingency management therapies use operant conditioning principles to shape behavior, usually through the use of rewards that clients can achieve by exhibiting desirable behaviors (such as abstaining from alcohol or drug use). • Family therapies: Family therapies are especially helpful when negative health behaviors involve family dynamics, as when family members cover up for an individual's alcohol-use disorder, unintentionally enabling the individual to persist in addictive behaviors. Disorders occur- ring in minors may also respond well to family therapies. • Brief behavioral interventions: Some individuals succeed in changing negative behaviors with only a few sessions of help from physicians, health educators, or other providers who typically use some form of behavioral counseling or MI. • Self-help programs: Many people change with support from books, online materials, or other media that teach goal-setting, self-monitoring, and other behavior-change skills.

Hydrostatic weighing or underwater weighing 333

For this test, a subject sits on a seat underwater. The seat is attached to a scale, which measures the person's weight. The heavier a person is in the water, the greater his or her density. Density refers to weight per volume. Two people with the same BMI may have different densities. A denser person has more FFM and less fat. By calculating density from water weight, a person's percentage of body fat can be estimated. Error can occur with this measure because the density of nonfat tissues, such as bone, varies from person to person, yet the test calculations rely on an average value. Similarly, body-composition prediction equations take into account the air remaining in the lungs after a complete exhalation. If this volume is estimated and not measured and/or if the per- son has difficulty exhaling and holding the breath underwater, body composition estimates will not be as accurate. Underwater weighing tanks are most likely to be found in research and academic settings, such as in kinesiology department facilities.

Interpersonal Level 348

Friends, family, and other close relationships sway people to consume certain types of foods and participate in physical activity or to be inactive. Close relationships can prompt people to eat when they are not hungry, form positive associations with certain types of foods and eating rituals, and develop habits of physical activity. In addition, studies suggest that when friends and family gain weight, obesity may become more accept- able to an individual.

Harm-Reduction Programs 385

Harm-reduction programs have been promoted by many experts to help people at least suffer fewer harmful consequences from negative health behaviors. For some negative health behaviors, abstinence is the ideal goal. People who have trouble regulating alcohol intake may find it too difficult to just have a drink or two and will be better off not drinking at all

BEHAVIOR-CHANGE APPLICATIONS FOR NEGATIVE HEALTH BEHAVIORS 388

Health and fitness professionals are behavior-change ex- perts. Not only do they help clients improve physical activity and dietary habits, they also help people with bad habits transform their lifestyles. Clients often approach health and fitness professionals with questions about alcohol use, quitting smoking, and harmful weight-control behaviors. The previous sections in this chapter have provided general background on negative health behaviors. This section will present behavior-change issues and applications for the most-common negative health behaviors that health and fitness professionals are likely to encounter in their work, including alcohol and tobacco use, harmful weight-control practices, eating disorders, and excessive exercise.

Educate Clients About Healthy Eating (P.296)

Health and fitness professionals may educate clients about healthy eating in many ways, following the guidelines described above. For example, it is fine for professionals to provide cooking demonstrations, teach clients how to read food labels, give grocery store tours, or provide guidelines for eating in local restaurants (Fig. 9-1). They may discuss how nutrient needs vary with life stage and provide statistics regarding how eating behaviors and nutrition are related to chronic illness

Support Clients Following Personal Dietary Recommendations (P.296)

Health and fitness professionals may find themselves working with clients who have consulted their healthcare providers and/or dietitians for individualized dietary recommendations. Professionals can help these clients as they work to implement the recommendations.

Body Dissatisfaction 394

Health and fitness professionals often hear clients (and coworkers) complain about their bodies. Most take it for granted that many of the people who seek their advice come on a mission of body improvement. Body dissatisfaction is part of the American way of life and has been for many years. Many health and fitness professionals are concerned about the prevalence and depth of the body dissatisfaction they see all around them and the pathogenic weight-control behaviors that are often the result.

Stick to Scientifically Sound Advice (P.296)

Health and fitness professionals should deliver main- stream, scientifically endorsed advice. In general, health and fitness professionals may give their clients nutrition recommendations that are backed by established public-health organizations, particularly their national government.

Avoid Interventions That Could Be Problematic (P.296)

Health and fitness professionals should never diagnose health problems or prescribe treatments, including dietary supplements. They should not design or prescribe individual nutrition plans, nor act as psychotherapists in situations where clients have problems with food. Health and fitness professionals should be ready to refer clients to a licensed nutritionist, dietitian, or other healthcare provider if: 1. Show symptoms of disordered eating or exercise behavior 2. Have a lot of questions about diet that go beyond "general information" 3. Have a medical condition, such as diabetes, heart disease, or cancer 4. Want to follow a very-restrictive diet, such as a low-carbohydrate diet 5. Want specific daily meal plans

Individualize Your Approach and Connect With Clients' Goals 388

Health and fitness professionals who work with clients to change negative health behaviors should individualize the strategies that they employ with each client. Professionals should begin with an effort to discern where the client appears to be in terms of the stages of change, listening carefully and reflectively to assess how committed the client is to changing.

Scope of Practice (P.295)

Health and fitness professionals' scope of practice, which describes the activities that they are allowed to do in their profession, is proscribed by several different institutions, including professionals' employers and their licensing and/or certification organizations

Health Education 381

Health education often focuses on preventing negative health behaviors by teaching people about the risks associated with the behavior. Adolescent age groups tend to provide one of the most-difficult audiences for health-education efforts.

Support Abstinence or Moderation 390

How should health and fitness professionals respond when clients express interest in changing their alcohol use behaviors? People who say they are concerned about their drinking behavior usually need to reduce consumption. Professionals should express support and help clients explore reasons for changing. They should also refer clients to substance-use professionals if they suspect a substance-use disorder

Hydrometry 332

Hydrometry methods give an estimate of total body water (TBW), how much water is contained in a person's body. Because fat tissue contains very little water, finding out how much water is in a given body allows researchers to estimate fat mass and fat-free mass for a given body size.

glucagon 299

If blood glucose levels fall too low, the pancreas releases the hormone glucagon. Glucagon signals the liver to break down glycogen and release glucose into the bloodstream. As the liver releases glucose into the blood, blood glucose rises, meeting the body's immediate energy needs. The liver can also produce glucose from other precursors such as amino acids.

Support Body-Image Resilience 396

If body dissatisfaction is a problem and associated with low self-confidence, a client will have a harder time sticking to a behavior-change pro- gram than a client who feels confident. Clients with high body dissatisfaction could benefit from confronting and coming to terms with these negative feelings so that their plans to improve their lifestyles come from positions of strength. As discussed above, health and fitness professionals should refer clients with significant body- image problems for professional support.

Coping Planning 323

If certain factors routinely interfere with behavior- change plans, clients may benefit from coping planning. For example, holidays often disrupt eating behavior-change plans. Clients often have experience with these routine factors and can draw on past experience to make future plans. When the holidays are approaching, clients can plan ahead of time to enjoy them and still follow through on their behavior-change plans. Clients may wish to plan for travel, vacations, eating out, illness, or any other events that tend to be disruptive

Orthorexia 309

If concerns about correct eating begin to exert a negative effect on a person's life, this person is sometimes said to have orthorexia. Orthorexia is not a medical diagnosis but simply a term describing people overly concerned with dietary perfection

Detoxification 383

In some cases, behavior-change efforts for serious substance addictions begin with some sort of detoxification program. Detoxification refers to the initial stage of abstinence from an addictive substance, during which the person addicted may experience a number of physical and psychological withdrawal effects. This period may require medical supervision and treatment to reduce withdrawal symptoms and help patients adjust to a new normal. -Inpatient programs are very expensive, so they are usually reserved only for behaviors with the most- serious consequences and for people who can afford them. Inpatient programs usually offer options for cultivating a healthful lifestyle to help guide patients into new practices that will promote physical and psychological well-being. -Residential programs for positive health behaviors do exist. They are usually called spas, retreat centers, or something nice. These programs can help people jumpstart new healthful behaviors, such as increasing physical activity, eating more healthfully, and managing stress more effectively. But, because of their expense, only a minority of people uses these programs. -Nonresidential behavior-change settings are less ex- pensive and more common for programs in both positive and negative health behavior change. These programs may include everything from individual counseling and psychotherapy, to group therapy and support, to alternative and complementary medicine treatments such as acupuncture, hypnosis, and therapeutic yoga

Dietary Supplements 314

In the United States, this industry is regulated by the Food and Drug Administration (FDA), a division of the Department of Health and Human Services. The Center for Food Safety and Applied Nutrition (CFSAN) is the branch of the FDA that works with food and dietary supplements.

Interaction Between Lifestyle and Genetics 347

It is likely that lifestyle and genetics interact during the development of obesity. Research has demonstrated that dietary factors and excess body fat appear to be associated with damage to the hypothalamus, an area of the brain that helps regulate hunger and thirst. Studies in mice have found epigenetic changes associated with both high-fat diets and with leptin deficiencies. In one study, both high-fat diet and leptin-deficient states altered the expression of genes and then, through these changes, neuron behavior in the hypothalamus

islets of Langerhans. 299

Knowledge of blood glucose regulation helps health and fitness professionals understand the difficulties pre- sented by conditions that disrupt this process. In people with type 1 diabetes mellitus, the pancreas loses the ability to produce insulin due to the destruction of insulin-producing cells, the beta cells in specialized tis- sue in the pancreas called the islets of Langerhans. (Alpha cells in the islets of Langerhans produce glucagon.) Without insulin, blood glucose levels rise after food consumption, yet the glucose is unable to enter the cells. People with type 1 diabetes are able to give themselves insulin.

Building Self-Efficacy for Change 387

Low self-efficacy for changing negative health behaviors is often part of a learned helplessness pattern. People who have repeatedly failed at behavior change may develop the idea they do not have the wherewithal to change. As discussed in previous chapters, health and fitness professionals can help build clients' self-efficacy by helping them set small, achievable behavior-change goals and then to perceive that they have achieved these goals. Professionals can expose clients to helpful role models and encourage clients to strengthen social support networks. Classes and group programs focused on behavior change often help increase clients' self- efficacy for behavior change.

