ISSA Certified Nutritionist Main Course Textbook

Nutrition: The Complete Guide
800.892.4772 • ISSAonline.edu

Second Edition
International Sports Sciences Association CERTIFICATION COURSES
Second Edition
John Berardi, PhD, CSCS
Ryan Andrews, MS, MA, RD
Brian St. Pierre, MS, RD, CSCS
International Sports Sciences Association Krista Scott-Dixon, PhD
1015 Mark Avenue • Carpinteria, CA 93013
Helen Kollias, PhD, CSCS
1.800.892.4772 • 1.805.745.8111 (international) • 1.805.745.8119 (fax)
Camille DePutter
www.ISSAonline.edu
Krista Scott-Dixon, PhD
Helen Kollias, PhD, CSCS
Camille DePutter
Nutrition
The Complete Guide
issaonline.edu
Nutrition: The Complete Guide (Edition 2)
Official course text for: International Sports Sciences Association’s Certified Nutrition Specialist program
10 9 8 7 6 5 4 3 2 1
Copyright © 2018 International Sports Sciences Association.
Published by the International Sports Sciences Association, Carpinteria, CA 93013.
All rights reserved. No part of this work may be reproduced or transmitted in any form or by any electronic, mechanical, or other means, now
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Direct copyright, permissions, reproduction, and publishing inquiries to:

International Sports Sciences Association, 1015 Mark Avenue, Carpinteria, CA 93013
1.800.892.4772 • 1.805.745.8111 (international)
DISCLAIMER OF WARRANTY
This text is informational only. The data and information contained herein are based upon information from various published and
unpublished sources that represents training, health, and nutrition literature and practice summarized by the author and publisher.
The publisher of this text makes no warranties, expressed or implied, regarding the currency, completeness, or scientific accuracy of
this information, nor does it warrant the fitness of the information for any particular purpose. The information is not intended for use
in connection with the sale of any product. Any claims or presentations regarding any specific products or brand names are strictly the
responsibility of the product owners or manufacturers. This summary of information from unpublished sources, books, research journals,
and articles is not intended to replace the advice or attention of health care professionals. It is not intended to direct their behavior or
replace their independent professional judgment. If you have a problem or concern with your health, or before you embark on any health,
fitness, or sports training programs, seek clearance and guidance from a qualified health care professional.
About the Authors | iii
About the Authors

Dr. Berardi has been recognized as one of the top exercise nutrition experts in the
world. He earned a PhD in Exercise Physiology and Nutrient Biochemistry at the
University of Western Ontario, Canada. His work has been published in numerous
textbooks, peer-reviewed academic journals, and countless popular exercise and nu-
trition books and magazines.
As an elite nutrition coach and exercise physiologist, Dr. Berardi has worked with
over 50,000 clients in over 100 countries, including Olympic gold medalists, world
champion UFC fighters, and professional sports teams. He is also an advisor to Apple,
Equinox, Nike, and Titleist.
Dr. Berardi was recently selected as one of the 20 smartest coaches in the world and
one of the 100 most influential people in fitness.
With a PhD from York University in Toronto and 10 years of university teaching,
Krista Scott-Dixon has over 20 years of experience in research, adult education, cur-
riculum design, and coaching and counseling. In addition, she has spent over 20 years
pursuing self-education in health and fitness.
Through writing, coaching, speaking, teaching, and curriculum development, Krista

has galvanized thousands of clients to transform their health and fitness for the better,
and is guiding a new generation of fitness professionals to a higher level of success and
satisfaction.
Krista is the author of several books, dozens of popular articles, and many academic
publications. She also inspires readers at her groundbreaking women’s weight training
website, Stumptuous.com.
Ryan Andrews is a world-leading educator in the fields of exercise science and

nutrition.
Ryan is a Registered Dietitian with two master’s degrees. He completed his education
in exercise and nutrition at the University of Northern Colorado, Kent State Universi-
ty, and Johns Hopkins Medicine.
A highly respected coach who has been a part of the Precision Nutrition team since
2007, Ryan’s body of work includes an impressive number of articles, presentations,
books, and certification manuals on the topics of eating, exercise and health.
A nationally ranked competitive bodybuilder from 1996-2001, and now a certified

yoga instructor, Ryan is also an active volunteer with non-profit organizations to help
promote a sustainable future.
International Sports Sciences Association

iv |
Brian St. Pierre is a renowned expert in performance nutrition.
Brian is a Registered Dietitian with a Masters in Food Science and Human Nutrition
from the University of Maine. He is also a certified strength and conditioning spe-
cialist, a certified sports nutritionist, and the author of five books including the High
Performance Handbook Nutrition Guide.
As Precision Nutrition’s Director of Performance Nutrition, Brian contributes to

ground-breaking research, education and curriculum development at PN, where he is
also an esteemed coach.
Brian shares his expertise on a global scale by presenting at conferences around the
world, serving as a nutrition consultant for pro sports teams such as the San Antonio
Spurs, Brooklyn Nets, and Cleveland Browns, coaching professional and Olympic
athletes, and writing for popular publications including Precision Nutrition.
Camille DePutter is an author, speaker, and communications consultant with a rich

portfolio of experience in marketing, public relations, and storytelling.
Camille received her HBA in English from the University of Toronto and trained at
the Humber School for Writers. An advisor to Precision Nutrition, Camille lends her
communication expertise to Precision Nutrition publications, course materials and
marketing content.
As a consultant, Camille has helped dozens of top brands and business leaders refine
their messaging and improve their customer relationships. Her work has been pub-
lished extensively in popular websites, magazines and newspapers.
Camille writes for the Precision Nutrition Encyclopedia of Food and is a frequent con-
tributor to the Precision Nutrition blog. She is also the author of the workbook Share
Your Story, and self-publishes at camilledeputter.com.
Dr. Helen Kollias is a researcher and L1 Certification advisor at PN. She is also a
regular content contributor to the blog, where she uses her witty and articulate writing
style to make complex science accessible and entertaining.
Helen holds a PhD in Molecular Biology from York University, specializing in the area
of muscle development and regeneration, and a Master’s degree in Exercise Physiology
and Biochemistry from the University of Waterloo. She has also held research posi-
tions at some of the most prestigious institutions in the world, including John Hop-
kins University and Toronto’s Hospital for Sick Children.
Outside the lab, Helen has played and coached varsity soccer, and has been involved
in fitness and weight training for almost two decades. She also has two daughters with
whom she wants to share her joy of inquiry and experimentation, but above all, she
wants to teach them resilience, bravery, and grit.

How to Use This Text | v
How to Use This Text

When faced with new information, students usually wonder one thing:
“Will I ever need to know this in the real world?”
Whether it’s the cosine of an angle, Kepler’s laws of planetary motion, or the enzyme
responsible for forming citrate, students’ most common questions about what they’re
learning are:
“Will this be on the test?”
“Will I ever need to know this again in my life?”
We, the authors, know these questions well. We’ve asked them ourselves, most often
during our own high school, undergraduate, and graduate studies.
So now, as instructors living in the “real world”, we’d like to level with you: Probably
not.
Unless you become an engineer, you probably won’t need the cosine stuff. Unless you
go to work for NASA, you can probably forget Kepler. And the Krebs cycle? Well, you
won’t need that unless you teach biochemistry.
So why learn all this information?
Well, most of us don’t know what we want to be when we grow up. Work (and life) is
full of surprises.
You never know what career path you’ll follow, or what hobbies you’ll take up.
Be prepared for anything. Learn as much foundational knowledge as possible. Now

you have options.
But there’s another, more inspiring, reason for learning this stuff.
It’s actually kinda interesting. It helps explain your world. And makes you super-fun at
parties.
In fact, when you really dig into this knowledge, you might just change what you want
to do for a living because of it.
What this means
In this program, we’ll provide a lot of foundational knowledge.
We give you more details below.
This foundational knowledge — about stuff like cells, digestion, metabolism and
whatnot — can feel a little heavy at times. Especially if you’re new to this material. Or
you’re a practical, hands-on kind of person who would rather spend more time doing
than reading.
Hang in there.

vi |
The payoff comes in the second section, where that foundational information gets
applied.
We’ll give you case studies. Strategies for working with real-world clients. Question-
naires and assessments to use with your clients. Psychological strategies for getting
clients excited about working with you. And all kinds of other fun things.
Even if you’ll never use the more theoretical material we teach you, you’ll still need
to know the science to apply it under “test conditions” — in other words, when you’re
sitting across from a client.
By the end of this course, we expect you to understand:

• how the body works;
• how to apply that knowledge to working with clients;
• how to assess, monitor, and revise client programs;
• how to communicate your knowledge effectively; and
• how to get your clients on board with your nutrition plans and programs — hopeful-
ly feeling just as inspired as you about making progress and changing their nutrition
habits.
How the program is organized

This course is split up into two units.
Section 1: Nutrition science
In Section 1, we’ll go through all the nutrition information you’ll need to know, such
as:
• How and why your cells work the way they do
• How carbohydrates, fats, vitamins, minerals, and other nutrients interact with
your cells
• How food becomes energy for maintenance functions, physical work, and repair
• How your body balances out the food you eat with the work it does
• How exercise affects nutritional needs and how nutrition affects exercise
Section 2: Nutritional practice
In Section 2, we’ll introduce you to how to coach, including:

• What it means to be a good coach
• How to prepare for clients
• How to interact with different clients
• How to assess clients
• How to know which approaches are best for which clients
• How to meet clients where they are (not where you want them to be)
• How to keep clients progressing from day one until they reach their goals

How to Use This Text | vii
Other learning tools

Throughout the textbook, look for things like:
Unit objectives
Each unit contains clear objectives at the beginning. This will tell you what to focus
on, and give you goals before you even start reading.
Unit summaries
At the end of each unit, we’ll summarize the most important points from that unit.
These will confirm that you’ve learned what really matters, and give you another handy
tool for review.
Key terms
The first time a key term appears in the text, it is highlighted and a definition provided
in the margin. Familiarize yourself with each key term.
Case studies
Most units end with relevant case studies. These give you “real-life” examples of ap-
plied nutrition.
Each story describes a client’s nutrition challenges, then provides practical solutions to
work through these challenges.
References
We’ll provide a comprehensive list of references used to create this course. If you’re
interested in learning more about nutrition and health, you can look up and read more
of this primary source literature.
How to focus your learning

Just like coaching or training, learning should be focused and systematic, with a clear
purpose.
Here are some ways to stay on track and on target with your Level 1 journey.
Learn what you need to learn
You know your own learning style. (And if you don’t, now’s a great time to discover it.)
Help yourself succeed by building a system that suits you.
Use as many ways of processing the material as possible: reading, writing, thinking
and reflecting, listening, watching, talking about the material, drawing maps and
flowcharts of ideas, etc.
We suggest…

viii |
1. Read the unit. (textbook)
2. Watch the video. (online)
3. Answer the workbook questions. (study guide)
4. Take the quiz. (online)
Set up a weekly self-study schedule so you get into a routine. Consistency and struc-
ture will help you move forward steadily and confidently.
Focus on key concepts
As the scientists working on the 1999 Mars lander mission found out when their
precious spacecraft wandered off into oblivion because they mixed up imperial and
metric measurements, details are important.
But details usually aren’t the most important things in this program. You don’t have
to memorize entire units, nor usually recall minute details (such as the exact body
density equation by Jackson & Pollock).
As long as you learn the concepts and study as we recommend, you have a great
chance of doing well on the quizzes.
Plus, you’ll always have your text available for reference. If you get stumped during a
quiz or a client interaction, you can always look things up.
It’s more important to know how to think. How to learn. How to connect ideas.
And to understand why things are important (and how they relate to one another) than
to recall specific details. (Unless detail memorization is your thing. Then go for it.)
What to look forward to

If you show up consistently, ready to learn and grow, and if you engage with this materi-
al using all the learning methods that work best for you, then this course will make you
a better coach.
Seek to master both the basic science (Section 1) and the applied art of coaching
(Section 2).
If you do, you’ll finish this program as a highly trained professional with the knowl-
edge to support your recommendations; the ability to communicate them effectively
and well; and a foolproof system for delivering outstanding, reproducible results.
Let’s get started.

Acknowledgements | ix
Acknowledgements
It’s really important to us that everyone who helped bring this major project to com-
pletion is recognized for their work. Because, as we all know, nothing worth doing can
be done alone.
To this end we’d like to thank Paul Bradbury, Rachael Bell, Phil Caravaggio, Al Cimi-
no, Alwyn Cosgrove, Alison Dungey PhD, Georgie Fear MS RD, Carmelo Galati RGD,
Jonathan Goodman, Sean Greeley, Mariane Heroux PhD, Timothy Jones, Bedros
Keuilian, Helen Kollias PhD, Sarah Maughan MS, Bob Moesta, John Nadalin, Spencer
Nadolsky DO, Tom Nikkola BA, Eric Noreen PhD, Prasanna Paul, Alex Picot-Annand
MS, Pat Rigsby, Francisca Ruff, m.c. schraefel PhD, Chris Spiek, Bryan Walsh ND, and
Erin Weiss-Trainor.

Contents 5 Aerobic and Anaerobic Metabolism, p137
How metabolism changes , p138
How exercise affects metabolism, p139
Introduction — Nutrition: The big picture, p2
Muscle and metabolism, p140
What is food?, p3
Energy demands of muscle, p143
What is good nutrition?, p6
Oxygen consumption, p144
What’s the best diet?, p11
Anaerobic versus aerobic exercise, p146
The cycle of food, p15
How we adapt to exercise, p148
What is nutrition coaching?, p16
Summary, p154
What this program will cover, p20
Summary, p20 6 Macronutrients, p155
Macronutrients, p156
Section 1: Nutritional science, p22
Summary, p195
1 Cells, p23
7 Micronutrients, p197
Cell structure and function, p24
Micronutrients, p198
How the body is organized, p25
Vitamins, p199
Nutrition and cellular interaction, p28
Minerals, p201
Parts of cells, p31
Getting vitamins and minerals right, p203
Body function, p39
Vitamin and mineral overview, p205
Cell types, p42
Phytonutrients and myconutrients, p226
Summary, p44
Summary, p229
2 Through the GI Tract, p45
8 Water and Fluid Balance, p230
Controlling the digestive process, p65
The big picture, p233
How do we absorb our food?, p70
Body water imbalances, p235
Summary, p76
Body water regulation, p241
3 Energy Transformation and Metabolism, Hydration strategies, p245
p77 Summary, p251
Energy intake, storage, and transfer, p78
How are nutrients metabolized?, p87 Section 2: Nutritional practice, p252
Summary , p111 9 What It Means To Be a Good Coach, p253
4 Energy Balance in the Body, p112 Why talk about coaching?, p254
Energy value of food, p113 What’s your story?, p255
Estimating energy needs and energy intake, What do great coaches do?, p259
p119 Understanding clients, p262
Energy balance and imbalance, p124 Mental skills, p264
Achieving energy balance… naturally, p133 Communication skills, p267
Summary, p136 Summary, p269
10 The ISSA Nutrition Coaching 15 Special Scenarios, p431
Methodology , p270 Start with the basics, p432
The process of change, p271 Disordered eating, p433
The 6 steps of coaching, p272 Food addiction , p442
The early stages of the change process, Alcohol , p446
p278
Nutrition and immunity, p447
Assessment and triage, p279
Injuries / inflammation, p452
Identifying and clarifying values, priorities,
and goals, p283 Sex and gender , p454
Choosing a direction for coaching and Ethnicity, heritage and genetics, p461
building an early action plan, p287 Life stages and aging, p462
Working through normal client Food sensitivities, p469
ambivalence, p290 Plant-based eating, p471
How to communicate effectively, p295 How we fit into the food system, p473
Putting it into practice: What’s ahead, p296 Summary, p478
Summary, p299
16 Business 101 for Fitness and Nutrition
11 Nutritional Levels, p300 Pros, p479
Working with nutritional levels, p301 What’s next for your coaching practice?,
Summary, p316 p480
Smart business strategies for nutrition
12 Working with Level 1 Clients, p317 coaching, p481
Level 1: Where it all begins, p318 How to attract clients: Frequently asked
Level 1 clients and your coaching process, questions about sales and marketing, p488
p321 Making it work: Avoid common mistakes,
Level 1 limiting factors and coaching p491
strategies, p327 Summary, p492
Troubleshooting Level 1, p353
17 Continuing Ed for the Coach, p493
Summary, p359
Keeping up to date, p494
13 Working with Level 2 Clients, p360 Taking it further, p495
Level 2: An introduction, p361 Staying on top of research, p496
Level 2 strategies, p370 Developing your coaching practice, p497
Troubleshooting Level 2, p393 Summary, p499
Summary, p397
References, p500
14 Working with Level 3 Clients, p398
Index, p522
Level 3: Special situation nutrition, p399
Level 3 strategies, p404
Troubleshooting Level 3, p424
Summary, p429
INTRODUCTION
Nutrition: The Big Picture

Nutrition: The Big Picture | 3
Unit Outline
1. Objectives 5. The cycle of food
2. What is food? 6. What is nutrition coaching?
3. What is good nutrition? 7. What this program will cover
4. What’s the best diet? 8. Case Study
9. Summary
Objectives
This unit will introduce you to the big picture of good • why good nutrition matters for personal health, as well
nutrition. as community and global health
You’ll learn: • how to answer the often-asked question: “What’s the

best diet?”
• how we define and think about food
• some of the things to think about when you sit down
• how we define and think about good nutrition
to eat a meal
What is food?
Seems like a dumb question with an obvious answer. Food is stuff we eat that
fuels our body. Right?
Well, that’s one way to think about it. Food contains energy. Or, more correct-
ly, “chemical bonds that, when broken, are used to create ATP, the fuel for our
cells.” (More on that in a later unit.)
But food also includes micronutrients, phytochemicals, zoochemicals, fiber, Zoochemicals: Components
water, and perhaps even organic molecules that we haven’t yet discovered. All of found in animal food sources
these substances play crucial roles in our body, even though they don’t necessari- Organic: Obtained from living
ly “fuel” it directly. things
Micronutrients: Vitamins and minerals

We need vitamins and minerals in our diet. Without them, our body breaks Vitamins: Organic compounds
down. required by an organism as a vital
nutrient in limited amounts
For example: Minerals: Naturally occurring,
inorganic substances
Vitamin C (also known as ascorbic acid) is a powerful antioxidant that can help
Inflammation: The reaction
control inflammation and cellular damage. of a tissue to injury or infection,
characterized by heat, redness,
The mineral magnesium plays a role in more than 300 enzyme systems and helps swelling, and pain
with protein synthesis, muscle and nerve function, blood sugar control, blood

4 | Introduction
pressure regulation, energy production, and transport of when you fill your car’s tank with gas, you know more or
other minerals. less how far you can drive.
The list could go on and on. You’ll learn more about But if you’ve spent any time doing “calorie math”, you’ll
these and other nutrients in later chapters. know that trying to calculate precise inputs and outputs
for a human body is frustrating.
While none of these nutrients provide “fuel”, we still
need them to live and thrive. • Maybe you ate more calories than you thought you
should… but got leaner.
When you’re missing key vitamins and minerals, your
• Or you ate fewer calories than you thought you
body doesn’t work properly. You feel rotten. And you get
should… and gained weight.
sick. That’s true no matter how much fuel is in the tank.
• Or you started eating breakfast instead of skipping
Phyto- and zoochemicals it…or vice versa... and dropped a couple of inches off
your waistline.
Phytochemicals (whose name comes from the ancient
Greek phuto, or plant) are nutrients that only occur in According to the simplistic “food as fuel” view, none of
plants. Phytochemicals are one of the main reasons that this should be possible. Yet it happens all the time.
eating fruits and vegetables is good for us.
Human bodies aren’t combustion
For instance, phytochemicals have been shown to:
engines.
• offer DNA protection against free radicals;
They’re complex, dynamic, organic, and infinitely sensi-
• protect against cancer;
tive systems.
• decrease the risk of heart disease; and
For example: Research now shows that all food isn’t creat-
• reduce overall mortality. ed equal, and what we eat isn’t necessarily what we absorb
or use. Dozens — maybe even hundreds — of factors
Zoochemicals (from the Greek zoion, or animal) are
affect how we digest, process, and utilize the food we eat.
nutrients found only in animal products, such as CLA (a
fatty acid), creatine, and carnosine. This means that the fuel, or calorie, value of food
outside the body isn’t necessarily the same as the value
Zoochemicals have been shown to:
inside the body.
• reduce inflammation and blood clotting;
Plus, our body has its own priorities.
• protect against heart disease;
• suppress cancer cell development; and

For instance, the body will extract nutrients to keep you
alive by any means necessary, often making tough com-
• inhibit complications from diabetes. promises along the way. This would be sort of like your
car suddenly driving itself to the gas station and holding
Phyto- and zoochemicals don’t provide “fuel.” Which up the cashier until it gets what it needs, or cannibaliz-
means that the “food as fuel” story leaves them out too. ing its own headlights for fuel.
Food is so much more than fuel. What’s more…
Your body isn’t even completely

Living organisms are not machines.
“human.”
They’re incredibly complex, self-regulating, and dynami-
cally responsive — almost magical — systems. The trillions of microbial critters living in and on us do
much of our digestion and nutrient extraction. Analysis
Machines have precise inputs and outputs. For instance,

of our bacterial environments shows that each of us has an individual gut flora
“microbiome”, like a fingerprint. Microbiome: The genetic
content of all the microorganisms
that inhabit the GI tract
Changing our microbiome changes our digestion and absorption, and hence our
body composition and health.
We’re incredibly complicated, self-organizing, agenda-driven, only-sorta-human

systems. Frankly, the machines should be jealous. So, if the “food as fuel” idea
doesn’t give us the whole story, what is food?
Food is — in part — information.

When we eat, we’re delivering messages to our body.
• Do this.
• Don’t do this.
• Release this hormone.
• Don’t release that one.
• Express this protein.
• Don’t express that one.
Food (and the act of eating) sends instructions that kick off a chemical chain
letter. Each molecule of food contributes to a beautiful cascade of events, sending
all kinds of signals throughout our body.
Make hormones! Trigger immune cells! Switch genes on and off! Tell the work
crew to clean up and the builders to get on standby! Lights! Camera! Action!
It’s like the biggest, busiest movie set you can imagine. And somehow — unlike
many film sets — it runs almost perfectly.
Our body processes millions of calories and (let’s be scientific about this) zillions
of chemical compounds a year, with nearly 100% efficiency. (Just for comparison,
gas-powered engines, like our car, would be happy to hit 30% efficiency.)
Even cooler: Our thoughts, feelings, and environment can affect these process-
es. If we smell a tasty meal, have a positive or negative thought about food (or
anything else), are happy and relaxed or worried and rushing…it affects nutrient
processing.
Food is smart. And so is your body.

Thinking about food only as fuel reduces food to gasoline, your body to a dumb
machine, and you to a calorie accountant. You’re more than that.
Food and your body deserve a lot more recognition and honor.
The more we learn, research, and work with clients, the more we’re amazed at the
power of food.

6 | Introduction
Food is packed with meaning, For a nutrition coach, knowing these stories is relevant.
information, and communication. Crucial. Powerful, life-shaping knowledge.
Every food decision we make sends a message to our Take a few minutes and consider these questions:
body. • What is food?
Every food choice is an opportunity to direct, shape, and • What is food… for you?
remake our health. Our body composition. Our perfor-
• For your clients?
mance. Our wellbeing.
Is it fuel? Is it information? Is it personal freedom? Is it
Food tells a story. shame? Is it self-esteem? Is it comfort?
Many of us in this field are physiologists and biochem- Then consider these questions:
ists. Sure, we look at food through a science lens. But
that’s not our only perspective. • What would you like food to be?
• What do you imagine it could be?

We know, too, that sharing food is a fundamental hu-
man act. Breaking bread (or whatever other food is on We encourage you to think big. Get imaginative. Learn
the table) is part of our history. Our culture. Our legacy a little more about physiology. Learn a little more about
as humans. humanity. Discover what makes food one of the greatest
stories ever told.
Food isn’t just a chemical story. It’s a story about
people. A story of the wonder of evolution and biology. A
collective grand epic of our humanity. A chemical story
How we eat, where we eat, and what we eat (or don’t)
written in molecules, not words. It’s a story that shapes
tells a story. Food helps us communicate about who we
your daily life, your health, and your function.
are, what we think about, and what’s important to us.
Food is fuel? No. It’s so much more than that.
For instance:
• I’m sophisticated. I’m a “foodie.”
What is good nutrition?
• I’m a thoughtful consumer. I’m a regular at the farm-
ers’ market. If food is more complicated than just fuel, then good
nutrition is probably more complicated than “following
• I’m from Mexico / Italy / Nigeria / Laos / [insert region
the rules.”
/ origin / ethnicity] and proud.
• I’m the social hub for my big family. Come on over Take a minute to answer this question for yourself: What
is good nutrition?
this Sunday for dinner!
• I’m adventurous. I’ll eat anything once. Once, when I We’ve given this question a lot of thought over the years.
was traveling, I ate… As of today, here’s how we answer it:
• I’m careful with my choices. I avoid processed food.

Good nutrition controls energy
• I’m low maintenance; my fridge is empty. Let’s grab
something on the go. balance.
• I’m a bon vivant. I love eating at fancy restaurants. As we’ve seen, food is more than fuel… but it does give
• I’m a caregiver. I love you. So I cook for you.
us energy.
And so on. Without enough energy coming into the body, we just
don’t work right. Our body starts to shut down processes
These stories are essential information about ourselves, that we don’t absolutely need to survive, such as reproduc-
about our family and friends, and about our clients. tion, some aspects of metabolism, and brain function.

Too much energy coming into the body also causes problems. We can become
resistant to important hormones (such as insulin or leptin). Inflammation may
increase. Plaques can form on vessels and blood pressure can go up. We risk
getting many chronic diseases. Chronic diseases: A long-acting
disease that does not quickly
resolve, e.g., cardiovascular
Good nutrition helps control energy balance. We don’t eat too much or too little. disease, cancers, chronic
We can stay healthy, fit and strong. We feel good, and our body shows it. respiratory diseases and diabetes
Good nutrition gives us nutrients.

Each food has a certain nutrient density, or nutrients per amount of food. Since
we want to eat the right amount of food for our needs, we want to make sure that
that food is loaded with nutrients.
Imagine several plates, each one full of one type of food:

• a plate of kale
• a plate of lentils
• a plate of cookies
• a plate of salmon
• a plate of berries
• a plate of saltine crackers
Now, per plate of food, ask:

• How many calories are in each plate?
• How many nutrients are in each plate?
In some cases, like the cookies, there are lots of calories but few nutrients. That’s
called low nutrient density.
On the other hand, with the kale, there are lots of nutrients but few calories.
That’s called high nutrient density.
We need nutrients to live, and to thrive. Nutrients help us be as healthy as possi-

ble, perform at our best, and live long, active and vibrant lives.
Good nutrition helps us balance energy intake and getting enough of these
valuable, essential nutrients.
Table I.1: High- versus low-nutrient-density foods

Higher nutrient density Lower Nutrient Density
Bright or deeply colored vegetables Potato chips
Bright or deeply colored fruits Soda and fruit juices
Beans, meats, eggs Hot dogs, deli meats
Whole grains Refined grains/flours, pastries

8 | Introduction
Good nutrition helps us look, feel,

and perform our best.
Good nutrition — and good nutrition coaching — helps
our clients do what is most important to them, without
other things getting out of balance. Performance Health
An athletic client might be focused mostly on perfor-

mance. You can also help them stay healthy and strong
as they train. Or to be the right weight (or body fat
percentage) for their sport.
Body Composition
An older client might want to simply live healthier and
better. You can also help them keep the bone and muscle
that will keep them active and mobile.
A client who dreams of looking good at the beach or at a

big event (such as a wedding) might want to lose weight.
Figure I.1 Good nutrition resides in the intersection between
You can also help them prevent chronic diseases. health, performance, and body composition.
Good nutrition is about helping people look better. Feel

better. Perform better. Live better. And just be better
overall. • A study of Canadians found that over 60% of the cal-
As a nutrition coach, take a holistic approach. Help your ories they eat come from highly processed foods.
clients balance specific goals with general benefits — • In the US, just over 11% of calories come from fast
perhaps even benefits they didn’t realize were possible. food.
• That “5 servings a day of fruit and vegetables” habit?

Good nutrition is outcome-based. Data show that only 30% of people in the UK are do-
ing it… and only 8% of Australians. (And often, those
Every nutrition choice you make will lead to an out-
vegetable servings are potatoes.)
come. Those outcomes can be measured. And they’re a
great mirror of reality. • Over 90% of clients report eating at least one meal in
a cafeteria or restaurant a day. While some people are
That’s why we love the question “How’s that working for
undoubtedly making healthy, less-processed choices
you?”
when they eat out, many folks are probably not.
Whenever someone tells us they eat really “healthy” —
That’s why good nutrition includes using outcomes (data
which is just a concept in their head — the best fol-
and reality) to inform future decisions.
low-up is “Great! How’s that working for you?”
We use this question because it tests perception Good nutrition is sustainable for
against reality. If someone thinks they’re eating really
“healthy”, but they just don’t have the body, health, both us and the planet.
or performance that could be expected, maybe that
Can we keep eating and producing food the way we are
person’s idea of “healthy” doesn’t match reality. Maybe
now? For how long?
they’re not making outcome-based decisions.
Research suggests that we waste between 30 and 50% of
Indeed, lots of people in North America think they have
all food produced.
a really healthy and balanced diet.
Yet, for example:

Food often travels thousands of miles between the farm and our dinner plate.
While global food production has gone up, hunger and malnutrition are still big
problems worldwide. And more crops than ever before are being grown to feed
livestock (not people).
With a planet that isn’t growing and a population that is, our food decisions need
to be more sustainable and environmentally considerate than ever before.
Luckily, what helps the planet usually helps our body and health as well. That’s why
good nutrition is about finding a diet that is sustainable for us and the planet.
Good nutrition is about removing limiting factors.

If you can help your clients identify their limiting factors — the things that stand
between them and reaching their goals — you’ll become a great nutrition coach.
While you’re building up your expertise, here’s a quick list of possible limiting
factors to look for. (We’ll share more examples later on.)
Genetics and epigenetics

Genetics (the blueprints of our body) and epigenetics (factors that control how
our genes are expressed) can affect how your clients respond to nutrition. Epigenetics: The study of
changes in organisms caused by
For example: modification of gene expression
rather than alteration of the
• Few clients will have the genetic makeup to reach the upper limits of human genetic code itself
performance.
• Some clients will have genetic factors that can make losing weight, gaining
muscle, completely avoiding chronic diseases, or other physical outcomes
easier or harder.
• Some clients will be genetically more or less able to metabolize certain foods
or chemicals, such as caffeine or particular amino acids.
Amino acids: The building
Genes are not destiny. Epigenetic factors — such as nutrition, stress, or a healthy blocks of protein. Organic
environment — can strongly affect genetic expression. So you might carry sev- compounds containing both
eral of the known gene variants for obesity… but you can also choose what to eat COOH and NH2
for dinner, or put on running shoes and get outside. Gene variants: Diversity in gene
sequence within a population
Almost everyone can make daily choices that will keep them as healthy, fit, and or among populations that are
vibrant as possible, for their individual body. most commonly due to single
nucleotide polymorphisms (SNPs)
or copy number variants (CNVs)
Exercise
Activity changes how our body uses nutrients. Active and fit people can eat
more, use nutrients more efficiently and effectively, and keep their metabolisms
healthier than sedentary and unfit people.
So exercise (or lack thereof) can be an important limiting factor.

10 | Introduction
At the same time, exercise alone isn’t enough to keep your clients healthy or lean.
(Which is one reason that your work as a nutrition coach is so important.)
Physiology
If you’ve ever had a serious metabolic or hormonal problem, or an imbalance of
neurotransmitters, you’ll know: Physiology is powerful.
Work with, rather than against, your clients’ unique physiological makeup, and
help them understand what’s realistic. (But stay hopeful.)
Take an integrated approach: Collaborate with your clients’ health care provid-
ers, if needed, to work together as a team.
Mindset
Every action starts with a thought. Thoughts become things.
Negative, sabotaging or inaccurate thoughts, self-talk and beliefs can hold your
clients back. Not only do negative mental dynamics affect clients’ behavior, they
also have physiological effects: Our brain and body treat these like any other
stressor, and respond accordingly.
Luckily, as a nutrition coach you can help replace negative mindsets with things
like positive self-talk or better information.
Notice how your clients think, and the stories they tell themselves. Consider how
you can also improve those thoughts and beliefs as part of your nutrition coach-
ing. (We’ll look more at this in Section 2.)
Also consider how you can help your clients move from knowing information to
taking action.
A winning mindset plus a great nutrition action plan… that’s a recipe for success.
Environment
What’s around your clients?
Who is on their team? (Besides you.) How are their relationships at work, home,
school, or elsewhere?
What’s their schedule like?
What’s their physical environment like? Are healthy choices close and
convenient?
Most of our daily decisions are unconscious. We don’t think about them. We
just make them. So our environment strongly shapes what we do, eat, and think
about.
Even if your clients really want to make better choices, they’ll probably also need
to adjust their environment to do so.

Good nutrition looks for strengths and wins.

Good nutrition isn’t about “following the rules” or “being strict.” It’s about en-
abling happier, healthier, fuller lives.
As a nutrition coach, you’re looking for limiting factors, but also for your clients’
advantages, strengths, and opportunities for success.
How can you take what’s already working, and improve on it?
Now, of course, if you’re looking for strengths and wins, you’ll probably wonder...
What’s the best diet?

As a fitness professional, one question you will often get asked is which “nutri-
tion camp” you fall into. Are you into Paleo? What about vegan? Intermittent Paleo: A diet built upon foods
presumed to have been eaten by
fasting? Detoxing? Or any number of other “flavors of the month” (so to speak)?
early humans
And clients will want to know: intermittent fasting: A diet
that cycles between periods of
“What’s the best diet?” eating and not eating
The secret:
There isn’t one.
Here’s why.
Clients are diverse.

Here are just a few ways that your clients can differ:
• Body type: Some clients are tall and thin; others short and stocky. Or every-
thing in between.
• Fitness level and body composition: Some clients are active, strong, lean,
and dense. Some clients have been sedentary for the last 50 years and may be
frail, without a lot of muscle.
• Dietary preferences and exclusions: Whether kosher, halal or Jainist;

plant-based or carnivore; scavenger or “picky eater”; iron stomach or “allergic
to everything”, clients have a vast range of food preferences and many reasons
for them.
• Budget: Your client might be a broke student, a middle-class family trying to

make ends meet, or a highly paid executive — perhaps even a pro athlete.
• Organic / conventional: Some clients live on boxed and packaged foods.

Some clients try to read labels, sometimes. Some clients may choose only kale
that has been lovingly grown by a sect of Californian monks who hand-pluck
the bugs off.

12 | Introduction
• Nutrition knowledge and diet history: Some • “real-life” testing and client experience.
clients will be devout followers of a certain dietary
practice, or a history of trying different diets. Others
Good coaches stay skeptical, think critically, and take a
broad perspective.
have very little nutrition knowledge at all.
• Time: Some clients have an open schedule, ready for Indeed, here’s one crucial piece of evidence:
any kind of health and fitness project. Others have
a crowded daily schedule and countless conflicting The healthiest people in the world
priorities.
don’t have a single nutrition
• Ethnic background and heritage: Our coaches
philosophy.
practice all over the world. Our clients live, and come
from, all over the world. A meal or cuisine that suits Physiologically, the human body can do well under all
an Anglo family may not suit their Hispanic, Somali, kinds of different nutritional conditions.
or Punjabi neighbors. A client from a northern Euro-
We can see this clearly if we look at the traditional diets
pean ethnic group may digest dairy easily, while the
of indigenous groups and ethnic groups throughout the
client of Japanese heritage next to them may not.
world.
• Age: As we age, our metabolisms change, our food
• For example, the Arctic Inuit and African Masai eat
tolerances and appetites change, and our digestive
traditional diets that are high in fat and animal prod-
abilities change.
ucts, with few vegetables.
You get the picture. • Conversely, Kitavans in the South Pacific, the Hadza
of East Africa, and many groups in the Amazon basin
As a nutrition coach, your job is to help your clients — as
(such as the Tsimane of Bolivia) eat traditional diets
unique people — get to their goals. To do what matters
to them, in the way that’s best for them. that are low in fat but high in vegetables and starchy
carbohydrates.
The best coaches don’t have a single • The !Kung of Africa eat traditional diets that are made
up of mostly nuts and seeds.
nutrition philosophy.
This is also true if we look at the world’s Blue Zones,
You might have the approach you like, or one that areas where people live exceptionally long and healthy
worked for you. Great. That’s a solid start. lives.
But good coaches take a flexible approach. They borrow You probably wouldn’t mistake Okinawan cuisine for
the best ideas from everywhere and everyone, and are the Mediterranean cuisine of Sardinia, Italy or Ikaria,
always looking for new insights or tools. They don’t get Greece. Or the Central American cuisine of Costa Rica’s
stuck in dogma. Nicoya peninsula.
These cuisines and dietary patterns differ.