Build on Success 320

Many clients will have stories of past failures and successes. As with any behavior-change plan, health and fitness professionals should keep track of these stories and use past successes to figure out which elements to incorporate into new programs.

What Factors Influence Metabolic Rate? 341

Many factors influence metabolic rate, so anything that affects these factors will influence the idle of the metabolic engine, both at rest and during activity. One of the most-significant factors is size, especially the amount of metabolically active tissue. Muscle is one of the most metabolically active tissues, so a large, muscular person will have a higher RMR than a small, obese person. This is why increasing muscle mass will increase RMR and why larger people can eat more than smaller people without gaining weight.

Dangers of Dieting 361

Many overweight clients have a long history of dieting. In fact, many blame their dieting history for their problems with weight and food. Very-restrictive eating can interfere with metabolism, hunger, appetite, and psychological relationships with food. Unsuccessful weight- loss attempts can lead to feelings of guilt, failure, food cravings, and, ironically, obesity, as food becomes too much of a focus in people's lives. Instead of short-term, restrictive diets, health and fitness professionals should encourage lifestyle modification that people can live with for a lifetime.

Coping With Food Cravings 361

Many people experience food cravings, defined as an overwhelming desire to consume a particular kind of food. Cravings feel uncomfortable in that the craving

water 306

Many people take water for granted, but it is the most-essential nutrient. People can only survive for a short time without water. A lean, adult body is about 60% water by weight.

Does College Life Cause Weight Gain? 350

Many students do gain weight in college, although in general the average weight gain is well below the mythical "freshman 15." One study found that on average, college women gained just under 4 lb during their 4 years of college. Yet this is still a concern if those few extra pounds represent the beginning of the gradual increase in body fat that tends to occur in adults in North America. And some students do gain 10 or 20 lb or even more, and plunge deeply into struggles with obesity and body image that may last several years or even a lifetime.

Certification and licensure organizations (P.295)

Most of these also provide guidance regarding scope of practice. Many fitness certification organizations, such as the American Council on Exercise, the American College of Sports Medicine, and the National Strength and Condition- ing Association, include some basic sports nutrition information in many of their certification programs, and they allow people with certain certifications to provide basic nutrition information to clients. Athletic trainers are qualified to discuss many dietary issues with their patients. Health and fitness professionals should consult their organizations for more information.

Stress Management 384

Not only does changing the negative behavior create stress, but the behavior itself is often the client's preferred method for coping with stress. A good example of this is people who turn to alcohol to cope with feelings of stress. If they are trying to cut back on or eliminate alcohol consumption, they may feel stressed by this change.

Problem-Solving and Behavior Chains 360

Once people have recorded their eating and exercise behaviors for a few days, the self-monitoring records can be assessed. What is working well? Which behaviors are problems? In particular, which factors are causing the weight problem? People who study behavior change and lifestyle modification look at both the causes and rewards of behavior. Are there certain things that seem to trigger problematic eating? If so, can the trigger be changed (stimulus control)? If not, can a new response to that trigger be learned (counterconditioning)?

Support for Tobacco-Use Cessation 392

One of the most important is how dependent one's body has become on nicotine. In general, the longer people have been tobacco users and the more frequently they use tobacco each day, the greater the chance that quitting will be difficult. Clients' personal situations may affect how hard it is for them to quit.

Model a Positive Attitude (P.296)

One of the most-important things that health and fitness professionals can do is to model positive attitudes toward eating. This may be difficult for many professionals, especially for those who struggle with eating and food, which is pretty common in the health and fitness fields. It is important for health and fitness professionals to make peace with food, to see food as fuel and as a friend, and to model these attitudes for clients.

mesolimbic dopaminergic pathway 373

One of the most-studied reward pathways involves the neurotransmitter dopamine. It is called the mesolimbic dopaminergic pathway. Mesolimbic refers to the location of some of the brain areas involved, in the central or middle portion of the limbic system. Dopaminergic relates to the hormone dopamine. Several areas of the brain participate in this reward pathway

dietary restraint 355

One type of self-control that has been extensively studied is dietary restraint. People who exert a great deal of self-control over their food intake, even though they are feeling hungry and unhappy about their diet, develop the ability to maintain dietary restraint. Although early research proposed that excessive dietary restraint might be linked to binge eating, other researchers have suggested that high dietary restraint may simply be a marker for people who have problems overeating

Tailoring Approach to Stage of Change 385

Open-ended questions and careful listening can help the professional determine the client's approximate stage of change and adjust behavioral-counseling approaches accordingly. Professionals can employ guiding discussions of the pros and cons for change with clients in precontemplation and contemplation stages to help them form the intention to change. Those with some training in motivational interviewing (MI) will find this approach helpful

Organizational Level 349

Organizations such as workplaces, recreational groups, and healthcare systems influence the many variables that contribute to body composition. For example, some work cultures value long hours at the job, which tends to be sedentary. Such cultures limit time for healthy activities such as exercise, grocery shopping, and cooking. High stress and not enough sleep translate into increased risk of obesity for many people.

Contemplation 318

People in contemplation are thinking about making changes in their eating behavior, weighing the pros and cons of changing. They may be wondering if they should make some changes but are ambivalent about the importance of changing and their abilities to change. When working with clients in the contemplation stage of change, health and fitness professionals should help clients shift their decisional balance by reinforcing change talk and by strengthening clients' perceptions of the benefits of dietary change and reducing the perceived barriers to change. In addition, professionals should help clients build confidence in their abilities to make improvements in eating behaviors.

Action 321

People in the action stage of change have decided to change certain eating behaviors and are at least at- tempting to stick to this decision. Because eating behavior is so complex, a person may look like action in the morning, contemplation in the afternoon, and even precontemplation in the evening, if the day really falls apart. During the action stage, some parts of the new eating plan may be working while others are not. For this reason, it can be hard to tell if people are really in the action stage or not. Psychologically, many people in the action stage still feel ambivalent about dietary change and may have low self-efficacy for making their planned changes.

Precontemplation 317

People in the precontemplation stage are not thinking about changing their eating behavior. As discussed pre- viously, precontemplators may be divided into two groups, depending upon their beliefs about the value of dietary change as well as their abilities to change their eating behavior

Preparation 319

People preparing to change their eating behaviors may be gathering information from books, articles, websites, and health professionals. They may be meeting with dietitians and health-care providers to get dietary advice. People in the preparation stage may be talking to health and fitness professionals with whom they work to get some guidance on eating behavior change. Clients may be cleaning up their eating environments: giving away the chips and sodas in their kitchens or the candy in their offices. They may be trying new recipes and foods or talking to their friends and families about changes they are thinking of making.

BEHAVIOR-CHANGE STRATEGIES FOR WEIGHT MANAGEMENT 356

People seek advice on weight control for many reasons. Some people may be seeking only a temporary weight loss. Athletes trying to make a weight class or lose a few pounds for their season fall into this category. Most people, however, are hoping for long- term change, even though their initial motivation might be to lose a few pounds for a big event, such as a relative's wedding, an upcoming class reunion, or travels that require public appearance in a swimsuit. Behavioral-Learning Theory and cognitive-behavioral approaches form the heart of most weight-management programs.

The Health Belief Model and Dietary Change 317

People start thinking about their eating habits for many reasons. The Health Belief Model highlights several factors that influence people's decisions to start thinking about changing eating behavior. If people see dietary behavior as a way to address an important health issue, they may be moved to consider changing. According to the Health Belief Model, factors that motivate the decision to change include: • Perceived susceptibility to and seriousness of a health problem • Perceived benefits of dietary change • Perceived barriers to dietary change • Cues to action

Holiday Excess 359

People who have a tendency to gain weight during the winter often find that the extra stress imposed by the holiday season, combined with extra exposure to high-calorie treats, turns that tendency into a reality. In addition to stress, there is usually less time to exercise and extra alcohol—a perfect recipe for weight gain. People concerned with winter weight gain should plan a holiday survival (and enjoyment) strategy that makes health a priority. Regular physical activity should be the cornerstone of every plan since exercise not only burns calories but also reduces feelings of stress. Individuals should think about factors that have made holiday exercise difficult in the past: loneliness, travel, busyness, lack of childcare, and so on. Health and fitness professionals should help clients with active problem solving to come up with realistic plans for staying active through the holidays. What about holiday eating? Again, a survival strategy is helpful. What treats are an essential part of the holidays? How can clients avoid munching and drinking just because "it's there"? Getting enough sleep, drinking plenty of water, and finding time for fun and relaxation can help reduce hunger by reducing feelings of fatigue and stress.

Academic institutions and sport-governing bodies (P.295)

People who teach physical education classes or coach a sport are similarly limited in how much nutrition information they may give their athletes. For example, most coaches may encourage athletes to drink plenty of fluids and replenish fuel stores with carbohydrates and proteins following workouts. However, coaches should not provide specialized diet plans to individual athletes with medical conditions such as diabetes or hypertension, for example. Teachers and coaches should check with their departments and sport governing bodies for more information.

type 2 diabetes mellitus 300

People with type 2 diabetes mellitus usually produce adequate insulin (until later stages of the illness), but the insulin receptors on the cell membranes do not respond well to insulin. People with this condition are said to be insulin resistant, meaning that their insulin receptors "resist" the action of insulin. Although insulin is present in adequate concentrations in the blood, blood glucose remains high because the cell membrane receptors for insulin are not responding and allowing the cells to take up glucose from the blood. As discussed in Chapter 1, insulin resistance and type 2 diabetes are components of the metabolic syndrome, usually associated with visceral obesity and low levels of physical activity.

Community Level 315

People's food choices are often limited by community re- sources, especially the restaurants and grocery stores to which they have access. Some communities have opportunities for gardening or offer farmers' markets where local growers sell their wares. In communities known as "food deserts," people may only have access to liquor stores and convenience stores for food shopping, with larger grocery stores too far away or unreachable with transportation options. Restaurant options in food deserts may be primarily cheap fast food operation

Intrapersonal Level 315

People's food choices are strongly influenced by intra- personal factors. Biological factors, such as feelings of hunger, taste preferences, and individual energy needs influence what and how much people eat. Other intrapersonal variables include whether the individual has food allergies or intolerances, enjoys cooking and/or eating, and values time spent shopping for and preparing meals. People have been eating all their lives and have developed personal beliefs, knowledge, and attitudes regarding eating behaviors and food. They may have emotional associations with certain foods and specific eating habits that are woven into the fabric of daily life.

Precontemplation Believers 317

Precontemplation believers might believe a healthy diet is a reasonable goal, but change is not something they are currently considering. Over time, they may have decided changing is not worth the considerable effort required, so they have stopped thinking about it. Pre- contemplation believers may feel unable to change. Certainly many people have repeatedly tried to change their eating behaviors, only to find themselves unable to stick to a (commonly unrealistic) plan. Experiences such as this may lead people to feel they do not have enough willpower to change eating behavior.

Precontemplation Nonbelievers 317

Precontemplation nonbelievers may not realize that some of their eating behaviors are problematic. Al- though information on healthy eating is everywhere, advice is often confusing and contradictory and leads some people to quit believing any of it. Nonbelievers may have reached the conclusion that diet just doesn't matter that much. For some, denial of the importance of diet may be a defense mechanism, to justify why they are not trying to change.

Applying the Principles of Self-Determination Theory 387

Principles of SDT should guide behavior-change efforts, including efforts to change negative health behaviors. According to Self-Determination Theory (SDT), people need to feel autonomous in their behavior, connected to others, and competent in the activities they under- take. Health and fitness professionals should keep all three of these in mind as they work with their clients

Resistance Training Strengthens Ability to Quit Smoking 393

Prior research had suggested that aerobic exercise may reduce many of the negative symptoms associated with nicotine withdrawal. Earlier research had also suggested that a single bout of resistance training was perceived by subjects to reduce nicotine cravings. The purpose of this study was to determine whether people who engaged in resistance training during a smoking-cessation treatment would be more successful in their efforts to quit smoking than control subjects. This project was a pilot study, which means that only a small group of volunteers was used, and one of the purposes of the study was to see whether the study methods were reliable and valid and would be feasible for a larger group.

Proteins 301

Proteins are composed of smaller units called amino acids. The body uses amino acids to build its own proteins. Protein is found throughout the body, in structures such as muscle and bone; the immune cells that fight infection; the red blood cells that carry oxygen to all parts of the body; neurochemicals and hormones such as serotonin and epinephrine; and the enzymes that regulate biochemical processes such as digestion and energy production.

Behavior-Change Theory and Negative Health Behaviors 382

Psychologists have long been interested in how people change negative health behaviors, including substance- use disorders and addictions. All of the behavior-change theories and models help explain negative behaviors and addictions. Indeed, some were originally developed with a particular focus on negative health behaviors. For example, Prochaska's Stages of Change Theory was developed in the 1980s to understand the processes of change associated with changing addictive behaviors such as cigarette smoking.

substance-related disorder 377

Psychologists use the term substance-related disorder to refer to problems involving the use of sub- stances, such as drugs, alcohol, and tobacco products, and associated difficulties such as coping with withdrawal symptoms or emotional health problems related to the substance

substance-use disorder 377

Psychologists use the term substance-use disorder (SUD) to refer to problems with substance dependence and abuse.

Public-Health Campaigns Target Prevention and Promote Behavior Change 381

Public-health campaigns make use of a variety of strategies to change negative health behaviors, frequently targeting both prevention and behavior change. Public- health efforts frequently select an issue where the re- turn, in terms of health improvement, is likely to be greatest for the resources devoted to the project. Two of the most-successful public-health campaigns have focused on reducing tobacco use and rates of driving under the influence of alcohol and drugs.

Public-Health Dietary Guidelines 306

Public-health dietary guidelines can provide helpful general advice on eating for good health. When devising these guidelines, the goal of nutrition educators and public policy specialists is to take the mountains of nutrition research available and synthesize the most- important points into easy-to-understand, universally applicable advice that will do the most good and the least harm.

Co-occurring Mood Disorders 384

Research suggests that substance-use disorders frequently occur alongside mood disorders, such as depression and anxiety. This increases the complexity of designing successful behavior-change programs for negative health behaviors and addictions.

French paradox 349

Researchers have remarked on the so-called French paradox, which refers to the observation that while French cuisine is high in fat and calories, the French have much lower rates of obesity and heart dis- ease than people in the United States. How do the French not become obese on such rich food? They enjoy delicious meals, snack less frequently, and consume less sugar. The high fat content of the diet may lower hunger and decrease calorie intake.

body image. 394

Researchers who study body dissatisfaction have focused a great deal on people's concepts regarding perceptions of their physical appearance, a concept known as body image. Body image is the image people have of their bodies and includes not only how people see their physical appearance but also their judgment of what they see. This judgment includes how satisfied people are with their appearance as well as the emotions associated with this judgment. These emotions vary in intensity depending on the extent to which a person values appearance as a measure of self-worth. This means that people with similar degrees of "beauty" may have very different body images.

Self-Monitoring 322

Self-monitoring is a very effective tool for helping people change eating behavior. Depending upon the behavior-change goal, people may benefit from very simple to fairly extensive self-monitoring systems. For example, people trying to consume more fruits and vegetables may simply record servings of those foods. People making more-extensive changes may record food consumed, time of day, reasons for eating, hunger level, and activities occurring during the meal or snack . Recording these details may help to uncover productive or unproductive eating patterns and behavior chains.

Conditions Requiring Extra Dietary Protein 301

Several conditions call for extra protein in the diet. Whenever more tissue is being built, more protein is required. Pregnancy, bodybuilding, strength training, and adolescent growth spurts place high demands for amino acids on the body. Lactating mothers may be producing a quart or more of milk per day and thus need a higher-than-normal protein intake.

Cognitive Restructuring 361

Significant changes in the way people think often ac- company successful weight loss. An interesting meta- analysis of the psychological factors associated with weight-loss maintenance found that the following factors were associated with success: • Ability to avoid dichotomous thinking: Dichotomous thinking refers to an irrational thought pattern that offers only two possible categorizations. In terms of weight control, com- mon dichotomous thinking that leads to failure is "I am either on the diet or not on the diet. I am either a success or a failure." In other words, people with dichotomous thinking are uncomfortable with shades of gray; things are either black or white. Successful losers are able to be more flexible in their thinking and view lapses as something they can recover from, rather than evidence that they are no longer with the pro- gram and therefore should abandon weight-loss efforts. This observation underscores the importance of helping clients view behavior change as a lifelong journey, filled with challenges and compromises. • Ability to avoid eating to regulate mood: Successful losers are able to find alternative strategies for coping with negative moods. • Dietary restraint: Higher levels of dietary restraint are associated with weight loss maintenance. Dietary restraint helps people avoid disinhibited eating. Disinhibited eating refers to a lack of dietary restraint, where people feel unable to control how much they eat. • Perception that lifestyle-change benefits outweigh costs: Successful losers have tipped the decisional balance in favor of lifestyle modification. Although they may sometimes face difficulties maintaining their eating and exercise behaviors, the pros outweigh the cons for them. • Lower or stable levels of depression: Higher levels of depression predict relapse. Behavior change, maintaining dietary restraint, and exercise all take energy. Depression depletes self- control energy. • More-positive body image: People with a more-positive body image may have positive associations with the results of their weight-loss programs. A more-positive body image may be one of the benefits that outweigh program costs. Health and fitness professionals who have the opportunity to work with clients for extended periods of time may be able to help them identify psychological factors that may help or hinder weight loss and weight- loss-maintenance efforts. Members of weight-loss groups often point these things out to each other and encourage more-positive perspectives.

The Theory of Planned Behavior 352

Similarly, the Theory of Planned Behavior provides directions for discussion. Exploring people's attitudes, both positive and negative, regarding possible behavior change can gently nudge clients still weighing the pros and cons of change. Through discussion, people can explore the reasons behind their attitudes. Discussing clients' perceptions of social norms regarding exercise and eating behaviors can uncover potential benefits and barriers. As health and fitness professionals explore these factors with their clients, clients may move toward forming an intention to change and thus a stronger likelihood of sticking to their behavior-change programs.

disaccharides 298

Simple carbohydrates contain two small sugar units and are called disaccharides. Each disaccharide is comprised of two monosaccharides. The molecules glucose and fructose are examples of monosaccharides. Table sugar, for example, is comprised mainly of the disaccharide sucrose, which consists of one glucose molecule bonded with one fructose molecule. During digestion, simple sugars are broken down into monosaccharides that are transported into the bloodstream. The liver converts fructose and other monosaccharides into glucose or other molecules, including large chains of glucose called glycogen. Monosaccharides can also be converted into fats.

Social Support and Weight-Management Groups 360

Social support can take many forms and can help people stick to their weight-management programs. Health and fitness professionals with some skill and experience at working with groups might find that running weight-management groups is a rewardingexperience. Professionals who have been part of similar groups themselves will have some good ideas about which techniques work to build group camaraderie. Weight-management groups typically meet weekly and discuss people's successes and challenges.

Societal and Cultural Level 349

Societal forces can push people out of energy balance. Government policies, food production and distribution structures, and social and cultural norms regarding eating and exercise behavior, as well as acceptable body size, all influence the choices that people make on a daily basis. Economic forces drive consumer behavior.

Stress Management 323

Some clients may find that stress strongly influences eat- ing behaviors. If stress-induced eating appears in the self-monitoring process, discuss how clients might better manage stress. For example, clients trying to consume less salt in efforts to reduce hypertension may be fine following their eating plan except when feeling stressed, and then they may reach for a bag of salty chips. Health and fitness professionals can work with clients to help them sense when a "stress-eating attack" may be coming and to be ready with alternate strategies. When stress is a problem, doing something active is often the answer, such as taking a walk or going out with friends. Clients may be able to identify emotions that trigger poor eating, such as anger, boredom, loneliness, irritability, and sad- ness. Health and fitness professionals can reinforce the observation that regular physical activity is helpful for reducing negative emotions and feelings of stress

intramuscular triglycerides (IMTG) 336

Some fat is found in muscle tissue, in the form of intra- muscular triglycerides (IMTG). This fat stores energy and can be used to support muscular contraction during physical activity. In general, IMTG are most commonly used during submaximal exercise of medium intensity. IMTG are also used along with muscle glycogen during resistance exercise. Research indicates that women use about twice as much IMTG as men during exercise and that exercise train- ing improves skeletal muscle's ability to metabolize IMTG for fuel.

glycemic load 301

Some researchers suggest that the glycemic index of a particular food is not as important as a variable called glycemic load, which represents the glycemic index multiplied by the grams of carbohydrate in the food, divided by 100 (Bao, Atkinson, Petocz, Willett, & Brand-Miller, 2011). So while GI is measured for a standard amount of carbohydrate, GL reflects the typical serving size of foods, and better represents what people actually eat. For example, cooked beets have a relatively high glycemic index (64) but a fairly small amount of carbohydrate per serving, and thus, a low GL (4).

essential fatty acids 302

Some types of fatty acids (a component of dietary fats) must come from the diet. These are called essential fatty acids, and they include alpha linolenic acid (ALA) and linoleic acid.