The best coaches use data and
evidence to make decisions. Yet people eating these ancestral or traditional diets have
much fewer of the chronic “diseases of affluence” (such
Throughout this course, we’ll encourage you to wear as cardiovascular disease, stroke, diabetes, obesity, etc.)
your scientist hat and gather data for outcome-based considered normal in industrialized areas.
decision making.
Good coaches look at the evidence. This can include: The human body adapts amazingly
• peer-reviewed clinical and scientific research; well to many different ways
• understanding the basis of how and why things work of eating.
(or don’t); and
You can be healthy and fit whether you eat mostly meat

or mostly veggies, mostly fat or mostly carbohydrates, many times a day or just a Carbohydrates: A group of
few times, and so on. compounds including sugars,
starch, and cellulose
Which means that, as a nutrition coach, you shouldn’t really belong to any spe-
cific nutrition camp at all.
When you work with actual human beings, you must be a nutrition agnostic:
• Explore and try anything and everything that could work.
• Be willing to test new methods, even if they fly in the face of current beliefs or
practices.
• Be humble and open-minded enough to let yourself be wrong, even if you

really like being right. (Which we do.)
Don’t focus on the food itself. Or on making sure everyone follows your “nutri-
tion rules.”
Focus instead on your clients. What do they need to be their best?
Good nutrition is more similar than different.

You might be wondering: How can such varied diets all keep people fit and
healthy? Well, despite their disparities, most effective nutrition programs are
more alike than different.
1. Good nutrition asks people to care about their food

and eating.
Research shows that your actual choices are probably less important than simply
paying better attention to what you eat.
When you really care about what you eat, and make mindful, deliberate choices,
you almost inevitably eat better.
2. Good nutrition focuses on food quality.

Almost no decent diet plan asks you to eat more processed, nutrient-depleted
pseudo-food.
Instead, pretty much every camp recommends eating whole, minimally pro-
cessed, nutrient-rich foods — foods with which our body has a longstanding
relationship.
Regardless of the macronutrient breakdowns or specific choices, just eating bet-

ter quality food will improve most people’s health significantly.
3. Good nutrition helps eliminate nutrient deficiencies.

When we care about what we eat, choose foods mindfully, and try to get the
best-quality foods we can afford, we usually get lots of valuable nutrients along
for the ride.
Often, when people start a certain diet program, they just start eating better

14 | Introduction
overall. They get more nutrients. They may get more variety. Or fresher foods. Or
less-processed foods. Or foods they chose mindfully.
Because of these factors, they feel better. And that’s one reason they start making
wild claims about the rejuvenating power of their new diet.
They didn’t do anything special, really. They often just started getting what their
bodies needed.
4. Good nutrition helps control appetite and food intake.

Hyper-palatable: Foods that For most people, “it’s hard to eat just one” of the hyper-palatable deliciousness
are exceptionally pleasing to the bombs of processed foods. We often keep eating and eating them, but don’t feel
sense of taste.
satisfied.
We may also eat them on the go, when we’re rushed and busy. So not only are we
eating foods that encourage us to eat more of them, we’re not even really paying
attention to the experience at all.
Conversely, when we’re more aware of what we’re eating; choose a variety of
more satisfying, higher-quality foods; and eliminate nutrient deficiencies, we
almost always end up eating less food overall.
We feel more satisfied — both physiologically and psychologically. We lose fat,

gain muscle, and perform better.
Notice that you don’t need calorie counting here. Focusing on food awareness
and food quality is usually enough for people to tune into their own hunger and
appetite. That means calorie control without the annoying calorie math.
It also means that your clients can stick with this, since almost nobody can count
calories (or wants to) forever.
5. Good nutrition promotes regular exercise.

When people start paying attention to their eating, they usually start thinking
about physical activity too. Or vice versa: If you take up an activity you love,
eventually you start wondering if your nutrition could help you do that activity
better.
Good nutrition fits with regular activity like a key into a lock.
And most nutrition programs suggest that people exercise along with eating well.
What this means for you as a nutrition coach

Stay open-minded and flexible. Question everything.
Learn more about global nutrition and eating habits. Broaden your focus.
Expand your world. (If possible, travel and actually experience different foods,
cuisines, and food philosophies.)
Test your theories and programs. See how they work on actual clients with real
lives and real bodies in the real world. Look for evidence. Gather data and mea-
sure outcomes.

Remember to ask our favorite question: “How’s that Sure, we might check a few labels for the word “organic.”
working for you?” But beyond that… well, many folks think that chicken is
just “protein” that comes in rectangular plastic packages.
And where possible, look for underlying themes that
make all good nutrition programs “work.” (Wait… a chicken is a bird? That has feet, and feathers,
and stuff?)
One key feature about successful diet plans — especial-
ly in the Blue Zones — is that good nutrition connects
people to the food itself. Food as information about the world
So now that you’ve thought about what food is, and what Just as food is information for your body, food is also
good nutrition involves, let’s think about where food information about ecosystems and the environment.
comes from. Or where it goes.
Food is information about how things get produced,
processed and sold all over the world.
The cycle of food
Someone had to grow that fruit or vegetable from your
Check your fridge and pull out a fruit or vegetable. fridge. Other people picked it, and packed it, and trans-
ported it, and sold it.
• Where was it grown?
• How was it grown? Obviously, a full discussion of the social, political, eco-
nomic, and environmental issues involved in agriculture
• Who picked it for you? is beyond the scope of this text. We’ll touch on it briefly,
• How did it get to you? to help you understand a few more parts of the bigger
picture of food. If you’d like to learn more about these
• What steps did it take?
issues, check out the agriculture resources in Unit 17.
• How far did it have to travel?
Sustainability
• What factors ensure you can get more of that fruit or
vegetable? Something sustainable is something that you can do
for a long time. That could be a well-planned nutrition
• Do you think that people could still be eating that
program, of course. Or in this case, a way of growing
fruit or vegetable in 100 years? What about 500?
and producing food.
Why?
Sustainable agriculture is agriculture that we can do for
In the world of nutrition for health, performance, and a long time. It involves things like:
body transformation, we don’t talk much about where
food comes from. Or where it ends up if we discard it. • preserving and replenishing soil with nutrients;
• preserving and replenishing water reserves, especial-

ly clean fresh water;
• growing a wide range of diverse crops that are prop-

erly adapted for their surroundings;
• making the best use of valuable farmland;
• making animal welfare a priority;
• understanding the interaction of living organisms as

a complex ecosystem rather than as a food factory;
• making sure that people involved (such as growers or

pickers) are safe and fairly treated;
• ensuring food safety and public health; and
Figure I.2 The food life cycle • minimizing waste and pollution.

16 | Introduction
At its most basic level, sustainable agriculture is about become more aware of these processes and priorities —
ensuring that we can produce safe, high-quality food for to help them see that choices are at the end of a pathway.
everyone, for a long time to come.
And, if needed, you can help them change those path-
Sustainability in agriculture isn’t just a nice thing to ways to change their choices.
have. It’s what will ensure we can keep eating the things
we want and need to eat. As you look to deepen your own practice and increase
your awareness, think about food within a larger web.
We’ll talk more about sustainability and organic versus
conventional foods in a later unit. We’ll talk more about how to implement small, manage-
able habits later in the course.
Food as a set of choices For now, just get the general idea:
• Think about the big picture of nutrition, food,
We’ve suggested that food is information, and a way of
telling a story. and eating. Notice how adding some context helps
expand your understanding of what nutrition, food,
Here’s another thing to think about: Food and eating is a and eating are all about.
set of choices.
• Think about what might be most important
As a nutrition coach, one of your jobs is to make your for both you and your clients. Notice how there
clients more aware of what they’re doing. Indeed, aware- are lots of options for diverse clients. (Don’t worry,
ness itself can often change people’s behavior. (We’ll talk we’ll help you sort things and focus later.)
about this more in Section 2.)
• Think about how you might work towards
As we’ve stressed, nutrition coaching isn’t about getting those values and priorities as part of nutrition
people to follow “the rules.” It’s about helping them coaching. We know it’s a long-term project. Just
make more conscious choices. Choices that align with start with today… and keep reading.
their values, priorities, and goals.
We (and our clients) think about lots of things before we What is nutrition coaching?
buy and eat a food, such as:
We’ve started to give you some ideas about what nutri-
• what’s convenient; tion coaching is.
• what it costs;
Let’s look more closely now at what the role of nutrition
• what’s healthy (or not); coach involves.
• what we’ve done before (and in that case, we don’t First, congratulations.
really “think” about it);
• what’s available; Being a nutrition coach is an

• what might taste good; important job.
• what might feel good, distract us, or change our
emotional state; and You’re often the first person a client sees when
• what is better for the environment, or more
they want to look, feel, and / or perform better.
sustainable. They might not go to their doctor or another health care
provider. Instead, they might come to see you.
Each client has their own decision-making process and
priorities.
You’re part of your client’s social support system.
Your role as a nutrition coach is to help your clients
Many clients don’t have family or friends who are willing

to help and support them as they improve their exercise Keep learning. Stay up to date.
and nutrition choices. In fact, sometimes those family and
friends can actively sabotage your client’s efforts. Your clients want reliable, current, practical information
they can understand and use.
In the beginning, you may be the only team member a
client has. This means that you should have a process of ongoing
learning, information gathering and filtering, and shar-
You have the power to change lives. ing that knowledge.
If food and eating is information and a story, we can offer Collaborate.

new information and revise that story.
Being a nutrition coach is a big and important job. But
You can help change your clients’ bodies. You can also you don’t work alone.
help change their mindset about who they are and what
Good nutrition coaches build and maintain a profession-
they can do. You can help change their ability to make
al network with other health care professionals such as:
choices and try new things — to fully experience the
world around them. • doctors
• registered dietitians
By helping prevent chronic diseases or nutrition-related
disabilities, or helping them change their relationships • nurses
with food, you might even save their lives sometimes.
• physical therapists
• naturopaths
What does a good
nutrition coach do? Think collaboration rather than competition. You’re all
working together on your client’s team.
Fundamentally, a nutrition coach is a guide for change.
We’ll talk about this more in Section 2. We also suggest you build a professional network to sup-
port your own practice. Look for people such as:
Here are some things that all good nutrition coaches
• business coaches
should do.
• accountants
Be client-centered.
• marketers
This means you’re an advocate and ally of the client. You • web designers
want to help them do what matters most to them… not
what matters most to you. Have good boundaries. Know your scope
of practice.
You listen to them. Try to understand their needs. Try to
understand their lives. You’re not a therapist, medical doctor, or general fixit
person. Good nutrition coaches understand clearly what
You see them as unique individuals, and try to match
they can and can’t do.
your nutrition programming to what’s best for them.
We’ll look more at client assessment and scope of prac-
Help clients take action. tice in Section 2, but here’s a general overview.
Knowledge and information are great, but they’re not
enough. Your clients need to do stuff. What’s your scope of practice?
Good nutrition coaches create clear, goal-driven, evi- You’re probably here because you’d like to be able to
dence-based nutrition plans that clients can immediately talk about nutrition with your clients, and to help them
start putting into action.

18 | Introduction
improve their food and eating habits. But it’s not always This means you can’t prescribe nutrition for specific
clear what you can and can’t talk about with clients. health conditions and illnesses, such as:
Here are the guidelines. • post-surgical nutrition
• diabetic nutrition
You can talk about nutrition with your
clients… if you’re qualified to do so. • cancer therapy nutrition
• nutrition to treat liver disease or kidney stones

In most jurisdictions, certified personal trainers or other
licensed health care professionals who have fundamental • nutrition for clinical eating disorders such as anorexia
nutrition knowledge can answer questions or address
concerns that their clients may have about nutrition. Of course, the general advice you give your clients will
probably improve their health and lower their disease risk.
Notice we emphasize the “fundamental knowledge”
part. With specific training, such as that provided in this You just can’t offer directed advice that could reason-
course, you’ll have that fundamental knowledge and be ably be considered part of medical therapy. You can’t
able to discuss nutrition with clients. use words like “diagnose”, “treat”, “cure” or “prescribe.”
(And unlike a lot of kooks on the Internet, you can’t
Know your options where you live. claim to magically eliminate all human suffering with
your wondrous diet plans.)
Each state, province, and country has different rules for
dispensing nutrition advice. It’s not always completely clear where the boundaries
are, so when in doubt:
We’ve given you some resources below, and on our web-
site, for learning more. Collaborate with your professional
network of other health care providers.
Offer general nutrition advice, not
medical nutrition therapy. It’s important to establish relationships with other health
care professionals, such as registered dietitians, nurses,
(Unless you’re qualified to do so, of course.) physical therapists, chiropractors, and physicians. By
networking and creating a cross-referral system, you’ll
With this ISSA credential, you’re able to make general not only be able to expand your business network, you’ll
nutrition suggestions in most jurisdictions. You can also have experts to turn to when you don’t know the answers
share nutrition education using materials from a public to certain questions.
or well-known entity such as the American Heart Asso-
ciation, the Centers for Disease Control and Prevention, Learn the rules and regulations of your
and the Academy of Nutrition and Dietetics. (And of area.
course, ISSA.)
The Center for Nutrition Advocacy provides a
But unless you’re licensed or otherwise certified to do comprehensive guide to statue laws. Visit www.
so, you can’t offer specific advice in the form of medical nutritionadvocacy.org/laws-state to fully understand
nutrition therapy. your states statutes.

Case Study
Many clients come to us with “diet experience.” carbohydrates. Or reducing fat. Or a specific macronu-
trient ratio.
Some have done lower-carbohydrate diets, like the At-
kins Diet. Others have done low-fat diets, like the Ornish All three plans create a negative energy balance in three
Diet. And others have done more “balanced” plans, like ways:
the Zone Diet.
1. When clients follow a “weight loss plan”, they usual-
One client followed all three plans at one point or an- ly eat less. This decreases “energy in.”
other, along with exercise.
2. Exercise increases “energy out.”
In each case, the process and results were the same:
3. Both Atkins and Ornish ask dieters to restrict either
• He followed the diet. dietary carbohydrate or dietary fat. The Zone plan
asks dieters to eat a specific ratio of macronutri-
• He lost about the same amount of weight.
ents — which usually means that people eat less of
• He gained it all back… and usually more. whatever they were eating “too much” of. Is it any
wonder that by asking dieters to avoid eating some-
• He tried another diet.
thing, they’ll end up eating less?
No matter what diet he tried — despite how “differ-
ent” these diets were from each other — the same stuff It wasn’t some magical macronutrient mix that made the
happened. client lose weight. It was plain old energy deficit. (You’ll
learn more about energy balance in an upcoming unit.)
How can this be?
However, all three experiments ultimately failed.
Well, instead of focusing on what makes diet plans dif-
ferent, let’s look at what makes them similar. Each time, the client rebounded. He gained more
weight after losing it. After giving up, he got off track,
The client got the same results with different diets stopped exercising, and started eating poorly again.
because all three plans forced him to follow a key rule of
good nutrition: However, it wasn’t the food that caused this rebound.
It was many other lifestyle factors. The problem wasn’t
All three plans, together with his exercise plan, forced him what he was eating necessarily… but how he was eating
to control his energy balance. and living.
To lose weight, we need a negative energy balance. In Only when we started to address these key factors did
other words, we need to take in less energy (in the form the client change his fundamental habits… and lose his
of food) than we expend (in the form of metabolism and excess body fat for good.
activity).
In this program, you’ll learn that both the what (i.e., the
If someone loses weight, they’ve somehow managed to food itself) and the how (i.e., how we eat and live) are
get into negative energy balance. crucial elements in change.
In this case, that’s what did the trick — not the lack of

20 | Introduction
What this program You should finish this course with both a better under-
standing of exercise nutrition and the tools used to deliv-
will cover er nutritional recommendations.
Here’s what we’ll do in the rest of this textbook and this Important note
course.
Completing this course will not qualify you as a
• Dispel common myths and fallacies associated with
registered dietitian, licensed dietitian, or licensed
nutrition.
nutritionist. Check with the licensing bodies in your
• Give you the foundational knowledge you’ll need area if you are hoping to get licensed.
to make general nutritional recommendations to a
variety of clients.
Nor will this course allow you to provide medical
nutrition therapy.
• Provide and explain nutrition theory and science.
Instead, this course will provide you with continuing
• Give you a clear process and walk you through the
education in the field of nutrition.
steps of preparing for, assessing, evaluating, and
making recommendations for clients. It will enhance your credibility, your confidence, and
your skill set.
• Give you a set of resources that you can use almost
immediately in your coaching practice (if you have And it will help you overcome the biggest limiting factor
one already). your clients face every day: poor nutrition.
Summary
Food is fuel, but it’s so much more than that. Food gives • give us nutrients;
us important substances such as micronutrients, phyto- • help us look, feel, and perform our best;
and zoochemicals. We need all of these nutrients to live
and thrive. • are outcome-based;
• are sustainable for both us and the planet;

Living organisms are not machines. Human bodies
aren’t combustion engines. They’re more complex than • are about removing limiting factors; and
simple inputs and outputs.
• look for strengths and wins.
Food is information and a story. Physiologically, socially,
What’s the best diet? Trick question! There isn’t one. The
and even environmentally, food and eating gives us
best coaches don’t have a single nutrition philosophy,
important information about things like:
and use data and evidence to make decisions.
• chemical interactions in our body;
Clients are diverse. The human body adapts amazingly
• how we relate to ourselves and one another socially well to many different ways of eating. You can be healthy
and culturally; and perform well on many diets.
• how we make choices about what to eat (or not); and
Good nutrition is more similar than different. It:
• how larger forces shape how food is produced and
• asks people to care about their food and eating;
consumed.
• focuses on food quality;
Good nutrition plans:
• helps eliminate nutrient deficiencies;
• control energy balance;

• helps control appetite and food intake; and • Offer general nutrition advice, not medical nutrition
therapy.
• promotes regular exercise.
• Collaborate with your professional network of other
Being a nutrition coach is an important job. You’re often health care providers.
the first person a client sees when they want to look, feel,
and / or perform better. You’re part of your client’s social • Learn the rules and regulations of your area.
support system. You have the power to change lives.
This program will:
A good nutrition coach will: • help to dispel common myths and fallacies
• be client-centered; • give you the foundational knowledge you’ll need
• help clients take action; to make general nutritional recommendations to a
variety of clients
• keep learning; stay up to date;
• provide and explain nutrition theory and science
• collaborate; and
• give you a clear process for preparing, assessing,
• have good boundaries; know your scope of practice.
evaluating, and making recommendations for clients
What’s your scope of practice? • give you resources that you can use almost
• You can talk about nutrition with your clients… if immediately
you’re qualified to do so.
• give you a better understanding of exercise nu-
• Know your options where you live. trition and the tools used in delivering nutritional
recommendations

SECTION ONE
NUTRITION SCIENCE
1 Cells, p23
2 Through the GI Tract, p45
3 Energy Transformation
and Metabolism, p77
4 Energy Balance in the Body, p112
5 Aerobic and Anaerobic Metabolism, p137
6 Macronutrients, p155
7 Micronutrients, p197
8 Water and Fluid Balance, p230

UNIT 1
Cells
24 | Unit 1
Unit Outline
5. Parts of cells
1. Objectives
6. Body function
2. Cell structure and function
7. Cell types
3. How the body is organized
8. Summary
4. Nutrition and cellular interaction
Objectives
In this unit, you’ll learn how your body’s cells: You should be able to recognize:
• get nutrients from the food that we eat, and • the main cell organelles;
• use these nutrients for the raw materials and fuel to • what each organelle does; and
keep us alive.
• how each organelle interacts with organic molecules
At the end of this unit, you should have a working knowl- to do its most important jobs in the body.
edge of how humans are organized, from the organismal
You’ll start to build the foundation of physiological knowl-
level all the way down to the atomic level.
edge that you’ll need to make and apply nutrition plans.
Cell structure and function

The cell is the most basic structural and functional unit of all living things. All
living tissues are built from ells.
In terms of nutrition, our cells have two basic roles:

• to get nutrients from the food that we eat, and
• to use these nutrients for the raw materials and fuel to keep us alive.
How your body works depends on how each cell works.
Adult humans have trillions of cells. All work together to keep us alive.
To do these basic jobs, cells must:

• grow, mature, and die;
• exchange gases like oxygen and carbon dioxide (i.e., respiration);
• absorb and digest nutrients;
• circulate blood and other fluids;
• get rid of waste; and
metabolism: Sum of reactions • reproduce.

that take place to build up and
break down the body Together, these cellular tasks are known as metabolism.

Cells | 25
F. Organ
Tissues combine
to form organs.
Example: heart.
E. Tissue
Cells form tissue.
Example: cardiac
muscle tissue.
D. Cell
Organelles work together
to form cells. Example:
cardiomyocytes (cardiac
muscle cells).
C. Organelle
Molecules and atoms combine
to form organelles.
Example: nucleus.
B. Molecule
Atoms combine to form a molecule.
Example: deoxyribonucleic acid
(DNA).
A. Atom
Chemicals, such as carbon, G. Organ System H. Complex Organism
hydrogen and oxygen, are Organs work together to form Organ systems sustain
the basic units of matter. organ systems. complex organisms.
Example: carbon. Example: circulatory system. Example: you.
Figure 1.1. Organization of the human body. Atoms combine to form molecules. Molecules and atoms combine to form organelles.
Organelles work together to form cells. Similar types of cells form tissue, and tissues join to make up the various bodily organs. Groups of organs
that work closely together form organ systems, and it is these organ systems that ultimately sustain an organism.
We need proper nutrition for our cells to work proper- And the body lives within even larger systems.
ly. This means getting the right nutrients in the right
amounts. Ecosystem
When we eat well, our cells function well. When we Our body lives within ecosystems — dynamic, interac-
don’t eat well, problems happen. tive, interconnected networks of living things.
Healthy cells means healthy metabolism. Unhealthy cells Some scientists even think that given how many bacteria
means unhealthy metabolism. are on us and in us, humans aren’t even really “separate”
bodies at all!
How the body is organized Organism

Cells — and by extension, the body — is organized into The organism is, well, you.
systems, each system nested into another. See Figure 1.1.
An organism is a definably self-contained living system.

26 | Unit 1
For the purpose of this program, we can say that you as a human are a distinct
organism. (Bacterial buddies notwithstanding.)
As an organism, the human body can reproduce, replace, and repair itself, all to
homeostasis: The body’s ability stay alive and to maintain homeostasis: the state of balanced function in the body.
to maintain a stable and constant
internal condition
Organ systems
Complex organisms, such as humans, are made up of organ systems.
• Integumentary system: This system protects the body from external
damage. It includes your skin, hair, nails, sweat glands, and other external
structures.
• Skeletal system: This system gives the body a rigid structure so that it can
move and hold itself up. It includes your bones, tendons, ligaments, and other
structures.
• Muscular system: This system moves us, whether it’s to move you across the
room, to move your blood through blood vessels, or to move food through
your intestines. This system includes your skeletal muscles, cardiac muscles (in
your heart), and smooth muscles (part of arteries and veins, bladder, gastroin-
testinal tract, respiratory tract, uterus, and more).
• Nervous system: This system sends electrochemical signals that trigger

thoughts, emotions, and movement as well as involuntary activity (such as
breathing). It includes your brain as well as a vast network of nerves and sup-
porting structures.
• Endocrine system: This is your cellular communication system. It includes

your hormonal organs and glands, including the hypothalamus, pineal gland,
pituitary gland, thyroid gland, liver, pancreas, kidney, adrenal glands, testes,
ovaries, and more.
enzyme: Substance that helps • Circulatory system: This system transports hormones, enzymes, nutrients,
catalyze chemical reactions and other chemicals throughout the body. It includes your heart, blood, and
blood vessels.
• Immune system: This system protects against pathogens, tumor cells, and
other foreign invaders. It includes your thymus, lymph nodes, spleen, tonsils,
and other similar organs.
• Respiratory system: This system brings in oxygen and excretes carbon

dioxide. It includes your nasal cavity, trachea, lungs, and other airways and gas
exchange organs.
• Digestive system: This system breaks down and absorbs nutrients from food
and drink. It includes your oral cavity, esophagus, stomach, intestines, and the
other organs associated with digestion including the liver, gallbladder, pancre-
as, and bile duct.
• Urinary system: This system produces, stores, and eliminates urine. It in-
cludes your kidneys, ureters, bladder, urethra, and related organs and glands.
• Reproductive system: This system controls reproduction as well as sexual

development. It includes your sex organs and glands.

Cells | 27
While these organ systems have distinct jobs, they also work closely together.
This is important for nutrition coaching.
For instance, if something is out of order in the gastrointestinal tract (say, with a
client who often gets an upset stomach), it’s probably out of order elsewhere (for
instance, in the endocrine system or nervous system). We’ll talk more about this
in later units.
Organs
Organ systems are made up of individual organs. Each organ has at least one spe-
cific job, and often several.
Tissues
Collectively, our tissues make up our organs.
• Epithelial tissues make up our skin.
• Connective tissues make up structures such as our joints and fascia.
• Muscle tissues make up our skeletal muscles and heart, and are part of sever-
al other organ systems
Nervous tissues make up our brain, nerves, and associated structures.
Our tissues do many things, such as:

• form protective barriers against outside invaders (epithelial tissues);
• hold us together (connective tissues);
• move the body around (skeletal muscle tissues); or
• communicate between cells (nervous tissues).
Cells
Tissues are made up of large groups of cells.
Cells range in size from about 7 to 300 micrometers. To give you some perspec-
tive, the dot over this letter “i” is about 100 micrometers.
Cells show us how living matter is wonderfully unique in its diversity. For ex-
ample, immune cells can engulf pathogens and destroy them, while muscle cells
have sliding filaments that cause muscle contraction and relaxation. (Fun factoid!
The axon of a motor neuron in the spinal cord can be up to 1 meter long.)
Organelles
Each cell is like a tiny city. Within each cell are organelles, collections of mole- organelle: Component of the
cules / chemicals that have particular jobs, much like different utilities (such as cell that is responsible for a spe-
cific task
power production or waste disposal) within a city.
There are over 24 known organelles. We’ll talk about the most important ones —
such as the endoplasmic reticulum (ER), Golgi apparatus, and mitochondria — in
this textbook.
cytosol: Internal fluid portion of
These organelles do their jobs in a semi-fluid matrix called the cytosol. the cell

28 | Unit 1
Chemicals
Fundamentally, we are a soup of chemicals.
atom: Basic unit of a chemical Chemicals are built from structures of varying sizes, from atoms (smallest), to
element molecules, to macromolecules (largest).
molecule: Group of atoms
bonded together Macromolecules are made up of groupings of molecules. Molecules are made up
of tiny particles called atoms. And these atoms, which are invisible to the naked
macromolecules: A large
molecule eye, make up all material things of the universe.
So if you think about it, nutrition coaching is really about harnessing the funda-
mental particles of everything that exists.
As astronomer Carl Sagan famously said, “The cosmos is also within us. We’re
made of star stuff.”
Our body can only do what it does if our cells, and the organelles within them,
can do what they do: send and receive messages, create proteins, etc. Indeed,
nearly everything that happens in the body is based on making proteins, and
what those proteins do.
Think of the body as a manufacturing plant — that also manufactures itself. The
proteins we make not only break down and rebuild the plant itself, they break
down and rebuild the machines, the workers, the messengers, and lots of other
stuff.
We’ll get more into this idea as the unit progresses. For now, just remember that
every level of human organization depends on the health of important subunits
— our cells — and the proteins they make.
Nutrition and cellular interaction

macronutrient: Nutrient the In general, the macronutrients (proteins, carbohydrates, and fats), micronutri-
body requires in large amounts ents (vitamins and minerals), phytochemicals, and zoochemicals we eat are bro-
(i.E., Protein, fat, carbohydrates)
ken down through the digestive process into smaller compounds such as amino
micronutrient: Organic com- acids, glucose, fatty acids, etc.
pound the body requires in very
small amounts (i.E., Vitamins and These digested and absorbed compounds then travel through our bloodstream
minerals)
to interact with our cells. Our cells use those compounds in many ways, such as:
compounds: Consisting of two
or more substances 1. To provide potential energy that’s later released by breaking the chemical
bonds between the macronutrients.
potential energy: Energy stored
within a physical system 2. To provide raw materials that can then be incorporated into our body structures,
including tissues and organs.
co-factor: Non-protein com- 3. To act as co-factors for chemical reactions in the body. All of the chemical
pound that interacts with
reactions that take place in the body require the help of particular proteins called
another substance to facilitate a
transformation enzymes. These enzymes often use nutrients gathered from the food we eat to
do their job.
hormone: Compound created by
one cell that travels to and stimu- 4. To stimulate the release of hormones, which act as chemical messengers,
lates another cell directing overall body function with their unique messages.

Cells | 29
Cell nucleus contains chromosomes.
DNA provides cellular instruction

for making proteins.
Chromosomes contain DNA.
Figure 1.2. DNA inside the nucleus. Wrapped up in chromosomes, our DNA, or genetic code, dictates which proteins are
formed in the body. The nucleus of each cell contains this genetic code. Each person has a unique genetic code that influences how
we respond to ingested foods.
Because of these various and important roles that nutrients have, the food we eat
can fundamentally change how our body works. No wonder nutrition is so critical!
Nutritional individuality
In the previous unit, we looked at why there is no one “best diet.”
One reason is that not everyone responds the same way to the digestion and
absorption of particular foods — or to the uptake of particular nutrients into
the cell. Research suggests that although the basic mechanics are the same, there
are important and intriguing individual differences, which are likely due to our
unique genetic makeups. genetics: Specific, inherited DNA
of an organism, which influences
Each cell in our body houses our genetic code, a series of nucleic acids called what they become, although
environment also plays a key role
DNA, in an organelle called the nucleus. This code, which is unique to each of
in the expression of an organism’s
us, provides cellular instructions for making proteins we need for our structure genetic code
and function.
DNA: Nucleic acids that contain
instructions for heredity
As we all have slightly different genetic profiles, the proteins we make may also
differ. These variations are responsible for our individual responses to the food nucleus: Organelle where ge-
netic material is housed
we eat. See Figure 1.2.
In general, these differences are quite small. All humans share over 99.9% of

30 | Unit 1
gene: A particular sequence in the same genes. You may have even heard that humans and chimpanzees share
DNA or RNA that controls the between 95% and 98% similarity in their DNA, which is also true.
expression of a protein, and, by
extension, influences the charac-
teristics of an organism
In addition, many important genes have been evolutionarily conserved. This
means that those genes appeared very early in our evolutionary history, perhaps
evolutionarily conserved:
Something that’s remained es-
even back in the days of single-celled bacteria.
sentially unchanged throughout
evolution For instance, much of what we know about the health effects of fasting comes
from research on a tiny, primitive flatworm known as Caenorhabditis elegans.
C. elegans has nearly 200 known genes that respond to dietary restriction. These
genes are involved in things like knowing when metabolism is disrupted; looking
for and repairing DNA damage; and hunting for cancer-type overgrowths. We
share 45 of those genes.
Thus, we are much more alike than we are different.
genetic polymorphism: However, these small genetic differences, called genetic polymorphisms, explain
Variation in the form of one or a why some people respond slightly differently to various types of foods. These
sequence of genes
differences may also explain why many research studies seem to have confusing
or conflicting conclusions.
Differences in nutrient processing

For example, we all have a gene in our liver for making a particular enzyme that
breaks down caffeine. However, due to these small genetic differences, some of us
have the enzyme that breaks down caffeine quickly. Others have the enzyme that
breaks down caffeine slowly.
• In people with the fast enzyme, caffeine is processed and removed quickly,
while the antioxidants found in coffee can help protect against free radicals.
• However, in people with the slow enzyme, the caffeine hangs around longer,
causing health problems.
So imagine a study that asks: “Is 1-3 cups of coffee a day healthy or unhealthy?”
The answer would be: “For whom?”
Differences caused by nutrients themselves

Not only are there individual differences in response to the same foods, different
bioactive: Having a biological foods have particular nutrients and other bioactive components that can actually
effect change the message expressed by our unique genes.
For example, isothiocyanates found in broccoli can switch on a gene in the liver
that detoxifies cancer-causing chemicals and other toxins.
Without the broccoli, this gene stays inactive. Our body looks for other detoxifi-
upregulated: An increase of a ers. With the broccoli, this gene is upregulated and participates more actively in
cellular component the detoxification process.
Some of us have this gene, and some don’t. If we don’t have the gene, broccoli
can’t help us fight cancer in this particular way. (Of course, broccoli does other
good things.)
Another example is cooked tomatoes, which contain compounds (lycopenes)

Cells | 31
that switch off growth-promoting genes in the prostate. With cooked tomatoes in
the diet, prostate cancer risk decreases; without the tomatoes, risk increases.
Fish oil is yet another example. Fish oil (specifically DHA — a fatty acid found in DHA: Docosahexaenoic acid, an
fish, other marine animals, and fish / algae oil supplements) might signal genes omega-3 fatty acid
in the brain to produce a chemical that preserves brain function with age. People
who consume more omega-3 fats tend to have better cognitive function as they
age, compared with those who consume less.
Thus, nutrition can strongly influence our gene expression. And our genes, in
turn, affect how we respond (or don’t) to a given nutrition plan. This genetic di-
versity and its relationship with nutrition is an emerging area of research called
nutrigenomics: Study of how
nutrigenomics. genes respond to nutritional
intake
Needless to say, there is an important relationship between what we eat and how
our cells function. Throughout this course, this interaction will become clearer.
By the end of this course, you should have a better grasp of how to optimize
health, body composition, and performance by controlling nutrient intake.
However, before we talk more about food, let’s discuss the cell in depth, and in
particular, the main cellular components and organelles.
Parts of cells
To better understand how the food we eat interacts with our body, it’s important
to learn about the structures, chemicals, and organelles within each of our cells.
In this unit, we’ll review the following organelles:
Plasma membrane Golgi apparatus
Mitochondrion Lysosome
Nucleus Peroxisome
Endoplasmic reticulum
These organelles and approximately 17 others (there are about 24 or so in total)
give our cells their structure and function, which are in turn often shaped by our
nutrient intake.
Plasma membrane plasma membrane: Lipid bi-

layer that is permeable to certain
Around the edge of each cell is a boundary, known as the plasma membrane, compounds that contains the cell
which separates the cell from its neighbors and from the rest of our body. The
lipids: Any class of organic com-
plasma membrane’s bilayer (double layer) acts like a protective wall, keeping pounds that are fatty acids or their
important chemicals in while keeping harmful chemicals out. derivatives
cholesterol: Synthesized in the
The plasma membrane is made up of lipids, proteins, cholesterols, and other liver; precursor of bile acids and
chemicals. It has an interesting nature: while it forms a structural boundary steroid hormones
between the cell and the rest of the body, this boundary is flexible and fluid-like.
phospholipids: A type of lipid
Membranous organelles — specialized sacs and canals — can float around with- with a hydrophilic phosphate
in the plasma membrane, rather like icebergs floating around in the ocean. group “head” and hydrophobic
fatty acid “tail” that forms cell
This fluid-like boundary is made up mostly of phospholipids, molecules with membranes
phosphate “heads” and fatty acid “tails.” The phosphate “heads” of the lipid hydrophilic: Strong affinity for
molecules that form the bilayer are hydrophilic (water-loving) and therefore can water

32 | Unit 1
Extracellular space
Hydrophilic
region
Phospholipid
Hydrophobic
region
Hydrophilic
region
Intracellular space
Figure 1.3. Plasma membrane. The plasma membrane is composed of lipids, proteins, cholesterol and other chemicals. The lipid
bilayer has water-loving (hydrophilic) heads and water-fearing (hydrophobic) tails. Substances generally pass through the plasma
membrane via a transmembrane protein.
bond to water-based molecules. On the other hand, the fatty acid “tails” of the
hydrophobic: Lack of affinity for lipid molecules that form the bilayer are hydrophobic (water-fearing) and bond
water best with fat-based molecules.
This dual-purpose membrane creates a boundary that regulates what gets into
and out of cells. See Figure 1.3.
The cell needs to be choosy about what can enter and exit. Thus, most molecules
must enter the cell through one of several membrane proteins. These proteins are
like gates in a fence, allowing only particular molecules to pass through. We’ll
talk more about these cellular proteins later in this unit.
Because of this lipid structure, the types of fats we eat can change how fluid or
flexible the cell membrane can be.
• Too much saturated fat may cause the membrane to be too rigid.
• Too much polyunsaturated fat may cause the membrane to be too fluid.

Cells | 33
Because most people eat too many saturated and trans fats, we often need to saturated fat: A fat with no dou-
balance that with getting enough mono- and polyunsaturated fats. We’ll look ble bonds between the individual
carbon atoms of the fatty acid
at this more later on. For now, just remember that fat balance affects how the cell chain
works in important ways.
trans fat: Fat derived from the
partial hydrogenation of vegeta-
Cytosol ble oils
The interior space of the cell is composed of a gel-like solution called cytosol. monounsaturated fat: A fat
with one double bond between
Many organelles, enzymes, salts and other organic molecules, including stored
the carbons in the fatty acid chain
carbohydrates and fats, are suspended and maintained by the cytosol. The body
carries out many of its chemical reactions in this gel-like matrix, including most polyunsaturated fat: A fat
with two or more double bonds
of its enzymatic reactions. Cytosol, together with all the organelles, except the between the carbons in the fatty
nucleus, are called cytoplasm. acid chain
cytoplasm: The protoplasm
The cytosol is rich in stored carbohydrates that can be broken down quickly and
within a cell, excluding the
used to transfer energy. This process is controlled by cytosolic enzymes. nucleus
Exercise and other physical activity creates a demand for more energy. The cell
responds by making more of these enzymes along with storing more carbo-
hydrate and fat for future use. The cell also gets better at breaking down these
carbohydrates for energy. This is especially true in skeletal muscle cells, since this
is where active people need most of their energy.
A key point here for nutrition coaching is that regular exercise and other activity
can powerfully affect cellular makeup, metabolism and function. Activity can fun-
damentally change how the body uses, processes, and stores nutrients. Active bod-
ies will thus respond differently than inactive bodies to the same nutrition plan.
Mitochondria
Mitochondria (plural of mitochondrion) convert nutrients into energy. mitochondria: Organelles that
supply the cells’ energy / ATP
Just like you can’t eat an egg until you crack open its shell (well, at least we don’t (singular: mitochondrion)
recommend it), you can’t use the energy stored in carbohydrates, proteins, and
fats until you break their chemical bonds. Mitochondria convert the energy
released from this process into adenosine triphosphate (or ATP), the energy adenosine triphosphate: ATP,
currency of the cell. source of energy for physiological
reactions
Mitochondria produce most of the body’s energy — about 95% of it. The rest is
produced in other parts of the cell. If mitochondria don’t work well, we don’t
work well. (Or at all.)
Mitochondria make ATP in their inner mitochondrial membranes. The outer mitochondrial membrane:
membrane of the mitochondrion is porous, while the inner membrane is the The double biomembrane sur-
rounding the mitochondrion
main barrier between it and the rest of the cell. The inner membrane contains
folds called cristae, which are studded with the enzymes and structures that help
make ATP.
Since the mitochondria generate power for the cell, more mitochondria means
more energy, and more active cells. Conversely, the more active we are, the more
mitochondria we likely have (and since your heart is beating all day, every day, it
also has plenty of mitochondria to keep pace). More mitochondria means more
total energy production for a muscle.

34 | Unit 1
Nutrition in practice
Your skin color, body size, hair type, and risk of specific illnesses all depend on
how your genes interact with your environment.
For instance, your genes may suggest that you’ll grow to somewhere between
5’5” and 5’8.” But your actual height is an interaction between genes and envi-
ronment. If you grow up malnourished, you won’t ever reach 5’8.”
What we eat early in life (and what our moms eat while they’re pregnant) can
affect our genes and regulate our traits — including the development of diseas-
es, even decades later.
For example, data from the WWII Dutch Famine show that children of under-
nourished mothers had higher risk for cardiovascular disease, obesity, and breast
cancer later in life. (In fact, this “famine memory” can persist for generations,
“remembered” by descendants’ genes.)
Our genes can be influenced by all kinds of things, such as:
• nutrient deficiencies or excesses (especially at crucial developmental

stages);
• dietary components (e.g., omega-3 fats, phytoestrogens, cruciferous

vegetables, lycopene, folate, carotenoids, and so forth);
• sunlight and vitamin D;
• toxins (such as industrial chemicals, pesticides, heavy metals);
• bacteria and viruses;
• exercise and activity;
• alcohol and other drugs;
• stress, trauma, and mood;
• circadian rhythms (such as sleep, shift work, light-dark cycles, and travel
circadian: Any biological process
that recurs naturally on a day- across time zones); and
night cycle
• a host of other factors we probably don’t even know about yet.
If that sounds a little scary, consider it from the opposite perspective: While we
can’t control our genes themselves, we can affect their expression — whether
they’re likely to get “switched on” or off.
Our genetic expression is strongly shaped by our environment… over which we

do have some power. So, if we know more about our genetic variants, we might
be able to adjust our lifestyle or environment in order to prevent some illnesses
or become healthier.

Cells | 35
For example, certain gene variants can tell us:
• how food is metabolized;
• whether carcinogens in cooked meats will influence the development of

colon and prostate cancers; or
• our inflammatory response and efficiency of DNA repair / replication.
If we know more about our own unique risk factors, we might be more likely to
make healthier choices — choices that could improve our genetic expression.
Genetic screening may show us the way to individualized nutrition and exercise
prescriptions. But we’re not quite there yet. Here’s what we know right now.
One size doesn’t fit all.

Genetic subgroups might respond differently to different foods and activity
types. In theory, genetic screening might help us customize food (and supple-
ment) intake and exercise prescriptions for each person’s unique needs.
The details are kinda hazy.

In practice, it’s not as clear how genetic diversity might play out or how much it
even matters. After all, we also choose food and exercise based on other things
like taste, preference, convenience, price, and cultural norms.
Gene expression isn’t a destiny. It’s a set of possibilities.

What if your genes show you’re all slow-twitch endurance athlete but you think
fast-twitch sprint events are more fun? How closely should you stick to your
“blueprint”? How much can you affect your genetic expression through envi-
ronment and habitual choices?
We don’t have all the answers yet.

Measuring nutrient-gene interactions takes time and effort. Genetic mapping is
complicated, sometimes expensive, and error-prone. And for any of this to mat-
ter, gene testing has to tell us what to actually do with that information. Genetic
testing is interesting. Provocative. Complex. And let’s be honest, kinda cool. But
for now, it raises more questions than it answers.
Stay tuned.
When genetic screening companies are able to more cost-effectively test the
entire genome (again, most only test a part of it) we should have a greater
understanding of gene sequencing and its use in nutrition. Most experts predict
that’ll happen within a few years, as the cost of sequencing the entire genome
drops from $10,000 to $500.

36 | Unit 1
Matrix
Cristae
Outer membrane
Inner membrane
Figure 1.4. Mitochondria. Inside the mitochondria is where energy converts to ATP. The number of mitochondria in a cell is directly
related to the activity of the cell.
Elite athletes usually have a high mitochondrial density. In general, although ROS are a natural part of this reac-
This means they not only build more total mitochondria tion, we don’t want to make too many at once, or have
with training, they also build more mitochondria per them hanging around too long. ROS can cause cellular
unit of muscle mass. This gives them the ATP they need damage, including damaging our DNA.
for high-level performance. Once again, we can see how
regular movement and activity can change the funda- Scientists used to think that the more oxygen we con-
mental structure and function of cells. sumed, the more ROS we’d make. However, we now be-
lieve that mitochondrial efficiency changes this equation.
Having a lot of mitochondria is good, but we also want
• People with less-efficient mitochondria make more
them to be effective. In other words, we want mitochon-
ROS with every unit of ATP they produce.
drial quality as well as quantity. In order to understand
this, let’s look at a little bit of biochemistry. • People with more-efficient mitochondria make fewer
ROS for the same amount of ATP.
When we make ATP for energy, our cells consume
oxygen, and produce reactive oxygen species (ROS) as a So if your mitochondria are efficient, you make lots of
byproduct. Just as with nutrient processing, not every- energy with fewer damaging waste products. You feel
one does this at the same rate. great, you perform well, and you live longer.
Different people may make ATP at different rates. They While there is a genetic component to mitochondrial
may use different amounts of oxygen to do this; they may function, it’s strongly affected by how we live, what we
need different amounts of food energy to do this; and they eat, and what we do.
may produce different amounts of ROS in the process.
See Figure 1.4 for more.

Cells | 37
Nutrient deficiencies can affect our mitochondrial function. Statin drugs, de-
pression, fibromyalgia, or Parkinson’s disease are all associated with low levels of
co-enzyme Q10 (CoQ10). We need this compound for energy production in the
mitochondria.
Another compound, an amino acid called L-carnitine, is also involved in energy

production in the mitochondria. L-carnitine is found mainly in animal foods.
While our body can make L-carnitine, clients who eat a mostly or entirely plant-
based diet might find supplementation helpful.
Nucleus
The nucleus, usually found in the central part of the cell, is the largest organelle.
Most cells have only one nucleus, though muscle cells have more than one. The
nucleus is Mission Control, home of our DNA, also known as the genetic code.
Wrapped up in chromosomes, our DNA dictates which proteins are formed in chromosomes: Located in
the body. This ultimately determines everything from how the body develops, the nucleus, contain genetic
information
to how it repairs itself, to how it transports and / or metabolizes every chemical
introduced into circulation. In many ways, our DNA also determines how mus-
cular we can get.
As we’ve discussed, there is an important link between our DNA, our food
intake, and our health. In fact, much of what we eat interacts directly with our transcription: The synthesis of
DNA or causes hormonal cascades that influence our DNA. RNA using a DNA template
These relationships begin in our nucleus: Chemicals can bond with our DNA to translation: Forming a protein
molecule based on the informa-
begin making cellular proteins, processes called transcription and translation. tion contained in the mrna
ER and Golgi apparatus endoplasmic reticulum:

Cytoplasmic membrane that
translates proteins
The endoplasmic reticulum, or ER, is a “circulatory” network found inside the
cytosol, near the nucleus. Golgi apparatus: Cytoplasmic
organelle necessary for the modi-
When our DNA sends out a signal to make proteins, the ER and Golgi apparatus fication and transport of proteins
receive this genetic message. They then make and transport the proteins. ribosomes: A complex rich in
RNA and protein found in cells
There are two types of ER: smooth and rough. steroid hormones: Hormones
possessing steroid ring system,
Rough ER is lined with ribosomes, which give it a “rough” appearance. Ribo- including androgens, estrogens,
somes are the protein factories of the cell. and adrenocortical hormones
glycoproteins: Protein that
Smooth ER doesn’t have ribosomes, so it doesn’t make proteins. Instead, it builds contains a carbohydrate group,
lipids, steroid hormones, and carbohydrates to use in glycoproteins. involved in membrane integrity

38 | Unit 1
Rough endoplasmic
reticulum (ER)
Nucleus
Transport vesicle Cis (C) face:

from ER receives transport
vesicles from ER
Golgi apparatus
Trans (T) face: produces

vesicles for cellular
use or for excretion
Transport vesicle
from Golgi apparatus
Figure 1.5. Endoplasmic reticulum and Golgi apparatus
protein synthesis: Making proteins, or protein synthesis, takes place using ribonucleic acids
Manufacturing of proteins from (RNA).
amino acids; guided by DNA
ribonucleic acids (RNA): Once these proteins are synthesized in the ribosomes of the rough ER, they move
Various nucleic acids on a single towards the Golgi apparatus. This organelle prepares the newly formed protein
strand containing ribose and molecules that will leave the cell.
uracil, necessary for the control of
cell activities
The Golgi apparatus contains cisternae (tiny disc-like “holding tanks”, similar to
cisterna: Flattened membrane the word “cistern”) that are stacked on one another and small, circular vesicles.
disc of Golgi apparatus (plural:
These vesicles (small sacs) act like little chaperones, engulfing the protein mole-
cisternae)
cules and transporting them to the cell membranes, where they’ll either be sent
vesicles: Fluid filled pouch/ elsewhere into the body, or incorporated into the membrane itself. See Figure 1.5.
sac that can transport and store
compounds
Proteins are thus always being built up and broken down within our cells. This
takes energy and protein for raw materials. If we don’t eat enough, or don’t eat
enough protein, our cells can’t do their jobs of synthesizing and transporting
the proteins we need. Over time, this can lead to problems such as hormonal
imbalances, depressed immune function, or poor recovery from exercise (per-
haps even injuries).
Lysosomes and peroxisomes

lysosome: Organelle containing Lysosomes are the “garbage disposal units” of our cells. They are vesicles, con-
hydrolytic enzymes taining more than 50 different enzymes, which can break down cellular com-
microorganism: Organism of ponents and protect cells. If a large molecule, such as an old cellular structure
microscopic size or a microorganism, enters the cell, the lysosome will engulf it then digest and
peroxisome: Cytoplasmic orga-
dispose of it. By keeping the cells clear of waste and debris, lysosomes help renew
nelle with enzymes that help with and protect the cell.
the breakdown of fatty acids and
other macromolecules Peroxisomes are similar to lysosomes: they are small membranous sacs

Cells | 39
containing enzymes (catalase and oxidase), which also detoxify harmful sub- detoxify: To remove a poison or
stances that enter cells. Found commonly in liver and kidney cells, peroxisomes toxin from the body
are also important in cholesterol synthesis, bile acid synthesis, ß-oxidation, and cholesterol: Synthesized in the
prostaglandin metabolism. liver of humans and other animals.
A precursor of bile acids and ster-
oid hormones
Like mitochondria, peroxisomes are able to break down fats for energy. However,
when they do this, they produce 30-40% more energy as heat but 30% less energy bile: A yellow or orange fluid pro-
as ATP. duced by the liver, concentrated
and stored in the gallbladder, and
released into the small intestine
Since dietary omega-3s increase fat breakdown through peroxisomes, more fat for fat digestion
is burned to do the same daily activities when omega-3 intake is high. Unfor-
ß: Beta, the second letter of greek
tunately, omega-3 supplementation is not a magic fat loss method: The overall
alphabet
impact is minor.
prostaglandin: Class of physi-
ologically active fatty acid com-
Body function pounds present in various tissues;
can have hormone-like effects
Let’s look now at how these cellular components, and the chemicals they make
and use, work together within the body.
Enzymes
Enzymes make up the largest group of proteins in the body. You can often spot
enzymes by their names, which typically end in “-ase”, such as:
• lipase (enzymes that break down lipids);
• protease (enzymes that break down proteins); or
• amylase (enzymes that break down carbohydrates).
Enzymes are important biological catalysts, substances that jump-start and catalyst: A substance that accel-
speed up nearly every chemical reaction that occurs in the body. erates a chemical reaction
Enzymes work by exposing their own “active sites” to connect with particular
molecules. Once the enzyme can hold these molecules in place, reactions can lock-and-key model: Model
occur. One model of this process is the lock-and-key model. In this model, the that explains enzyme specificity
Products
Substrate
weakened
substrate bonds
active site
Enzyme Enzyme-Substrate Enzyme
Figure 1.6. Enzymes. Enzymes expose their own “active sites,” connecting with spe-
cific molecules. Holding these molecules in place, they allow reactions to occur, which
allows for product formation.

40 | Unit 1
enzyme and its chemical partner fit together tightly and carry out their reaction.
induced fit model: Model that In another model, the induced fit model, the enzyme and chemical partner
suggests enzymes are rather flex- undergo structural changes when close to one another, eventually fitting together
ible structures
properly and starting the reaction. You can think of this like puzzle pieces that
change their shape when they are near each other.
No matter what model you apply, the key idea is that enzymes must somehow fit
and connect with their chemical partners. Lipase can only work with lipids; it can’t
work with proteins.
See Figure 1.6.
Many environmental, genetic, and nutritional factors — including temperature,

pH, substrate concentration, and vitamin and mineral status — influence how en-
zymes work. Thus, nutrition plays an important role in most enzymatic reactions.
Co-enzymes
co-enzyme: Non-protein com- Just like a co-pilot works with a pilot, co-enzymes work with enzymes. Coen-
pound that forms the active por- zymes are non-protein molecules, made up wholly or partly of vitamins. We
tion of an enzyme system need them for enzyme-catalyzed reactions.
catalyze: Initiate or increase the
rate of a chemical reaction For instance, pyridoxal phosphate, the active form of vitamin B6, acts as a co-en-
zyme in all transamination reactions, a particular kind of chemical reaction
involving amino acids. We’ll talk about these types of chemical reactions later in
the text.
And you may already have heard of co-enzyme Q10, which we mentioned earlier,
and which is involved in cellular respiration reactions.
Protein receptors
Protein receptors are found both in the plasma membrane and inside the cell.
As we’ve discussed, cell membranes help control what gets in and out of our
cells. They do this, in part, with membrane protein receptors that act like little
chemical gates.
signal transduction: Cells get information about their outside world by signal transduction. The
Conversion of one signal to an- process is a little bit like the telephone game you played as a kid.
other by a cell
receptor-ligand binding com- A receptor on a cell binds to what is known as a ligand, forming a receptor-ligand
plex: A complex formed between binding complex. A ligand attaches to its specific receptor and no other. The
a receptor and a substance to ligand activates its receptor, which then activates a second messenger inside the
allow for further cellular activity
cell. Then the second messenger activates another second messenger, and so on
ligand: An ion or molecule that until the last second messenger goes into the nucleus and triggers changes in gene
binds to another molecule or
metal atom
expression that leads to some sort of cellular response.
second messenger: Substance An example of this process is our cellular response to insulin.
that mediates intracellular activity
by relaying a signal from an extra- • After we eat, insulin is released from our pancreas and travels through the
cellular molecule bloodstream.
• From there, it can bind to specific, insulin-friendly protein receptors on the

membrane of our cells.

Cells | 41
Once bound, this connection signals to proteins inside the cells — usually called
second messengers — to get more channels to the membrane and accept glucose
more readily.
As we’ve stressed already, physical activity changes how our cells respond to
nutrients. Repeated muscular contractions (for instance, 30 minutes of pumping
our legs on a bike) tell the cell to move more protein receptors to the cell mem-
brane. This helps glucose get into the cell more efficiently and effectively to help
refill the fuel tank.
What we eat can also influence second messengers. For instance, caffeine in
coffee / tea, theobromine in cacao, and theophylline in tea / cacao can all inhibit
phophodiesterase, an enzyme that breaks down second messengers in cells. So,
in the case of caffeine, this means stronger / faster heart muscle contractions,
greater blood vessel constriction, and enhanced stomach acid secretions.
Transport proteins
Transport proteins are also involved in cellular communication. These live in
cell membranes and let molecules pass between spaces inside the cells and spaces
outside of cells.
This movement across the plasma membrane can take place via one of two
mechanisms:
• passive transport (which doesn’t need energy), or
• active transport (which needs energy).
Active transport allows vitamins, minerals, glucose, and amino acids into cells. See
Figure 1.7
In the next unit, we’ll look at how some of these chemical processes and cellular
structures and tasks are involved in digestion.
Extracellular space
Intracellular space
Figure 1.7. Transport proteins. Transport proteins specifically allow the passage of
water-soluble molecules between the spaces inside the cells and the spaces outside the
cells. Movement across the plasma membrane can take place via one of two mechanisms:
facilitated diffusion or active transport. Cellular transport allows things like vitamins,
minerals, glucose and amino acids into cells.

42 | Unit 1
Salivary amylase is an enzyme in saliva that starts the digestion of starch. It helps
to improve our “mouth experience” while eating (e.g., enhanced taste of certain
foods). We’ve known about it for over 100 years.
Just recently, researchers found a correlation between obesity and a person’s

ability to make amylase. People with fewer AMY1 genes — thanks to genetic
polymorphisms — might not tolerate carbohydrates as well. People whose
ancestors traditionally ate diets higher in starch seem to have more AMY1. This
is another example of the interaction between our environment, culture, genes,
and optimal dietary choices.
Cell types
In the next unit, you’ll meet some different cell types.
You’ll notice that many types end in the suffix “cyte.” This suffix will tell you that
something is a cell. (For more on this, see the “Language matters” sidebar.)
Each cell’s structure can tell you about its job. For instance:
• Enterocytes, which line the intestine, are shaped like little brushes. This increas-
es their surface area and helps them absorb nutrients.
• Much of the gastrointestinal tract is lined with columnar epithelial cells.

columnar epithelial cells:
Pillar-shaped cells that line many These are tall skinny cells.
surfaces of the body
• If their job is to absorb nutrients, there’s only one layer of them.
goblet cells: Mucus-secreting
epithelial cell that distends, taking • If their job is to secrete things (like saliva), they’re stacked on top of each other
on the form of a goblet; found like cases of beer. Stacked cells are known as stratified cells.
often in respiratory and intestinal
tracts • Some columnar epithelial cells are known as goblet cells because of their
shape.
• Cuboidal, or cube-shaped cells, are found in the salivary glands and the lining
of the mouth. Because of their shape, they tend to be a little stronger and
tougher, so they’re often used as structural cells.
• Squamous cells are flat cells that look a bit like layers of fish scales. They line the
esophagus and help protect it from stomach acid. They’re easily sloughed off
and replaced.
• The structure of myocytes, or muscle cells, allows them to produce force in

order to move our body around.
There are many types of cells within the human body. You won’t learn them all.
Just get the general idea: Cells are not only diverse inside, they’re diverse outside
too. Each unique cell type and structure is adapted for a specific job.

Cells | 43
Language matters
Many of our English medical terms come from ancient Greek or Latin, or even
older sources. You’ll notice we often mention where these terms come from.
Obviously, you don’t have to brush up on the classics to become a nutrition

coach.
But you may find it helpful to understand where words come from, so that you
can guess at what an unfamiliar word might mean.
For instance:
“Entero” comes from the Greek enteron, or intestine.
“Hepatic” comes from the Greek hepatikos, or liver.
“Gastric” comes from the Greek gaster, or stomach.
“Cyte” comes from the ancient Greek kyto, which refers to a hollow or empty
container. We now use it to refer to cells.
“Epi” comes from the even more ancient Proto-Indo-European epi, meaning near,
at, or against.
So any time you see a form of these words, you’ll know what you’re dealing
with.
For instance, enterocytes are intestinal cells. Hepatocytes are liver cells. Epithelial
cells are cells that are the top layer of something, such as the innermost layer of
the esophagus.
This study of where words come from is known as etymology. This can give us
clues about what those words mean. It can also help you if English is not your
first language.
If you’re having trouble recalling a particular term in this course, try Googling
“etymology” and that term. You might learn a little factoid or two about that
term that helps it stick with you.
Get to know the language of your field and where it comes from, and you’ll
probably find that your understanding and comfort with the terminology im-
proves. (And you’ll remember it better when tested!)

44 | Unit 1
Summary
The trillions of cells of the human body work together as enzymes and co-enzymes, or protein receptors) to
to form tissues, organs, and organ systems. The total of begin and carry out chemical reactions; to send cell
all of the activities taking place in these systems is what signals; and / or to transport other molecules.
most people refer to as “metabolism.”
The food we eat interacts with the small chemical reac-
There are many levels of organization in the body, from tions and processes taking place in our cells.
microscopic atoms up to fully functional organisms (and
beyond, to ecosystems). These systems are interconnect- Food thus affects our health in five ways. It:
ed, and all must work properly for organisms to thrive.
1. provides energy
Our cells have many jobs, including:
2. provides molecules involved in chemical reactions
• converting nutrients into energy (particularly ATP)
3. is incorporated into body structures
• making proteins (under the direction of our DNA)
• moving those proteins, nutrients and other substanc- 4. influences chemicals such as hormones and
es around (including in and out of the cell across the neurotransmitters
membrane) and
5. affects genetic protein-making signals as well as the
• clearing waste and debris from the cell. quality of the proteins that are made
Our cells use specialized structures and molecules (such

UNIT 2
Through the GI Tract

46 | Unit 2
Unit Outline
1. Objectives 4. How do we absorb our food?
2. Digestion 5. Case study
3. Controlling the digestive process 6. Summary
Objectives
In this unit, you’ll learn: • how nutrients are transported to and into cells.
• how your body transforms the food you eat into By the end of this unit you should be able to describe and
material that your cells can use understand the basics of how these processes work, and
• how your digestive system breaks down your food how they generally apply to the practice of fitness nutrition.
into smaller molecules and controls how nutrients are

absorbed into the bloodstream
Digestion
In order to use nutrients, our body has to process them Food is more than just nutrients
first. This is known as digestion, from the Latin digerere
— to separate, divide, or arrange — a term that captures In this unit, we’ll focus on the chemistry and components
exactly what our body does: of food. But as you learn the details of food chemistry and
how it relates to digestion, keep the big picture in mind.
• separate molecules and break up more complex
substances; Food isn’t just a pile of nutrients. It has physiological,
psychological, social-cultural, and environmental
• sort and divide molecules by type and where they
dimensions.
should go; and
• arrange and transport them throughout the system This is important to remember as you practice fitness
to our cells. nutrition. Most people don’t eat “nutrients” — they eat
foods and meals. Complex foods aren’t just macronutri-
It’s often said that you are what you eat. More accurately, ent sources.
you are what you digest, absorb, and transfer to your
cells. Our body carefully manages these processes to So: Learn and understand the science, then translate it
control what gets into our cells, and to keep a dynamic when communicating with clients.
balance within the body.
To a client (and hopefully, most of the time, to you too),
chicken is chicken, not “protein.” Chicken is part of
What is food? a meal like curry, rotis, a fajita, or chicken soup. And
a meal is part of a complex set of social and cultural
As you’ll remember from the Introduction, there are behaviors.
many ways to think about food: food as fuel, food as
information, food as a story, etc. When working with clients, always take a holistic view
of nutrition and eating, no matter how awesome and
interesting the science is.

Through the GI Tract | 47
The composition of food

For now, let’s look at what food is made of. Food contains:
• macronutrients: proteins, carbohydrates, and fats
• micronutrients: vitamins, minerals
• phytonutrients and zoonutrients phytonutrients: Used

interchangeably with
• water. phytochemicals. Components
found in plant food sources
Food also contains other substances, such as fiber, that we don’t use directly, but
zoonutrients: Used
that are used by the bacteria living in our intestines. interchangeably with
zoochemicals. Components found
Because food was once other living organisms (such as plants or animals), it’s in animal food sources
chemically complex. Our body has to take this complexity and simplify it. We
must break food into smaller pieces that can be moved safely and easily around
the body, then transported into cells in forms that those cells can use.
For instance:
Most proteins must be broken down into amino acids.
Most carbohydrates must be broken down into glucose.
Most fats must be broken down into fatty acids.
We’ll look more at the production of energy, and how these macronutrients are
broken down and used, in upcoming chapters.
How digestion works

The gastrointestinal tract
Our gastrointestinal (GI) tract is a muscular canal through our body that’s gastrointestinal (GI) tract:
about 26 feet (8 m) long and includes everything from mouth to anus. While The long tube through the
body composed of stomach and
digestion is one of its main roles, the GI tract does more than that. intestines
• It brings in and processes nutrients.
• It gives us a physical and chemical barrier against pathogens.
• It detoxifies potentially harmful substances and excretes waste.
• It contains a “second brain”, known as the enteric nervous system.
• It secretes some hormones and helps process others.
• It helps regulate our immune system.
• It’s innervated by nerves also involved in social engagement and emotion, giv-
ing us important (often instinctive and subconscious) signals about the world
and how we feel.
In this unit, we’ll focus on the GI tract and its role in digestion, but bear in mind
that the GI tract does lots of other cool things too.
Fundamentally, the process of digestion involves a few key steps:

48 | Unit 2
When we see or even think about food, the brain tells

the rest of the body to prepare for eating.
After all, most of us don’t like uninvited surprise guests

who wake us up and expect us to start partying with
Mouth them immediately. The same is true of our GI tract — it
likes to know in advance what’s coming down the pipe.
Esophagus Every stage of digestion alerts the next stage to expect
food and nutrients to arrive.
Thus, if food seems nearby, our brain immediately tells

our mouth to start salivating, our stomach to start
secreting digestive enzymes, and so forth. (If you think
about how often we see food cues during an average day,
you can imagine that these ever-present reminders can
Stomach
cause our appetite to get out of whack. In the 21st centu-
Liver
Pancreas ry, our brain is constantly told that it’s chow time.)
Gallbladder
Small Intestine We’ll look more at this process later.
Large Intestine
The nervous system

Our digestion is controlled by our autonomic nervous
system (ANS), which regulates our internal organs out-
Figure 2.1 Digestive system. side of our conscious control.
The ANS has two branches:

• the sympathetic nervous system (SNS), aka our “fight
• breaking down foods mechanically and chemically
or flight” system
into smaller pieces, and eventually smaller molecules;
• the parasympathetic nervous system (PNS), aka our
• moving those molecules from inside the GI tract to
“rest and digest” system
elsewhere in the body (either for use or storage); and
• excreting whatever our body doesn’t want or won’t Our GI tract responds to both SNS and PNS signals.
use. • SNS activation (with intense activity, stimulation, or
stress) tends to shut down digestion and appetite.
Where digestion begins: The brain Our mouth goes dry, we stop wanting food, our GI
and nervous system tract stops moving food through the system, and we
may get “butterflies” in our stomach.
We might think of digestion as starting in the stomach. • PNS activation (with rest and relaxation) tends to reg-
In fact, digestion starts in the brain and is organized by ulate digestion and movement through the GI tract,
the nervous system.
so that things proceed steadily and calmly. (However,
The brain in situations of extreme fear or trauma, once our SNS
response has been exhausted, the PNS might also
Hunger activates systems in our brain that tell us to get activate. Since intestinal motility is one of the PNS’s
up and get moving. To go find food, we have to override jobs, we might lose bowel control.)
our natural desire for staying put and staying safe. Thus,
the parts of our brain that help us find food are also in- Digestion can be affected by both internal signals (such
volved in movement, stimulation, curiosity, reward, and as what’s happening elsewhere in the body) as well as
looking for things. environmental signals (such as outside stressors).

This relationship between our nervous system, the GI tract, and our outside envi-
ronment is important for nutrition coaches to understand. For instance:
Internal or external stress can affect our digestion and how our GI tract behaves.
What we think and feel (internal), or what we see or smell (external) can affect
our appetite, hunger, and fullness.
Nose and mouth

Olfaction
It’s not technically part of digestion, but smelling our food (known as olfaction)
is an important part of eating. olfaction: Action of smelling
Smelling food before we eat it not only tells our GI tract that food is coming, it
helps us decide whether to eat something in the first place.
Then, retronasal olfaction happens when odors from food travel up the back of
our throat into our nasal passages as we chew and swallow. retronasal olfaction: Smelling
from behind the nose
Interestingly, retronasal olfaction seems to be important for satiation, or fullness.
Keeping food in our mouth longer, which lets us smell and taste it better, tells
our brain that we’re getting enough nutrients. This is probably why slow, mindful
eating leaves us feeling more satisfied with less food. (And why many cultures
seem to be able to combine delicious, decadent cuisine with smaller portions and
leaner people.)
And of course, if we don’t smell food, we can’t taste it properly. You’ve probably
found that when you have a cold, food just isn’t as appealing.
Salivating and chewing

Once food is in our mouth, our teeth rip, shred, and grind it into smaller pieces
with help from our powerful jaw muscles. Our saliva moistens the food and satu-
rates it with enzymes that start to break it down. Our tongue tastes the food and
eventually push it back into our throat to swallow.
Teeth, jaw, and palate
Teeth are uniquely adapted to each organism’s diet. We have omnivore teeth — a
mix of cutters, choppers, and grinders that allow us to masticate, or chew, many
types of foods. Teeth are covered by enamel, the hardest and most chemically
stable substance in the human body.
In terms of the amount of force they can produce for their size, our jaw mus-
cles are among the strongest in our body. Chewing also stimulates pleasurable
neurotransmitters, which is one reason we may enjoy eating (or chew on things
when we’re anxious).
The palates on the roof of the mouth separate the nasal passages and the mouth.
They also protect the teeth and help us create sounds.

50 | Unit 2
Tongue, taste buds, and mucous membranes
Our tongue is covered with papillae, tiny bumps that in- The mouth is lined with a mucous membrane. Because
crease the surface area of the tongue and help move food this membrane is thin, somewhat porous, and rich with
around the mouth. Most types of papillae also contain blood vessels, we can absorb many substances through
taste buds. it, such as sublingual (under the tongue) drugs.
Is sweet taste enough to refuel us?
As you’ll learn later, carbohydrates in the form of glu- has receptors that signal the brain that carbohydrates
cose are an important fuel for our body. are available. Functional MRI (fMRI) studies have found
that sweet taste activates areas of the brain associated
Glucose is absorbed and processed by our small intes-
with movement.
tine and our liver, and sent to our cells to help make
energy in the form of ATP. We can use this ATP to power Indeed, studies that have injected athletes with glucose
us through exercise. (thus bypassing the mouth, so athletes taste nothing)
have found that their performance doesn’t necessarily
But you may be surprised to know that often, a sweet
improve. We may have to taste sweetness “centrally”,
taste in our mouth — without that sweetness ever get-
i.e., with our conscious awareness and our taste recep-
ting further into our GI tract — may be enough to give
tors, in order for it to work best.
us energy.
But not every study finds that a carbohydrate “mouth-
Recent research suggests that when athletes swish out
wash” improves performance. Research on this topic is
their mouths with a sweet carbohydrate-containing
still ongoing.
solution, but don’t swallow it, their bodies act as if those
carbohydrates got into circulation. This means the ath- Still, the idea offers some intriguing possibilities. At the
letes can perform better and exercise longer — again, as very least, it tells us that taste is more than just a pleas-
if they had really consumed those carbohydrates. ant side effect.
Scientists speculate that this works because the mouth
Salivary glands
We have salivary glands under our tongue (sublingual), In the 1.5 or so liters of saliva we make every day, we find
along our bottom jaw (submandibular) and in our digestive enzymes like amylase and lipase.
cheeks, along the backs of our jaws (parotid), along with
up to 1000 tiny minor salivary glands scattered through Amylase begins the digestion of starch.
our mouth.
Lipase begins the digestion of fats. However, we don’t
Saliva is about 95% water, with the rest being mucus, en- digest much fat in our mouth. It takes a relatively long
zymes, glycoproteins, and antimicrobial chemicals that time to digest fat, and unless you like sucking on pats of
help prevent pathogens from getting into our system. butter, dietary fat doesn’t usually stay long in our mouth.
Saliva moistens our mouths, keeping our mucous mem-
As with all aspects of the GI tract, salivary secretion is
branes healthy and washing away harmful bacteria.
connected to both our parasympathetic and sympathetic
nervous systems. When we are anxious or stressed, our
mouth tends to go dry.

Oral microbiome
Although our saliva washes away unwanted bacteria, our mouth is not sterile.
Like most other places in and on our body, our mouth contains an active micro-
biome, or microbial community.
There are nearly 300 known species of friendly bacteria in our mouth; research-
ers speculate there may be as many as 700. Each species lives in its own little oral
neighborhood (such as along the gumline or under the tongue).
Digestion, metabolism, and your mouth
Getting a regular dental checkup may do more than keep our pearly whites
shiny and cavity-free. It may also help ensure your clients can chew and swallow
their food properly, and aren’t suffering any underlying health problems.
For example:
• Older clients, clients with dental work, or clients with misalignment of

the temporomandibular joint (TMJ) may find it hard to chew properly.
• Bad breath can signal gum disease or a love of garlic, but it can also be a
sign of digestive problems such as acid reflux. (See more below.)
• Gum disease can signal untreated diabetes, potential cardiovascular dis-

ease, inflammatory bowel disease (IBD) or other inflammatory conditions
— even colon cancer.
• Clients with bulimia that includes vomiting may have tooth erosion and
damage to their mouths.
Most of these are outside your scope of practice, but you may find yourself col-
laborating with your clients’ dentists at some point as part of a holistic approach
to fitness nutrition.
amylase: Of pancreatic and

salivary origin, this enzyme
Swallowing catalyzes the hydrolysis (splitting)
of starch into smaller compounds
Once the food mass is chewed, lubricated, and formed into a lump, it’s known as lipase: Catalyzes the splitting of
a bolus. The bolus is passed to the pharynx. fats into glycerol and fatty acids
bolus: A formed mass of soft,
While we can move the bolus to the back of our mouth voluntarily and decide partially chewed food
whether to swallow it, the process of swallowing itself is actually involuntary. pharynx: Throat
When swallowing, the epiglottis involuntarily closes to stop food from entering
our trachea. The uvula also closes off the nasopharynx, preventing food from epiglottis: Lid-like cartilaginous
structure suspended over the
entering the nose. entrance of the larynx; swallowing
closes the opening to the trachea
These actions stop food from getting into our airway. However, sometimes fluid by placing the larynx against the
epiglottis

52 | Unit 2
sneaks down before the closing of the epiglottis. This is what people describe as
water “going down the wrong pipe.” (And of course, most of us have accidentally
snorted liquid through our nose when our dinner companion cracks a joke.)
The esophagus
The esophagus is a tube, lined
with a mucous membrane, that
transports food and water from Mouth
the mouth to the stomach. Its
name is derived from the ancient
Greek oiesin, “to carry”, and Esophagus
phagein, “to eat” — thus, the
esophagus carries what we eat
from the mouth to the stomach.
The saliva that moistened food

in the mouth now helps move it
through the esophagus, with the
help of the mucous membranes
Stomach
in the esophagus. Gravity does
peristalsis: Waves of involuntary Liver
much of the job. A series of wavelike muscular contractions, called peristalsis,
muscle contraction moving the Pancreas
handles the rest. Gallbladder
contents of the GI tract forward
Small Intestine
lower esophageal sphincter The esophagus ends in a ring-like Intestineknown as the lower esophageal
Largemuscle,
(LES): Also known as the cardiac sphincter (LES) (or cardiac sphincter), which regulates food entering the stom-
sphincter, a thick, muscular ach. The LES also prevents food and acidic stomach juices from splashing back
ring surrounding the opening
between the esophagus and upwards. an unwanted situation known as gastroesophageal reflux disease
stomach (GERD).
gastroesophageal reflux
Gastroesophageal reflux is caused by the sphincter opening more often than it
disease (GERD): Condition in
which acidic stomach contents should, or opening at the wrong times. While your diet doesn’t likely cause gas-
flow back up into the esophagus troesophageal reflux, it can make it worse. (See sidebar “Gastroesophageal reflux
disease (GERD)” for more.)
Most people experience GERD as heartburn, usually after eating. GERD can also
involve other unpleasant symptoms such as:
• burning in the back of the throat, or a persistent cough or hoarseness;
• nausea and vomiting;
• pressure and / or pain in the chest;
• bloating and burping; or even
• tooth erosion.
If you have a client diagnosed with GERD, consider the simple dietary action
plan we suggest in the sidebar.