Cognitive Restructuring 323

Sometimes clients find that they have unhelpful thought patterns that interfere with eating behavior change. Most common is dichotomous thinking, where clients feel like they are either totally successful or a total failure. Eating behavior is rarely perfect. Clients often benefit from practicing mindful eating and learn- ing to enjoy their food, savoring its flavors and textures. Many clients have spent years seeing food as "the enemy." Health and fitness professionals should en- courage clients to see food as fuel and even as delicious and nutritious.

Seasonal Affective Disorder 359

Sometimes winter weight gain is a byproduct of seasonal depression. Seasonal depression ranges in severity from quite mild, as in the winter doldrums, to quite severe, a condition known appropriately as seasonal affective disorder, or SAD. SAD is a type of depression characterized by recurrent episodes of depression, sleeping more than usual, fatigue, increased appetite with carbohydrate cravings, and weight gain. These symptoms typically begin in September, when the days become shorter, and continue into March. Yearly appearances of winter symptoms and their disappearance in the summer months tend to confirm a SAD diagnosis. Research suggests that in general, about 1% to 10% of people experience SAD, while an even larger number have milder forms of winter depression

Cravings 384

Strong cravings pose a significant challenge for people trying to change many negative health behaviors. People with addictions to substances or behaviors often experience strong urges to resume the behavior or substance use as they are trying to make positive changes. This makes changing negative health behaviors different in emotional tone from trying to add positive behaviors or to change behaviors that are not as habit forming.

One exception to the supplement picture appears to be eye health. 305

Studies suggest that supplements contain- ing antioxidants, especially lutein and zeaxanthin, and zinc may delay the progression of macular degeneration, an eye condition involving progressive damage to the retina, which results in a loss of vision in the center of the visual field.

Substance Dependency 374

Substance dependencies are especially likely to occur with addictive substances. Some substances, including nicotine, alcohol, and habit-forming drugs, appear to be particularly addictive. What does this mean? When a highly addictive substance, such as nicotine or morphine, activates a reward pathway, it changes the behavior of the affected neurons in some way.

MyPlate 306

The "MyPlate" icon (Fig. 9-9) replaces the older food pyramid icon as a visual guide to making better food choices. The move to a plate (rather than a pyramid) was calculated to encourage people to build healthier meals, one meal at a time, rather than to think about food choices throughout an entire day, as the nutrition information in the pyramid was designed to do. The main thrust of the nutrition advice included in the MyPlate materials is to help people eat well to prevent chronic illness, especially obesity and obesity-related health problems.

The Health Belief Model 351

The Health Belief Model highlights factors involved in forming a decision to change behavior. This model can provide topics of discussion for health and fitness professionals working with clients in the precontemplation and contemplation stages of change. This may be most likely in medical settings with people newly diagnosed with obesity-related disorders, such as type 2 diabetes or hypertension, where the Health Belief Model may be helpful.

The Theory of Planned Behavior and Dietary Change 318

The Theory of Planned Behavior highlights several variables important in helping people form a decision or intention to change and has shown some promise in moving people to consider changing eating behaviors. As discussed in previous chapters, intentions may or may not result in actual behavior change, but behavior change usually requires a conscious decision to change, along with subsequent planning. Health and fit- ness professionals may be able to guide discussions of these variables with clients in the contemplation stage: • Attitudes toward nutrition, food, and eat- ing behaviors • Subjective norms regarding eating behavior and nutrition • Perceived behavioral control or self-efficacy

Dietary Guidelines for Americans 307

The U.S. Dietary Guidelines for Americans was created by the Departments of Agriculture and Health and Human Services to guide nutrition policy in the U.S. It is revised every 5 years. These guidelines sound similar to the MyPlate advice but go into more depth on each recommendation.

net endogenous acid production 306

The Western diet, with its rich supply of meat and grain, may increase risk for osteoporosis through a variable known as net endogenous acid production (NEAP). NEAP does not reflect the acidity of foods eaten but how digestion of these foods affects the body's acid-base balance.

A meta-analysis published in 2007 examined 385 peer-reviewed publications that came out of 68 randomized trials involving 232,606 participants that examined the effect of various antioxidant sup- plements (Bjelakovic, Nikolova, Gluud, Simonetti, & Gluud, 2007). 305

The analysis found no significant positive effect for any of the supplements and in fact found an increase in mortality rate for subjects receiving beta-carotene, vitamin A, or vitamin E. Re- searchers have noted that food provides a complex mixture of hundreds of different antioxidants that work together to promote health (Van Horn et al., 2008;Van Horn, 2011). It is possible that high intakes of single antioxidants may throw the mixture out of balance, perhaps limiting the absorption or utilization of other important substances or altering the bio- chemical processes in which they are involved.

Portion Sizes Influence Individual Eating Behavior 346

The availability of food seems to motivate people to eat or continue eating even in the absence of hunger or the presence of satiety. Obesity researchers have proposed that larger portion sizes push people to overeat

Community Level 349

The community level includes neighbors and the built environment, both of which can exert strong influences on physical activity and eating behaviors and, thus, on body weight. Of course, community often overlaps with interpersonal relationships and socioeconomic status. But an interesting study that randomly assigned participants to housing groups that varied in neighborhood conditions found that level of neighborhood poverty was associated with changes in body weight

Addiction Self-Assessment 371

The following questions can be applied to use of a substance, such as alcohol or marijuana, or to the performance of activities such as exercise, gam- bling, or use of social media. Even a single "yes" answer indicates that the behavior may become a problem and possibly an addiction. 1. Does the behavior provide the primary source of gratification in my life? 2. Does it provide the primary means of escape or avoidance of problems? 3. Does it decrease my self-esteem? 4. Am I developing a tolerance for the sub- stance or activity, needing more than I did earlier to achieve the desired effect? 5. Do I need it to function? 6. Is it causing (or will it cause) the development of health problems? 7. Have others suggested I change or stop this behavior? 8. Does this behavior occur as a predictable, ritualistic, and compulsive activity? 9. Do I sometimes plan to decrease the behavior but then find I can't follow through on my plan, instead resuming previous levels of use

glycemic index 300

The glycemic index of a food is a measure of how quickly the carbohydrate in that food is digested and absorbed into the bloodstream as glucose. Specifically, glycemic index is a measure of how quickly glucose appears in the blood after a standard amount (such as 50 or 100 grams) of carbohydrate from a given food is consumed, relative to the same amount of a standard such as white sugar. This means that GI is simply a relative value rather than a precise number. In general, a GI of 55 or less is considered low; 56-69 medium; 70 or more high. Foods like sugar, white bread, and instant white rice have a high glycemic index. The sugars and starches in those foods are digested quickly, since they contain very little or no fat or fiber. Foods such as whole-grain breads, oatmeal, and berries have a lower glycemic index, since these foods are higher in fiber.

The Biopsychosocial Model of Negative Health Behaviors and Addiction 378

The neuroscience of addictive substances helps explain why people develop negative health behaviors and addictions. Yet the biochemistry of addiction is only a relatively small part of the addiction picture. In order to understand how people develop and have difficulty changing negative health behaviors, one must consider the many factors that can reinforce, influence, or even in some cases, prevent these behaviors. Factors that influence the acquisition and development of negative health behaviors often occur in clusters and interact with one another. Factors may be classified as biological, psychological, or social/environmental, although these classifications are somewhat arbitrary since the factors related to them often overlap.

12-Step Programs 383

The original 12-step program was designed by Alcoholics Anonymous (AA), which published its method of overcoming addiction in 1939 in the book Alcoholics Anonymous: The Story of How More Than One Hundred Men Have Recovered from Alcoholism (Alcoholics Anonymous, www.aa.org/timeline). Twelve-step programs generally endorse abstinence from the substance causing the addiction problem, such as alcohol, believing that any amount can trigger re- lapse. The original AA 12-step program is deeply rooted in spiritual practice, with participants guided to receive strength from the support of a higher power for relapse prevention.

substance dependence 371

The psychophysiology of substance dependence (compulsive use of chemicals such as drugs and alcohol) and addiction is discussed in more detail in the next section. Addiction is also not defined only by frequency or amount of use. Rather, whether use of a substance or performance of a behavior is categorized as an addiction depends on the reasons for and context of use or performance as well as the effect of the sub- stance or activity on the user

blood sugar 299

The term blood sugar refers to blood glucose levels. The body regulates blood glucose levels very carefully, since blood glucose is an important source of energy, especially for the central nervous system (CNS). When blood glucose levels fall too low or rise too high, people experience symptoms of CNS dysfunction: dizziness, disorientation, confusion, unconsciousness, and, in extreme cases, even death. Blood glucose levels are controlled by two important hormones produced by the pancreas. The pancreas releases insulin when blood glucose levels get too high. Insulin binds with receptors on cell membranes that encourage cells to take up glucose from the blood, thus reducing blood glucose levels.

Muscle Dysmorphia 396

The term muscle dysmorphia was coined by psychiatrist (and weight lifter) Harrison G. Pope, Jr., to described people abnormally preoccupied with the appearance of their muscles. Before the creation of this term, bodybuilders themselves had recognized the existence of the disorder among their peers and referred to it as "bigorexia" and "reverse anorexia nervosa". These terms were coined to capture the obsessive and compulsive eating and exercise behaviors observed in people with muscle dysmorphia, behaviors that resemble those seen in individuals with anorexia nervosa. But, rather than pursuing a smaller size, as seen with anorexia nervosa, people with "reverse anorexia nervosa" were trying to get bigger.

nonexercise activity thermogenesis 341

The term nonexercise activity thermogenesis (NEAT) was coined by James Levine to describe activities that do not fall into the categories of sleeping, eating, or exercise (Levine, 2004). In this context, Levine uses the word exercise to refer to activity performed specifically for the purpose of playing sports or physical condition- ing.

Winter Lifestyles 359

The weight gain associated with the winter doldrums or with SAD is often made worse by winter lifestyles. Whether clients are depressed or not, winter can lead to a decline in weekly caloric expenditure, as darker days and inclement weather limit opportunities for physical activity. This is the perfect time for prospective clients to join a fitness center. Indoor options become more attractive when winter darkness sets in. However, getting outdoors can be beneficial for combating winter weight gain. Clients whose schedules let them get outdoor exercise, especially at midday, will get double benefits of exercise and light exposure. Clients with both indoor and outdoor exercise options have more ways to fight winter weight gain

Gastrointestinal Microbiota 347

These organisms, including bacteria, viruses, and other single- celled organisms, are called microbiota; the total collection is known as the microbiome. The number of microbiota cells inhabiting the body outnumber human cells 10 to 1. A majority of these, approximately 100 trillion organisms, inhabit the GI tract

Mindful Eating Exercise 309

This exercise asks you to focus mindfully on eat- ing, trying to keep your attention focused on the food and the act of eating. Mindfulness means simply observing with awareness your sensations, feelings, and thoughts in the present moment. Try to observe your experience without judging or analyzing it. You may wish to try this with a friend, so that one of you can read the instructions aloud while the other does the exercise. This exercise should last for at least 1 minute.

Realistic and Motivational Goals 358

Too often people begin a weight-management program, either alone or working with health and fitness professionals, by focusing solely on a particular goal weight. Professionals should encourage clients to broaden their goals to include improvements in psychological and physical health variables. They should also advise clients to include process goals, such as exercising 5 days a week and attending their weight-management group meetings. Using open questions, health and fitness professionals should explore clients' hopes and dreams and link health behaviors to these goals, if reasonable. Studies have found that overweight people who lose only 5% to 10% of their initial body weight experience good improvements in many health variables, including blood pressure, blood sugar, and lipid levels. This amount of weight loss is also more likely to be achieved and maintained, the important and most difficult part. Although clients may come in with hopes of losing 25% or more of their body weight, health and fitness professionals should encourage them to think more realistically and to focus on lifestyle change rather than on dramatic but unrealistic weight loss.

Vitamins and Minerals 304

Vitamins and minerals are needed by the body in relatively small amounts, compared with carbohydrate, protein, and fat. Vitamins are fairly complex organic molecules created by plants and animals, whereas minerals are elements found in nature. Minerals are absorbed by plants from the soil and by animals from food. People do not obtain energy directly from the chemical bonds in vitamins or minerals. But vitamins and minerals play thousands of important roles in the physiological functioning of the body, from helping enzymes speed chemical reactions to providing components for stomach acid, joints, bones, and teeth. People require 13 vitamins: A, C, D, E, K, and the family of eight B vitamins (thiamine, riboflavin, niacin, pantothenic acid, biotin, vitamin B6, vitamin B12, and folate). People can usually get plenty of vitamins from the foods they eat. People can also make vitamin D (from exposure to the sun) and vitamin K (made by helpful bacteria in the GI tract). Vegetarians may need to take a vitamin B12 supplement, since this vitamin is only found in foods of animal origin. Minerals needed by people include the macrominerals calcium, phosphorus, magnesium, sodium, potassium, chloride, and sulfur. Macrominerals are needed in larger amounts than the other minerals, known as trace minerals, which are needed in small amounts. Trace minerals are equally as important as macrominerals. Trace minerals essential for humans include iron, manganese, copper, iodine, zinc, cobalt, fluoride, and selenium. The best way to obtain the wide variety of vitamins and minerals needed for good health is to consume a variety of foods, making good choices from all food groups.

Weight-Management Advice and Scope of Practice 360

Weight-control clients who are new to meal planning should meet with a dietitian to plan a personalized weight-loss pro- gram. Health and fitness professionals can support client adherence to the prescribed diet guidelines and offer practical suggestions for following the advice. Patients who are receiving medications for weight loss, on special very-low-calorie eating plans, or undergoing or recovering from bariatric surgeries should be under continuous medical care

Negative Health Behaviors: Importance of Prevention 381

With negative health behaviors, an ounce of prevention is worth a pound of cure. Any smoker who has had difficulty quitting can attest to the fact that never beginning to smoke is much easier than quitting. Once the reward pathways have been nurtured and have adapted to the negative behavior, they are upset when the behavior is withdrawn. It is better to never get these established. Prevention efforts can take many forms.

Cholesterol 304

a waxy substance that does not dis- solve in water. In the diet, cholesterol is only found in animal products. Many people confuse cholesterol with dietary fat. In fact, much of dietary cholesterol is found in animal cell structures, so even very-lean meats, such as shrimp and chicken, still have cholesterol. Cholesterol is also found in milk and eggs. Most of the cholesterol in the body is manufactured by the liver. Cholesterol is not an essential nutrient for this reason. Cholesterol is an important precursor for all steroid hormones, including vitamin D, the sex hormones (including testosterone, estrogen, and progesterone), and the glucocorticoids (such as cortisol) and mineralocorticoids (including aldosterone), which participate in the stress response.

Carbohydrates 298

are a large group of organic molecules that include starches, sugars, cellulose, and other types of fibers. Plants make carbohydrates from carbon dioxide and water, using energy from the sun.

William R. Miller and Stephen Rollnick 386

are best known for creating a client-centered approach to behavior change known as motivational interviewing (MI). While MI techniques were originally developed in the context of addiction treatment, they have been implemented and scientifically evaluated in many other health contexts and have become the basis for most evidence-based behavioral counseling today. Miller, Rollnick, and colleagues helped to radically change the way addiction was viewed and the way therapists and health and fitness professionals work with clients trying to change addictions and negative health behaviors. The game-changing nature of Miller and Rollnick's work can best be appreciated in the historical context of addiction treatment. In the early 1900s, a variety of addiction treatments were available, from snake oil magic potions to AA groups to psychotherapy. AA meeting styles tended to be supportive, viewing alcoholism as a disease and alcoholics as people needing help and guidance to overcome their addiction. Similarly, psychotherapy techniques of the time were generally discussion based, encouraging clients to explore and resolve deep- seated reasons for the addiction

Complex carbohydrates 298

are larger molecules of carbohydrate and include starches and some types of dietary fibers. Starches are composed of over two glucose units, and can be hundreds of glucose units strung together in various formations. Foods high in starch include grains and grain products; root vegetables such as potatoes, carrots, beets, and cassava; and vegetables that are the seeds of plants, such as corn, peas, and beans are high in starch. During digestion, starches are broken down into glucose units

Registered dietitians (P.297)

are licensed professionals who specialize in nutrition and health. In the United States, R.D.s have completed a baccalaureate degree program approved by their licensing organization, the Academy of Nutrition and Dietetics (formerly the American Dietetic Association). In order to earn a license, R.D.s also complete a supervised internship of at least 900 hours and pass a licensing exam. In order to maintain their license, they participate regularly in continuing education pro- grams.

Pleasure, addiction, and substance dependence 373

are mind-body phenomena. They are best understood using a biopsychosocial model, since biological, psycho- logical, and sociological factors all play important roles in the perception of pleasure and the development of positive and negative health behaviors as well as addictions.

simple carbohydrates 298

are relatively small molecules of carbohydrate found naturally in fruits and vegetables as well as milk. They are especially concentrated in sweeteners such as table sugar (usually made from sugar beets or sugar cane), honey, molasses, and maple syrup. Corn syrup is a sweetener made from the sugar in corn. Many food products contain added sweeteners.

Nutrients (P.298)

are the substances in food that provide raw material for growth and maintenance of the body and the chemical bonds that supply the energy captured and used by the cells for fuel. Nutrients are classified into six categories based on their chemical composition: carbohydrates, proteins, fats, vitamins, minerals, and water.

Trans fatty acids (trans fats, or TFAs) 302

are usually created by hydrogenation, a process used by food product manufacturers to make fatty acids in foods more saturated, and thus more stable and with a longer shelf life. While TFAs have a carbon-carbon double bond, the arrangement of other atoms around the bond lead to a shape of the fatty acid that is similar to saturated fatty acids. Greater intake of trans fats in the diet has been linked to higher rates of artery disease. Trans fats may increase this risk through effects on blood lipid levels (raising LDL cholesterol levels and lowering HDL cholesterol levels), artery lining function, and making the blood more likely to form blood clots

Water-soluble fiber 299

attracts water and forms a gel-like mix in the digestive system. This mixture slows stomach emptying, helping eaters feel full longer. Delayed stomach emptying also means that glucose is absorbed from the digestive mass more slowly, thus preventing a rapid rise in blood glucose, which can lead to high blood insulin levels. Water-soluble fiber tends to bind bile acids in the small intestine. Bile acids are high in cholesterol. When the bile acids are bound to the fibrous mixture, their cholesterol is not available for reabsorption; thus, soluble fiber is thought to be beneficial for people trying to reduce blood cholesterol levels

Skinfold and circumference measurements

can be demoralizing. Many people, especially overweight people, do not like being measured in such a personal way. Having one's abdominal fat pulled or pinched by a technician can be embarrassing or demeaning.

visceral adipose tissue (VAT) 337

consists of fat stored around the abdominal organs, including the liver, stomach, intestines, and kidneys. Excess VAT appears to be the link between obesity and negative health effects such as artery disease, type 2 diabetes, hyper- tension, and inflammatory disorders. Although waist circumference gives some information about central obesity (excess fat storage in the torso), it does not reveal whether the excess fat is sub- cutaneous or VAT.