Gastroesophageal reflux disease (GERD)
As of 2014, the third-most prescribed and top-selling Processed foods, especially fatty foods, can cause
drug in North America was Nexium. This drug type, problems. In part, this is due to how our GI tract pro-
known as a proton pump inhibitor (PPI), causes the cesses fat.
stomach to produce less acid. This in turn reduces the
• When dietary fat enters the small intestine, it
painful symptoms of GERD.
triggers relaxation of the LES. Medium and long-
However, PPIs don’t help everyone, they have side chain fatty acids seem to create the strongest
effects, and they don’t solve the fundamental problem response.
underlying GERD. In addition, reducing stomach acid
• Dietary fat slows gastric emptying, meaning that
may leave us with less protection from whatever patho-
food and acids stay in the stomach longer. This
gens stomach acid normally kill.
increases stomach pressure, which in turn can
It’s not surprising that Nexium and over-the-counter promote reflux as stomach contents are pushed
remedies such as antacids are selling so well: As many as upwards.
one-quarter of people in North America will suffer from
Having a lot of body fat may worsen GERD as visceral
GERD at some point.
fat (around the internal organs) compresses the space
GERD hurts, but it can also increase people’s risk for around the stomach.
abnormal esophageal tissue growth, and perhaps even
Bacterial overgrowth, such as Helicobacter pylori, the
esophageal cancer. The long-term damage and inflam-
bacteria responsible for ulcers, may also be involved.
mation caused by stomach acid and undigested food
can lead to these more serious problems. Age tends to weaken muscles, including sphincters.
Over time, the LES is less able to seal the esophagus
It’s hard to know exactly what causes GERD. Most likely,
properly.
there are many factors.
Smoking can worsen not only GERD but also increase
Gravity can play a role. Eating a big meal then lying
the risk of esophageal cancer.
down often causes heartburn, as the fluids slosh back
upstairs and it’s harder for the LES to block the entrance There may even be a genetic component to GERD risk.
to the esophagus. If you have clients with night-time As a nutrition coach, you can offer some simple steps to
heartburn, try having them elevate the head of their bed help your clients alleviate GERD:
slightly, prop up on pillows, or simply eat earlier in the
• eat slowly;
evening if possible, so that the stomach has more time
to empty itself. • eat mindfully in a relaxed setting;
Stress also affects digestion. When we’re rushed and • eat smaller meals;
stressed, we tend to eat faster and less mindfully. We
• keep a food journal to see if there is a link be-
may not chew properly, and gulp our food in chunks.
tween what they eat and their GERD symptoms;
Additionally, stress activates the SNS, which then slows
and
down gastric and intestinal motility, or the movement of
food through the GI tract. • choose less-processed, whole foods.
Your heavier clients may also notice that if they lose

body fat, their GERD eases as well.

54 | Unit 2
The stomach
The stomach is a roughly J-shaped pouch that sits more or less around the base of
your breastbone, slightly to the left.
A normal stomach capacity ranges from 0.25-1.7 liters. The stomach has stretch
receptors that tell us when it’s filling up. (You can help clients learn to “tune in”
to this feeling of expansion and fullness to better decide when it’s time to stop
eating.)
While we absorb most nutrients in the small intestine, our stomach can absorb a
short-chain fatty acids: few. Certain drugs, water, some vitamins, alcohol, and specific short-chain fatty
Fatty acid with fewer than eight acids (e.g., acetate, butyrate, and propionate) can cross the thick stomach lining
carbons that is taken up directly
through the portal vein, and
and enter general circulation.
produced while fiber is fermenting
in the colon Stomach anatomy and function
The stomach is divided into three parts. (See Figure 2.2):
• the fundus (the first part, just below the esophagus)
• the body (the central part)
• the antrum (the lower part)
chyme: Partly digested food While in the stomach, food is churned and mixed into a liquid called chyme.
formed as a semi-fluid mass Another ring-like muscle, the pyloric sphincter, lies at the end of the antrum
pyloric sphincter: Thick, and controls the passage of chyme into the small intestine.
muscular ring of mucous
membrane surrounding the Interestingly, because the stomach begins toward the left side of the body and
opening between the stomach ends toward the right side, lying on your right side will help the stomach con-
and the duodenum
tents pass through the pyloric sphincter. In a famous comedic novel, A Confed-
eracy of Dunces, the main character, who is having problems with his pyloric
sphincter, lies down on his right side and bounces, taking advantage of gravity
and this anatomical situation to help move things along.
A hernia occurs when tissue pokes through tissue, such as the abdominal wall,
hiatal hernia: Protrusion of the that should normally contain it. In a hiatal hernia, a small piece of the fundus
stomach through the esophageal peeks through a small tear in the diaphragm. Hiatal hernias usually improve
hiatus of the diaphragm
with exercise, weight loss, sleeping on a slight incline, or prescription medica-
tions. Most cases don’t need surgery.
Gastric mucosa
The innermost layer of the stomach, the gastric mucosa, secretes a variety of
gastric juice: Acidic fluid substances that are collectively known as gastric juice.
secreted by the stomach glands
and involved in digestion Chief cells secrete enzymes such as pepsin or gastric lipase to begin protein and
fat breakdown, respectively.
hydrochloric acid: Solution of Parietal cells secrete the stomach’s main acid, hydrochloric acid, along with
hydrogen chloride in water; found intrinsic factor, a glycoprotein that we need to absorb vitamin B12.
in gastric juice
Aging, gastrointestinal diseases, bariatric surgery, and alcoholism can make it
harder for us to produce intrinsic factor. This means we might not get enough

Figure 2.2 The stomach.
vitamin B12 from food or vitamin supplements that we about the same as battery acid. This helps kill most patho-
swallow. We might need to supplement B12 by injection gens and further breaks down the food.
or sublingually (under the tongue) to bypass the need for
intrinsic factor. Stomach emptying
Other gastric mucosal secretions include: After working its way through the stomach, the chyme
(which consists of partially digested food, water, acids,
• histamine (which is involved in the immune response
and digestive enzymes) begins to empty into the small
and increases gastric acid production) intestine.
• glucagon (a hormone that helps release glucose into
This happens very slowly — only a few milliliters at a
the bloodstream)
time. Thus, it usually takes between one and four hours
• serotonin (a neurotransmitter) for the stomach to empty, depending on what we’ve eaten.
As its name suggests, the gastric mucosa is also lined • Carbohydrates empty first, then proteins. Fats and
with mucus, which helps protect it against the powerfully fiber move the slowest.
corrosive hydrochloric acid. When acid secretion is at its • Liquids empty more quickly than solids.
highest during digestion, the stomach has a pH nearing 1,
• Small particles more quickly than large particles.

56 | Unit 2
Helicobacter pylori: Friend or foe?
At first, you’d think that stomach bacteria is a bad H. pylori is sneaky and versatile. It can easily slip past
thing. Certainly, when the bacterium known as Helico- our immune system, and may even have modified
bacter pylori was discovered as the cause of ulcers by a our immune response to suit its needs. If allowed to
courageous (or crazy) scientist who purposely infected over-colonize, H. pylori can lead to inflammation of the
himself with it, it seemed to be. stomach and / or esophagus, ulcers, tissue damage and
scarring, and perhaps even cancer.
However, as we are learning more about the role of
our microbiome, the microbial communities that live in Yet not everyone infected with H. pylori gets sick.
and on us, H. pylori seems like less of a supervillain and
Why not?
more of an evolutionary co-pilot that has been with us
for millions of years of co-evolution. Different strains of H. pylori seem to have different
effects. Our microbiomes are not only unique to us, but
Most bacteria would wither and die in the extremely
also may depend on things like our genetic or ethnic
acidic environment of the stomach. Yet H. pylori seems
subgroup, our immune system makeup, our diet, where
to live there happily, snuggled into the gastric mucosa
we live, and other factors in our environment.
along with approximately 200 other known bacterial
species. Somewhat ironically, H. pylori may even protect us by
preventing the overgrowth of other species of bacteria.
The secret to this wary yet potentially useful co-exis-
tence seems to be a dynamic balance between the host As we learn more about our microbiome, we will
(that’s us) and H. pylori’s growth. undoubtedly learn more about our bacterial friends…
and foes.
Stress / anxiety, many medications, over-eating, hor- • For a client who is trying to lose weight, but doesn’t
mones, and other factors can all affect gastric emptying. like feeling hungry: You might make sure their meals
are higher in fat, slow-digesting proteins and fiber to
All of this is useful to know when considering how to slow down gastric emptying and help them feel more
plan meals with your client.
satisfied for longer.
For instance: • For a client under stress: You might have them eat
• For a client who needs a quick energy boost that smaller meals, and take an extra 5-10 minutes at each
won’t weigh them down, such as an athlete with meal to eat a little more slowly.
several training sessions a day: You might make one
We’ll look more at designing nutrition plans later. Just
or more of their meals a liquid meal that’s lower in
get the basic idea of how understanding gastric function
fat and higher in carbohydrate, with quick-digesting might apply to your fitness nutrition recommendations.
proteins (such as whey or rice protein powder).

Does gastric bypass do more than shrink the stomach?
More and more people are opting to have some kind of bariatric surgery for bariatric: Often related to GI
obesity. surgical procedures to control
bodyweight
One of the most common surgeries is gastric bypass surgery. This type of
surgery re-sections the stomach, making it a much smaller pouch that can only
hold a few ounces of food.
The initial idea behind this surgery was simple: Smaller stomach means less food
in there. Less food means weight loss.
But then doctors discovered unexpected side effects of bariatric surgery: chang-
es in appetite and other gut hormones.
Many people found, for instance, that after surgery, their insulin sensitivity
improved and consequently their Type 2 diabetes improved. Or they secreted
fewer hunger hormones and more satiety hormones.
Not every patient experienced this. Nor is weight loss surgery a magic process.
Many other people struggled with malabsorption syndromes, vomiting, and
other unpleasant after-effects. In addition, many people did not address the
lifestyle and behavioral factors that led to obesity in the first place.
Nevertheless, the fact that changing the physical structure of the stomach can
change hormones gives us intriguing clues about how the GI tract might work
as an integrated signaling system.
The small intestine

Once chyme enters the small intestine, peristalsis propels it along slowly. It takes
between 4-8 hours or more just to get through the small intestine.
This plodding pace lets the small intestine absorb most of the nutrients we’ve
eaten, such as:
• electrolytes including potassium and sodium
• minerals including iron, calcium, magnesium, and zinc
• carbohydrates
• amino acids
• fats
• water-soluble vitamins (such as vitamin C or the B vitamins)
• fat-soluble vitamins (such as vitamin A or E)
• cholesterol and bile salts
• nutrients we have yet to identify
We also absorb most oral drugs, such as alcohol and other medications, in the
small intestine.

58 | Unit 2
Small intestine anatomy and function

The small intestine is lined with cells called
enterocyte: Absorptive cell of the enterocytes. These are shaped a bit like
intestine brushes, full of folds, pits, and finger-like
villi: Small projections (singular: projections known as villi. This distinctive
villus) covering the surface of the cellular shape and lining, known as the Liver
mucous membrane lining the “brush border”, dramatically increases the
small intestine, through which
nutrients and fluids are absorbed surface area of the intestinal lining. Stomach
intestinal brush border: All Healthy villi are important. When they’re
of the villi that form a brush-like Large Intestine
border inside the intestine
damaged, we don’t absorb nutrients
properly. This can happen, for instance,
Small Intestine
with inflammatory bowel disease, un-
treated celiac disease, food poisoning,
or untreated food intolerances. Indeed,
villus atrophy: When the a “flattened” brush border with villus
threadlike projections covering atrophy is a common sign of intesti- Rectum
the lining of the small intestine
decrease in size
nal disease.
The small intestine is subdivided into

three main parts. Anus
Figure 2.3 Small and large intestines.
duodenum: First portion of • The duodenum is the first section
small intestine past the stomach. In adults, it’s about 1.5 feet (45 cm) long.
jejunum: Second portion of • The jejunum is the second section and is 7-10 feet (about 2-3 m) long. Most
small intestine nutrient absorption takes place in these two portions of the intestine.
ileum: Distal portion of small • The final section of the small intestine is the ileum. It is 10-13 feet (about 3-4
intestine m) long. It absorbs vitamin B12, bile salts, and whatever products of digestion
were not absorbed by the jejunum.
Duodenum
pancreas: Large gland behind The first segment of the intestine, the duodenum, secretes juices from the pan-
the stomach that secretes creas. The juices, which contain bicarbonate, lipase, amylase, and proteolytic
digestive enzymes and the
hormones insulin and glucagon
enzymes, have two tasks:
bicarbonate: Organic salt (HCO3 • first, to neutralize the formerly acidic chyme with the very alkaline bicarbon-
) that can neutralize acids ate; and
proteolytic enzyme: Enzyme • second, to further break down the foodstuffs into their component parts.
that hydrolyzes (breaks down)
protein or peptides
During this time, the gallbladder releases bile (made up of bile salts and choles-
gallbladder: Muscular sac where terol) to emulsify fat. Emulsification happens when two otherwise unblendable
bile is stored substances (such as oil and water) are mixed. (A salad dressing, for example, is
emulsification: To disperse, usually an emulsion, as is dairy cream.) Mixing fat with bile makes the fat more
convert and suspend one liquid as soluble and thus more easily absorbed.
droplets into another
You might have noticed that we included bile salts above in the list of nutrients
that our small intestine can absorb. This is because our body partially recycles
these salts by re-absorbing them. If we didn’t, we wouldn’t be able to make new
bile salts quickly enough for digestion.

A key part of digestion and detoxifying any potentially harmful chemicals (such enterohepatic circulation:
as medications or hormones) is moving substances from the small intestine to Circulation of substances such as
bile salts between the intestine
the liver and back. This process, known as enterohepatic circulation, happens and the liver
through the portal vein, a sturdy network of vessels that shuttles material be-
portal vein: A vein conveying
tween the intestines and the liver. This includes bile salts. blood to the liver from the spleen,
stomach, pancreas, and intestines
Once food passes through the duodenum, jejunum, and ileum, which absorb
as many nutrients as possible, it goes to the large intestine. To do so, it passes ileocecal valve: Two folds of
mucous membrane that form a
through another sphincter-like structure called the ileocecal valve. valve between the large intestine
(cecum) and the small intestine
By this point, any intestinal contents are no longer acidic, thanks to the actions (ileum)
of bicarbonate earlier in the duodenum. So food entering the large intestine will
hepatic portal system:
have a more or less neutral pH. Veins that carry blood from
the capillaries of the stomach,
intestine, pancreas, and spleen to
The liver the liver
Before we get to the large intestine and the next stage on

the journey, let’s stop briefly and take a detour. There are
several other organs involved in this part of digestion. First
up is the liver.
The liver is between 3-4 lb (1.4-1.8 kg), and roughly the

size of an American football, which makes it the largest
gland in the body. It lies in the upper right portion of
the abdomen, just under the diaphragm and next to the
stomach. It’s made up of two main lobes, called the right
and left lobes.
As we’ve mentioned, blood from the liver’s hepatic portal

system passes through the liver for “inspection.”
The cells of the liver metabolize molecules by either building

them up or breaking them down as needed. The liver also
makes about one pint of bile per day, which is made up of
Figure 2.4 The hepatic portal system. Responsible for direct-
bile salts, bile pigments and cholesterol. This bile secretion, as ing blood from parts of the GI tract, through the portal vein
discussed earlier, helps emulsify fats. to the liver for inspection before going to the heart.
Most of our nutrients (and anything else that’s come along

for the ride) are screened in the liver. See Figure 2.4. triglyceride: Compound with
three molecules of fatty acids
Fats bound with one molecule of
glycerol; the storage form of fat in
humans
The liver can convert fatty acids to triglycerides or release them into circulation
lipoprotein: A class of proteins
as plasma lipoproteins (such as HDL and VLDL), molecules that are able to with hydrophobic core of
transport fats in water-soluble blood. triglycerides or cholesterol
surrounded by hydrophilic
When fat intake is very high and carbohydrate intake very low or absent, the phospholipids, apolipoproteins
liver can form compounds called ketone bodies to use as another fuel source. and cholesterol
ketone body: Either
acetoacetic acid, acetone or
Carbohydrates beta-hydroxybutyric acid with a
carbonyl group attached to two
The liver helps maintain carbohydrate homeostasis. carbon atoms

60 | Unit 2
Synthesis
tion
S ec r e
a ry
Bili
Colon
Ileum
Portal Venous Return

Fecal Excretion
Figure 2.5 Enterohepatic circulation. Moving substances from the small intestine to the
liver, and back.
glycogen: Chief source of stored • If blood glucose is high, the liver stores it as glycogen in its own hepatocytes
glucose in selected tissues
for later use.
hepatocyte: Liver cell
• If blood glucose is low, the liver provides glucose to the blood from previously
stocked up liver glycogen stores.
• The liver also converts other sugars, such as fructose and galactose, to glucose.
Proteins
deamination: Removal of an The liver can deaminate amino acids, converting them into glucose derivatives
amine group from a compound and free nitrogen for excretion through the urine.
first pass metabolism: When Other substances

a substance is swallowed and
absorbed, it first travels through
the hepatic portal system for Finally, the liver will filter toxins, drugs, or many of our own hormones before
metabolism by the liver; this “first allowing them into general circulation.
pass” can reduce the availability
of the substance to the body In the pharmaceutical industry, this is referred to as first pass metabolism.

Proteins Carbohydrates Fats
Amino acids TG
Glycogen
Gluconeogenesis Free fatty acid

B 12, B 6, Folate, Biotin (FFA)
Lactate
Glucose Glycerol
Riboflavin, Lipolysis
Thiamine, Niacin, Biotin
Ketogenic Niacin
amino acids
Pyruvate
Lipogenesis
Thiamine,
Pantothenic acid
Glucogenic Niacin, Biotin
amino acids
Thiamine, Acetyl-CoA
Niacin
Alcohol
Ketones
Blood Muscle
Krebs cycle
Amino acids Glucose Glycogen
Glucose Amino acids Protein
FFA FFA TG
O2
Electron
transport
chain
CO2 ATP H2O
Figure 2.6 Interrelationships among macronutrients in metabolism
It’s why the liver is so often damaged by oral drug overdoses or even too many
“healthy” supplements.
We’ll learn more about how macronutrients are processed in later chapters. For a
general overview, see Figure 2.6
The gallbladder
This small pear-shaped sac sits next to the small intestine. It stores the bile that
the liver produces.
The pancreas
The pancreas is about the length of your hand, and sits next to the small intes-
tine. It releases pancreatic juices through the pancreatic duct into the duodenum
at the same point that bile is released.
The pancreas is about 98% exocrine acinar cells, which secrete pancreatic exocrine: Secretion, such as
saliva or bile, released outside its
juice containing digestive enzymes. These are released in an alkaline bicar-
source by a duct
bonate-based fluid that helps to neutralize stomach acid. Pancreatic enzymes
include: endocrine: Secretion, such as a
hormone, distributed in the body
• trypsin and chymotrypsin, which help to digest proteins; by the bloodstream
• amylase, which helps to digest polysaccharides; and glucoregulatory hormone:

Hormone that balances blood
• lipase, which helps to digest fats. glucose levels, such as glucagon
or insulin
The other 2% of the pancreas is made of endocrine cells, which produce several feces (next page): Waste
important glucoregulatory hormones including insulin, glucagon, amylin, and discharged from the body
somatostatin. through the anus

62 | Unit 2
Cholesterol and dietary fiber
You may have seen ads for breakfast cereals claiming clients who find it hard to get enough high-fiber foods
that they help lower cholesterol because they’re high in such as whole grains, beans and legumes, or fruits and
fiber. How does this work? vegetables.
While we recycle some bile salts, we excrete others. Conversely, if you have a female client who is suffering
Soluble dietary fiber can bind to bile salts in the small from low sex hormone levels and disrupted menstrual
intestine and help us eliminate them. cycles, review her fiber intake.
Since we need cholesterol to make new bile, if we get Many “health-conscious” women, especially plant-
rid of bile salts by binding them to fiber, our body has based eaters or women trying to lose weight, eat a lot of
to use up more cholesterol. This is why dietary fiber can fiber but have a lower energy intake. They may also have
help lower blood cholesterol. less body fat and be physically active. All of this can tell
Fiber can also bind to other fat-soluble chemicals, such their bodies to gear down sex hormone production.
as sex hormone metabolites, and help excrete those too. The higher fiber intake then binds what little hormones
Of course, you’re not allowed to officially treat medical are being produced, and removes them from the body.
conditions such as high cholesterol or a sex hormone So these women are getting rid of scarce hormones
imbalance such as estrogen dominance. But you can too readily.
generally mention that your clients could increase fiber In this case, review your female clients’ energy intake and
intake from whole foods, or add a fiber supplement for fiber intake to make sure they’re getting enough to eat,
and not literally flushing their hormones down the toilet.
The large intestine

Once the remaining food enters the large intestine (also What’s left at the end of this process is the semi-solid
known as the colon), it will stay in there about 12-25 waste we call feces.
more hours, moving along at about 2 inches (5 cm) per
hour, before being excreted as waste. Large intestine anatomy and function
While the small intestine absorbs most nutrients, the The large intestine is, well, larger than the small intes-
large intestine can absorb a few leftovers, including: tine, at least in diameter. However, it’s much shorter,
only about 5-7 feet long (1.5-2 meters).
• water
• salts such as sodium and potassium The large intestine is subdivided into several parts:
• vitamin K • the cecum
• acids (e.g., acetate, butyrate, and propionate) • the ascending portion
• gases (e.g., hydrogen and carbon dioxide. Note: • the transverse portion
You might have heard of a hydrogen breath test for • the descending portion
someone with a suspected digestive disorder. An
• the sigmoid portion
overproduction of hydrogen can occur in the large in-
testine when someone isn’t properly breaking down • the rectum
food. This hydrogen can then enter the bloodstream, • the anus
where it travels to the lungs and is exhaled).
The sigmoid portion of the colon is shaped like an “S”
See Figure 2.7: Principal absorption sites for nutrients for that bends toward the left. Thus, a person getting an
more on where nutrients are absorbed.

Esophagus
Fundus
Body
Pylorus Stomach
Minerals
Antrum
Monosaccharides
Bile
Pancreatic
Duodenum
Fatty acides, mono-

enzymes
Vitamins
and diglycerides
A&D
Disaccharides
Water and sodium
Amino acids and

simple peptides
Water-soluble
vitamins Jejunum
Bile salts
Vitamin
Ileocecal valve
B12
Ileum
Cecum
Ascending colon
Water, sodium,
potassium, vitamin K
Figure 2.7 Principal absorption sites for nutrients. For nutrients to reach cells, they must cross the gastrointestinal-body barrier.
This barrier has a vast surface area to assist with nutrient absorption. Nutrients are absorbed at various sections along the GI tract.
enema will be turned on their left side, to let gravity Humans are somewhere in the middle, signaling that at
help the flow of enema fluid. least in evolutionary terms, we are omnivores — able to
eat and digest a wide range of foods.
Different species of animals will have differently sized
and shaped colons. These differences can tell us about Understanding how colon size relates to diet is import-
the animals’ diet, as well as the specific jobs of each ant because it helps us appreciate the role that GI bacte-
portion of the GI tract. ria play in digestion.
• Meat eaters (such as dogs or cats) usually have a
The role of bacteria
relatively longer small intestines and relatively shorter
large intestine. The large intestine contains many diverse species of bac-
• Plant eaters (such as horses or cows) have a relatively teria, making this organ the most metabolically active in
shorter small intestine and relatively longer large
the body.
intestine. Rabbits, for instance, have a very large ce- Just as bacteria can ferment sugars and starches in
cum that branches off from the ileum, almost like the cabbage or milk to create sauerkraut or yogurt, intesti-
letter “Y.” This intestinal structure lets plant eaters (or nal bacteria ferment dietary carbohydrates such as fiber,
at least, their GI bacteria) spend more time digesting
plants’ fibrous material.

64 | Unit 2
oligosaccharide: Saccharide oligosaccharides, and sugars (such as lactose and sugar alcohols) that our small
composed of a small number of intestine can’t digest and absorb on their own. This fermentation process turns
monosaccharides
these carbohydrates into beneficial short-chain fatty acids, producing strong-scent-
ed gases in the process. Bacteria can also ferment other things, such as enzymes,
dead cells, bacterial cells, and the collagen and elastin found in foods.
Along with simple fermentation of undigested nutrients, a healthy balance of

these bacteria may help to:
• prevent harmful bacteria and yeast from colonizing the gut;
• remove carcinogens and boost the immune system;
• prevent allergy;
• regulate inflammation;
• regulate our moods and nervous system function;
• regulate our hormonal responses;
• regulate our level of body fat; and
• prevent inflammatory bowel disease.
As you can see, our GI microbes have lots of important and wide-ranging jobs.
Many things can disrupt this healthy bacterial balance, such as taking antibiotics.
prebiotic: Compound that is not In this case, some clients may benefit from supplementing with (or eating) prebiot-
digested but rather fermented by ics and probiotics.
microflora and stimulates growth
of healthy bacteria in the GI tract • Prebiotics give bacteria stuff to eat, such as dietary fiber.
probiotics: Live microorganisms • Probiotics are foods (such as sauerkraut, yogurt, or kimchi) that are fermented
that help to restore beneficial
bacteria in the GI tract and thus colonized with bacteria, or supplements containing bacteria (and
sometimes friendly yeasts).
Why do farts smell?
As part of their natural metabolic activities, bacteria produce several gases,

including methane and hydrogen sulfide (H2S). These gases are what give farts
their distinctive smell.
Although it seems like a pointlessly stinky waste product, hydrogen sulfide is
gastrotransmitter: Gases actually an important gastrotransmitter, or signaling molecule within the GI
which act as neurally released tract. H2S helps regulate processes like GI motility and inflammation, and may
transmitters keep our epithelial cells healthy. It may even play a role in regulating adipocyte
adipocyte: Fat cell (fat cell) function.
As with all things biological, balance is important. If a person is over-producing
H2S, it may be a symptom of an underlying health problem, disrupted colonic
bacterial flora, or trouble digesting particular foods.
Clients who have IBS (irritable bowel syndrome), bloating, flatulence,
or room-clearing gas can do a hydrogen breath test to look for problems like:
• difficulty absorbing particular sugars, such as fructose or lactose;
• difficulty absorbing sugar alcohols, such as sorbitol or mannitol;
• intestinal bacterial overgrowth or imbalance;
• poor gastric motility; and / or
• production of H2S and methane gases.

Transit and excretion Controlling the digestive

Once food passes through most of the large intestine, it process
compacts into feces and moves through the rectum to be
eliminated through the anus. Earlier in this unit, we started to look at how the brain
and nervous system are involved in digestion. Let’s
In case you’ve ever wondered what your poop is made of: look more closely at that now, along with the role of the
• About 1/3 is dead bacteria.
endocrine system.
• About 1/3 to 1/2 is inorganic material (e.g., calcium

phosphate and iron phosphate) and fats / cholesterol.
The endocrine system
• The rest is made up of protein, sloughed-off cells, cel- The endocrine system is a chemical messaging system that
lulose (plant fiber), digestive juices and bile pigments identifies changes in the body and sends out messengers
(which give feces its color). (called hormones) to tell the body how to respond. Several
important hormones do this in the GI tract.
How fast food moves through our body depends on
many things, such as stress, how much we eat, what we Ghrelin
eat, and how active we are.
A high-fiber diet moves things faster. Physical activity This hormone is found in many places: It’s released by
does too. Stress usually slows things down, although some cells of the stomach, pancreas, placenta, kidney, pituitary
folks find that stress has the opposite effect — they might and hypothalamus.
have nausea, vomiting, or a quick run to the bathroom. Ghrelin is a hunger hormone that acts directly on the
brain.
• It’s released when food and energy intake is chron-
Do you need an appendix? ically low (for example, on a restrictive diet) or when
fasting.
You’ll find the appendix in the cecum, the portion of the
large intestine just after the small intestine ends. • After meals, ghrelin goes down.
The appendix is shaped like a little worm, giving it the

name “vermiform”, from the Latin vermis, or worm. Gastrin
Scientists used to think the appendix was vestigial, or an
evolutionary holdover with no purpose now — like our
When food enters through the lower esophageal sphinc-
tailbone that no longer carries a tail. ter into the stomach, it triggers gastrin release from G
cells in the stomach and small intestine.
However, we are now learning much more about the GI
tract’s role in immunity. And it seems that the appendix Gastrin starts the digestion process by helping to
still has a job to do. signal the release of hydrochloric acid and pepsinogen
Specific tissues in the gut — known as gut-associated (a substance that helps digest peptides, or proteins)
lymphoid tissues, or GALT — are part of our immune sys- in the stomach. This has several important functions,
tem. In fact, the GI tract has the most lymphoid tissue of including:
anywhere in the body! These tissues store, release, and
regulate immune cells and cell signals. • increasing stomach peristalsis;
The appendix may be a reserve tank of friendly gut • keeping the lower esophageal sphincter closed;
bacteria. Research shows that people who’ve had their
• causing gallbladder contractions; and
appendix removed are more likely to have inflammatory
bowel conditions or get GI tract infections, such as Clos- • promoting the release of bicarbonate from the
tridium difficile. pancreas.
Some say that health begins in the gut… and they may
be right. Foods high in protein seem to stimulate the most gastrin
release.

66 | Unit 2
Secretin Pharmaceutical companies now sell analogues of GLP-1,

which have made a big impact on diabetes treatment.
When stomach acids reach the small intestine, they
trigger cells known as S cells to release the hormone Glucagon-like peptide 2 (GLP-2)
secretin. Secretin tells the pancreas and bile ducts to
produce pancreatic fluid high in bicarbonate to neutral- This form of GLP increases nutrient uptake in the GI
ize the acids. tract. It’s not clear how or whether it affects appetite.
Secretin also inhibits gastrin release (to slow down
the stomach related processes, which should now be Motilin
complete) and enhances the effects of another hormone,
cholecystokinin (CCK). When bicarbonate is dumped into the small intestine to
create a less acidic / more alkaline environment, the cells
of the small intestine also release the hormone motilin.
Cholecystokinin (CCK)
While secretin and CCK are responsible for slowing
When partially digested proteins and fats enter the small down stomach-related digestive functions and speeding
intestine, mucosal epithelial cells in the duodenum up intestinal digestion, motilin promotes smooth muscle
secrete the hormone CCK. contractions of the GI tract. This moves chyme along
through the intestines and breaks it up further through
CCK tells the pancreas that the small intestine is ready the process called segmentation.
for pancreatic enzymes to help out with digestion. Like
secretin, CCK also inhibits gastrin (again, to slow down Motilin is also released at regular intervals between
the stomach and its acid production). CCK also stimu- meals. This is one of the reasons we may notice a “growl-
lates gallbladder contraction so that bile is forced into ing stomach” when we’re hungry.
the small intestine along with the pancreatic enzymes, to
help with emulsification. Somatostatin
CCK is a satiety hormone: It indirectly tells your brain
that you’re full and should wait longer to eat again. Somatostatin is a hormone secreted by the stomach,
intestine and pancreas. In the stomach it suppresses the
release of the hormones discussed above. Thus soma-
Gastric inhibitory polypeptide (GIP)
tostatin slows gastric emptying, reduces smooth muscle
contractions, reduces blood flow, and reduces enzyme
Epithelial cells of the small intestine secrete GIP while release.
CCK is doing its work. GIP enhances insulin release,
preparing the body for the glucose that’s about to appear Between meals, somatostatin reduces digestive activity.
in the blood with further digestion and absorption.
As the name suggests, GIP inhibits gastric secretions Peptide YY (PYY3-36)

and motility since these processes should no longer be
needed — at least until the next meal time. This hormone is released in the hours following a meal.
It directly signals the brain to suppress appetite and
slows down stomach motility and pancreatic enzyme
Glucagon-like peptide 1 (GLP-1)
secretion, while increasing water and electrolyte absorp-
tion in the colon.
GLP-1, like GIP, can enhance insulin release and slow
gastric emptying. These are both important between meals, as food should
now be arriving in the large intestine. Meals high in
When your small intestine detects carbohydrates, it protein cause PYY3-36 to go up the most. For your clients,
helps tell your pancreas to respond with insulin. This this means that getting enough protein will help them
intestinal action of GLP-1 is why you get more insulin feel full longer.
in response to eating glucose than to injecting it directly
into your veins.

Pancreatic polypeptide Leptin can also help to regulate GI organs such as the
liver or ß-cells of the pancreas.
Released after meals by the pancreas (and in small
amounts by the colon). It is secreted in proportion to cal- Like many hormones, leptin has a diurnal 24 hour
orie intake. The more released, the more it will suppress pattern, peaking between midnight and 4:00 AM and
appetite. It also reduces gastric emptying. bottoming out at around noon. (So when you get the
mid-afternoon munchies, blame your leptin.)
Oxyntomodulin
The pancreas releases oxyntomodulin after meals in Amylin
proportion to calorie intake, together with GLP-1. The Released from the pancreas along with insulin after
more oxyntomodulin released, the more it will sup- eating, amylin suppresses appetite by directly acting on
press appetite. the brain.
Bombesin Insulin
Bombesin peptides have wide-ranging effects in the GI We mention insulin here because its influence goes
tract, including stimulating gastric motility and help- far beyond glucose disposal. Insulin is released from
ing to regulate food intake, as well as the secretion and the pancreas and suppresses appetite by acting on the
release of gastric neurotransmitters. brain. This satiety effect is one of the lesser-appreciated
roles of insulin.
Obestatin
Produced by the stomach and small intestines, obestatin The Nervous System
may suppress appetite and reduce gastric emptying.
As we’ve seen, the nervous system also regulates digestion
Leptin along with the endocrine system through nerve impulses
and neurotransmitters (hormone-like chemicals).
Although it works throughout the body, leptin is secret-
ed mainly by fat cells. In general, the more fat we have, Indeed, the nervous system is the master controller
the more leptin we usually have. Thus, one of leptin’s of the entire process. Every function; every secretion;
main jobs seems to be as an energy sensor and regulator and every chew, squish and squeeze is governed by the
of energy balance in the body. It also helps control appe- all-seeing, all-knowing nervous system.
tite by acting directly on the brain.
To coordinate this large operation, the nervous system
• When we have a lot of body fat or energy coming in,
uses many branches.
leptin is usually high. Because they normally signal
that we’re well fed, insulin and blood glucose can
Central nervous system (CNS)
stimulate leptin production. When leptin is high,
we’re not hungry. The central nervous system (i.e., the brain and spinal
cord), controls energy balance, appetite and food-seek-
• When we don’t have a lot of body fat or energy coming behavior, and our response to sensory input and
ing in, leptin is usually low. When leptin goes down, food cues (such as the smell of food). It also stores ideas,
we get hungry. Leptin can also be suppressed by SNS thoughts, beliefs, and memories about food.
activity, catecholamines, and free fatty acids. This is
one reason why stress and / or restrictive dieting can Peripheral nervous system (PNS)
make many people ravenously hungry.
The peripheral nervous system of our body, limbs, and
Leptin plays many other roles as well, such as in bone skeletal muscle is also involved in eating, as it helps us
metabolism or the regulation of other hormones. For move towards food, grab it, put it in our mouth and
instance, leptin levels are low in women with hypotha- chew it. Indeed, some of the very first movements we
lamic amenorrhea, in which sex hormone production make after birth are grasping and sucking.
goes down and women stop normal menstrual cycles.

68 | Unit 2
Sensory part of PNS Motor part of PNS Acts on:
Somatic and special sensory Somatic motor neurons

SNS Skeletal muscle
receptors and neurons (voluntary)
CNS:
brain and
Autonomic motor
spinal cord
neurons (involuntary): Smooth muscle,
Autonomic sensory
ANS receptors and neurons
sympathetic and cardiac muscle
parasympathetic and glands
divisions
Sensory receptors and Enteric motor neurons Smooth muscle,

ENS neurons in GI tract and (involuntary) in enteric glands, and endocrine
enteric plexuses plexuses cells of GI tract
Figure 2.8 Signaling in different branches of the nervous system
Autonomic nervous system (ANS)
As we’ve seen, the ANS is what controls our internal organs and involuntary
functions like breathing, heart rate, and of course, digestion. Again, the ANS has
two branches:
• The sympathetic nervous system (SNS), our “fight-flight” system
• The parasympathetic nervous system (PNS), our “rest-digest” system (some-

times also known as the “feed and breed” system).
Enteric nervous system (ENS)
The digestive system has its own, localized nervous system. This system is re-
ferred to as the enteric nervous system and can be thought of as a second brain
located in your gut.
There’s two-way traffic between the CNS and ENS, with much of it going “back
upstairs.” In other words, the ENS gives important signals to the CNS about
what is going on, including our physiological emotional state. “Gut feelings” are
a real thing.
Neurotransmitters
neurotransmitter: Substance While each nervous system has its own main jobs, it uses the same types of struc-
that transmits nerve impulses tures (e.g., neurons) and signaling chemicals (e.g., neurotransmitters). Thus, all
across a synapse
neurotransmitters found in the gut are found in the brain, and vice versa. Howev-
vasodilation: Widening of blood er, neurotransmitters often have different jobs depending on where they are.
vessels

Gamma aminobutyric acid (GABA) This makes sense, as we don’t need our esophagus or
stomach to be working by the time a meal is making its
GABA is mainly an inhibitory neurotransmitter — it way into the large intestine.
acts as a “downer” on the CNS. However, GABA has the
opposite effect on many other tissues of the body, and Neuropeptide Y (NPY)
can act as an excitatory neurotransmitter, or stimulant.
NPY goes up when body fat is low or food is scarce.
In the ENS, GABA can either excite or inhibit, depend-
ing on which cellular receptors it binds to. However, In the brain, NPY tells us to eat and stop wasting energy by
GABA mainly stimulates gastrointestinal motility and moving around. It also works with leptin and corticotropic
gastrointestinal mucus production. releasing hormone (CRH) to regulate metabolism and body
composition.
GABA’s inhibitory role in the brain but excitatory role in
the gut makes sense: Digestion happens when we’re calm In the gut, NPY slows gastric emptying and transit time,
and restful. which makes sense: If our body thinks we’re hungry or
too lean, it’ll want us to get the most nutrition possible
Norepinephrine from our food.
This catecholamine, one of our “fight or flight” hor- Serotonin

mones, shuts down digestion, which makes sense during
stressful situations: We need immediate, decisive, or Serotonin is one of our natural antidepressants and
aggressive action more than nutrient absorption. mood regulators. It also controls other basic functions
like sleep, appetite, and body temperature.
Unfortunately, our body can’t tell the difference be-
tween an actual threat and something like a traffic jam, Although we often think of serotonin as a brain hor-
upcoming deadline or argument with a loved one. Acute mone, about 90% of our body’s serotonin is used in the
or chronic stress of any kind — real or imaginary — can GI tract and made by enterochromaffin cells in the small
shut the GI system down. intestine. Here, serotonin helps with smooth muscle
contractions and gut secretions.
Acetylcholine
After we eat, serotonin goes up. This is why many people
feel more relaxed and calm after eating.
Although acetylcholine tells muscles to contract, it’s
actually part of the parasympathetic action in the gut, Too much serotonin can cause nausea, which is why
allowing “rest and digest” by stimulating smooth mus- antidepressant drugs like Prozac or party drugs like
cle contractions (i.e., peristalsis) that help move food MDMA (Ecstasy) can sometimes lead to diarrhea and
through the GI tract. nausea: They cause serotonin to go up in the brain (to
make us feel happier) but also in the gut (where they can
It also stimulates the release of many of the hormones
cause serotonin excess).
discussed earlier, dilates blood vessels, and increases
intestinal secretions.
Nitric oxide and Substance P
This “rest and digest” role opposes the “fight or flight”
actions of norepinephrine. Both of these substances help improve blood flow to the
gut through vasodilation. This circulation helps trans-
Neurotensin port and absorb nutrients.
As dietary fat reaches the ileum, the last section of the Vasoactive intestinal peptide (VIP)
small intestine, N cells in the intestinal walls release
neurotensin. Neurotensin relaxes the lower esophageal VIP relates to the hormone secretin and has many im-
sphincter, blocks the release of stomach acid and pepsin, portant jobs in digestion.
and regulates gastrointestinal contraction and relaxation.

70 | Unit 2
It inhibits gastrin release and acid secretion while stimulating bicarbonate secre-
tion from the pancreas and pepsinogen in the stomach; smooth muscle relax-
ation and vasodilation; and the secretion of water and electrolytes into the small
intestine (which will be re-absorbed later in the digestive process).
Most of these slow down stomach activity while stimulating intestinal activity.
A complex process
While the list of hormones and other cell signaling molecules above might seem
daunting, it’s only a handful of the chemicals involved in regulating the physi-
ological processes of energy balance, appetite, hunger, fullness, gastric motility,
and gastric secretions.
Other hormones and cell signals help regulate psychological processes and be-
havior that are related to food and eating, such as seeking rewards or soothing
emotions.
We are learning about new chemicals all the time, as well as how those chemicals
and their effects vary from person to person.
Moreover, hormones and cell signaling molecules aren’t the only things that tell us
what, when, how, and how much to eat. Our eating habits are also shaped by who’s
around us, what’s important to us, what’s available, what we think tastes good, and
potentially dozens of other factors. We’ll look at this more in upcoming chapters.
How do we absorb our food?

Somehow, nutrients must get through the lining of the gastrointestinal tract and
into the rest of our body. This process of absorption happens in many ways.
simple diffusion: Spontaneous While there are three major processes (simple diffusion, facilitated diffusion,
movement of particles from an and active transport), there are hundreds of enzymes and carrier proteins pres-
area of high concentration to an
area of low concentration
ent in the small intestine, each designed to help absorb particular nutrients.
facilitated diffusion: These three different systems enable the body to absorb many things in a con-
Transport that requires a carrier trolled way. The most critical nutrients are easily taken in; unwanted substances
molecule; occurs when diffusion
of a substance on its own is not are kept out.
possible
Simple diffusion
active transport: Movement
of particles from an area of low
concentration to an area of high
Simple diffusion doesn’t need a carrier protein or energy. Compounds just move
concentration; requires energy from an area of higher concentration to an area of lower concentration (known
and enzymes as a concentration gradient).
concentration gradient:
Difference in the concentration Water is often transported this way.
of solutes in a solution between
two areas Facilitated diffusion
Facilitated diffusion is like simple diffusion, in that substances move from higher
to lower concentrations, and it doesn’t require energy. However, facilitated diffu-
sion uses a carrier protein to do this. Thus, how fast this happens (or whether it
happens at all) depends on how many carriers are available.

Fructose absorption, which requires sugar transport proteins, is an example of

this type of transport.
Active transport
Active transport relies on a carrier protein. This form of transport also uses energy,
because it moves against the concentration gradient (moving from low to high),
like swimming upstream. Thus the rate of absorption can be limited by whether
both carriers and energy are available.
Examples of nutrients absorbed this way include glucose and galactose.
Table 2.1
The three major processes that allow for controlled cellular transport
Simple Facilitated Active
diffusion diffusion transport
Needs energy No No Yes
Needs a carrier protein No Yes Yes
Concentration With With Against
gradient (high to low) (high to low) (low to high)
Rate of absorption Difference in Available carrier Available carrier
limited by concentrations proteins proteins
Available energy
When absorption goes wrong

The digestive system is a complex yet well-coordinated system. However, prob-
lems can sometimes happen.
Ulcers
Ulceration of the gut can develop when alkaline mucus production slows down,
when tight cellular junctions are pulled apart, and when cell turnover rate is tight cellular junctions:
reduced. You may be familiar with peptic ulcers, which we discussed earlier. Intercellular junctions between
epithelial cells in which outer
layers of the cell membranes
Duodenal ulcers can form when the pancreas and duodenal cells of the small
fuse, reducing the ability of larger
intestine can’t properly buffer the acidic chyme coming from the stomach. molecules to pass between cells
Vomiting peptic ulcer: Found on the wall

of the duodenum or stomach, this
ulcer results when gastric juices
Otherwise known as emesis or reverse peristalsis, vomiting can result when and H. pylori combine
neural signals are sent to the vomiting centers of the brain. This can have many
emesis: Vomiting
causes, such as:
• excess serotonin
• inflammation
• microorganism irritation of the intestinal wall
• stress or anxiety
• disrupting the vestibular (balance) system

72 | Unit 2
Epithelial cell of villus Capillary

Glucose Secondary active
Galactose transport with Na+
Facilitated
Monosaccharides
diffusion
Fructose Facilitated diffusion
Secondary active
Amino acids
transport with Na+
Amino acids Diffusion
Peptides Secondary active

transport with H+
Short-chain
Simple diffusion Short chain FA Diffusion
fatty acids
Lacteal
Triglycerides in
Micelle Simple diffusion
chylomicrons
Figure 2.9 Absorption in the small intestine. Adapted from: http://www.sharinginhealth.ca/biology/small_intestine.htm
Clients with some forms of disordered eating may also Inflammatory bowel diseases
deliberately make themselves vomit.
Inflammatory bowel diseases, such as ulcerative colitis
Gallstones and Crohn’s disease, cause chronic inflammation, espe-
cially in the intestines. These are characterized by a few
Gallstones are solid deposits of cholesterol or calcium features:
salts that form in the gallbladder or nearby bile ducts.
• Inflammation causes a lot of water and salt to be se-
There are few symptoms; however, in severe cases, gall- creted into the intestines — too much for the colon to
bladder attacks can cause nausea and a steady ache in completely re-absorb. This results in chronic diarrhea,
the upper abdomen and between the shoulder blades. intestinal cramping, and other unpleasant symptoms.
Gallstones are formed when too much cholesterol or too • Inflamed digestive tract tissues bleed and ulcerate.
much bilirubin is produced relative to bile production. The quality of the intestinal wall degrades.
If either of these situations occurs, the bile becomes idle
• Enzymes are less active and we absorb fewer nutri-
in the gallbladder and crystallizes into a stone. Since
ents. This can result in malnutrition and weight loss,
this may prevent bile formation, fat is not digested or
even if we are eating enough.
absorbed properly, which leads to fatty stools.
Gallstones can also be a symptom of yo-yo dieting. Eat- Diarrhea

ing a lot of fat followed by eating very little fat can cause
Diarrhea usually occurs when the epithelium of the
idle bile in the gallbladder, since at least 10 g of dietary
intestines becomes infected and / or inflamed. This can
fat are needed to stimulate bile release.

lead to a lot of water and ions moving into the intestines, else, because they can travel in the bloodstream. This
or not being well absorbed. makes many food allergies hard to track down.
Diverticulosis and diverticulitis Any food can cause an allergic response. So far, more
than 170 foods have been reportedly linked to IgE-medi-
This condition, which is common as people age, occurs ated reactions. The most common foods involved in an
when small pouches in the colon (known as diverticula) allergic reaction include eggs, fish, shellfish, milk, pea-
bulge outward through weak spots in the colon wall. nuts, tree nuts, soy, and wheat. These eight foods account
This creates increased pressure and small tears in the for 90% of all food allergies. It’s also estimated that 40%
colon, resulting in inflammation. When bacteria be- of food allergies in children disappear by age 5.
come trapped in a outpouching, it can lead to infection
and diverticulitis. Food intolerances
Since the outpouchings often occur in the sigmoid colon, Many people say they are “allergic” to foods when they
people may feel pain in the lower left of the abdomen. are actually intolerant.
People may also notice other symptoms such as vomit-
ing, bloating, bleeding, and frequent urination. This can often happen when we can’t properly digest
particular foods or their components. For instance:
Food allergies • If we don’t have the enzyme lactase, we won’t be
Our immune system makes antibodies to help fight able to digest lactose, the main sugar in milk.
viruses and bacteria. Antibodies work by binding to • If we don’t digest complex carbohydrates or sugar
invading pathogens and provoking the body’s immune alcohols well, we’ll often have trouble with particular
system to attack them. fruits or vegetables.
Allergies happen when our body makes antibodies to Food intolerances are uniquely individual, and have a
substances that would normally be harmless. The main range of symptoms.
antibody in most food allergy conditions is called im-
munoglobulin E (IgE). IgE antibodies are produced in Some symptoms are obvious (such as an upset stom-
response to an innocent food molecule. ach or bloating) and appear fairly soon after eating the
offending food.
Millions of mast cells line our skin, nose, intestines, and
bronchial tubes, and they’re covered in IgE antibodies. Other symptoms don’t affect the GI tract, and may ap-
Think of the mast cell like one of those loud, obnoxious pear later, such as hives or rashes, headaches, mouth ul-
car alarms. It doesn’t always go off due to a true car thief cers, stuffy nose, mucus buildup in the lungs, and more.
(car thief = virus, bacteria, and / or parasite). It may be
triggered by a strong wind or a passing jogger (the inno- Keep in mind that recommendations for food intol-
cent food molecule). erances and allergies fall under medical nutrition
therapy. So, unless you are a health professional with
When chemical messengers such as histamine are appropriate training and credentialing in that area,
released from mast cells, the body generates a powerful you’d want to refer out.
inflammatory reaction. Blood vessels dilate, blood pres-
sure drops, and the mouth, throat, and airway swells. However, as a nutrition coach, you can help your client
This combination of symptoms, when powerful enough, become aware of potential patterns. (More on this in a
is referred to as anaphylaxis. moment.)
A common example of this is a peanut or shellfish Leaky gut syndrome

allergy. If someone eats one of these foods and has a true
allergy, they could die without medical assistance. It’s a In leaky gut syndrome, the intestinal lining becomes ex-
severe condition with severe consequences. tremely permeable, which means that it may allow large
molecules and toxins to enter the body undigested.
Food allergies may also cause symptoms somewhere
This can happen when the intestinal lining becomes

74 | Unit 2
Healthy intestinal lining

‘brush-like’ absorption surface of cells lining the small intestine
cells fit tightly together
blood capillaries
Leaky gut
damaged absorption surface of cells lining the intestine
gaps between cells are wider - partially digested food particle can slip through
blood capillaries
Figure 2.10 Leaky gut syndrome
inflamed or damaged, which disrupts the normal func- Working with GI health problems
tion of the villi and microvilli.
You don’t have to be a gastroenterologist to work with
“Spaces” develop between the cell walls, and unwanted clients who are dealing with these GI complaints. (Al-
macromolecules, antigens, and toxins sneak in. As these though you may want to work with their gastroenterolo-
molecules invade the GI wall more frequently, more gist if their problem is severe, or doesn’t respond to basic
damage occurs. Carrier proteins and enzymes may also good nutrition.)
become damaged, which can cause nutrient deficiency.
Following the fundamentals of fitness nutrition will
The body may also treat these molecules as foreign in- often reduce or alleviate these symptoms of GI distress.
vaders and trigger immune defenses. The body aggres-
sively rejects otherwise healthy food, and potentially Gather information about your client. What is the
damages its own cells. problem like? When and how does it happen? What are
the specific symptoms? We’ll cover assessment in more
Leaky gut syndrome can cause GI distress (bloating, flat- detail in Section 2.
ulence, and abdominal discomfort), immune reactions
(including hives, mucus buildup in the lungs and nasal Monitor and track data. Look for patterns. Having
passages), and nutrient deficiency. Indeed, some of the your client keep a journal of their food and symptoms
symptoms of leaky gut syndrome are similar to those of can help you see patterns — such as an upset stomach on
food intolerances. a stressful day or after eating a particular food.
See Figure 2.10. Teach clients to eat slowly and mindfully. It’s amazing

Case study
As we’ve seen in this unit, it becomes much easier to and absorbing fat efficiently, the answer to his problem
understand the nutrition and exercise-related problems became clearer: There was probably something wrong
your clients are experiencing when you understand how with his gallbladder.
the digestive system works. Of course, many problems
are well beyond the scope of your practice. The most likely causes were either gallstones blocking
his bile duct or biliary dyskinesia, a condition in which
However, sometimes your knowledge can help in the there is gallbladder pain and improper bile release. This
diagnostic process. This was the case with an Olympic blockage could have caused the gall bladder spasm that
triathlete. was prompted by intense exercise.
For months this athlete had complained of pain and As we aren’t medical doctors and have no training
cramping in his right upper abdominal region with intense in medical diagnosis, we found him a specialist, who
exercise. MRI, CT, and standard blood chemistry revealed confirmed the gallbladder assessment. Together with
nothing, which ruled out most forms of muscle damage this doctor, we treated this issue first by changing the
and / or severe organ damage. athlete’s diet.
This led the client’s doctors to think it was a nutritional • We lowered his total dietary fat intake.
condition and might be related to either a nutritional
deficiency that caused muscle cramps, or a reaction to • However, we added medium chain fats such as
a nutritional supplement this athlete was taking. His MCT oils (medium chain triglycerides) and coco-
doctor sent the athlete to us to talk about his diet. nut oils. These oils are more easily digested and
absorbed.
After doing a full diet analysis, working with the client
for about six weeks to improve his diet, and removing • We also added fish oil to his diet to prevent essen-
all nutritional supplements, we were disappointed to tial fatty acid deficiency.
see that the pain continued and exercise was still very • We increased his intake of protein and carbohy-
difficult. Indeed, the only way he was able to continue drates.
to compete was to freeze the area with local anesthetics
prior to racing — not an ideal solution at all! • Finally, we included a high-quality lipase supple-
ment to help with the digestion of the dietary fats
At this point we’d need some additional tests, so we that remained on his plan.
did a host of standard gastrointestinal tests, looking for
While these changes helped with the fat absorption
digestion and absorption problems.
part, the athlete did need a medical procedure to im-
Interestingly, all the test results came back within the prove his gallbladder function.
normal range except for one: his fecal fat content (the
Although we’re not medical doctors, nor do we pretend
amount of fat measured in his feces over the course of a
to be, our fundamental knowledge of digestive function
day) was high — indeed, at 21 g, it was three times the
helped this athlete get back to competition.
normal value of 7 g. This gave us another important clue.
We hope it also provides a real-world example of how
After considering the organs located in the right upper
learning the fundamentals, even when you think you
quadrant of the abdominal region (namely the gallblad-
might never use them again, can be very important in
der) and considering the fact that he was not digesting
your practice.
how many cases of mild GI distress respond to careful, Conversely, foods higher in soluble fiber may help slow
conscious eating. down diarrhea.
Help clients move towards less processed, whole-food Try to correct nutrient or fluid deficiencies where possi-
diets. Many GI problems go along with eating a lot of ble. If diarrhea or vomiting has left your client depleted,
processed foods that may be higher in industrial fats or you can try supplementing with an electrolyte solution.
sugar, and low in fiber.
If appropriate, encourage regular physical activity. Ex-
Avoid a one-size-fits all approach. Some IBD clients may ercise is usually a good habit for gastrointestinal health,
find that higher-fiber foods irritate them during flare-ups. as it helps move things along.

76 | Unit 2
Nourish the microbiome. Clients may benefit from Let’s go back to our three transport systems:
adding prebiotics and probiotics to their diet. However,
• simple diffusion
again, using targeted supplementation to treat a specific
disease is outside of your scope of practice. • facilitated diffusion
• active transport
Keep the big picture in mind. Look at all aspects of
your clients’ lives as much as possible. Do they smoke or Regardless of the differences between them, these sys-
drink? Are they stressed out? On any medications? Have tems need a variety of membrane bound proteins and
they traveled recently? And so on. transport receptors to:
• recognize specific nutrients as they approach our cell
Nutrient delivery membrane structures;
After nutrients are processed by the liver and enter sys- • bind to the most appropriate nutrients; and then
temic circulation, they need to be delivered to the cells of
• start moving them into the cells.
our body.
The most important destinations for nutrients are our
Most nutrients dissolve in the blood and are transported
muscle tissues, our adipose (fat) tissues, our brain, and
by floating along in general circulation. Lipids, however,
our liver.
need lipoprotein carriers: proteins that can bind to the
fat portion while still floating in the water-soluble blood, We’ll look more at where nutrients go and what they do
much like little passengers on a whitewater raft. in upcoming chapters.
Often when people talk about their “cholesterol”, they We’ll also explore how these nutrients can provide
really mean lipoproteins such as HDL, IDL, LDL, VLDL, energy for everything from daily function to high-level
and chylomicrons. athletic performance.
Summary
While it’s interesting and important for nutrition coach- (from the intestines / pancreas) combine with rhythmic
es to learn about specific nutrients, we must remember contractions to break our foodstuffs down into smaller
that people eat food and meals within a particular social, pieces while breaking complex molecules into simple
cultural, and environmental context. molecules.
Our physiological response to food is determined by the Digestion is centrally and locally controlled by the ner-
nutrients in that food, but also by many other factors such vous and endocrine systems.
as our genetic makeup, our activity levels, our microbi-
ome, our age, potential food intolerances or allergies. After digestion occurs, nutrients must make their way
into cells to be useful. For nutrients to be absorbed into
The GI tract is a complex yet well-coordinated system the body, they must cross the gastrointestinal-body bar-
that recognizes, separates, and selectively absorbs and rier through one of three mechanisms: passive diffusion,
uses nutrients while protecting us from potentially facilitated diffusion, or active transport.
harmful toxins and pathogens.
Many diseases, disorders, and intolerances can interfere
The digestive system starts at the mouth and ends at the with these processes. Thus, we need a healthy gastro-
anus. Throughout this 25 foot muscular canal, acidic intestinal tract for optimal digestion, absorption, and
secretions (from the stomach) and alkaline secretions nutrient delivery.

UNIT 3
Energy Transformation and Metabolism

78 | Unit 3
Unit Outline
1. Energy intake, storage, and transfer 3. Case study
2. How are nutrients metabolized? 4. Summary
Objectives
The sum of all chemical reactions in the body is known as By the end of the unit, you should have a basic understand-
metabolism. Most of these reactions turn the food we eat ing of how the body stores and uses protein, carbohydrate,
into energy that our body can use. and fat energy to both stay alive and perform when we ask
it to.
In this unit you’ll learn:
• how this important process happens
• how the body changes food energy into the energy

we need for daily physiological tasks and activity
Energy intake, storage, and transfer

In the previous unit you learned that after nutrients are digested and absorbed, the
liver screens them and sends them into general circulation throughout the body.
Once these nutrients get into cells, our body can do many things with them,
such as:
• oxidize them for energy;
• use them to build the body’s components;
• store them to use later; and / or
• excrete them.
In this unit, we’re going to focus on the first of these: how we produce and trans-
fer energy.
laws of thermodynamics: Well, to be more accurate, we don’t really produce energy. According to the laws
Principles that govern energy of thermodynamics, energy is never really created nor destroyed — it just moves
exchange, including heat
exchange and the performance
around or gets transformed from one form to another.
of work
Human bodies are no exception to these laws. So, instead of making energy for
metabolic function, what we’re really doing is converting energy that’s already
stored within our food.
Breaking the chemical bonds that normally hold the molecules of our food
energy transfer: Movement
of ATP from one compound to together releases energy. This energy, in turn, fuels the processes we need to form
another so that it can be used ATP. We call this process energy transfer.

Energy Transformation and Metabolism | 79
Thus, we eat, we digest, we absorb, we circulate, we store, we transfer energy, we

use the energy, and then we repeat.
Let’s look at this general process in more detail.
What is ATP?
ATP is the body’s “energy currency.” We need ATP for nearly every action in the
body.
• It moves our skeletal muscles.
• It contracts our digestive muscles.
• It produces enzymes.
• It carries molecules across cell membranes.
We even need it to form more ATP.
Where do we get energy from?

With all these important jobs going on all the time, we need a constant stream
of ATP. We can get this ATP from “new” nutrients (i.e., nutrients that we have
recently absorbed and passed through the liver) and from stored nutrients (i.e.,
nutrients that have been stored in the liver, in the muscle, or in the fat cells, wait-
ing for a call to action).
We can carry some nutrients in our bloodstream to use immediately, but not
enough to keep us going for long. So, our body often needs to use stored nutri-
ents. Indeed, most of the energy you require today is derived from nutrients that
you ate (and stored) yesterday, the day before, and the day before that.
Most of the time (including during shorter-duration exercise) our energy comes
from nutrients that have been stored in our hepatocytes (liver cells), myocytes hepatocyte: Liver cell
(muscle cells), and adipocytes (fat cells). myocyte: Muscle cell
The two most important “raw materials” for making ATP are: adipocyte: Fat cell
• triglycerides, the storage form of fatty acids, which are kept in both fat cells
and, in smaller amounts, in muscle cells; and
• glycogen, the storage form of carbohydrate, which is kept in both muscle cells
and in liver cells.
You’ll notice that these types of fuel are stored in one form and used in another,
and that these two forms may be different from the form in which they were
eaten.
So, for instance, if we eat some beans with avocado guacamole:

• Our digestive system breaks down the beans’ complex carbohydrates
(polysaccharides) into simple sugars (glucose) for energy, and fiber for our GI
bacteria to eat (and convert into short-chain fatty acids such as acetate, propi-
onate, and butyrate).

80 | Unit 3
• We break down the beans’ protein into amino acids.
• We break down the avocado’s fat into fatty acids.
• The glucose goes to our liver, where it’s packaged and stored as glycogen.
• The short-chain fatty acids that our bacteria make from fiber are usually used
for energy within the colon by intestinal epithelial cells.
• The avocado’s longer-chain fatty acids pass through the liver to be converted into
triglycerides.
amino acid pool: Amino acids • The amino acids become part of the body’s amino acid pool, which the body
available for protein synthesis at normally uses for building new proteins, but which can also be used for fuel
any given time in the body
when needed.
Notice how this complete meal thus gets broken down into smaller pieces and
repackaged. By the time glycogen, amino acids, short-chain fatty acids, and
triglycerides find their way to our cells, they no longer look anything like their
original forms.
In a moment, we’ll look at how fuel gets converted from “storage format” to “ac-
tive use format” (and sometimes, back again).
See Figure 3.1 for a broad overview of our metabolism.
Amino acids Fatty acid, glycerol
Glucose
glycogenesis
Glycogen 6-phosphate
OPO 3
N Nitrogen pool Lipogenesis

glucose
glycogenolysis
gluconeogenesis
Fatty
acid
glycolysis
spiral
Tissue
protein
lactic acid pyruvate
ADP
NH3 Acetyl-CoA ADP
CO2
ADP
H+
Urea Electron
Krebs cycle transport O2
cycle
Urea chain
CO2
2e- ATP
H2O
ATP
ATP
Figure 3.1 Summary of metabolism

How ATP makes “energy” the cytosol re-attach, and thus regenerate the ATP that’s
been broken apart. It’s like breaking apart and re-build-
ATP is an adenosine molecule with three phosphate ing Lego blocks, over and over.
molecules attached to it. The molecules are “glued”
together with (covalent) bonds, as are the molecules that All life can be boiled down to this straightforward ex-
make up carbohydrates, fats, and proteins. Breaking change of breaking and fixing chemical bonds.
these bonds releases energy. Our body can make and replenish ATP in many differ-
When we need ATP to power cellular work, we break ent ways, depending on:
one adenosine-phosphate bond. This leaves us with ADP • how quickly we need the energy;
(adenosine bonded to two phosphates) and P (a free
• how fast the reactions are happening;
phosphate) floating around in the cytosol of our cells.
• what nutrients are available (carbohydrates, fats, and
Although ATP is crucial, we don’t have much of it hang- / or proteins); and
ing around. Our body stores only about 80-100 g of ATP
— just enough for a few seconds of intense effort. • whether there’s enough oxygen to contribute to the
reaction.
In fact, we use so much ATP per day — about 51 kg (or
about 112.5 lb) for a 68 kg (150 lb) person — that the The three main processes or systems are:
total weight of ATP used and regenerated would equal 1. The ATP-PCr system
about 75% of our bodyweight.
2. The glycolytic pathway
So it’s much easier for our body to make what it needs
3. The oxidative phosphorylative pathway
as it goes along. When we break those adenosine-phos-
phate bonds, we have to regenerate ATP quickly to help As we explore these more below, you might get the
supply energy for our daily needs. That’s where energy idea that only one energy system is active at any time.
transfer comes in. In fact, all three systems are always running to some
extent. Our body coordinates these complex activities
In this process, the free ADP and P floating around in
elegantly and neatly.
The energy systems in action

Pi ADP As you read through the descriptions of each energy
system, imagine an example.
O– O– O– adenine
–
O–P–O –
+ –
O – P – O – P – O – CH2 Let’s say you are standing at the edge of a running track.
O O O In this moment, you don’t need much extra ATP.
ribose
Energy used Suddenly, you burst into a sprint. The first explosion of
from food to
bind phos-
movement uses up your stored ATP.
phate to ADP
Energy available After a second or two of running, you need help from
for physiological
processes the ATP-PCr system. This will give you about 10-15
O– O– O–
seconds’ worth of energy, enough to run that Olympic
adenine
–
gold medal sprint.
O – P – O – P – O – P – O – CH2
O O O As you keep running, the ATP-PCr system can’t keep up,
ribose
so your body switches to the glycolytic pathway. This is a
little slower, so you can’t run quite as fast.
ATP After about a minute or two, depending on how accus-
tomed you are to this type of training, your glycolytic
pathway also can’t keep up. You have to switch to the
Figure 3.2 ATP turnover

82 | Unit 3
oxidative phosphorylative pathway. This is the slowest system, so you have to

drop your pace even more.
Eventually, you gear down to a shuffling jog or a walk around the track, out of
breath with your heart pounding. Your oxidative phosphorylative pathway can
keep you going for a long time. But you can’t keep up that sprint pace forever.
The differences between the systems help explain why you have to run this
way. (And why you end up huffing and puffing afterward.) Let’s explore them
further now.
The ATP-PCr system

When we start to demand more energy (for instance, when we start exercising
ATP / PCr system: Composed intensely), the ATP / PCr system is usually the first to kick in.
of ATP and phosphocreatine, this
system replenishes energy rapidly This system, which operates in the cytosol of cells, helps to make more ATP
without the use of oxygen from ADP and P. It uses an enzyme called creatine kinase to break the chemical
creatine kinase: Isoenzyme bonds between creatine (Cr) molecules and phosphate (P) molecules that are
found in muscle and brain tissue already joined in a phosphocreatine molecule (PCr).
that catalyzes the formation of ATP;
higher after tissue injury
To help you remember what this enzyme does, remember that “-ase” usually
creatine: Nitrogenous substance, refers to breaking something, and “kin” comes from the ancient Greek kinein,
derived from arginine, glycine and “to move.” Usually, a kinase breaks a phosphate from one molecule and moves it
methionine, found in muscle tissue
to another.
phosphocreatine (PCr):
Compound of creatine (Cr) and Breaking these bonds releases creatine and phosphate molecules (as well as ener-
phosphoric acid (P) found in
gy) into the cell. This helps to regenerate ATP.
muscle
This energy (as well as the new phosphate molecules that have been released in
this reaction) in turn helps to regenerate ATP. With this new ATP, our body can
supply energy to meet the new, and higher, physiological demand.
Yet this new ATP can only help out for a short time. Although we have about
six times more PCr than ATP, during times of intense energy demand, such as
sprinting, it can only help provide energy for about 10 seconds.
This is one reason supplementing creatine can help improve muscular perfor-
mance: With more creatine in the muscles, more creatine (and PCr) is available
for high-intensity, short-burst muscle contractions. This means we can exert
more force (for instance, when lifting weights) and perform better in high-inten-
sity exercise bouts.
The glycolytic pathway

After your 10-15 seconds of sprinting, your PCr stores begin to run out. The
glycolytic energy system takes over to help make ATP.
Interestingly, this glycolytic system turns on at the same time as the ATP-
PCr system. But it makes ATP much more slowly. So it doesn’t help out much
during the first 10 seconds of exercise.
The glycolytic system in the cytosol breaks down stored muscle glycogen, imme-
diately available blood glucose, and the glycerol backbone from triglycerides to
help regenerate ATP. The suffix “-lysis” comes from the ancient Greek luein, or
“loosen.” So glycolysis literally means “breaking glucose.”

glucose
ATP ATP
ADP
ADP
fructose
diphosphate
PGAL PGAL
NAD+ NAD+
NADH NADH
ADP ADP
ADP ADP
ATP ATP
ATP ATP
pyruvate pyruvate
to Krebs cycle
Figure 3.3 Summary of the ATP input and output of glycolysis
The glycolytic system is much more complex than the ATP-PCr system, using
10 enzymatically controlled chemical reactions to make ATP. It regenerates
four molecules of ATP (from ADP and P) for every molecule of glucose put
through the system. However, because the process of glycolysis “costs” two
molecules of ATP, we actually only get two ATP for every glucose molecule
that goes through the system.
Also created during glycolysis are two molecules of a chemical called pyruvate and pyruvate: Salt of pyruvic acid;
two molecules of a chemical called NADH. And at the point of pyruvate genera- the end product of glycolysis
tion, the last step of the glycolytic pathway, we come to a biological crossroads. NADH: Reduced form of NAD;
used to transfer electrons
When the glycolytic pathway is running quickly (for example, when we’re still
trying to run fast), we end up producing a lot of pyruvate as a byproduct. This is
a good thing: The faster glycolysis occurs, the more ATP we regenerate.
But a fast glycolytic process also releases a lot of hydrogen ions into the cell when
it breaks chemical bonds. These hydrogen molecules can quickly fatigue the
muscle cells. So our body must “buffer” this hydrogen to keep going.

84 | Unit 3
NAD+: Co-enzyme of Through glycolysis, the natural hydrogen acceptors NAD+ and pyruvate come
dehydrogenases; plays a role in to the rescue. Grabbing hydrogens as fast as they can, NAD+ becomes NADH
intermediary metabolism as an
oxidizing agent or reducing agent and pyruvate becomes the infamous lactic acid. Contrary to popular opinion,
for metabolites rather than causing muscle burning, fatigue and the soreness that comes after a
lactic acid: An organic
workout, lactic acid buffers hydrogen ions and carries them out of our cells. In
byproduct of anaerobic essence, NAD+ and pyruvate let us keep exercising.
metabolism derived from pyruvic
acid; can be used as an energy About 90 seconds after you start exercising intensely, you’ll come to another
source for cells biological crossroads.
If you keep running fast or exercising hard, the hydrogen ions being produced
will make the muscles so acidic, you’ll have to slow down again. Now another
energy transfer system has to take over. Again, this one is slower, so you’ll have
to drop your running pace or exercise intensity.
See Figure 3.3 for a summary of glycolysis.
The oxidative phosphorylative pathway

If you keep exercising but slow your pace down, oxidative phosphorylation will
come to your rescue to give you energy.
Oxidative phosphorylation is the less glamorous work horse of the energy trans-
fer systems: It shows up late and plods along at a leisurely pace. It doesn’t give you
the spectacular “blast off the sprint blocks”, but it’ll keep you going indefinitely if
you just move slowly enough.
The oxidative phosphorylative pathway is made up of two processes:
Krebs cycle: A major metabolic 1. The Krebs cycle. (Is also known as the citric acid cycle and tricarboxylic acid
pathway that involves a series of cycle [TCA])
enzymatic reactions that convert
pyruvic acid from food to acetyl-
2. The electron transport chain.
CoA for energy
electron transport chain: You’ll remember that during glycolysis, the body uses pyruvate to make lactic
Set of compounds that transfers acid to buffer hydrogen ions. This is when exercise intensity is high.
electrons to a donor that creates
energy
But if things slow down and glycolysis is slow enough to match the Krebs cycle,
the body funnels the pyruvate into the Krebs cycle instead.
This pyruvate from the breakdown of carbohydrates (via glycolysis) is then con-
acetyl-CoA: Co-enzyme that verted into a chemical called acetyl-CoA. Both fats and proteins can be broken
plays a role in intermediary down to acetyl-CoA. Acetyl-CoA is the chemical entry point into the Krebs
metabolism; can enter the Krebs
cycle. See Figure 3.4.
cycle to produce energy and be
used for fatty acid synthesis
You don’t need to memorize the 11 steps (or the 9 enzymes) involved in a single
rotation of the Krebs cycle, which takes place in the inner chamber of the mito-
chondrion. Just remember that a few things come out every turn of the wheel:
• 1 ATP molecule
• 2 carbon dioxide (CO2) molecules
• 8 hydrogen (H+) ions (NADH and FADH2)

from glycolysis
pyruvate
NADH+
H+ + NADH CO2
CoA
H+
HH++ Acetyl CoA
CoA
+
NADH
NADH
NADH CO2
to electron transport chain
CO2
+
NAD
NAD
NAD ++
Krebs Cycle
ADP
ATP
FADH2
FAD
Figure 3.4 Summary of the input and output of the Krebs cycle
Since two acetyl-CoA molecules are produced from each glucose molecule, this
means that the wheel turns twice for each glucose molecule. So, after two turns of
the wheel, you have:
• 2 ATP;
• 4 CO2; and
• 16 H+ ions.
As you can see, the Krebs cycle produces lots of hydrogen ions. Unlike those made
during glycolysis, these hydrogen ions won’t fatigue us quickly. Instead, they’re
bound to the chemicals NAD+ and FAD+ within the mitochondria. Then, they FAD+: Riboflavin-derived
move quickly into the next portion of the oxidative phosphorylation process: the hydrogen acceptor in the Krebs
cycle
electron transport chain, where all of this cellular effort starts to pay off.
The NADH (NAD+ and hydrogen) and FADH2 (FAD+ and two hydrogens) FADH2: The reduced form of
formed during the Krebs cycle carry these hydrogens through the mitochondria FAD+
and transfer their energized electrons to a set of special molecules (called cyto- cytochrome: Protein found in
chromes) embedded in the cristae of the inner mitochondrial membrane. mitochondria (inner membrane)
that transports electrons
Here, these hydrogen molecules (namely, their electrons) jump between these
five cytochromes and as they jump, their energy is used for a very interesting

86 | Unit 3
cytosol
outer chamber H+ H+
H+ H+
H+ H+
Complex I
Complex III
VI
plex
ATP Synthase
Complex II
Com
H+
H+ H+
NADH NAD+ FADH2
H+
inner chamber ADP H+ ATP
Figure 3.4 The electron transport chain.
proton: Particle with a positive purpose. This energy actually pumps the hydrogen molecules (namely, their pro-
charge, usually regarded as tons) from the inner chamber to the outer chamber of the mitochondria.
a hydrogen ion; when the
proton gradient shifts in the
While this may seem like a waste of energy, since we’ve got so much ATP to
electron transport chain, energy
conversion occurs make, this pumping action has an important job. When these protons build
up in the outer chamber, they rush forcefully back into the inner chamber, like
water rushing through a dam, through a special carrier called the ATP synthase
complex. This rushing in of hydrogen protons yields a lot of energy: 32 molecules
of ATP per molecule of glucose if everything is just right. Now we’re getting
somewhere, energy-wise.
Biology is full of trade-offs, and oxidative phosphorylation is no different.

reactive oxygen species Although it’s an excellent source of slow-burn energy, it also produces reactive
(ROS): Any oxygen-containing oxygen species (ROS). ROS can damage cells if there are too many or if they
compound that is particularly
reactive
stay too long.
Luckily, there are trade-offs to trade-offs: Our cells have antioxidant enzymes
and vitamins to counteract ROS. We can also eat antioxidants in foods such as
colorful fruits and vegetables (although it seems that supplementing with isolated
antioxidants isn’t as useful, and may be actively harmful, perhaps because it may
interfere with our cells’ naturally balanced antioxidation process).
transamination: The transfer

of an amino group from one
molecule
to another

Activity and nutrition can affect how fast and how well So although these B vitamins don’t actually give us
our energy systems work. energy directly, you can imagine how we might need
them to help with the transfer of energy and the regen-
We can make our energy systems more efficient and
eration of ATP throughout glycolysis, the Krebs cycle,
effective with regular exercise, especially if we directly
and the electron transport chain.
target individual systems with specific activities (such
as training the ATP-PCr system with short-distance You can also imagine what might happen if we don’t get
sprinting, or the oxidative phosphorylation system with enough. Indeed, people who are deficient in B vitamins
longer-duration, lower-intensity endurance exercise). often report that they feel sluggish and tired.
Now, remember our hydrogen carriers NAD+ (nicotin- We can thus also improve how our energy systems work
amide adenine dinucleotide) and FAD (flavin adenine by ensuring we eat a varied diet and correcting any
dinucleotide)? nutrient or enzyme deficiencies.
These two molecules act as co-enzymes and are derived

from the vitamins B3 (niacin) and B2 (riboflavin).
How are nutrients metabolized?