Body- composition tests used in a health and fitness context typically divide body mass into 332

fat mass (FM) and everything else, or fat-free mass (FFM). Some body- composition assessments also calculate bone mass. There are many ways to estimate body composition. Some are used primarily in research and medical settings, whereas others are likely to be avail- able in exercise physiology laboratories and in health and fitness facilities.

Unsaturated fatty acids 302

have at least one carbon- carbon double bond. Monounsaturated fatty acids have one carbon-carbon double bond, whereas poly- unsaturated fatty acids have more than one. The location of this carbon-carbon double bond helps to name the fatty acid and affects the fatty acid's structure and behavior in the body

Omega-3 fatty acids 302

have the carbon-carbon double bond at the third carbon from the end of the fatty acid. Dietary sources of omega-3s include fish oils and some plant and nut oils. Fish oils contain special long-chain omega-3 fatty acids, including docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA). DHA and EPA have been associated with beneficial health effects, including reduced levels of inflammation and slower rates of blood clotting. This is why many public-health recommendations suggest that people increase their consumption of fish. Oily fish such as salmon, tuna, sardines, mackerel, and herring have the highest concentrations of these fatty acids. In some studies, fish oil supplements have also been associated with reductions in symptoms of depression, although results have not been consistent. ALA is another type of omega-3, although its effects on the health variables mentioned above do not appear to be as strong as those of DHA and EPA. On the other hand, omega-6 fatty acids, found primarily in plant oils, have been associated with higher levels of inflammation and increased rates of blood clotting.

Glycogen 298

is a form of starch manufactured by animals. Humans manufacture and store glycogen primarily in the liver and in skeletal muscles. Glycogen serves as a source of glucose when the body needs fuel. Liver glycogen is converted to glucose and released into the bloodstream when blood glucose levels fall too low. Skeletal muscles use glucose liberated from glycogen to fuel muscle contraction. Many athletes are careful to consume adequate amounts of carbohydrate to maximize glycogen stores so that they have adequate energy for training and performance. Athletes preparing for important endurance events may even consume extra-high amounts of carbohydrate for a few days prior to an event to maximize glycogen stores. (Glycogen stores will also be more likely to be at maximal levels if athletes taper training—reduce training volume—for several days before their event.)

Mike Durham, L.S.W., L.I.C.D.C. 391

is a substance abuse counselor and educator. He works with students at the Kenyon College Counseling Center and teaches a course on drug abuse and treatment for the Social Work Department at North Central State College in Ohio. The initials after his name stand for licensed social worker and licensed independent chemical dependency counselor. Mike has more than 20 years of experience in drug abuse treatment and prevention, relapse prevention, and education. Motivating young people in the precontemplation and contemplation stages of change to address drinking and drug-use behavior is not easy work. Mike often works with students who don't even want to see him, so it is a testament to his patience, compassion, and communication skills that by and large the students think he is pretty cool

ventral tegmental area 373

is found in the limbic area of the brain. Neurons originating in the VTA project to other areas of the brain, including a group of neurons in the limbic system known as the nucleus accumbens. Stimulation of the VTA in both laboratory animals and in humans causes feelings of pleasure. Neurons from these areas run to many other parts of the brain, including the amygdala, which helps process emotions, and the hippocampus, which is involved with memory. Neurons also connect these areas to the prefrontal cortex, an area of the brain important for making decisions and planning complex behaviors.

Walter C. Willett, M.D., Dr. P.H 303

is professor of epidemiology and nutrition, chair of the Depart- ment of Nutrition at the Harvard School of Public Health, and professor of medicine at the Harvard University Medical School. Willett has been a guiding force in some of the largest and most highly regarded epidemiological studies on lifestyle and health, especially nutrition and health. These landmark studies include the following. • The Nurses' Health Study began in 1976 under the direction of Frank Speizer, collecting data on lifestyle behaviors and health of 121,700 women. Willett joined the research team soon thereafter. This study was one of the first to examine lifestyle and health in women. • The Nurses' Health Study II, established by Willett and colleagues in 1989. This study is gathering data on 116,000 younger women. • The Health Professionals' Follow-up Study was organized by Willett and colleagues in 1986 to examine data from 52,000 male medical professionals. • The Growing Up Today Study began in 1996 and is looking at 16,000 children of women participating in the Nurses' Health Study II.

Metabolic rate 341

is the energy expenditure required to sustain metabolism in a given time period, usually expressed per hour. Most people are familiar with the terms "metabolic rate" and "metabolism" and generally use these words to mean how quickly the body consumes fuel, or burns calories.

Harm reduction 385

means acknowledging that total abstinence may be an unrealistic goal at the present time. While help- ing professionals may still promote abstinence, in the meantime they also take immediate steps to at least reduce the level of harm associated with a given behavior.

Tolerance 375

means that it takes increasing amounts of the substance in question to produce a given effect

Antioxidants 304

neutralize harmful chemicals that are produced as a byproduct of energy metabolism or from the intake of pollutants. Fortunately, plants and animals, including humans, have evolved complex antioxidant systems.

Abuse 372

occurs when use of the substance or performance of the behavior hurts or endangers the user or those around him or her. Alcohol abuse can occur in a single episode of drinking; driving while intoxicated is always considered alcohol abuse. Or alcohol abuse may consist of frequent heavy drinking that can lead to many health and behavioral problems. Going to class or work while intoxicated, getting into legal trouble as a result of drinking, experiencing blackouts, and getting injured while intoxicated are indicators of a drinking problem.

water loss 311

of even 1% or 2% can cause a decrease in physical performance.

Dietary fat 302

provides a concentrated source of energy, with 9 kilocalories (kcal)/gram, compared with 4 kcals/g for carbohydrates and proteins. (Alcohol has 7 kcal/g.) This is usually why people trying to limit calories generally attempt to limit fat intake. Some fat in the diet is important, however. Fat gives food flavor and slows gastric emptying and the rise of blood sugar following a meal.

Water-insoluble fiber 299

provides bulk to the feces and speeds their passage through the GI tract. Water- insoluble fiber reduces risk of constipation. Like most dietary components, too much soluble or insoluble fiber can be problematic, causing diarrhea and intestinal discomfort.

Saturated fatty acids 302

refer to fatty acids in which the bonds between carbon atoms are all single. Single carbon-carbon bonds are more stable than double bonds and affect the behavior of these fatty acids. For example, saturated fats tend to be more stable at higher temperatures. This explains why butter (higher in saturated fatty acids) is solid at room temperature, and plant oils are not (lower in saturated fatty acids).

Withdrawal symptoms 375

refer to signs and symptoms experienced by users when the substance to which they are addicted is not used. Withdrawal symptoms are somewhat specific to the substance of addiction.

Mindful eating 308

refers to a present-moment, nonjudgmental awareness of the physical and emotional experience of eating. Mindful eating means paying attention to the appearance, smell, textures, and tastes of food (Health Psychology in Your Life 9-1). Mindful awareness during food consumption may enhance people's ability to tune into their physiological feelings of hunger and satiety (feeling like one has had enough to eat).

Appetite 345

refers to a psychological desire to eat. Appetite is affected by hunger, of course; however, hunger refers to a strictly physical drive while appetite includes other physical and psychological drives.

craving 375

refers to a strong and usually uncomfortable drive to consume a given substance or participate in a given behavior.

Body composition 330

refers to an estimate of how much of a person's mass is composed of fat. Body-composition estimates are sometimes helpful for planning weight- management strategies.

Dietary fiber 298

refers to structures that are not broken down by the digestive system. Dietary fiber comes primarily from plants. Some types of dietary fiber, such as cellulose, are composed of carbohydrates.

hunger 344

refers to the biological drive to eat. Hunger's opposite, a feeling of having had enough to eat, is called satiety. Many different hormones and physiological systems influence feelings of hunger and satiety. For example, the hormone ghrelin is released by the stomach, and as ghrelin levels rise, hunger in- creases. As one eats, these levels fall as the stomach senses the presence of food. Similarly, as food reaches the small intestine, it releases several neuro- chemicals, including cholecystokinin, which promote many digestive processes and tell the brain the body is no longer ravenous.

Addiction 371

refers to the compulsive use of a substance or performance of an activity even though the person experiencing the addiction knows it is causing or is likely to cause harm. Addiction is also characterized by a loss of control over the substance use or performance of the activity as well as denial, since addicts do not accurately perceive the negative effects of the addictive behavior

Energy balance 340

refers to the relationship between energy taken in (or eaten) and energy expended, or "burned." A negative energy balance means that more energy is expended than taken in. Over time, a negative energy balance will result in pushing the body to use stored fat for energy, causing weight loss. A positive energy balance means that more energy is consumed, or eaten, than expended. Over time, a positive energy balance encourages the body to store energy as adipose tissue.

pathogenic weight control 394

refers to weight-control practices that can be harmful to physical and psychological health. Examples of pathogenic weight-control practices include using tobacco products and drugs to lose weight

The use, abuse, addiction continuum 373

represents the idea that people's relationships with potentially addictive substances and behaviors can be somewhat fluid. People's behavior may suggest different points on the continuum on different days.

One of the most-common weight-for-height measures of size 331

the body mass index, or BMI. The higher the weight for a given height, the greater the BMI. A BMI of 25 or more is considered overweight, and a BMI of 30 or more is categorized as obese. A BMI of 18.5 or less is considered underweight.

Nutrition (P.294)

the process of nourishing the body with food. The science of nutrition studies everything related to this process, including how people decide what to eat; the biochemistry of consuming, digesting, absorbing, and metabolizing food substances; and the relationship between eating behavior and health.