Each macronutrient follows a unique path on its quest to Protein metabolism pathways
help replenish ATP.
1. Protein turnover (protein synthesis and breakdown)
Here’s a quick overview. We’ll look at each of these in
2. Amino acid catabolism and deamination
depth.
3. Transamination
Carbohydrate metabolism pathways
1. Glycogenesis: From glucose to stored glycogen Pathways for carbohydrate
2. Glycogenolysis: From glycogen to glucose metabolism
3. Glycolysis: From glucose to pyruvate Carbohydrates are the fastest-acting macronutrient source
4. Krebs cycle and electron transport chain: Ace- for energy transfer. But we don’t store much of them.
tyl-CoA to ATP, CO2 and H2O
For instance: Although a 150 lb (68 kg) person who
5. Gluconeogenesis: Non-carbohydrates to glucose has 15% body fat carries around 22.5 lb (or 10.2 kg) of
stored fatty acids, they can only store about 1.1 lb (or
Fat metabolism pathways 0.5 kg) of glucose.
1. Fat transport and lipogenesis Put in terms of calories, this is the difference between
2. Fat mobilization and lipolysis carrying almost 92,000 fat calories on your body and
2,000 carbohydrate calories on your body.
3. Fatty acid synthesis
The fat would last a long time during a famine. The car-
4. ß-oxidation bohydrates? Barely a day.
5. Ketone formation
This means that to have glucose available for energy
6. Cholesterol synthesis and catabolism transfer, it’s easiest to get it from our diet. However, we

88 | Unit 3
can also make glucose from dietary protein and triglycerides. This means that
your clients can fuel up and thrive on many types of diets.
Carbohydrates travel through five main metabolic pathways to help make ATP.
1. Glycogenesis: From glucose to stored glycogen

2. Glycogenolysis: From glycogen to glucose
3. Glycolysis: From glucose to pyruvate
4. Krebs cycle and electron transport chain: Acetyl-CoA to ATP, CO2 and H2O
5. Gluconeogenesis: Non-carbohydrates to glucose
We’ll look at each one now.
Carbohydrate pathway 1: Glycogenesis

Glycogen is the storage form of dietary carbohydrate. Glucose molecules are
chemically bound together to form tightly packed glycogen molecules which are,
in turn, stored in tissues like the muscles and the liver.
glycogenesis: Synthesis of This process is called glycogenesis, or the creation of new glycogen from glucose.
glycogen (Think of the word “genesis”, or beginning, to remember this.)
For glucose to be added to glycogen stores, it must enter the muscle or the liver
Highly branched glycogen molecule
CH2OH
O H
O OH
O
OH
Branching occurs here
CH2OH CH2OH CH2 CH2OH

O O O O
O OH O OH O OH O OH O
OH OH OH OH
Glucose monomer
Figure 3.5. Glycogenesis. Glycogenesis is the synthesis of glycogen from glucose.

Glycogen is variable in size and stored in the liver and muscle cells. The enzyme neces-
sary for this process is glycogen synthase.

using membrane carrier proteins (known as glucose transporters, or GLUT).

Once in these tissues, it’s converted into a high-energy carbohydrate called glu- glucose 6-phosphate:
cose 6-phosphate, a process that costs the body one molecule of ATP. Phosphorylated form of glucose
that won’t diffuse out of a cell
Once glucose 6-phosphate is formed, the glucose is added to a previously
existing chain of glucose molecules (i.e., glycogen). The most important en-
zyme in this process is glycogen synthase. glycogen synthase: Enzyme
necessary for the conversion
Glycogen molecules can vary in size, depending on how much excess carbohy- of excess glucose into stored
glycogen
drate is currently available, versus how much carbohydrate the body needs for
energy transfer.
• If there is extra glucose from the breakdown of dietary carbohydrate, and we
don’t need that glucose for energy, insulin tells muscle and liver cells to bring
the glucose inside. Insulin also ramps up glycogen synthase enzymes to help
make glycogen for storage. We release insulin in proportion to carbohydrate.
Thus, more glucose normally means more insulin, which eventually means
more glycogen storage in the liver and muscles.
• On the other hand, if we need energy and / or don’t have enough glucose
around (for instance, during fasting or exercise), hormones like epinephrine epinephrine: Hormone and
and norepinephrine tell glycogen synthase to stop making glycogen. These neurotransmitter; also known as
adrenaline
hormones also promote glycogen breakdown (glycogenolysis) by increasing
the activity of an enzyme called glycogen phosphorylase. norepinephrine: Hormone and
neurotransmitter; also known as
noradrenaline
Glycogenesis isn’t perfectly efficient. We lose about 5% of the available energy.
glycogen phosphorylase:
Carbohydrate pathway 2: Glycogenolysis Enzyme necessary for
glycogenolysis; breaks glycogen
When we need to tap into that stored glycogen fuel for energy, our body kicks off into glucose units
glycogenolysis to break off glucose units from the ends of the long glycogen mol- glycogenolysis: Breakdown of
ecules. (Notice that suffix “-lysis” again. Glycogen + lysis means we’re splitting stored glycogen to glucose
up glycogen.)
To do this, our body activates the glycogen phosphorylase enzyme. This enzyme
adds a phosphate group to one of the glucose units packed into glycogen, which
breaks the bond holding the glucose unit to the glycogen molecule.
This glucose+phosphate compound (known as glucose 6-phosphate) can do

two things.
• In the muscle, glucose 6-phosphate can enter glycolysis and run through the
glycolytic pathway in order to regenerate ATP.
• In the liver, glucose 6-phosphate can either be used in the creation of ATP, or it
can become free glucose that the liver can release into the bloodstream.
This brings up an important point. As with real estate, glycogen is all about
location.
• The liver can use glycogen to regenerate ATP or release it into the blood. This
is especially important for tissues such as the brain or red blood cells that can’t
store their own glucose.
• Muscle tissue can’t do this trick. Once stored in the muscle, glucose must
be used in the muscle.

Carbohydrates
glucose fructose galactose
Glycogen cogenesis Glucose Glucose

gly 6-phosphate
OPO3 glucose
glucose
gl
yc o is
g e n ol ys s
si
to blood and brain
neogene
stored in muscle
o l y si s
and liver cells
g ly c
uco
gl
O O
OH OH
OH O
Figure 3.6 Summary of carbohydrate metabolism
Glycolysis
Glucose
ATP C6
C3 Pyruvate C3
molecules
Cytoplasm
Transformation of pyruvate into acetyl-CoA
Pyruvate C3
CO2
Acetyl-CoA CoA
Krebs cycle
CO2
Mitochondrial matrix
ATP
Oxidative phosphorylation
ATP e- e-
ATP e- Electrons removed

from glucose, pyruvate,
and acetyl-CoA Mitochondrial
ATP e-
inner membrane
Redox reactions
ATP e-
H2O 2H+ + O2 + e-
Figure 3.6 Overview of cellular respiration

Glycogenolysis is stimulated largely by two hormones: glucagon and glucagon: Hormone secreted by
epinephrine. the pancreas to increase blood
glucose levels
• Glucagon is a hormone secreted by the alpha cells of the pancreas in response
to low blood glucose and stress.
• Epinephrine is a hormone released primarily from the adrenal medulla. It also adrenal medulla: Central part
responds to stress and intense exercise, helping to mobilize carbohydrates for of the adrenal gland that secretes
epinephrine, norepinephrine and
quick “fight or flight” energy. dopamine
Carbohydrate pathway 3: Glycolysis

Now that we have our glucose 6-phosphate compound from the previous step,
the body needs to do something else with it.
Using enzymes, the body transforms the glucose 6-phosphate into pyruvate. This
process is known as glycolysis. (Here we have “glyco”, or glucose, plus “-lysis”: glycolysis: Series of reactions in
The breaking up of glucose.) the cytosol that converts glucose
into pyruvic acid and ultimately
ATP
You may remember that during this process, hydrogen atoms are released, which
glucose
energy investment
ATP ATP ADP ADP
ADP ATP ATP

ADP
ADP
ADP ATP ATP
NAD+ NADH
NAD+ NADH
energy payoff
pyruvate
net pyruvate + H2O

glucose pyruvate
H2O
Pi
ADP ADP +P ATP ATP
i
NAD + NADH + H+ +
NAD+ NADH H
Figure 3.7 Glycolysis

92 | Unit 3
need to be buffered to prevent fatigue. These atoms are picked up by NAD+,

forming NADH.
As glycolysis cannot continue unless NADH gives up its hydrogen atoms and
recycles back to NAD, the hydrogen atoms either end up joining with pyruvate
(to form lactic acid) or being passed along to the Krebs cycle and eventually to
the electron transport chain.
Where hydrogen atoms end up depends on how fast glycolysis runs.

• If energy demand is high and glycolysis runs quickly, as in the case of anaero-
bic exercise, the hydrogens are bound to pyruvate. Lactic acid is formed with
the help of the enzyme lactate dehydrogenase. This allows NAD+ to be recy-
cled, glycolysis to continue to regenerate ATP, and the excess hydrogen ions to
be shuttled out of the cell before they cause fatigue.
• If energy demand is more moderate, as in the case of activities below the

anaerobic threshold: The point anaerobic threshold, the Krebs cycle can keep up with the rate of glycolysis.
at which lactic acid begins to Hydrogens are passed along to the electron transport chain, creating a lot of
accumulate in the bloodstream
ATP in the process. See Figure 3.6.
Carbohydrate pathway 4: Krebs cycle and electron

transport chain
Unlike other energy systems, the Krebs cycle is not picky about which nutrients
it can use. Carbohydrates, fats and proteins can all be broken down into ace-
tyl-CoA, the major entry molecule into the Krebs cycle.
ATP
H+
glucose
Electron Transport
H+
H+
ATP ATP Chain: + 32 ATP
ADP
H+
ADP
ADP
fructose
Mitochondria
H+
H+
diphosphate
H+
Inner Membrane
PGAL PGAL
NAD+ NAD+
Acetyl-CoA
NADH NADH
H+
H+
ADP ADP
ADP ADP
FADH2
CO2
ATP ATP
CO2
ATP ATP FAD
pyruvate pyruvate
NAD+
Krebs Cycle
Glycolysis: + 2 ATP + 2 ATP
H+
H+
NADH
NAD+ P
AD
Cytosol
ATP
Figure 3.8 Krebs cycle and the electron transport chain

Other substances can also enter the Krebs cycle but this occurs further along the
pathway. We’ll discuss these entry points later.
Remember that our previous pathway ended with pyruvate after carbohydrates
went through glycolysis. Now, at this stage, the body can convert pyruvate to
acetyl-CoA by removing CO2 and adding co-enzyme A to the pyruvate molecule.
Depending on how fast pyruvate is produced (in other words, how much energy
we need, and how quickly), the mitochondria will convert some to most of that
pyruvate to acetyl-CoA.
• When the energy demand is high, only some of the pyruvate is converted to
acetyl-CoA, since the pyruvate will be created at a rate faster than it can be
converted to acetyl-CoA and run through the Krebs cycle.
• When the energy demand is lower, most of the pyruvate is converted to ace-
tyl-CoA since the relatively slower rate of glycolysis will match the rate of Krebs
cycle activity.
Carbohydrate pathway 5: Gluconeogenesis

Brains are kinda important. So they’re usually first in the cafeteria line for nu-
trients. Maintaining blood glucose, especially to the brain, is one of the highest
physiological priorities.
But what happens when we haven’t eaten for a while, and no glucose is immedi-
ately available? The body has to find another way to get glucose to our brain and
potentially other working parts.
As our blood glucose master commander, our liver is called into action. The first
line of defense against low glucose is glycogenolysis, which you learned about. In
this case, glucose can be released from stored liver glycogen and shipped out into
the blood.
However, if liver glycogen concentrations are low, the body has a back-up system:
The liver can also make glucose from non-carbohydrate compounds.
This process of creating glucose from non-carbohydrate sources is called gluco- gluconeogenesis: Conversion
neogenesis, or the genesis of new glucose. Gluconeogenesis can produce around of non-carbohydrate compounds
(i.e., amino acids, pyruvate,
130 g of glucose per day without carbohydrate ingestion (if other nutrients are glycerol) to glucose
abundant), which is just about how much the brain requires each day. Conve-
nient system.
There are four main compounds that can go through the process of
gluconeogenesis:
• pyruvate from glycolysis;
• lactate from glycolysis;
• most amino acids; and
• glycerol from triglycerides.

94 | Unit 3
Occurs mainly in the liver

Glucose Glucose
6-phosphate
OPO3 glucose
glucose
oxaloacetate: Sometimes known
gluconeogenesis
as oxaloacetic acid, a molecule glycerol to blood and brain
involved in many metabolic from lipids
processes
amino acids

O O
OH OH
OH O
Figure 3.9 Gluconeogenesis
These nutrients, which are either already available in the liver, or exported from
muscle and other tissues, can be converted into glucose through a process that’s
pretty much the reverse of glycolysis. While the liver takes care of most of the
gluconeogenesis required by the body, during periods of extreme energy imbal-
ance (such as starvation), the kidneys can also contribute to gluconeogenesis.
Remember our lactic acid (lactate) production from high-intensity exercise?

Well, this gluconeogenic pathway can also help control the high levels of blood
lactate that go along with high-intensity activity.
Indeed, lactate released from the muscles is circulated to the liver, where it’s
converted to glucose. This glucose can then travel back to the muscle for further
energy transfer.
Cori cycle: Process during which This process is known as the Cori cycle. Even when carbohydrate intake is low,
lactate produced in the muscles we can still produce glucose for energy by breaking down proteins and fats. This
goes to the liver and is used for
the production of glucose.
means we can still maintain blood glucose even when we’re on a “low-carbohy-
drate diet.”
Also note: Sometimes, even gluconeogenesis is limited. In these situations, we

can make ketone bodies for fuel. Our body’s mission: Fuel the brain by any
means necessary!
Speaking of ketones, we’ll now look more at fat metabolism.

Nutrition in practice: Low or high carbs?
As a fitness professional, you may have heard the ex- — probably less than 100 g of carbohydrates per day.
pression: “Fats burn in the carbohydrate flame.” People And this is far less than most people, even those on a
typically use it to suggest that we need dietary carbohy- carb-controlled diet, would take in.
drates to burn fat.
Second, if people have enough body fat and are eating
They’re right, to some degree. Here’s why. enough dietary fat, the body compensates after 7-14
days to this new intake with an increased production
For the Krebs cycle to run best, acetyl-CoA likes to join of ketone bodies as well as an increase in Krebs cycle
with a compound called oxaloacetate, or oxalocetic enzymes.
acid, as a first step. This occurs with the help of an en-
zyme called citrate synthase. Indeed, as carbohydrate intake drops off and carbohy-
drate metabolism dwindles, the liver starts to take the
Without enough oxaloacetate in the cells, acetyl-CoA extra acetyl-CoA that’s not being run through the Krebs
doesn’t gain access to the Krebs cycle and the Krebs cycle and converts it into ketone bodies. These ketone
cycle doesn’t run properly. bodies are then shipped out to tissues such as the mus-
When we transform glucose to pyruvate, we can then cles, the brain, etc. where they’re converted back into
convert pyruvate into oxaloacetate. So oxaloacetate is acetyl-CoA.
also a byproduct of carbohydrate metabolism. At this point this acetyl-CoA is more usable, since the
Without adequate carbohydrate metabolism, oxaloace- Krebs cycle will have upregulated (increased) its activity,
tate will be in scarce supply, acetyl-CoA will accumulate, even though there is less oxaloacetate.
and the Krebs cycle will slow down. This adaptation is commonly referred to as “fat adapta-
This is partly why many people feel more sluggish on tion” since much of the acetyl-CoA formed comes from
a low-carbohydrate diet, especially when they first the metabolism of fatty acids.
decrease their carbohydrate intake. They simply aren’t When this happens, some people feel good — better
regenerating enough ATP through the Krebs cycle and than they did while eating more carbohydrates. How-
electron transport chain to meet their energy demands. ever, other people feel worse. For them, a moderate to
In this situation, the liver doesn’t have enough stored high carbohydrate diet is better.
glucose to ship it out to the brain and red blood cells. As a nutrition coach, you should remember that there is
Everything from brain function to physical activity levels no one-size-fits all approach.
slow down to match this new, reduced nutrient and ATP
availability. Thus, even though fat does “burn in the flame of carbo-
hydrates” via the Krebs cycle, this doesn’t mean every-
Does this mean that everyone always has to fol- one needs a lot of carbs to thrive.
low a higher-carbohydrate diet?
Indeed, the body adapts surprisingly well to many types
Not necessarily. of diets. Monitor your clients’ energy levels and other
For starters, for this reduction in Krebs cycle activity to physical indicators to see which diet ultimately works
occur, carbohydrate intake would have to be very low best for them.
Pathways for fat metabolism

Fatty acids and triglycerides have four key roles in our Fat is involved in the energy transfer process in several
body: important ways. It’s the nutrient we use most for energy
• They provide the structure of our plasma
when we don’t need a lot of that energy quickly — for in-
stance, when we’re sleeping, puttering around the house,
membranes.
or going for a leisurely stroll.
• They provide the raw materials for many hormones,
and help regulate the function of other hormones. Although we can make most of our own fatty acids,
there are a few fats we can’t make. So we have to get
• They help transport certain vitamins and minerals. them from our diet.
• They’re the largest fuel depot in the body.

96 | Unit 3
There are six important metabolic pathways related to fat breakdown and
synthesis.
1. Fat transport and lipogenesis

2. Fat mobilization and lipolysis
3. Fatty acid synthesis
4. ß-oxidation
5. Ketone formation
6. Cholesterol synthesis and catabolism
Fat pathway 1: Fat transport and lipogenesis

Most fatty acids are transported as triglycerides (although some, usually those
released by adipose tissue, circulate through the blood as free fatty acids).
Triglycerides are made up of three fatty acid molecules joined together by a
3-carbon molecule called glycerol, with one fatty acid hanging from each carbon.
Because blood is water-based, triglycerides need to bind to special types of pro-
teins to travel around in it.
chylomicron: A lipoprotein Protein-fat packages that pass into circulation from food are called chylomi-
that transports cholesterol crons, a type of lipoprotein. Protein-fat packages that pass into circulation from
and triglyceride from the small
intestine to tissues of the body
liver synthesis are packaged as other types of lipoproteins. Lipoproteins circulate
through the body and can be taken up by the cells with the help of an enzyme
lipoprotein: A class of proteins called lipoprotein lipase.
with hydrophobic core of
triglycerides or cholesterol
surrounded by hydrophilic
These triglycerides are stored in many tissues including our liver, our adipose
phospholipids, apolipoproteins tissues, and our muscle tissues.
and cholesterol
When we digest and absorb triglycerides, we break them down into mono-
lipoprotein lipase: An enzyme
that catalyzes the hydrolytic glycerides, diglycerides, and free fatty acids. These partially or fully broken down
cleavage of fatty acids from triglycerides are then put back together into triglycerides as they enter lymphatic
triglycerides and portal circulation.
adipose tissue: Tissue made of
fat cells Just as glucose molecules are packaged together to form glycogen, stored fatty
acids are joined together in tightly packed molecules (triglycerides) through a
lipogenesis: The formation of fat process known as lipogenesis. The fat in our food and in our cells is made up of
triglyceride units. We have to break these triglycerides down into fatty acids to
use them.
Triglycerides can’t easily pass through plasma membranes. So lipoprotein lipases

break down the triglycerides into three individual fatty acids and one glycerol to let
them enter the cell. Once they’re in the cell, fatty acids are either oxidized and used
to transfer energy, or converted back into triglycerides for storage by adding the
fatty acids back to the glycerol molecule.
The glycerol backbone has three carbon “docking stations” to which fatty acids
can bind. And glycerol isn’t picky. It’ll bind to all kinds of fatty acids. So differ-
ent fats can bind to each one of those carbons. For example, a single triglyceride
could be made up of one saturated fatty acid, one polyunsaturated fatty acid, and
one monounsaturated fatty acid. Another triglyceride could be made up of three
saturated fatty acids. And so on.

Do “fat burning supplements” work?
Hormones like epinephrine and norepinephrine, part of our “fight or flight” hor-
mone roster, stimulate lipid mobilization. In other words, when these hormones
go up, it tells the body to release fatty acids into the bloodstream for energy.
These hormones can go up for a few reasons. Exercise and stress are two of the
most common. In both cases, the “fight or flight” hormones release fuel for
quick energy to the muscles. As you learned in the previous unit, these hor-
mones also suppress appetite and gastric function, so we’re not hungry.
You’d think that it would be good to have these hormones high if you wanted
to lose body fat. This is the basis for almost all “fat-burning” supplements. They
contain stimulants, such as caffeine, that amp up our epinephrine and / or nor-
epinephrine. They also lower our appetite temporarily.
However, without exercise, releasing our “fight-flight” hormones isn’t as effec-
tive for losing fat, since the signal is “artificial.” Although the fats are available
to use as an energy source, there’s no increased muscle activity that needs the
energy. The fats thus simply recycle back into fat storage.
So the fats may be released, but if we’re not exercising, they don’t do anything.
Eventually, they shrug and go back home again.
As the saying goes, stimulants don’t give you energy (because energy can’t be
created or destroyed). Instead, stimulants borrow energy. And if we don’t use
energy, it gets put back, often leaving us feeling less energetic than before. (Or
worse, hungrier.)
But if we combine mild stimulants (such as a cup of coffee) with an exercise
session where those fatty acids can be used, now we’re in business. Caffeine is
an ergogenic aid (a substance that can boost performance).
Be aware that most stimulants are banned in athletic competition. Help your
clients’ choose supplements wisely!
Fat pathway 2: Fat mobilization and lipolysis

When we need triglycerides for energy, we break them down with a process
called lipolysis, or the “-lysis” (splitting) of lipids. This process, carried out by an lipolysis: Breakdown of
enzyme known as hormone sensitive lipase (HSL), breaks triglycerides down triglycerides into fatty acids and
glycerol
into their constituent parts: three individual fatty acids and one glycerol.
hormone sensitive lipase
If we need energy in the tissues where lipolysis is happening, the glycerol can en- (HSL): Enzyme of the cytosol that
ter the glycolytic pathway while the fatty acids are further broken down through frees fatty acids and glycerol
a process known as beta oxidation (more on this later).
If our body needs energy elsewhere, these components can be released into the
blood. This process of triglyceride breakdown and fatty acid release into the blood
is called lipid mobilization. It happens when our energy needs go up. Indeed, the lipid mobilization: Using lipids
concentration of free fatty acids in the blood is directly related to our muscle cells as a fuel source
using that fat during physical activity.
Lipid mobilization, including the activation of HSL, is stimulated by high con-

growth hormone (GH):
centrations of the hormones epinephrine, norepinephrine, glucagon, and growth Anabolic hormone that causes
hormone. Each of these hormones is released during exercise to tell your fat cells growth and cell reproduction;
that the muscles need energy. also known as somatotropin

98 | Unit 3
How do we get fat?
Fatty acid synthesis happens when energy intake is high and energy demands
are low. In other words, we package and store fat when we eat more than we
burn through metabolism and activity.
It’s a basic law of thermodynamics: Energy has to go somewhere. If we can’t
expend it as heat, movement, or some other metabolic activity, we have to store
it. And our body’s preferred storage method is adipose tissue, or fat.
This synthesis of fatty acids can come from either excess dietary fat, or excess dietary
carbohydrate (which is called de novo lipogenesis). Theoretically it could also occur
from excess dietary protein, but this requires a unique set of conditions.
In general, the body tends to follow these three rules:
1. Excess dietary fat is directly stored as body fat (some of which gets syn-
thesized into different types of fat).
2. Excess dietary carbohydrate increase carbohydrate oxidation, thus im-
pairing fat oxidation, and cause more dietary fat to be stored as body fat
(along with a very small amount of de novo lipogenesis).
3. Excess dietary protein increases protein oxidation, thus impairing fat
oxidation, and causing more dietary fat to be stored as body fat.
This means that no matter what combination of macronutrients you eat, if you
eat more than you expend, you’ll store the excess energy.
Other factors affect how our body processes nutrients. These include:
• exercise and daily-life movement;
• body composition;
• hormones;
• genetic programming;
• age;
• our gastrointestinal microbiome; and
• the type of food we eat.
Outside of a lab, we will never know exactly how many calories we are taking in
or expending. But this doesn’t mean that energy balance doesn’t matter. It just
means that we don’t know all the inputs and outputs, so doing a lot of precise
and complicated “calorie math” won’t help us very much.
Energy balance is the ultimate equation that determines weight loss or gain.
If we take in more energy than our body needs or uses, we will gain weight.
If we take in less energy than our body needs or uses, we will lose weight.
Since calorie math isn’t very useful, we have to track our clients’ intakes, out-
puts, and long-term results closely to know what the right amount of food for
each individual client is.

Fat pathway 3: Fatty acid synthesis

The synthesis of new fat takes place mostly in the liver, although it can also hap-
pen in adipose (fat) tissues when energy intake from food is high, energy output
from metabolism and activity is low, and when insulin is high (so nutrients are
easily transported into cells). More on this in a moment.
This process is governed by a complex of enzymes called the fatty acid synthase fatty acid synthase system:
system. This system is activated when energy demand is low but high concentra- System of enzymes involved in the
synthesis of fatty acids
tions of acetyl-CoA are present in the liver (in other words, when we’ve eaten a
lot of nutrients, but don’t have any demand for that energy).
During this seven-step process:

• 2 carbon units are added to an ever-growing fatty acid chain until it becomes
the saturated fatty acid palmitate. palmitate: Common saturated
fatty acid; end product of
• From here, the palmitate can be elongated (to make a longer saturated fat- mammalian fatty acid synthesis
ty acid, such as stearic acid) or desaturated (to create monounsaturated
elongation: Addition of carbons
fatty acids such as palmitoleic acid or oleic acid). on a fatty acid chain
• The liver can package these fatty acids, whether saturated or unsaturated, as saturated fatty acid: A fatty
acid with no double bonds in the
triglycerides in very low density lipoprotein particles (VLDL) and ship
chain
them out to other tissues for fat storage.
desaturation: Removal of
Although we can synthesize most fatty acids, there are two polyunsaturated fats hydrogen atom(s) to form a
double bond
that we can’t make:
monounsaturated
• alpha linolenic acid (an omega-3 fat) fatty acid: Having a single
double bond in the fatty acid
• linoleic acid (an omega-6 fat) chain
We must get these from our diet. very low density lipoprotein
particles (VLDL): Particles used
in lipid transport; assembled
Fat pathway 4: ß-oxidation in the liver by cholesterol and
apolipoproteins, converted to LDL
Once we’ve converted triglycerides to fatty acids, the next step is beta oxidation
(the Greek letter beta is often written as “ß”). This process breaks down fatty polyunsaturated fat: A fatty
acid with multiple double bonds
acids into acetyl-CoA, which you should realize by now is an essential molecule in the chain
in energy transfer. ß-oxidation is sometimes called the “fatty acid spiral” because
alpha linolenic acid (ALA):
it is similar to a cycle, like the Krebs cycle with a series of enzymes. It is called a Unsaturated omega-3 fatty acid,
spiral because each time through the process the fatty acid gets shorter as ace- see linolenic acid
tyl-CoA is made.
omega-3: Family of unsaturated
fatty acids characterized by a
Fatty acids are long chains of carbon-hydrogen bonds. Acetyl-CoA is made up of carbon-carbon double bond three
only two carbons. So most fatty acids can produce a lot of acetyl-CoA. spaces in from the methyl end
linoleic acid: Unsaturated
Each 16-carbon fatty acid (like palmitate) can regenerate approximately 106 ATP. omega-6 fatty acid considered
essential to the human diet
Since triglycerides contain three fatty acid molecules, multiply that Figure by
three and you end up with 318 ATP molecules per triglyceride. omega-6: Family of unsaturated
fatty acids characterized by a
carbon-carbon double bond six
Since glycerol also contributes to ATP regeneration, helping to produce 19 more spaces in from the methyl end
ATP molecules, the breakdown of each triglyceride generates a whopping 337
ATP molecules.

100 | Unit 3
Compared with the 36 ATP molecules generated by one glucose, fat emerges as
an ATP superstar.
aerobic: A process that requires Fat oxidation is efficient but slow, because it’s aerobic (from the ancient Greek
oxygen aero, or “air”). It needs oxygen to accept hydrogen ions after they’ve moved
through the electron transport chain. And we can only take in and transfer a
certain amount of oxygen. So there’s a limit to how much energy we can get from
ß oxidation.
If we need a lot of energy but don’t have a lot of oxygen (for instance, while
sprinting), we stop using the ß oxidation pathway for energy and use mostly
anaerobic: A process that does glycolysis instead. This process is described as anaerobic.
not require oxygen
Fat pathway 5: Ketone formation
When we need energy but don’t have a lot of carbohydrate coming in (and / or
don’t have enough oxaloacetate), our liver can make ketones for energy.
ß oxidation dominates when available carbohydrates are low (for example, after
a long period of fasting). As a result of this process, fatty acids create a surplus of
acetyl-CoA. If there aren’t enough oxaloacetate molecules to run this acetyl-CoA
through the Krebs cycle, the cycle stops. Acetyl-CoA builds up.
Ketogenesis
r Increased
e
ketone
Liv
production
d
se Increased ketones
r ea gon in bloodstream
c
ed In uca
reas gl
Dec lin
insu
id
ac
tty
Fa s
c rea
n
Pa
Fat cell
Fasting State
Blood vessel
Figure 3.11 Ketone formation

This build-up of acetyl-CoA shifts the liver into ketone Because cholesterol is so important, we make our own,
body formation. Ketone bodies can then be sent out to and lots of it. Indeed, we usually make much more than
other tissues for energy. Using ketone bodies for energy we eat — about 1 g per day, although it varies.
is known as ketosis.
Our body synthesizes cholesterol from acetyl-CoA.
There are three basic ketone bodies: (Yes, here it is again, that ever-present acetyl-CoA!)
Through a series of about 26 enzymatic reactions,
• ß-hydroxybutyrate
acetyl-CoA units are joined together to eventually form
• acetoacetate the end product, cholesterol.
• acetone
Nearly all tissues in the body are able to make cholester-
These ketones are water soluble and can be reconverted ol. How much we make, and where we make it, seems to
into acetyl-CoA to help supply the brain, red blood cells, depend on how much cholesterol we eat and absorb from
and muscle tissue with energy transfer nutrients when food. The liver often plays a major role here.
glucose is low. This isn’t how our body prefers to get fuel, Interestingly, as dietary cholesterol goes up, cholesterol
but it’s an excellent back-up system when glucose isn’t synthesis goes down, and vice versa. There is a dynamic
available. See Figure 3.9. balance that also seems to vary from person to person.
It’s not clear what the long-term effects of ketosis are. Some people seem genetically predisposed to have high-
Ketogenic diets do seem to help certain health condi- er cholesterol levels than others.
tions, such as childhood epilepsy. And it’s early, but Like many other types of fats, cholesterol is not especial-
these diets might also benefit other neurological dis- ly water soluble. To get around the body, it has to hitch a
orders. Unfortunately, there seem to be some potential ride on lipoproteins.
drawbacks to permanent ketosis, such as:
• high blood lipids; Apolipoproteins, the protein portion of lipoprotein
molecules, form the surface of these particles. Current-
• lowered neutrophil (white blood cell) function; ly, there are five known classes of apolipoproteins (A
• optic neuropathy (damage to the nerves of the eye); through E). Each class has distinct subclasses. These
and lipoproteins carry cholesterol, among other molecules
such as triglycerides, phospholipids, and apoenzymes,
• lower bone density. throughout the body.
And children who follow ketogenic diets to prevent sei- The ratio of protein to lipids in each lipoprotein deter-
zures have developed hydration problems, constipation, mines the density of that lipoprotein. Protein is denser
decreased bone mineral density, and kidney stones. than fat, so lipoproteins higher in protein and lower in
fat are known as high-density lipoproteins (HDL). Low
In addition, because people following ketogenic diets
and very low density lipoproteins (LDLs and VLDLs)
must cut out so many foods, they may not get enough
have more triglycerides and cholesterol. (Ever see that
food variety for good health.
T-shirt saying “I’m not fat, I’m fluffy”? Well, it’s actu-
Fat pathway 6: Cholesterol synthesis and ally kind of true. Relative to protein, fat molecules are
“fluffier.”)
catabolism
Lipoproteins have different jobs.
Cholesterol is a molecule with several essential roles.
• Our LDL particles deliver cholesterol and tri-
• It helps cell membrane function.
glycerides to our cells. Our cells then use those fats
• It helps absorb dietary fat. to build and maintain cell membranes, to make
• It’s the basis of steroid hormones (including vitamin hormones, or for storage.
D). • Our HDL particles carry cholesterol from cells
• It helps synthesize bile salts. and other lipoproteins to the liver where it can be
excreted in the bile, or recycled to be sent out again
to tissues that need cholesterol.