Some suggestions for healthy weight gain include: 313

• Assess current lifestyle and solve any problems that prevent adequate food intake and regular strength training. Are clients skipping meals? Grabbing meals that are too small? A little organization and planning may help clients have access to the foods they want to eat and make more time for eating. • Reduce feelings of stress, if stress interferes with appetite. Encourage clients to eat more mindfully and in a relaxing environment. • Increase strength training. Resistance training triggers muscle building, so clients should include a good amount of lifting in their exercise programs. Clients new to strength training should start slowly and build gradually. Guidance from a personal trainer or other qualified fitness professional can help clients prevent injury and maximize muscle building. Some people worry that exercise will make them thinner, but, as long as they increase their calorie intake, this will not occur. Exercise can reduce feelings of stress, stimulate appetite, and help clients eat more as they build muscle. • Have a good snack after exercise. Strength training stimulates muscle repair and growth. During recovery, the body replenishes muscle glycogen stores and rebuilds muscle fibers to make them bigger and stronger. Consuming some protein within 30 minutes of exercising allows recovery metabolism to work in high gear. Most people are not very hungry immediately after exercise, so cool beverages such as smoothies and shakes may work best. • Allow muscles at least 48 hours of recovery time to optimize muscle building. If clients strength train almost every day, the health and fitness professional must structure workouts to alternate muscle groups and include at least one rest day each week. • Eat more food. Clients should add more meals and snacks to their day, thinking of snacks as small meals. Clients will probably need to plan ahead to be sure that good food choices are available when they need to eat. Encourage clients to choose calorie-dense foods as much as possible. For example, they should choose chili or split pea soup rather than broth-based soups. Granola has more calories per bowl than puffy cereal. Beverages such as smoothies are a great way to add calories. • Consume some protein foods with each meal or snack. This recommendation is especially important for frail elders, who build muscle much more slowly.

Athletes sometimes speak of low- and high-glycemic- index foods as slow and fast carbohydrates. 301

• Athletes (and all people) who experience hypoglycemia (low blood sugar) need a snack that can bring blood sugar quickly up to normal. High-glycemic-index foods are best in this situation: sports drinks, fruit juice, or dried fruit, for example. • People with diabetes may strive to minimize spikes in blood glucose levels. Consuming carbohydrate foods with protein, fat, and fiber can slow carbohydrate absorption. • Athletes participating in multiple contests or practices during the day need to replenish muscle glycogen stores quickly between sessions. High- glycemic-index foods are helpful in this situation. • Athletes often want to avoid a rapid rise in blood sugar immediately before exercise, since that can be followed by a release of insulin and then a rapid drop in blood sugar, causing fatigue. Low- glycemic foods and meals are often preferred for pre-event meals: pasta dishes, smoothies (yogurt-fruit drinks), or bananas, for example.

Self-Determination Theory reminds health and fit- ness professionals that people have three important drives. All three have great bearing on behavior-change work in weight management: 353

• Autonomy: People seek autonomy. They want to feel like they have choices and that they are acting in accordance with their own wishes. Health and fitness professionals should use a guiding style when recommending behavior change in any situation, including behavior change for weight management. Professionals should support weight-management clients in shaping meaningful goals and rewarding lifestyles, rather than "telling clients what to do" and focusing solely on weight loss. • Competence: People like to feel as though they have some skill in the activities in which they engage. They like to feel competent, or at least as if they are improving and doing fairly well. When people feel incompetent, they lose motivation to continue trying. Health and fitness professionals should uncover clients' strengths in the health behaviors that are the program focus. • Connection: Relationships that generate positive feelings are motivational. Here is where many health and fitness professionals fall short, as their lifelong biases against overweight people, stereo- typical beliefs, or simply feeling superior to people who are overweight can interfere with authentic relationships.

Strategies that may help clients to quit using tobacco products include the following: 392

• Building social support. Many people find that smoking-cessation programs are extremely helpful. Clients may be able to find a program through their workplace, health insurance, local healthcare organizations, or community groups. The American Lung Association has designed a program offered both in groups and online called Freedom From Smoking. These pro- grams help people design effective quit-smoking strategies. In addition, most people appreciate the help of family and friends. Smokers might try spending as much time as possible with people who support their intentions to quit. • Improving lifestyle to prevent fatigue, stress, and weight gain. Relapse is most likely when people are feeling tired and stressed. Clients can fight fatigue by eating well and get- ting enough sleep. They should try to avoid snacking unless truly hungry. Some ex-smokers develop a tendency to replace cigarettes and other forms of tobacco use with chewing. If chewing helps, encourage clients to try crunchy vegetables or sugarless gum. They should drink at least four glasses of water a day to prevent fatigue from dehydration. • Use of medical support as necessary. Nicotine-replacement products such as electronic cigarettes, nicotine patches, and nicotine gum dramatically decrease the risks associated with the use of tobacco products and can help people overcome their behavioral addictions to tobacco use first and then gradually taper their reliance on nicotine. Some people find that they need antidepressants or other medications to help them overcome a tobacco-use habit. • Identification of behavior chains. Health and fitness professionals can help clients identify their personal tobacco-use patterns. Smoking- cessation programs often begin by asking participants to monitor smoking behavior throughout the day. As they break down the antecedents and consequences of tobacco-use behaviors, clients can then avoid or come up with alternative responses for the situations that tend to trigger tobacco use. Those who have quit before can learn from previous attempts. They can anticipate situations and feelings that might lead to a relapse and think of ways to get through these times without resuming a life-threatening habit. • Exercise. Studies have found that people who exercise regularly while quitting smoking have better success than nonexercisers. Exercise can relieve feelings of depression, anxiety, irritability, and tension. Exercise helps combat the negative health effects of smoking, especially by reducing risk for heart disease. Regular physical activity improves sleep quality and helps prevent or reduce the weight gain that sometimes occurs when people quit smoking

Health Effects 389

• Cardiovascular Health: Moderate drinking, which means about one drink per day for women or one to two drinks per day for men, confers some benefit on the circulatory system • Liver Disease: Alcohol consumption is associated with a wide range of liver diseases. Alcohol and its toxic metabolites (breakdown products of alcohol metabolism) damage liver cells. A large majority of heavy drinkers (over five drinks per day) develop steatosis, or fatty liver. Fatty liver describes the disease: fat deposits accumulate in the liver, and the liver becomes enlarged. Fatty liver is reversible with abstinence from alcohol. If steatosis is accompanied by inflammation and other damage to liver cells, it progresses to alcoholic hepatitis, or steatohepatitis. This condition is somewhat reversible, at least in earlier stages. Liver cirrhosis is diagnosed when collagen scar tissue replaces healthy liver tissue, thus leading to a decline in liver function. Cirrhosis is a very-serious illness and the 12th leading cause of death in the United States Cirrhosis can also set the stage for the development of liver cancer, hepatocellular carcinoma. Cancers: Alcohol and its metabolites can initiate cancers in other areas of the body as well. Alcohol intake, even at relatively low levels, is associated with increased risk of cancers of the respiratory system; breast cancer; and cancers of the gastrointestinal (GI) tract, including the mouth, esophagus, stomach, colon, and rectum• Pancreatitis: Excessive alcohol intake is the primary cause of pancreatitis, chronic inflammation of the pancreas. • Immune System Damage: Acute and chronic alcohol abuse appears to interfere with many aspects of immune response, leading to a higher risk of all kinds of infections. Alcohol abuse is also associated with behaviors that increase the transmission of infectious diseases, which can exacerbate alcohol's negative effects on immune function. Especially harmful are the increased rates of pneumonia, tuberculosis, hepatitis C infections, and HIV infections associated with alcohol abuse. • Changes in Brain Structure and Function: Alcohol abuse is associated with damage to several brain areas and symptoms of poorer brain function. Memory, decision-making, motor coordination, and other functions can decline with alcohol abuse. • Fetal Alcohol Spectrum Disorders: Scientists have long known that alcohol can be a teratogen, a substance that disrupts fetal development, causing irreversible damage. Fetal alcohol spectrum disorders include a wide range of physical, behavioral, and cognitive abnormalities, caused by exposure to alcohol during fetal development. • Harmful Behaviors: Alcohol abuse is strongly associated with a plethora of harmful behaviors, including accidental death and injury due to motor vehicle accidents, drowning, burns, and firearm accidents.

Basic Characteristics of Addiction 371

• Compulsive drive to use addictive substance or perform addictive activity • Loss of control over the behavior • Harmful consequences • Distorted perceptions and denial concerning the addiction and its consequences

People with muscle dysmorphia may have several of the following characteristics 396

• Devotion to daily resistance exercise, even when injured. • Profound dissatisfaction with their bodies. • Extremely rigid or ritualistic eating behaviors. • Anabolic androgenic steroid use. • Additional psychological disorders.

Several health behaviors can increase the drive to overeat, alter appetite, and interfere with the sensation of satiety, including the following: 345

• Food choices: One might think that a calorie is a calorie, but the body thinks differently. Some foods make the body think it has had a satisfying meal, while others don't seem to connect with hunger level the way they should. Foods high in fiber, such as fruits, vegetables, and whole grains, lead to more stomach fullness than foods high in fat and lower in volume. • Sleep habits: Even a single night of missed sleep is accompanied by a rise in ghrelin and a higher intake of calories. Chronic sleep deprivation has become more common over the past several decades, and some researchers speculate that this is one of the reasons that obesity rates are rising in many countries (Knutson et al., 2007). • Chronic feelings of excess stress: A lack of relaxation and chronic high levels of stress affect feelings of hunger and satiety as well as appetite. Although some people lose their desire to eat when feeling stressed, the majority of people tend to eat more than usual, perhaps turning to food for comfort. Since food in- take alters neurotransmitter levels and behavior in the central nervous system (CNS), food can indeed soothe. Stress may also leave people with less time to shop and plan healthy meals, so they grab whatever is near with less thought for nutritive value. • Emotional eating: Research has demonstrated that food cues exert powerful effects on the CNS, especially in areas that integrate emotion, arousal, cognition, and energy balance. Food cues include food's appearance, taste, and smell, or even just thoughts about food. Studies have also found that food intake, independent of food cues, can affect emotion. • Knowledge-based work: Several intriguing studies have found that people eat more after per- forming demanding mental tasks than after sitting quietly. People whose jobs involve challenging mental work (students take note!) may find themselves eating more. The brain uses glucose for energy, so perhaps the energy required by knowledge-based work lowers blood sugar level. Physical activity level: Many people are afraid to exercise because they fear exercise will increase hunger. Ironically, people who engage in moderate exercise usually eat the same or only a few more calories than they do on days when they don't exercise .

Some of the factors associated with the development of eating disorders include: 397

• Genetic predisposition • Gender. Females have much higher rates of eat- ing disorders than males, comprising about 85% to 90% of those diagnosed with eating disorders • Anxiety disorders, depression, and substance- use disorders. • Cultural factors.