102 | Unit 3
HDL
Liver excess cholesterol

from cells
LDL cholesterol to cells
VLDL
chylomicrons (lipoprotein lipase)
(from enterocytes) TAG to cells
Figure 3.10 Cholesterol transport
LDL particles: A lipoprotein Interestingly, HDL can bind to both cellular receptors and to LDL receptors. Thus
that transports triglyceride and HDL can “steal” cholesterol from LDL and carry it out of the body. They do this
cholesterol from the liver to body
tissues with the help of an enzyme called lecithin-cholesterol acyltransferase (LCAT),
which allows cholesterol molecules to be freely released from the cells of our body,
HDL particles: A lipoprotein
that transports fatty acids and
as well as from LDL, to travel back to the liver.
cholesterol from the body tissues
to the liver This is why HDL is cardioprotective. As LDL particles take cholesterol to other
tissues, these molecules can unfortunately drop off cholesterol in our blood ves-
lecithin-cholesterol
acyltransferase (LCAT): An sels, sort of like boxes falling off a truck. Fatty plaques can build up, eventually
enzyme that is used to convert leading to atherosclerosis.
cholesterol to a transportable
form for lipoproteins HDL, on the other hand, carries this cholesterol back to the liver for excretion,
cardioprotective: Something reducing the risk of plaque build-up. This is why high HDL is known as “good”
that is protective to the cholesterol, and why doctors look for higher HDL levels and lower LDL levels. See
cardiovascular system Figure 3.10 and the sidebar “Is high cholesterol bad” for more.
atherosclerosis: Development
of plaque in the lumen (interior
space) of blood vessels

Is high cholesterol bad?
One of the most common types of drugs prescribed in turned out to have many unwanted side effects, like:
North America is statins. These drugs work by blocking • muscle pain and damage;
an enzyme that the liver needs to make cholesterol. • lower CoQ10 levels;
Initially, many health care providers saw statins as a • diabetes or problems controlling blood glucose;
good thing. Statins could lower cholesterol production and / or
by up to 70%. • elevated liver enzymes.
But just making HDL cholesterol go up or LDL cho- Combining statins with niacin (vitamin B3) can in-
lesterol go down with drugs doesn’t actually seem to crease the risk of serious myopathies (muscle damage),
decrease heart disease incidence much. There is more to including rhabdomyolysis. This is important for clients
this story than that. to know if they are combining these medications with
supplements (even apparently harmless multivitamins).
Recent research has found that the amount of these lipo-
Conversely, grapefruit juice can inhibit the action of
protein particles may be far more important than simply
many medications, including statins.
their cholesterol content. In essence, the more particles
you have, the longer they stay in the vascular system, So if you have any clients on medication, work with
and the more likely they are to eventually penetrate the their doctor and pharmacist to make sure any supple-
endothelium and start progressing into atherosclerosis. ments you recommend will be safe.
Thus, both particle size and particle amount matter.
Luckily, many doctors are now recommending a much
Given how important cholesterol is in the body, statins cheaper and safer alternative to drugs: good nutrition
and exercise.
Pathways for protein metabolism

The name protein derives from the ancient Greek protos, except in the case of gluconeogenesis, as we discussed
meaning first, primary, or most important. Indeed, previously. Most of the time, proteins do other things.
proteins are the body’s building blocks. The amino acids Let’s look at how that works now.
that make up our proteins:
There are three important protein pathways to know.
• give our body structure and strength;
1. Protein turnover (protein synthesis and breakdown)
• make many hormones and cell signaling molecules;
2. Amino acid catabolism and deamination
• make enzymes;
3. Transamination
• make immune system chemicals such as immuno-
globulins and antibodies; But first, let’s talk about amino acid pools.
• make transport proteins; and many other things.
Amino acid pools
We can make some amino acids. But we have to get
most from our food. And since proteins are always being Biologically, we use the term “pool” to describe a group
broken down and rebuilt, we need to get enough protein of particular molecules in a specific location or tissue
to stay healthy. (e.g., adipose tissue triglyceride pool, plasma amino acid
pool). There are several amino acid pools in the body.
Our cells don’t often use proteins directly for energy,
When we digest protein, it is broken down to its

104 | Unit 3
Figure 3.11 Amino acid pool and the eventual fates of individual amino acids
individual amino acid components. After we absorb these amino acids and they
pass through the liver, they enter the bloodstream and become part of what’s
plasma pool of amino acids: known as the plasma pool of amino acids. This is a collection of essential and
Reserve of amino acids found in non-essential amino acids, which also includes the amino acids broken down in
blood plasma
our body tissues and shipped out into the bloodstream. In total, this blood-based
essential amino acid: Amino pool usually has about 100 g of amino acids, which can easily interact with other
acid that must be included in the
amino acids and proteins in our cells.
diet
non-essential amino acid: This regular exchange, or flux, of amino acids into and out of our body tissues
Amino acid that does not need to is an important protein-related metabolic pathway that can then be used to pro-
be included in
the diet
duce important molecules such as:
• enzymes
• hormones
• neurotransmitters
• antibodies
• transport proteins
• muscle proteins
Our body normally prefers to use amino acids for these important metabolic
functions. However, as we’ve seen, if our body needs energy and no other nutri-
ents are easily available, it can also break protein down to either help create other
nutrients (such as glucose, fatty acids, cholesterol, or ketone bodies) or to help
regenerate ATP. See Figure 3.11.

Indeed, we lose some of our body’s amino acids to breakdown. How much we lose
will depend on our energy balance: If we’re well fed and / or energy demands are
low, we won’t lose much. If we’re poorly fed or fasted, and / or need a lot of energy,
we’ll lose more amino acids.
Where those amino acids come from depends on our protein balance. Because
we’re constantly “leaking” amino acids from the pool, we have to keep it topped
up by eating enough protein.
If we need more amino acids than we’re eating, the body starts to get those ami-
nos from elsewhere. It’ll start cannibalizing muscle tissues, structural proteins
(such as bone and connective tissues), hormones and other chemicals, etc. If this
deficit goes too long, vital functions will shut down.
Luckily, almost all foods contain some protein. And the body doesn’t discrim-
inate: Amino acids are amino acids, no matter what their source. While some
foods have more protein than others, it doesn’t matter whether that protein is
plant or animal.
Protein pathway 1: Protein turnover (protein synthesis

and breakdown)
The process by which cellular proteins are continually “recycled” by being de-
graded and re-synthesized is called protein turnover.
All tissues of the body go through a regular course of turnover. We can see this,
for instance, in the skin, which sloughs off dry, dead skin cells while new, healthy
skin cells take their place. Bone cells respond to loading and stress in their
process of resorption and new bone formation. (Yes, bones are mostly protein!)
Indeed, every cell that makes up our bones is different than it was a year ago
today. Of course, muscles need protein turnover to become bigger and stronger
when stimulated by exercise.
The turnover of these tissues is governed by two independent processes: protein protein synthesis: (Re)building
synthesis and protein breakdown. of proteins
protein breakdown:
Both protein synthesis (putting amino acids together into new protein struc- Degradation of proteins
tures) and protein breakdown (breaking down proteins into amino acid units)
are regulated by several factors including:
• nutritional intake;
• exercise habits;
• health and illness;
• stress;
• hormonal status; and
• genetic programming.
There are three types of protein status, depending on the relationship between
protein synthesis and breakdown.
If we’re building new proteins at the same rate as we’re breaking them down, our
protein status is neutral. Proteins have been equivalently turned over and replaced.

106 | Unit 3
+ Positive protein status:

synthesis rates exceed
breakdown rates
am
i
no
ac
m
id c
o acid anabolis
N
Amino Acid Pool
atabolism/de
protein protein
synthesis breakdown
in
a
am
mina
ti
on
Negative protein status:

breakdown rates exceed
synthesis rates. -
Figure 3.12 Summary of protein breakdown and protein synthesis
If we’re building new proteins faster than we’re break- Protein pathway 2: Amino acid
ing them down, our protein status is said to be positive. catabolism and deamination
We’ve renewed and built new things.
Amino acids have three eventual fates in the body:
Finally, if we’re building new proteins more slowly than
we’re breaking proteins down, our protein status is 1. They can be joined together to create new proteins.
negative. We may have renewed some proteins, but we’ll 2. They can be catabolized to form non-protein com-
soon run out. We need to eat more protein to replenish pounds (as in gluconeogenesis).
the body’s protein pools.
3. They can be catabolized in order to transfer energy
This process of protein turnover uses the amino acid ca- (i.e., regenerate ATP).
tabolism / deamination steps that we’ve already discussed.
In this section, we’ll discuss the latter two processes,
Our DNA directs protein synthesis. Signals such as ex- both involving amino acid catabolism, or breakdown.
ercise, hormones, and so forth trigger DNA to start the
process of transcription and translation. New proteins All amino acids contain nitrogen in their chemical
are then made, with the help of the muscle amino acid structure, along with their carbon-hydrogen bonds.
pool and ribosomes in the endoplasmic reticulum. After When new proteins are synthesized from individual
processing in the Golgi apparatus, these new proteins amino acids, these nitrogen molecules stay with the ami-
either stay in the cell or are shipped out. Now they can no acid as the growing peptide chain gets larger.
do their jobs, whether that’s being enzymes, providing
structural support, etc. However, when amino acids are needed to form non-pro-
tein compounds or to transfer energy to ATP, these nitro-
Eventually, however, they’ll also be broken down into gen groups must be eliminated. This process of nitrogen
individual amino acids for recycling back into body removal is called deamination. See Figure 3.13.
proteins or for the transfer of energy. And when the
original proteins are gone, new proteins will take their As we’ve seen, the proteins within our cells are con-
place. See Figure 3.12. tinually being broken down and rebuilt. This protein
turnover allows our cells to adapt quickly to changing

NH 2
O
C C C C
OH HO OH
HO +
NAD
O O O O
glutamic acid alpha-ketoglutaric acid

+ +
+
H2O NADH + H NH3
ammonia
Urea
cycle
Figure 3.13 The process of deamination
environmental and physiological conditions by synthesizing new and better peptide chain: Short polymer
proteins to replace those recently broken down. formed from linking amino acids
deamination: Removal of an
For example, the mechanical and chemical stress of physical activity tells our amine group from a compound
body that our current enzymes don’t work well enough; that our current carrier
proteins don’t transfer nutrients fast enough; and that our current contractile
proteins aren’t strong enough. The body adapts to this stimulus by breaking
down and restructuring proteins in stronger and more efficient forms.
Once proteins are broken down, many of the resulting amino acids hang out in
the muscle protein pool for recycling into new muscle proteins. Some of these
amino acids (for example, the branched chain amino acids, or BCAAs for short) branched chain amino acid
can be used locally in the muscle (especially during longer-duration exercise, (BCAA): Amino acid with
aliphatic side chain that is non-
where BCAA contribution to energy transfer can increase several-fold).
linear
This process happens in 3 steps:
1. Nitrogen is removed from these amino acids.
2. This nitrogen is bound to hydrogen and flushed out of the body.
3. The remaining carbon-hydrogen chain (called a carbon skeleton) is used for carbon skeleton: Chains,
energy transfer, or is exported for further processing in the liver. branches or rings of carbon atoms
that form organic molecules
In addition to local muscle metabolism, some of the amino acids are shipped
out into the blood, returning to the plasma amino acid pool, where they join
with dietary amino acids and other amino acids that have been exported by
other cells of the body.
As the plasma amino acid pool circulates throughout the body, the liver can grab
some of these amino acids. It will deaminate and catabolize over half of them in
order to use them for gluconeogenesis, ketone body formation, cholesterol syn-
thesis, fatty acid synthesis, or, finally, energy transfer. See Figure 3.14 for more.
When bound to amino acids, nitrogen groups typically appear in the form of

108 | Unit 3
Amino Acid Pool
Catabolism
Deamination:
Nitrogen groups N
eliminated
non-protein α-keto acid residues = urea, ammonium,

products (as in carbon skeletons of and other waste
gluconeogenesis) amino acids products in urine
energy metabolism
in glucose or fatty acid
metabolism pathways
Figure 3.14 Summary of amino acid catabolism pathways
NH2 or NH3 (one nitrogen bound to two or three hydrogens). These groups, typi-
amine: One of a group of organic cally called amines, are removed from amino acids in the first step of amino acid
nitrogen compounds catabolism (deamination).
ammonia: Also known as NH3 , a When amine groups break away from the amino acids, they form free NH3 (am-
very basic end product of protein monia) and a carbon skeleton. Ammonia is very toxic to humans. So we must
metabolism
convert it to a non-toxic chemical. Using a process called the urea cycle, CO2 and
urea cycle: Cycle that takes place NH3 are joined together to form urea, a non-toxic, water-soluble chemical that
in the liver and creates urea from
can safely diffuse in the blood and be excreted in the urine. This is why you’ll
ammonia and carbon dioxide
often see more urea in the blood and urine of someone who eats a lot of protein.
In people with kidney or liver disease, the urea cycle may not work properly, and
ammonia levels can increase in the blood.
The portion of the amino acid that remains after the amino group has been re-
α-ketoacid: An organic acid moved is called its carbon skeleton or α-ketoacid. (“α” is the Greek letter alpha.)
containing a functional ketone This carbon chain can be converted to five important substances:
group and a carboxylic acid
1. glucose;
2. ketone bodies;
3. cholesterol;
4. fatty acids; or
5. a Krebs cycle compound for entry into oxidative phosphorylation and the
eventual resynthesis of ATP.

Amino acids Glucose Fatty acids
ATP
pyruvate
Acetyl CoA
Krebs Cycle
ATP
CO2
Electron
Transport
Chain
ATP H2O
Figure 3.15 Summary of metabolic pathways for proteins, carbohydrates, and fats

110 | Unit 3
Protein pathway 3: Transamination

In addition to deamination, some amino acids can un- Understanding the details of how this works helps us
dergo a process known as transamination. Rather than understand what we should eat and why. It also helps us
the amine group being lost, in this process it’s simply understand how changing our diet can change our body’s
transferred to another amino acid carbon skeleton. The health, performance, and composition.
fate of the original amino acid can be the same as with
deamination reactions. In the next unit we’ll take this one step further to ex-
plore the concept of energy balance, or the relationship
In this unit, we’ve looked at how we get energy from food. between energy input and energy output.
Case study
Potatoes. Bread. Pasta.

What comes to mind when you read those words? Many ably sized dessert after some meals.
of our clients think of “enemy”, “evil”, “off-limits”, and
“fat-inducing.” With this new plan, his diet was nutrient-rich and
satisfying. He didn’t feel deprived and compelled to
One client in particular had such a fear of carbohy- over-eat. He didn’t end up with too much or not enough
drate-dense foods that he eliminated all of them. No carbohydrate. He simply ate reasonable portions, based
wild rice. No baked potatoes. No oatmeal. No apples. on his body’s needs. Imagine that!
Instead, his meals were built around meats, eggs, fish, With this new plan, he felt better and saner. He got rid
oils, nuts, seeds, butter, and non-starchy vegetables. of strict “food rules” and eventually, some of that extra
He created “good” versus “bad” food rules in his head. body fat too.
All non-carbohydrate foods were “good”, and all carbo- Dividing foods, or entire groups of nutrients, into
hydrate-dense foods were “bad.” “good” or “bad”, almost never helps. If people take in
“Bad” meant “Don’t eat any.” “Good” meant “Eat as more energy than they expend, they’ll gain weight no
much as you want.” Since the “good” foods didn’t have matter what they’re eating. Period.
carbohydrates, he figured they couldn’t possibly result As a nutrition coach, one of your jobs is to help clients
in accumulation of body fat. So he ate the “good” foods develop perspective and reasonable limits.
until he was stuffed.
A slice of toast with breakfast, a side of brown rice at
Well, we channeled our inner Dr. Phil and asked him, lunch, a piece of fruit as a snack, and a baked potato
“How’s that working for you?” with dinner likely won’t be “limiting factors” for most of
After six months, his answer was: “Not so good.” your clients.
Instead of losing weight (like he’d hoped), he’d gained Instead, it’s probably the sugary sodas, candy snacking,
weight. He also felt worse in general and his doctor said forgotten late-night desserts, and weekend bingeing —
his lipid panel wasn’t moving in a healthy direction. ironically, that often go along with stringent restriction
— that are the real problems.
After some troubleshooting and sanity checking, we
worked with him on building more balanced, reason- With most clients, the more they restrict, the more likely
able meals. No more 22 oz steaks with veggies soaking they are to make up for it in other ways. Classifying all
in butter. Instead, his meals looked more like a 6 oz carbs as “bad” will probably lead to eating more — in
steak, a baked potato, and plenty of veggies, drizzled the form of processed carbs or just excess calories in
with a little olive oil. He would even include a reason- general — in the long run.

How much protein can we use?
At some point, you’ll be asked the following question: • a woman who is pregnant
“Can I absorb more than 30 g of protein per meal?” • an athlete new to intense physical training.
First, we absorb most of the protein we eat, because • a person on a restricted calorie diet.
absorbing simply means digestion followed by digestive They will all need more protein.
products entering circulation.
Then think about a sedentary adult. They won’t need as
Second, how much protein we can use will differ from much protein.
person to person.
Later, we take a closer look at meal templates and how
Think about: to make sure your clients are getting what they need. For
• an adolescent going through puberty now, just remember that while we need protein, like any
• a 70-year-old trying to preserve lean mass other nutrient we want to eat it in the right amounts.
Summary
Adenosine triphosphate (ATP) is the energy currency The ATP-PCr pathway gives us energy when we need it
of our cells. Breaking ATP’s chemical bonds to create quickly. This process, which uses stores of creatine phos-
adenosine diphosphate (ADP) and phosphate (P) releases phate in the muscle, can transfer energy very quickly.
energy. Though fast-acting, it’s short-lived.
When the energy in ATP is released, ADP and P must be The glycolytic pathway uses glucose molecules and
recycled so that we can keep going. glycerol to transfer energy when it’s in high demand
and when the ATP-PCr pathway has been depleted. This
We store only a little ATP. So we must get more energy system can provide energy for about 80 seconds before
from nutrients like carbohydrates, fats, and proteins. it’s maxed out.
Carbohydrates, fats, and proteins transfer their energy Oxidative phosphorylation gives us lots of ATP but it’s
through many different metabolic pathways in the body, relatively slow and needs oxygen to run. Through the
which split the carbon-hydrogen bonds in these nutri- Krebs cycle and the electron transport chain, oxidative
ents and help replenish ATP. phosphorylation takes acetyl-CoA derived from carbo-
hydrates, proteins, and / or fats and uses it to transfer
There are three main energy transfer pathways: the ATP-
energy to form a large amount of ATP.
PCr pathway, glycolysis, and oxidative phosphorylation.

UNIT 4
Energy Balance in the Body

Energy Balance in the Body | 113
Unit Outline
1. Energy value of food 5. Case study 1
2. Estimating energy needs and energy intake 6. Case study 2
3. Energy balance and imbalance 7. Summary
4. Achieving energy balance… naturally
Objectives
In this unit, you’ll learn about energy balance: the rela- We’ll also explore how food type (for instance, minimally
tionship between energy we take in (in the form of food) processed versus highly processed foods) affects energy
and energy we put out (in the form of activity and basic balance and our body’s natural abilities to control our
metabolic functions). appetite, hunger, and fullness.
Energy balance affects many processes in the body, rang-

ing from bodyweight to hormones — even our moods.
Energy value of food

As you learned in previous chapters, the food that we eat contains potential potential energy: Energy stored
energy. Potential energy is energy that’s stored in a physical system and can be within a physical system
converted into work, or kinetic energy. As we’ve also discussed in previous chap- kinetic energy: Energy
ters, the chemical bonds in our food give us a rich source of potential energy. generated by motion
When we break these bonds, we can transfer this energy to regenerate ATP, and Joule: Unit of energy; 4.184 Joules
eventually, the ability to do the work of metabolism and movement. equal 1 calorie
Measuring energy
With most energy systems, the standard unit of measure for potential energy
is the Joule. Technically speaking, one Joule is the amount of energy it takes to
move an object that weighs one Newton (0.445 lb) across a one-meter distance.
If you live or travel outside of North America, you’ll often see Joules or ki-
lo-Joules (1000 joules) as units of measurement on food labels. In North Ameri-
ca, it’s still most common to measure this energy in Calories. Calorie (large calorie):
Amount of energy required to
One Calorie equals 4.18 Joules. Therefore, if you eat a 1000-Calorie diet, you’re raise the temperature of one
kilogram of water by 1 degree
getting 4180 Joules of potential energy. Technically speaking, a Calorie is a unit
Celsius; equal to 4184 Joules
of heat measurement. (If you speak Spanish — or know your ancient Latin —
you’ll know the term calor, or heat.)
There are small calories (cal) and large Calories (Cal or kcal). calorie (small calorie): Amount
of energy required to raise the
• Small calories represent the amount of heat required to raise the temperature temperature of one gram of water
of one gram of water by 1 degree Celsius. by 1 degree Celsius; equal to
4.184 Joules
• Large Calories represent the amount of heat required to raise the temperature kcal: Used to express food
of one kilogram of water by 1 degree Celsius. energy, represents a Calorie

114 | Unit 4
In other words, one large Calorie (kcal) equals 1000 calories (cals).
This can seem a little confusing at first. However, just think of it this way:
• Small calories are smaller and use a lower case c.
• Large Calories are 1000 times larger and, appropriately, use an upper case C.
We have to be careful to refer to our Calories correctly. When it comes to food

Calories, we usually mean large C or kilocalories (kcals). So, when we tell our
friends that we ate a 500 “calorie” lunch, we actually ate 500 Calories or kcals. In
this textbook, we’ll generally use the layperson term most often used to describe
food energy (for instance, on food labels), which is “calories.” Just remember that
most of the time, this less-precise use of “calories” actually means kilocalories.
Why use units of heat (calories or Calories) to measure the potential energy in
food versus units of work (Joules)?
Well, scientists measure the energy content of food by combusting the food
bomb calorimeter: A rigid (i.e., burning it) in what’s called a bomb calorimeter. This device is sort of like
vessel used for measuring heat of a little kid’s Easy Bake oven toy.
combustion
Food goes into the chamber, which is sealed. Electrical energy ignites the
food. As the food burns, it heats up the surrounding air in the chamber, which
expands and escapes through a copper tube. As the air escapes, it also heats
up the water outside the tube. Observers can then calculate the food’s calorie /
Calorie content by measuring the change in the water’s temperature.
Here, the amount of energy in the food determines how hot the water can get. So
in this case, it makes sense to describe food energy in terms of heat units.
Energy differs by nutrient type

Different macronutrients and substances make different amounts of heat. Here
are some examples of the energy released from particular molecules in a bomb
calorimeter.
1 gram of fat = 9.44 kcal

1 gram of starch = 4.18 kcal
1 gram of sucrose = 3.94 kcal
1 gram of glucose = 3.94 kcal
1 gram of protein = 5.65 kcal
1 gram of alcohol = 7.09 kcal
Perhaps you’ve heard that fat contains 9 kcal per gram, carbohydrates 4 kcal per
gram, protein 4 kcal per gram, and alcohol 7 kcal per gram.
Are these just rounding errors?No, not really.
This seems like a contradiction only because the numbers you’ve heard are actual
physiological values (in other words, how the substance behaves in the body) while
the numbers above are those obtained outside the body (in a bomb calorimeter).

The mystery of the microbiome
Decades ago, most people probably never thought that body composition. Scientists have turned fat mice into
the medicine of the future would involve swapping lean mice and vice versa by swapping their intestinal
poop around. microbes (though this is unlikely to be as effective in
humans).
However, now that we have learned how important
the microbiome is for our GI and overall health, fecal And in early 2015, news agencies reported that a
transplants (which transfer, well, poop from one per- woman became obese, rapidly gaining over 40 lb (18
son’s colon to another person’s colon) have become a kg), after a fecal transplant from her daughter, who also
low-tech medical miracle for many formerly devastating rapidly became overweight herself.
illnesses such as Crohn’s disease or Clostridium difficile
“It is now our policy to use non-obese donors for fecal
bacterial infections.
microbiota transplantation,” concluded the woman’s
Fascinatingly, fecal transplants can actually change our doctors dryly.
What affects the energy we can get from food?

This brings up an important point: Humans are not Although we lose some of the potential energy in our
bomb calorimeters. As you’ve learned in previous chap- food through digestion and excretion, we still do a pretty
ters, there are many factors that can affect how food is good job of saving much of this potential energy for the
digested, absorbed, and used. Biological systems are not resynthesis of ATP. We use about 91% of the energy in
the same as simple machines. our food. That’s pretty efficient! (By comparison, the
efficiency of a car’s internal combustion engine — how
Even if we know exactly how many calories are going well it uses the gas to get you to your destination — is
into the body (which we usually don’t), it’s very hard to estimated to be around 12-30%.)
know exactly how many calories we will absorb and use.
This means that for the most part, precise calorie count- Factors affecting nutrients and energy
ing won’t help you or your clients. Here’s why. in food
Factors affecting digestion and As you can see, there are many things about our body
absorption, and use that can affect how much and how well we get energy
from our food. The food itself can also vary.
We lose some energy through the process of digestion.
So even if food contains a given amount of energy, we Although numbers on food labels may seem scientific,
will always lose at least a little bit of it. they’re just approximations. Most foods aren’t directly
measured in a lab. Imagine trying to combust a sample
The health and function of our GI tract — including that of every one of the 40,000 foods on grocery store shelves
of our intestinal bacteria — can affect how much energy as the food comes out of the ground, is removed from
we absorb and use. Some evidence suggests that the the animal, or is dispensed by the assembly line. It’s not
bacteria living in the guts of obese people are better at happening!
getting energy out of food than the bacteria living in the
guts of lean people. See sidebar below for more. Here are just a few of the factors that can change the
nutrient and energy content of foods:
We may also lose energy in excretion. For instance,
some of the potential energy stored in protein’s nitrogen Resistant starches / fibers
bonds can be lost through deamination (which we cov- These will be shown on labels as kcal and grams of car-
ered in the previous unit) and excretion. So some energy bohydrate. But we don’t get as much energy from them
remains trapped in the protein’s nitrogen bonds, and we as a bomb calorimeter does. So energy counts can be
urinate it out. overestimated here.

116 | Unit 4
Outdated data may be wildly different from reality — as much as 25%

Some data on foods can be out of date and inaccurate, more or less than what the package claims. Research also
throwing off energy and nutrient calculations on the shows that some frozen foods can contain 8% more cal-
label or in nutrient databases. ories than the package lists. And some restaurant meals
can have up to 18% more calories than they claim.
Imprecise analytical methods
An analysis is only as good as its testing method. And All of this means that, outside of a lab:
the way we currently test nutrients and energy doesn’t
• We can’t know exactly how many calories and nutri-
always provide reliable results, for many reasons beyond
ents we absorb, use, and / or excrete.
the scope of this text.
• We can’t know exactly how many calories and nutri-
Product variety ents are in our food.
Different batches of both natural and processed foods
vary in their exact contents. A single test at a single point • We can’t know exactly how many calories and nutri-
in time can’t accurately describe all batches. ents we expend through metabolism and movement.
Soil and growing conditions All this points to one thing: Calorie counting as a way
Plants are dynamic organisms. They differ depending on to manage diet and exercise is time consuming, difficult,
soil, climate, sunlight, latitude, and other factors. This and grossly inaccurate. We’ll talk about a better way to
will affect the nutrients and energy they contain. (Wine- balance energy intake later.
makers refer to this as terroir, the subtly varying and
characteristic flavor or composition of a wine depending The body’s need for energy
on the very specific location where its grapes are grown.)
As we’ve discussed previously, the total amount of energy
Ripeness at time of harvest
required for each of our physiological actions is referred
Ever had a fresh-picked tomato at the end of the sum-
to as metabolism. We can group these into five general
mer? Completely different than a tomato you bought at
categories:
the supermarket in mid-winter, right? Produce picked
fresh, at its seasonal peak, will have a much different 1. Basal metabolic rate (BMR)
nutrient makeup than produce picked out of season 2. Resting metabolic rate (RMR)
and / or unripe. And some foods, such as wheat, can be
harvested at different times of the year, which changes 3. Thermic effect of feeding (TEF)
the nutrient composition. 4. Exercise activity
Animals’ diets 5. Non-exercise activity thermogenesis (NEAT)

The nutrients / energy found in milk, meat, and eggs
vary based on what animals eat and how they live. Let’s look at each one in turn now.
Length of storage 1. Basal metabolic rate (BMR)

There’s a big difference in nutrient count between
produce harvested this morning and produce harvested Imagine you’re asleep and haven’t had a meal in a while.
three weeks ago in a different time zone. You’re breathing. Your heart is beating. Your cells are
doing the bare minimum to keep you alive. But you’re
Preparation / method and cooking time not digesting, moving, or doing much else. That’s your
Eating raw produce is different than eating cooked basal metabolic rate, or BMR.
produce. The amount of cooking and processing affects
the amount of energy and the nutrients we are able to The BMR is the minimum level of energy we need to use
get from the food. In fact, cooking usually makes more to maintain vital functions of the body. To accurately
energy available to us. measure a person’s BMR, scientists make them fast (so
there’s no digestive activity) and then lie motionless in
All of these factors combined mean that the energy and an environmental chamber.
nutrients listed on food labels or in nutrient databases

Since oxygen consumption is related to energy production, scientists then mea-

sure BMR by figuring out how much oxygen that person consumes per minute.
This can be done in a laboratory setting using what’s called a metabolic cart.
What’s especially interesting is that BMR accounts for over 70% of the oxygen
(and energy) we consume each day! That’s right, 70% of the energy we expend goes
toward non-movement related physiological activity. Keeping us alive is hard work!
2. Resting metabolic rate (RMR)

Like BMR, RMR is measured during rest. However, it’s easier to figure out RMR,
since measuring BMR requires extreme conditions (e.g., fasting, extended bed
rest, tight environmental control).
RMR is measured in a similar way as the BMR, using measures of oxygen

consumption. Although RMR is slightly higher than BMR, it’s usually no more
than a 10% difference. Small amounts of movement, different environments, and
digestion will affect RMR.
3. Thermic effect of feeding (TEF)

Digestion, absorption and assimilation of ingested food / nutrients is an active
process — it takes energy. The very act of eating food increases the metabolism.
How much our metabolic activity goes up depends on which macronutrients we

eat. We often speak of this in terms of thermic effect, which comes from the an-
cient Greek therme, or heat, and which also gives us the term “thermogenesis”, thermogenesis: The process of
or the production of heat. heat production in the body
Proteins tend to have the highest thermic response, as it takes the body more en-
ergy to process them, while fats tend to have the lowest thermic response. (You’ll
know this if you’ve ever had the dreaded “meat sweats.”)
TEF is usually around 10% of total daily energy expended. It can be affected by
other factors, such as insulin resistance, which lowers TEF.
4. Exercise activity (EA)

The energy used to perform purposeful exercise (like going for a run, or doing a
gym workout) is typically called EA. Of course, this component of daily energy
expenditure varies widely from person to person.
• For sedentary folks, this component of metabolism can make up 10-15% (or
less) of their daily energy demand.
• However, for highly physically active folks, it can be 30% or more.
As you may already know, higher-intensity exercise activity not only creates a
demand for energy transfer during the actual activity; it also creates a higher
demand after the activity. This increase in excess post-exercise oxygen consump-
tion (also known as EPOC) helps to make up for the energy deficit created during
the activity itself. It also increases daily energy expenditure / metabolism.

118 | Unit 4
Total daily energy expenditure for sedentary

and physically active individuals
Physical activity - 30%

Physical activity - 15%
Other factors Other factors

(Cold, effect of food intake) - 10% (Cold, effect of food intake) - 10%
Energy expended
Basal metabolic rate - 75% Basal metabolic rate - 60%
Sedentary person Physically active person

(Low physical activity)
Figure 4.1 Total daily energy expenditure (or metabolic rate) breakdown
5. Non-exercise activity thermogenesis But it’s an important part of weight loss or gain. And it
(NEAT) can vary a lot between people. See sidebar below.
Non-exercise activity thermogenesis (NEAT) is another Total daily energy expenditure (TDEE)
part of metabolic rate. This is all the daily-life movement
that isn’t deliberate exercise, such as: Together, these metabolic and movement activities make
up our total daily energy expenditure (TDEE).
• moving around our homes or workplaces;
Since RMR = BMR + metabolic maintenance activity
• fidgeting and pacing, wiggling or tapping our feet;
and physical activity = EA + NEAT, we can represent
• housework or yard work; TDEE like this:
• playing with our kids or pets; RMR + physical activity + TEF = TDEE.
• carrying groceries; and See Figure 4.1 for how these vary in sedentary and physi-
cally active individuals.
For most folks who don’t have physically active jobs,
NEAT contributes the least to daily energy expenditure.

Eating more but not gaining weight? Well, that’s NEAT.
While it’s true that our weight depends on energy in humans and animals gain weight pretty well and keep it
versus energy out (aka energy balance), it’s not always a on, many don’t.
straightforward mathematical equation.
Instead of storing that extra energy in fat tissue, many
Our body has all kinds of tricks to maintain homeostasis, people’s bodies expend it as heat and movement.
or a dynamic equilibrium. When over-fed, many people just get warmer and move
around more, instead of getting fatter.
Have you ever wondered why some people seem to be
able to eat more but not gain weight? (And why there’s Some people are able to burn off nearly 700 extra calo-
always That Guy who runs in shorts in the winter?) ries per day from NEAT, while others hardly burn off any!
The answer may lie in NEAT. Many people also naturally compensate later on: If over-
fed one day, they’ll eat less the next day, without even
Humans and other animals can regulate their body-
thinking about it.
weight and eating behavior in many ways, which we
look at throughout this textbook. One interesting fea- Somehow, their appetite and hunger regulation systems
ture of this dynamic balance is that over the long term, know exactly how much they should be taking in and
the body often tries to stay or get back to its preferred expending through NEAT to maintain homeostasis.
weight.
So if you have that family member or friend who seems
Most of us know this happens on crash diets. People to stay “naturally lean”, look at how they move and
eat a lot less. They lose weight. And then they gain it all whether they wear a coat on cold days.
back. We saw this in one of our earlier case studies.
Or perhaps you are that “naturally lean” person who al-
But did you know that this can also happen when peo- ways wondered why you “eat a lot” but don’t gain much
ple try to gain weight? mass. Now you know: You’re a human furnace (that,
and the arcuate nucleus region of your hypothalamus is
Scientists have tried to make humans and other animals
simply better at maintaining homeostasis than most).
fat by overfeeding them. Interestingly, while some
Estimating energy needs and energy intake

In this section, we’ll get into some equations. If math oxidative phosphorylation. Thus, knowing how much
isn’t your thing, don’t get freaked out: We won’t ask you oxygen we consume can help us estimate energy cost
to remember exact numbers (without help from your and metabolism.
open textbook). The exact numbers are not the point.
What matters is that you understand the relationship Energy transfer will differ slightly depending on whether
between things, such as: we are oxidizing fat or carbohydrate.
• oxygen consumption goes up as energy demands go • About 4.7 kcal of energy are transferred when 1 liter
up; of oxygen is consumed in the oxidation of fat.
• there are many ways to measure energy balance; and • About 5 kcal are transferred when 1 liter of oxygen is
consumed in the oxidation of carbohydrate.
• bodies will differ in their energy needs depending on
factors such as genetics, bodyweight, age, and sex. But remember, we never really burn just fat or just car-
bohydrate for energy. We’re always using a mix. Thus:
Oxygen and energy balance On average, about 4.82 kcal of energy are transferred
when 1 liter of oxygen is consumed in the oxidation of
You may remember from the previous unit that we need
this mixed fuel.
oxygen for the electron transport chain activities of

120 | Unit 4
To put this into perspective, at rest we typically consume about 3.5 milliliters of
oxygen per kilogram of bodyweight per minute.
Let’s look at a sample person who’s 154 lb (70 kg).
At rest, they’d consume:

3.5 mL of oxygen x 70 kilograms of bodyweight x 60 minutes =
about 14,700 mL or 14.7 liters of oxygen per hour
14.7 liters x 24 hours = 352 liters of oxygen a day
4.82 kcal x 352 liters of oxygen = 1700 Calories a day
Add exercise and our 154 lb person would breathe harder and faster, consuming
more oxygen. As more oxygen is consumed, more kcal are burned, increasing
total Calorie cost and total metabolic rate.
Again, the exact numbers don’t matter. The most important thing to understand
here is that oxygen consumption and energy demand are directly linked.
As we need and use more oxygen, we need and use more energy.
Measuring metabolic rate

Indirect calorimetry
In the laboratory, the main measurement technique used to quantify metabolic
indirect calorimetry: rate is known as indirect calorimetry.
Estimation of energy expenditure
via the measurement of oxygen When using this technique, researchers give a test subject a mouthpiece (attached
consumption and carbon dioxide to a computerized measurement device) and a nose clip. As all air exchange
production
happens through the mouth in this set-up, the computer can then measure how
much oxygen is consumed and how much carbon dioxide is produced during a
given activity.
This air sampling is recorded, providing direct, real-time measurements of

oxygen consumption. Based on these measures, testers can determine the energy
cost of whatever activity is being measured, whether it’s lying on a bed or run-
ning on a treadmill.
Respiratory quotient
Here’s an interesting side note. You may have wondered: How can someone know
exactly what mix of fuel types they’re using?
During indirect calorimetry, testers can estimate the fuel mixture using the
respiratory quotient (RQ): respiratory quotient (RQ). The RQ is calculated by dividing the number of car-
Ratio of the volume of carbon bon dioxide molecules produced by the number of oxygen molecules consumed
dioxide expired to the volume
during the activity.
of oxygen consumed in a given
period of time, indicative of the RQ = VCO2 produced / VO2 consumed
substrates being used

Volume (in l/g) CO2 Respiratory energy equivalent

Substance RQ
0 2 consumption production
O2 CO2
Protein 0.94 0.75 4.46 5.57 0.80
Carbohydrate 0.81 0.81 5.05 5.05 1.00
Fat 1.96 1.39 4.74 6.67 0.71
Alcohol 1.46 0.98 4.86 7.25 0.67
Figure 4.2 Respiratory quotients (RQ) for the major macronutrient categories
For instance:
• The RQ for glucose is 1.0. (6 CO2 molecules are produced as 6 O2 molecules are
consumed during the oxidation of glucose.)
• The RQ for fat is 0.7. (16 CO2 molecules are produced as 23 O2 molecules are
consumed during the oxidation of fat.)
• Since proteins are broken down into individual amino acids and the nitrogen
groups are removed, the RQ for protein is about 0.8.
See Figure 4.2.
Direct calorimetry
Another measurement strategy used for this purpose is called direct direct calorimetry: Direct
calorimetry. measurement of heat output by
the body; used as an index of
energy expenditure
With direct calorimetry, energy expenditure is recorded by measuring the rate at
which heat is produced by the body. This method is more precise as it puts sub-
jects in an air-tight chamber that carefully measures all the heat lost and gained.
However, this method requires large, expensive environmental chambers that

few research laboratories can afford.
Predictive equations
Both indirect and direct calorimetry measure oxygen consumption and energy
expenditure accurately. But they’re not very practical for everyday use.
Instead, we can use predictive equations to estimate how much energy the body
uses. These are based on a number of factors such as sex, age, height, and weight.
They’re less accurate than calorimetric methods, but they can give us some rea-
sonable estimates of normal energy expenditures for particular types of people.