Experts have offered many explanations for the wide spread body dissatisfaction found in many cultures: 395

• Impossible standards of ideal appearance • Body objectification. Objectification means to regard something as an object. Body objectification refers to the practice of regarding the body, especially one's appearance, from an outsider's perspective. Most of the research on body objectification and body-image dissatisfaction focuses on females. Research has found that to enhance their social desirability and self- evaluation, girls and women tend to be very concerned with their appearance and often go to great lengths to increase their physical attractiveness • Family behaviors and attitudes • A belief that self-control can give one the perfect body. • Living in a culture of first impressions.

Foods and nutrients to increase 308

• Increase vegetable and fruit intake: Health and fitness professionals have been pleased to see this advice take center stage in both the MyPlate and the U.S. Dietary Guidelines. • Eat a variety of vegetables: This guideline en- courages consumers to expand their vegetable choices and to include dark-green, red, and orange vegetables in their diet as well as beans and peas. • Consume at least half of all grains as whole grains: This guideline encourages people to re- place refined grains with whole grains. For example, the guidelines advise people to replace white rice with brown rice, and use whole-wheat products in place of those made with white flour. • Increase intake of fat-free or low-fat milk and milk products: Consumers are encouraged to look for non- or low-fat dairy products such as milk, yogurt, and cheese. • Choose a variety of protein foods: The protein food group is no longer called the "meat" group. Sources of protein include seafood, lean meat and poultry, eggs, beans and peas, soy products, and unsalted nuts and seeds. • Increase the amount and variety of seafood: Consumers are encouraged to consume seafood in place of some other meats. • Replace protein foods that are higher in solid fats with choices that are lower in solid fats: This guideline encourages people to reduce intake of saturated fat. • Use oils to replace solid fats: This guideline's goal is similar to the one above. • Choose foods that provide more potassium, dietary fiber, calcium, and vitamin D: These nutrients are likely to be low in the average diet. The guideline urges consumers to increase consumption of vegetables, fruits, whole grains, milk, and milk products.

Some of the activities that have contributed to a reduction in tobacco use rates have included 382

• Increased taxation on tobacco products, making them more expensive to consumers. • More laws regulating allowable levels of secondhand smoke in the air of workplaces and public places. This led to prohibitions on smoking in many public venues, such as transportation centers and modalities, restaurants, offices, and schools. • Laws regulating the advertisement of tobacco products. • Legislation requiring health-risk warning labels on tobacco products. • Increased enforcement of penalties for businesses selling tobacco products to minors. • Health-promotion programming at schools, workplaces, and community centers supporting people's efforts to quit smoking. • Increased communication with medical and allied health professionals regarding the importance of advising patients to quit smoking and providing suggestions on how to help patients quit. • Development of medical products, such as nicotine gum and other nicotine medications as as the electronic cigarette, to help people reduce tobacco use or to at least reduce some of the harmful effects of smoking.

The following factors suggest that it's time for people to take a closer look at their caffeine habits: 376

• Irregular heartbeat • Feelings of stress and anxiety • Insomnia • High blood pressure • High intakes • Concerns about bone density and osteoporosis • Reproductive concerns • Ulcers and heartburn • High blood cholesterol levels

In addition to referring clients with disordered eating for professional help, health and fitness professionals can do the following: 398

• Model healthy behaviors. Education is not always helpful. Ironically, talking to your clients about eating disorders can make things worse. Instead, model healthy attitudes: food is delicious and nutritious; food is fuel, and healthful eating supports exercise and sports performance. • Pay attention. Don't ignore eating disorders. They have the highest mortality rate of any psychological illness. Your feedback may help get your client into treatment. • Take a team approach. Work with your supervisor and colleagues when you are worried about a client. Your workplace should have guidelines and procedures in place for referrals for eating disorders and other psychological problems • Speak to your client in private. Express your concern and cite specific, objective, observable behaviors that worry you. Encourage the client to meet with a counselor. • Keep your distance. Don't counsel your clients about eating disorders. Offer sympathy and a referral. Avoid discussions about food and weight. • Be patient. Eating disorders are difficult to overcome, and recovery may take a long time. Be tolerant, respectful, and supportive. • Learn about eating disorders.

Suggestions for minimizing the self-control needed for eating behavior change include 320

• Set reasonable goals that feel attainable to clients. Don't expect unlimited self-control. • Manipulate eating environments to promote desired behaviors. Reduce foods that lead to unwanted eating at home and work and urge clients to have healthy foods for meals and snacks readily available. • Help clients set up grocery shopping lists and meal plans. Try to make healthy eating as simple, convenient, and affordable as possible. • Urge clients to prevent hunger by eating delicious, nourishing, well-balanced meals and snacks. Hunger is stressful for most people, and distress depletes self-control energy. Plus, the brain uses blood glucose in its efforts to exert self-control. Hunger is also a powerful drive in its own right and can easily overwhelm self-control efforts. • Encourage clients to get adequate sleep, manage stress, and exercise. Self-control energy increases with these behaviors.

Researchers have identified important components common to successful behavior-change programs. These include the following: 388

• Social support • Structure and goal setting • Rewards, including rewarding activities that reinforce positive behaviors • Normative models for behavior change success • Improvement in self-efficacy for behavior change • Development of coping skills

Foods and food components to reduce 308

• Sodium: The guidelines recommend that sodium intake be reduced to less than 2,300 mg per day for healthy young people. The guidelines suggest an even lower limit, 1,500 mg, for about half of the population, including people over 50, all African Americans (who have a higher risk of hypertension), and anyone with hypertension, diabetes, or kidney disease. • Saturated fatty acids: The guidelines recommend reducing these to less than 10% of total daily calories, replacing them with unsaturated fats. • Cholesterol: The guidelines recommend less than 300 mg per day. • Trans fatty acids: The guidelines recommend keeping these as low as possible by limiting consumption of products with hydrogenated oils. • Refined grains: The guidelines suggest limiting food with refined grains, especially those with added sugars, sodium, and solid fats. Solid fats refer to saturated fats and TFAs. • Alcohol: The guidelines suggest limiting alcoholic beverages to one per day for women and two per day for men, if alcohol is consumed.

S.M.A.R.T. goals 320

• Specific: Consume five servings of vegetables a day, incorporating a wide range of choices. • Measurable: Consume two servings of vegetables with lunch, a cup of vegetable juice around 4 p.m., and two servings of vegetables with dinner. • Attainable: Clients should try to be realistic about their abilities to attain the above, adjusting as necessary. • Relevant: Professionals should listen to clients as they discuss goals and verify that the goals address health concerns. • Time-bound: Clients should spell out a time frame for achieving this goal. While some clients who are already consuming three or four servings of vegetables per day may be comfortable jumping to five servings right away, others may find that it is more realistic to begin with three and then the following week move to four, then five.

symptoms of exercise addiction to show that these symptoms resemble descriptions of behavioral addictions: 399

• Tolerance. People addicted to exercise may find they need more exercise than they used to in order to achieve the desired effect, such as feelings of euphoria, reductions in anxiety, or feelings of accomplishment. • Withdrawal. When people addicted to exercise are unable to exercise, they experience negative effects such as restlessness, irritability, anxiety, and problems sleeping. • Lack of control, lack of ability to follow through with intentions to change behavior. People addicted to exercise may be unsuccessful in their attempts to decrease exercise volume. Even though they may have intentions to exercise less, they are unable to do this. They persist in excessive exercise despite knowledge that the exercise behaviors are harming physical or psychological health and/or interfering with interpersonal relationships. • Time spent on exercise and behaviors related to exercise. A great deal of time is dedicated not only to exercise itself but also to preparation for and recovery from exercise activities. • Reduction in other activities. People with exercise addiction usually decrease time spent on other activities, including activities related to work and social and recreational activities they used to enjoy.

The most-common negative health effects of obesity include the following: 338

• Type 2 diabetes and heart disease: Diabetes may result when some of the chemicals produced by the macrophages interfere with blood sugar regulation. These chemical messengers prevent the body's cells from responding appropriately to the hormone insulin, which signals cells to take up sugar (glucose) from the blood. High blood sugar levels in turn cause more dam- age, including accelerated aging of the arteries, thus contributing to artery disease, the leading cause of heart disease and stroke. High blood sugar also causes damage to the eyes, kidneys, and nerves .• Hypertension: High insulin levels create a stress response in the body, raising levels of stress hormones and activating the fight-or-flight response. This can contribute to hypertension. • Risky blood lipid levels and heart disease: Excess triglyceride production (from excess calories) raises levels of blood fats, including blood triglycerides and low-density lipoprotein (LDL) cholesterol levels. These lipids contribute to the formation of arterial plaque and more inflammation, as macrophages attempt to deal with damaged arteries. • Other inflammatory disorders: The inflammation caused by obesity may contribute to other disorders associated with inflammation, such as liver disease, pancreatitis, asthma, and rheumatoid arthritis. Obesity also increases risk for Alzheimer's disease .• Cancer: Obesity is associated with increased risk for many types of cancers. Researchers have suggested that fat tissue may secrete chemicals that make people more susceptible to cancer. The inflammation associated with VAT may promote the transformation of precancerous cells into cancer cells, so that the immune system is aiding in cancer promotion rather than destroying dangerous cells. Adipose tissue may also promote existing cancers in other ways. For example, higher levels of adipose tissue increase estrogen levels, and estrogen promotes the growth of certain types of cancers, such as ovarian and breast cancer. In addition, excess subcutaneous fat may decrease the efficacy of cancer screenings, hiding cancer tumors. Health professionals emphasize, however, that this research is preliminary and advise that cancer patients not lose weight, as extra weight can be protective once cancer has already developed. • Nonalcoholic fatty liver disease: Excess fat can be deposited in the liver. Excessive alcohol intake can also cause excess fat deposits, so non- alcoholic fatty liver disease is diagnosed when fatty liver develops in people who drink little or no alcohol. In severe cases, the fat that accumulates in the liver can cause inflammation and scarring. • Physical strain: The physical strain of excess weight can overload weight-bearing joints such as the hips, knees, and feet, and accelerate development of the joint degeneration and pain associated with osteoarthritis. Excess weight in the belly can alter posture and cause back problems.