122 | Unit 4
Table 4.1 Sample RMR values from various equations

Harris-Benedict Owen Mifflin-St. Jeor
Male, 80 kg, 66.5 + (13.75 x 80) 879 + (10.2 x 80) (10 x 80) + (6.25 x 178)
178 cm tall, + (5.0 x 178) – (5 x 45) + 5
45 years old – (6.76 x 45)
RMR 1,752.3 1,695 1,692.5

Female, 54 kg, 655 + (9.56 x 54) 795 + (7.2 x 54) (10 x 54) + (6.25 x 160)
160 cm tall, + (1.85 x 160) – (5 x 19) – 161
19 years old – (4.68 x 19)
RMR 1,378 1,183.8 1,284
Here are a few examples of commonly used equations:
Harris-Benedict equation for RMR Owen equation for RMR

For men For men
RMR (in kcal / day) = RMR (in kcal / day) =
66.5 + (13.75 x weight in kilograms) + 879 + 10.2 (weight in kilograms)
(5.0 x height in centimeters) - (6.76 x age in years)
For women
For women
RMR (in kcal / day) =
RMR (in kcal / day) = 795 + 7.2 (weight in kilograms)
655 + (9.56 x weight in kilograms) +
Mifflin-St. Jeor equation for RMR
(1.85 x height in centimeters) - (4.68 x age in years)
Note: You can adjust the Harris-Benedict equation if For men
you want to lose weight. This will give you a formula RMR (in kcal / day) = 10 (weight in kilograms) +
for the RMR of your desired weight. Use the following 6.25 (height in centimeters) - 5 (age in years) + 5
formula, plugging the adjusted weight (in kg) into the
formulas above. For women
Adjusted weight (in kg) = RMR (in kcal / day) = 10 (weight in kilograms) +
[(actual bodyweight in kg - ideal weight in kg) x 6.25 (height in centimeters) - 5 (age in years) - 161
0.25] + ideal wt in kg Table 4.1 shows an example of the RMR values that two
So, for instance, if you are a 6’2” (188 cm), 40-year-old, hypothetical people might achieve with each equation.
250 lb (113.4 kg) man and want to get to 200 lb (90.7 kg): Welcome to the wonderful world of variations.
(Actual bodyweight of 113.4 kg -
ideal weight of 90.7 kg) x 0.25 = 5.68
You may wonder why age and biological sex are so
important. On average, younger people have more lean
5.68 + ideal weight of 90.7 kg =
mass than older people, and men have more lean mass
96.4 as adjusted weight
than women. Lean mass costs energy to maintain, and
Then you would use the men’s formula and keep your so it’s a major factor in RMR.
age the same, but put in 96.4 kg as your ideal weight.
Thus: Yet even when we match subjects based on their lean
mass, age, and sex, they can still vary quite a lot from
RMR = 66.5 + (13.75 x 96.4) +
one another (up to 30% difference).
(5.0 x 188) - (6.76 x 40)
RMR = 66.5 + 1325.5 + 940 - 270.4 Restrictive dieting and chronic physical stress can also
RMR = 2062 kcal per day lower RMR significantly (usually 5-10%, up to 15%).
Many dieters, for instance, report being cold. Persistent

Go on a diet By far, the most commonly used predictive equation is

(restrict energy intake)
the Harris-Benedict equation, which was developed in
1919. However, as you can see in Table 4.2, the Mifflin-St.
Jeor equation predicted metabolic rate better (when com-
Weight re-gain Lower energy intake
pared with calorimetry) than the other equations.
(often heavier than before) reduces metabolic activity
No equation is perfect. Even the best equations only get

within about 10% of the actual RMR value measured in
Despite more energy coming in,
a lab.
Body tries to restore
metabolism may not go back up energy balance with
to previous baseline; RMR stays increased appetite Therefore, if a predictive equation approximates your
lower than before dieting
RMR at 1700 kcal / day, consider yourself lucky if your
RMR is actually anywhere between 1530-1870 kcal / day.
Dieter “falls off the wagon”
(or simply stops dieting
once goal is achieved) and If you’re obese, or just someone for whom the equation
increases food intake
doesn’t really work, this number could be off by as much
as 43%!
Figure 4.3 The diet-overeat-repeat cycle
So unless you live in a research lab and can measure both
dieters may find that their thyroid function or sex your intake and expenditure with tightly controlled labo-
hormone production goes down, or that they become ratory observation, trying to count calories and measure
constipated as their GI tract slows its pace. them against expended calories is a losing battle. Food la-
bels and energy expenditure equations are just estimates,
If you have a client who presents with signs of a low- and not very good ones at that. Although they get you
ered metabolic rate, ask about their history of dieting. in the right ballpark, following the numbers as if they’re
See Figure 4.3. true and accurate can lead to immense frustration.
Table 4.2 Accuracy of RMR equations versus actual measurement

Equation Nonobese, 20-82 y, Obese, 20-82 y, BMI >30 Older adults, 60-82 y,
BMI = 18.5-29.9 nonobese and obese
Mifflin-St. Jeor 82% of estimates are 70% of estimates are accurate Accuracy within 10% not available
accurate Error range: Underestimation by Error range: Underestimation by 18% to
Error range: Underestima- 20% to overestimation by 15% overestimation by 5% in men
tion by 18% to overesti- Underestimation by 31% to overestimation
mation by 15% by 7% in women
Harris-Benedict 45-81% of estimates are 38-64% of estimates are accurate Accuracy within 10% not available
Actual bodyweight accurate Error range: Underestimation by Error range: Underestimation by 19% to
Error range: Underestima- 35% to overestimation by 43% overestimation by 9% in men
tion by 23% to overesti- Underestimation by 27% to overestimation
mation by 42% by 12% in women
Harris-Benedict N/A 26% of estimates are accurate Individual prediction accuracy using ABW is
Adjusted bodyweight Error range: Underestimation by not reported for older adults
42% to overestimation by 25%
Owen 73% of estimates are 51% of estimates are accurate Accuracy within 10% not available
accurate Error range: Underestimation by Error range: There is no error range for men
Error range: Underestima- 37% to overestimation by 15% In white women, maximal underestimation
tion by 24% to overesti- by 27% to overestimation by 12%
mation by 28%
Table adapted from: Frankenfield D, Roth-Yousey L, Compher C. Comparison of predictive equations for resting metabolic rate in healthy nonobese and obese
adults: a systematic review. J Am Diet Assoc 2005;105:775-789

124 | Unit 4
What does your daily energy expenditure involve?
Take a minute to think about all of the various factors starting to infect you. You’ve got a slight fever.
that might affect your energy expenditure each day.
Sitting, you notice your belly is hanging over your waist-
Let’s walk through a sample day of a hypothetical you. line a little bit. You think about aging and your own
mortality for a few minutes.
You wake up early because your child is sick. You run
around the house trying to clean up after your child, Okay, end of work and you need to chill out. One more
transfer him to your caregiver, and get ready for work. call to the caregiver while you walk to yoga. Your child
seems better, so you relax a little bit.
No time for breakfast. You chug a cup of caffeinated
coffee instead. Yoga is relaxed and meditative. No fancy poses or grunt-
ing today.
You get in the shower. Darn it! No hot water left! You
take a cold shower. After yoga (one more call to the caregiver — child is
happy, healthy, and playing with action figures) you go
You get dressed (having to fling some clothes out of the
out for dinner. You treat yourself to white pasta, dessert,
dryer to find your pants) and run out the door. The bus
and two glasses of wine.
is on its way. You sprint to catch it while carrying your
heavy briefcase. You arrive home, tuck your little one into bed, and relax.
You tuck yourself into bed, where you enjoy a deep
It’s mid-summer and the bus doesn’t have air condition-
sleep and surge of growth hormone release.
ing. You’re sweating like crazy.
Of course, this is just a random combination of events
You hop off the bus and scurry to work. The escalator is
for one made-up person.
packed with people standing, so you rush up the stairs
instead. Think about how each one of those variables might
influence energy expenditure. Then think of the vast
At work, you eat a bowl of lentils and steak for lunch
numbers of combinations that take place each day in all
while thinking about your looming deadline. Your heart
of our lives.
rate goes up just thinking about all the PowerPoints and
TPS reports you have to do. Plus you’re fretting about You could probably never capture all of those variables
your child. for each unique person with a simple mathematical
equation that predicts energy expenditure.
Late in the afternoon, you think maybe your kid’s virus is
Energy balance and imbalance

As we’ve seen, energy balance affects bodyweight.
• If we take in more energy than we use or excrete, we gain weight.
• If we take in less energy than we use or excrete, we lose weight.
In either case, when the input and output sides of the energy balance equation
energy imbalance: When the don’t match, we say there is an energy imbalance.
amount of energy intake doesn’t
meet, or exceeds, the amount of Energy balance and imbalance don’t just affect bodyweight. They can affect every
energy output
physiological function right down to our cells’ function.
Energy balance: Simple, and not simple

In one sense, losing or gaining weight seems simple. You just take in less or more
energy than you expend. So you change what you eat and you change how much
exercise you do.
But there are many other factors at work. (As several frustrated dieters trying

to lose weight or skinny folks trying to put on muscle bones and lean muscles to body fat. For this to happen,
have found.) the body needs a signal to store nutrients in this lean
tissue.
Among others, these factors include:
Signals for lean mass building can include things like:
• our individual environments;
• puberty
• our genetics and epigenetic expression;
• exercise
• our hormones;
• pregnancy
• what we can digest and absorb; and / or
• anabolic hormones such as testosterone (either what
• physiological and psychological stressors.
we produce, or what we supplement)
All of these can work together in subtle (or obvious) • some nutritional supplements
ways to affect how much you eat, how much you move,
and how much energy your body uses for metabolism • other anabolic drugs
and movement.
Yet even if we have the right signals, our body can only
This doesn’t mean the energy-in versus energy-out build lean mass so fast. So if we eat much more than our
equation doesn’t hold. Bodies can’t break laws of ther- body can keep up with, we’ll still gain fat along with that
modynamics. (Even though sometimes it might feel that
way.) We just don’t always know all the pieces of input
or output.
As a Certified Nutrition Specialist, your job will often

involve hunting for the mystery input or output that is
affecting your clients’ results.
Gaining weight
When we take in more energy than we put out, we have
to store that energy somewhere.
As we’ve seen: Glycogen Other

Water
• The main storage form of carbohydrate is glycogen Phosphorous 42 kg Mg, Cl,
Fe, Zn, Cu
(stored primarily in the muscle and liver). Calcium
Potassium
• The main storage form of fat is triglyceride (stored
primarily in the muscle and adipose tissue, and some- Sodium
times the liver).
• Protein doesn’t quite get stored in the same way as

Fat 12 kg Protein 12 kg
carbohydrate or fat. But you can still think of the
body’s amino acid pools and protein sources as a
“reserve” of protein.
Everything, no matter what it is, has to go somewhere.

More energy in than out means we gain mass.
We can either gain that mass as fat (with triglyceride

storage) or lean mass (with carbohydrate storage and
muscle gain, along with things like proteins in bone
and connective tissues).
Of course, most of us would prefer having strong, dense Figure 4.4 Body composition of a normal-weight male

126 | Unit 4
Liver glycogen level
An evening
snack
Lunch
Breakfast
Dinner
8:00 12:00 16:00 20:00 24:00 4:00 8:00
Time
Figure 4.5 Typical daily variation in liver glycogen concentrations
valuable lean tissue. (This is why the “seefood diet” — Exercise and energy balance
eating everything in sight — isn’t a great plan even for
clients who really need to put on some muscle.) We can’t control many of the factors that make up our
basal metabolic rate, and hence about 70% of our daily
Losing weight energy demand. For instance, we can’t do much about
how old we are.
When we take in less energy than we put out, we lose
weight. But we can change how much and how intensely we
exercise. Different types of exercise have different effects
As you now know, about 70% of our daily energy goes on how we use energy.
towards simply keeping us alive. Even if we don’t exer-
cise, we’re still always using energy. Of course, if we add • High-intensity, short-duration activity burns a
exercise, we increase energy output. We also send our modest amount of energy during the activity. How-
body signals about how to use nutrients (i.e., for energy ever, after the activity, total energy expenditure can
regeneration, or to preserve lean mass). Thus, exercise is stay up for hours (depending on the activity type and
an important part of a weight loss plan. intensity).
As you’ve already learned, glycogenin the liver (which • Low-intensity, long-duration activity burns
fluctuates throughout the day, as shown in Figure 4.5) more energy during the activity (since the person is
and muscle is broken down to glucose, which can in exercising for such a long time). However, after the
turn, regenerate ATP (see Figure 4.5). Our triglycerides activity, total energy expenditure returns quickly to
in muscle and adipose tissue are broken down into fatty the resting baseline.
acids and glycerol.
Both forms of exercise can help us control energy
If energy intake is low enough, or our carbohydrate and balance.
fat stores are in short supply, our body will turn to pro-
tein from our muscles and other structures (such as bone High-intensity, short-duration activity
or internal organs). We definitely don’t want this, which
is why proper nutrition + resistance training is essential Here, we might find things like CrossFit, short track
for healthy and sustainable weight loss. cycling or downhill mountain biking, speed skating or
hockey, strength sports, or sprinting.

During these types of activity, our body prefers to use carbohydrates for energy.
This happens for a few reasons:
• As we learned in previous chapters, the ATP-PCr system and the anaerobic gly-
colytic system run much quicker than the oxidative phosphorylation system.
• Muscle glycogen isn’t fully depleted during short-duration activity. Thus, we

often have enough glycogen on hand for energy transfer early in our training
session.
• We use mainly fast-twitch muscle fibers in high-intensity activity. These fast-twitch muscle fibers:
fibers use glycolysis as a main energy transfer pathway. Muscle fibers, characterized
by fewer mitochondria and
capillaries, which contract quickly
These activities tend to create an “afterburn effect.” We still use more fuel after and with relatively more force, yet
they’re done — often for several hours afterwards. fatigue more quickly than slow-
twitch muscle fibers; includes
Yet while we use mostly carbohydrates during these activities, after these activi- three subgroups
ties, we use mostly fats.
Low-intensity, long-duration activity

Here, we find endurance activities such as hiking, long-distance running or cy-
cling, cross-country skiing, leisurely swimming, or even plain old walking.
During these types of activity, our body prefers to use fat for energy. This
happens for a few reasons:
• Lower-intensity energy demands can easily be met by the Krebs cycle and
electron transport chain.
• This type of activity involves mostly slow-twitch muscle fibers, which use
slower pathways. Thus more fat can be used to meet energy demands through
ß-oxidation.
• As low-intensity activity stretches out over time and muscle glycogen becomes
depleted, our body will use more of the available muscle triglycerides and
plasma free fatty acids released during the activity.
See Figures 4.6, 4.7, and 4.8.
Choosing the right activity

This difference in fuel type has led to debates about which type of exercise is
“best” for losing weight and body fat.
As a Certified Nutrition Specialist, the most important consideration is what

your client actually enjoys and will do consistently. Don’t get too bogged down in
finding the “perfect” form of exercise, and don’t assume that one method will fit
everyone’s body or lifestyle.
But if you have the freedom to plan your clients’ exercise programs (and you
know that those exercise programs are right for those clients), consider a few
things.
First, the fuel used during any activity is just a percentage of the total, not all the
possible energy someone could expend.

100
Figure 4.6 2 - 5% 2 - 5% 2% 5 - 10%
How macronutrients 90
are used at different Protein
exercise intensities 80 35%
40%
Glucose + Glycogen
70
% of contribution
60 Fats
75%
50 95%
40
30 60% 55%
20
10
15%
3%
0
Rest Light to moderate High-intensity High-intensity
exercise sprint-type endurance
exercise exercise
Figure 4.7 100

Percentage of energy
derived from the 90 Muscle triglycerides
four major substrates
during exercise 80
% of Energy expenditure
70 Plasma free fatty acids

60
50
40
30 Blood glucose
20
Muscle glycogen
10
0 1 2 3 4
Exercise time (hours)
100
Substrate as percentage of oxygen uptake
Figure 4.8 Muscle glycogen

Energy substrate
contribution during 75 Plasma free
endurance exercise fatty acids
50
25 Blood glucose
0
0 100 200 300
Minutes
So, let’s say a client expends 200 calories during a very short, high-intensity
exercise session. During that session, 80% of the fuel may come from carbo-
hydrates. But your client has still expended only 200 calories.
Conversely, let’s say your client goes on a long hike with a backpack. During
that session, 80% of their fuel may come from fat. But they’re hiking for 3
hours, so they expend around 1500 calories.
Second, look at all the time your client realistically and consistently has available.
They may have, for instance, 45 minutes available, 4 times a week, no matter
what. Any activity of any type has to go in that slot. In that case, you might
prioritize higher-intensity activity so that your client spends those 4 x 45 minutes
doing the highest-demand exercises possible.
Third, look at what your client can do and manage. Higher-intensity work is hard
on the body. Most people can’t recover from doing “beast mode” high-intensity
work every day. One client’s “all-out sprint” may be racing Usain Bolt. Another
client’s sprinting may be a fast walk or a jog uphill.
All of this simply means that for most people, a mix of high- and low-intensity
exercise, and a range of activities, is probably the best choice. Clients are most
likely to recover well, enjoy what they’re doing, and (most importantly!) stick
to the plan when they have this kind of variety.
One more note on training and energy use: Different bodies respond differently
to exercise.
• A highly trained body will be very efficient at exercising. For instance, a long-
time runner will have a well-developed circulatory system with lots of vascu- vascularization: The
larization. They’ll have plenty of the enzymes they need to transfer energy. development of vessels in a tissue
Their mitochondria will be well-oiled machines. And their heart will pump
more blood with every beat.
• An exercise beginner’s body, or the body of someone switching sport types,

will be very inefficient. They’ll huff and puff with the slightest effort. Even
simple movements will seem hard.
Contrary to what you might think, we don’t always want to be efficient at

exercise.
• If we’re trying to be the best in the world at a certain sport, then efficiency is
good. We want our body to use less energy to do more stuff.
• If we’re trying to lose weight, we want the body to work harder and use more
energy. We want our energy output to go up as the body struggles to do things.
Again, if you’re in charge of helping clients with their exercise, you’ll probably
want a variety of efficient and inefficient. Clients need to be challenged, but they
also want to see progress. Nobody wants to feel inefficient all the time!

130 | Unit 4
Nutrition and energy balance What matters is the amount of energy expended versus
the amount of energy consumed over time, not the pre-
As we’ve seen, nutrition can affect your energy balance cise fuel burned during a workout or training session.
and total daily energy expenditure (TDEE) in import-
ant ways. Energy balance and body functions
Overall energy intake Along with weight gain and loss, energy balance affects
other processes in our bodies, such as reproduction,
If energy intake is too low for too long (or if output is cognitive functions, metabolic functions, and repair
too high for too long, which is less common but can and regeneration.
happen), the body will slow down important metabolic
functions to preserve what energy is left. Reproductive functions
This will also usually slow down people’s exercise activ- Low energy intake
ity and NEAT. Athletic performance will get worse, and
people will feel sluggish. Reproduction and fertility take energy. The body moni-
tors energy balance carefully to decide whether it’s safe
Thermic effect of food to make a baby.
As we’ve seen, protein is costly to process, and thus in- This is especially true for women, whose bodies are ex-
creases the thermic effect of food, or TEF. A higher-pro- tremely sensitive to changes in energy. But men can also
tein diet will thus raise TDEE. be affected, as many male athletes, particularly those in
physique or weight-cutting sports, have found out.
Nutrition and macronutrient use When energy intake is low (and especially if energy
demands are high, such as for athletes), the body cuts
Nutrition can also affect what macronutrients we use down production of sex hormones such as testosterone
during exercise. and other androgens, estrogen, and progesterone.
If we eat a lot of carbohydrates around our exercise For women, this can mean irregular or lost menstrual
sessions, that’s what we’re more likely to use for energy cycles, hormone disruptions (such as higher levels of
regeneration. For clients doing long exercise sessions, androgens, or masculinizing hormones), pre-menopause
or clients trying to gain mass, taking in carbohydrates symptoms or even early menopause. See Figure 4.9.
during training can help keep their energy up, and the
body won’t have to turn to stored nutrients as much. For men, this can mean impotence and lowered energy.
Conversely, if we eat meals with lots of protein and fat, And for both sexes, this can mean infertility, loss of
our body is more likely to use fat during exercise. Higher interest in sex, and mood changes.
levels of the hormone glucagon, combined with lower
levels of blood carbohydrate and insulin, tell our body to Our body can’t tell the difference between real and po-
do this. tential starvation through self-imposed dietary restric-
tion or even just obsessing about food and dieting. It
But remember: The body is all about the big picture and shuts down either way, just to be safe.
long-term regulation.
High energy intake
Loading up on fat before training may not actually help
your client burn more body fat during training (espe-
Having too much energy coming in and not enough
cially since fat is so calorie-dense… and since few people
going out can also affect reproductive function.
want a big fatty meal in their stomachs during train-
ing). The body will usually just figure out other ways to Adipose tissue stores fat, but it also produces hormones.
manage energy balance over the course of that day, or Indeed, it’s one of the main sources of estrogen for wom-
the next few days. en as their ovaries shut down in later life.

Normal nutrition Under-nutrition Overweight / PCOS
Gonadotrophin
releasing hormone
(GnRH)
Brain Brain GnRH Brain GnRH
Pituitary
Gland
Leptin
(+ other metabolic signals) Leptin Leptin
Fat Fat Fat

cells cells cells
Insulin Insulin Insulin
LH LH
LH
FSH FSH
_ + _ + _ +
Pancreas Pancreas Pancreas
Insulin Insulin Insulin
Ovary Ovary Ovary
'Physiological'
hyperinsulinaemia
Testosterone (T) at puberty reduces T Hyperinsulinaemia
Estradiol (E2) SHBG and thus E2 T reduces SHBG levels
Progesterone (P) Puberty amplifies normal P Delayed P and thus amplifies
Menarche production of puberty Anovulation ovarian androgen
Sex steroids Ovulation sex steroids Sex steroids Amenorrhea Sex steroids Hirsutism production
Figure 4.9 Influence of nutritional status on sex hormone production in females
When we have a lot of body fat, we get a lot of hormone We also tend to get crabbier, lethargic, and / or anxious.
production — more than we need. When the adipose When energy is chronically low for a long time, we may
hormone factories get too active, they release eicosa- even get depressed, or have hair-trigger tempers.
noids, cytokines, and hormones (over 300 compounds
in total!) that disrupt the endocrine balance and cause Metabolic functions
reproductive problems.
Along with our brain, our other organs also cost a lot to
For instance, women with polycystic ovary syndrome maintain.
(PCOS) usually have insulin resistance and sex hor-
mones out of balance. For instance, every day:
• Our heart needs around 600 kcal per kg of heart
Obese men often convert too much testosterone to estro- weight.
gen, which can deposit fat onto their chests or even lead • Our kidneys need around 400 kcal / kg of kidney
to the growth of breast tissue (aka gynecomastia). weight.
• Our liver needs around 300 kcal / kg of liver weight.

Cognitive functions
The brain needs a lot of energy constantly, around 300 Compare this to the “metabolic superstar” skeletal
kcal / kg of brain weight every day. While it can use both muscle, which checks in at only 17 kcal per kg of muscle
glucose and ketone bodies to regenerate ATP, severe weight per day.
energy imbalances can slow down brain metabolism. See So, just keeping our insides healthy and functioning
Table 4.3. each day requires a basic level of kcal intake.
This means we get dumber when energy is low. We forget Our RMR adjusts itself to match energy intake. When
things. Our thinking is foggy. We find it hard to be cre- energy intake goes down for a while, RMR goes down
ative or have ideas. too. When energy intake goes up for a while, the opposite

132 | Unit 4
Table 4.3 Energy requirements of the human brain from birth to adulthood*
Bodyweight (kg) Brain weight (g) Brain’s energy Body’s energy Energy to brain
consumption consumption bodyweight (kg)
(kcal / day) (kcal / day) (% of whole body)
3.5 (newborn, term) 400 118 161 74
5.5 (4-6 months) 650 192 300 64
11 (1-2 years) 1045 311 590 53
19 (5-6 years) 1235 367 830 44
31 (10-11 years) 1350 400 1160 34
50 (14-15 years) 1360 403 1480 27
70 (adult) 1400 414 1800 23
* Modified from Holliday (1971)
happens: RMR goes up. (This adjustment up or down is You can still make people lose weight if their bodies are
the arcuate nucleus of the hypothalamus at work). gearing down… you just have to starve them. You can still
make people gain weight if their bodies are throwing off
This metabolic decline with low energy intake happens energy as heat and NEAT… you just have to stuff them.
for three reasons:
• Thyroid hormone output goes down. (And other Of course, we try to avoid starving or stuffing our clients.
important hormones that affect weight and body There are other, better, saner and more humane ways to
composition also change - leptin, testosterone, and change body composition or lose / gain weight. We’ll look
sympathetic nervous system output go down; corti- at those later.
sol goes up.)
• TEF goes down (because less food is being eaten). Repair and restoration
• We lose both total and lean mass (a smaller body
As we’ve seen, our body’s tissues are always being broken
burns less energy).
down and rebuilt or replenished. This is especially true if
This “gear up / gear down” mechanism helps prevent we damage them, as with exercise.
large fluctuations in weight status.
If active people don’t eat enough, they won’t recover and
It also makes controlling energy balance difficult when / or refuel properly. Conversely, if they eat enough to
people are strictly controlling their intake. When energy meet their energy demands, new and healthy tissues will
intake goes down for too long, the body simply “down- be created, and the fuel stores will be topped up, ready to
shifts” metabolism to adjust. Research suggests that the kick butt in the next bout of training.
largest decreases in RMR occur when diets reach about
1000-1200 kcal (or fewer) per day. Vitamins, minerals and energy
Likewise, when energy intake goes up, RMR goes up. balance
People trying to gain mass often struggle to eat enough
to put on weight. Vitamins and minerals don’t directly transfer energy in
the regeneration of ATP. However, they can play im-
Yet in both cases, the energy-in versus energy-out equa- portant roles as co-factors and / or co-enzymes in the
tion still applies. It’s just that the body has changed the energy transfer processes. This means we need them for
rules of the game. They aren’t static, mutually exclusive a healthy metabolism.
numbers — every time you take steps to affect energy
in, the body takes steps to adjust energy out according- When certain micronutrients are too low, this can
ly (though not perfectly, or it would be really hard to affect the energy producing processes of the body. For
change bodyweight).

Hungry! Stuffed!
165
>>
160 ain
tg
igh
— Weight —
Higher
Lower metabolism we
metabolism
155
145 s
os
h tl
weig
<< Just right.
140
Eat too little Ideal intake Eat too much
— Calories per day —
Figure 4.10 Resting metabolic rate scales with chronic energy intake
instance, iron deficiency can lower oxygen transport, while a deficit of vitamin
B3 (niacin) can limit NAD and NADH activity.
The main nutrients involved in energy transfer are biotin, riboflavin, niacin,
pantothenic acid, thiamin, pyridoxine, cobalamin, and choline.
In addition, some dietary minerals such as sodium and potassium can act as
electrolytes, which are important regulators of muscle contraction, fluid balance electrolyte: Compound that
and nerve impulses. As these functions are strongly related to energy expendi- when placed in solution becomes
an ion; regulates flow in and out
ture, these minerals are critical to energy balance as well.
of cells
When vitamins, minerals, and electrolytes are low, important metabolic func-
tions and energy production don’t occur.
Achieving energy balance… naturally

We may sometimes want to change our body. But our body doesn’t like to
change. It looks for dynamic balance, aka homeostasis.
As far as the body’s concerned, the ideal scenario would occur when energy
intake perfectly matches energy expenditure. In fact, one definition of homeosta-
sis is “unchanging” — although in the body’s case, several complex mechanisms
are in place, and many regulatory processes must occur, in order to keep things
the same. You can think of it like standing on a moving subway train: You must
always move slightly to keep standing still.
Yet many of these processes, which evolved over millions of years, aren’t always
well matched to the way we live now.
For instance, wild animals naturally match their food intake to their activity and
bodies’ needs. If they eat more, they move more. Or they eat less later on.
This works great in the wild. Not so great in the 21st century, where we have
abundant tasty and convenient food but fewer opportunities for daily movement.

134 | Unit 4
On top of that, we have other stressors and factors affect- highly processed foods that are engineered to be too
ing our appetite, hunger and fullness cues, such as stress good to put down. They overpower our normal satiation
or light exposure at night. mechanisms. And we over-eat.
In fact, we depend on movement and activity to help This problem of energy balance in the modern age
us regulate ourselves. When we stop moving, we stop is one reason it’s so important to help our clients eat
working well. When we get too sedentary, our energy whole, less-processed foods (along with getting regular
regulation mechanisms get out of whack. Since appetite movement and living a healthy lifestyle). These types of
can only drop so low, it often outpaces the sedentary foods work best with our physiology. Our body recog-
metabolism, making us gain weight. nizes them and knows what to do with them. And these
foods help us regulate our energy intake as well.
And our food culture today is made up of energy-dense,
Case study 1
Why can’t some people lose weight despite eating less? He wasn’t expending much energy. He slept about 12
hours per day. His only exercise was walking around the
After all, each of us knows an overweight or obese per-
hospital corridors pushing around an IV pole.
son that doesn’t “seem” to eat a lot of food. Maybe you
too struggle to get or stay lean despite a “healthy” diet. Still, according to calculations, his energy needs were
around 1800-2200 kcal a day. Many days he probably
One problem is that perception and memory are very
ate much less. He almost never ate more.
inaccurate. It’s very, very easy to under-report food and
energy intake. You would have expected him to lose weight quickly.
But that’s not what happened. Instead, during his treat-
That’s not because we’re all liars. It’s because we’re all
ments, he gained over 50 lb.
human. And it’s very hard to keep accurate food logs
and energy intake records (as research has shown us Indeed, most people think the typical cancer patient
over and over again). gets skinny during treatment. Nowadays, chemotherapy
drugs lead to something called “sarcopenic obesity.” In
Plus, as we’ve seen, even if we’re diligently reading
other words, cancer patients lose a lot of lean mass while
food labels, those food labels can be inaccurate. A few
easily gaining fat weight.
restaurant meals over the course of a week, with lots of
hidden calories, can easily add up, even if we’re doing According to most conventional metabolic assump-
our best to choose the “healthy” salad option. tions, you’d have to guess that this client “gained
fat without over-eating.” After all, his energy intake
Some of us are also invested in forgetting. Who wants to
(around 1000 kcal per day) was less than his estimated
remember the moment of grabbing an extra muffin at
energy expenditure (around 2000 kcal per day).
the morning meeting, or picking off the kids’ plates as
dinner is cleared? Not us, that’s for sure. Of course, you may have guessed the reasons why. The
calculations are based on average healthy people, not
But what if you truly do have a client who seems to be a
cancer patients on drugs.
medical mystery? Like our client who went through two
rounds of chemotherapy for lymphoma. In this case, it The chemo (plus, probably, his bed rest) changed the
seemed like he was breaking all the laws of nature by inputs and outputs of energy balance.
gaining weight.
The energy-in versus energy-out rule didn’t change.
As you probably know, chemotherapy makes you nau- Only the factors on each side of the equation did.
seated and vomit often. During his time in the hospital,
our client barely ate two small meals a day, usually just The bottom line: Weight gain or loss is always a function
an Ensure shake and a bowl of soup. And most of the of energy balance.
time he couldn’t even keep these small feedings down. Nobody’s body — not even a cancer patient’s — breaks
the laws of thermodynamics.

Case study 2
Lowering energy intake to lose weight seems logical. And Here are some possible explanations.
for many people, it can be as simple as that. But for ath-
• She ate more protein. Since she wasn’t eating
letes, who need more nutrients and energy overall, losing
much protein to begin with, more protein may
fat may require a little more fine-tuning.
have led to both a faster metabolic rate and an
One of our clients was an elite cross country ski athlete. increased protein turnover in the body.
At 5’6” (1.71 m), 165 lb (75 kg), and 23% body fat, she was • She ate more food energy. The severe energy
heavier than most elite participants in her sport who are, imbalance from training a lot but eating relatively
on average, closer to 135 lb (61 kg) and 12% body fat. She little may have depressed her metabolism. Maybe
needed to lose both bodyweight and body fat to become more food stimulated her metabolic rate. Or
more competitive. maybe it just let her train harder, which meant
she expended more calories during and after
Before coming to see us, she tried a higher-carbo-
training.
hydrate, energy-restricted diet. See September data
below for a summary of the nutritional prescription. • She changed the types of food she ate. She
started out eating lots of sugar and saturated fat,
She lost a combination of fat and lean mass, ending up
and ended up eating more whole foods, fiber,
at 160 lb (73 kg) and 22% body fat. Needless to say, a
slow-digesting carbohydrates, and protein. Plus
bit discouraging.
she balanced out her fat intake. This may have led
Then she came to see us for nutrition coaching. After to a hormonal environment that helped her lose
twelve weeks of following a modified set of recommen- fat.
dations (outlined below), she achieved the results in
It was likely a combination of all of these factors and
Table 4.4.
more.
Why did this happen? How did she lose 25 lb (11 kg) of
body mass while eating more?
Table 4.4 Comparison of 12-week results

September December Net result – 12 weeks
Height and weight 5'6" / 160 lb 5'6" / 135 lb 25 lb lost1
Body composition 125 lb lean, 35 lb fat 123 lb lean, 12 lb fat 23 lb fat lost 2, 2 lb lean mass lost 2
Body fat % 22% 9% 13% lost
Exercise expenditure ~1200 kcal / day ~1200 kcal / day Same
Energy intake ~2500 kcal / day ~4000 kcal / day +1500 kcal / day3
Macronutrient 15% protein 35% protein +20% protein
65% carb 40% carb -25% carb
20% fat 25% fat +5% fat
Notes:
1. This dramatic and rapid shift in body composition was achieved with a large increase in food intake – from 2500 kcal per day to 4000 kcal per day.
2. Body composition data was recorded via a calibrated-weigh scale and air-displacement plethysmography (Bod Pod). In addition, energy intake
data was collected and analyzed as weighed diet records, and expenditure data estimated based on ACSM MET values.
3. Note: not all clients will benefit from a similar increase in energy intake. Indeed, many clients are likely over-eating on a weekly basis, relative to
their activity levels, and this is putting them into a positive energy balance. So, rather than a prescription for all struggling clients, this case study
provides a simple example of when the concept of “eat less, exercise more” is insufficient.

136 | Unit 4
Summary
Energy balance is the relationship between energy we approximately with one of several equations. The equa-
take in from food, and the energy we use or excrete tions can have a wide margin of error.
through metabolism and activity. This relationship de-
termines our bodyweight as well as our overall health. When we take in more energy than we put out (or vice
versa), we have an energy imbalance. This will lead to
We measure energy intake, or the potential energy pres- changes in bodyweight. Other functions such as repro-
ent in our food, in Calories or kcals. duction, cognition, metabolism, and recovery can also
be affected. Eventually this can make us sick or injured,
The body’s energy needs include the amount of energy and we won’t perform well.
required for maintenance at rest; the amount of energy
required for physical activity and movement; and the The exercise we do and the food we eat affects our energy
amount of energy required for food digestion, absorp- balance and the fuel we use, determining whether we use
tion, and transport. more carbohydrates or fat for energy transfer.
We can estimate energy needs by measuring how much Micronutrients act as co-factors and / or co-enzymes to
oxygen we consume, either directly in the laboratory or help us get energy from food. We need to get enough of
them to properly regulate energy.

UNIT 5
Aerobic and Anaerobic Metabolism

138 | Unit 5
Unit Outline
1. How metabolism changes 6. Anaerobic versus aerobic exercise

2. How exercise affects metabolism 7. How we adapt to exercise
3. Muscle and metabolism 8. Case study
4. Energy demands of muscle 9. Summary
5. Oxygen consumption
Objectives
In this unit you’ll learn about how the human body re- We’ll explore the structure and function of skeletal muscle
sponds to the metabolic demands of exercise. Creating cel- tissue, and how energy is transferred within skeletal muscle
lular stress through exercise changes the body’s processes. during both aerobic and anaerobic exercise.
This can affect both energy balance and long-term health.
How metabolism changes

In the previous unit, you learned about metabolic differ- After 25, on average, people lose about 2-4% of their
ences. Many factors affect our metabolic function. But RMR every decade. Most of us don’t notice right away.
one thing is the same for all of us: We’re all getting older. We’re too busy finishing school, getting our first big jobs,
raising young families, or having other adventures.
If you’re younger than mid-20s, you’re probably enjoying
a revving metabolism. If you’re fit, strong, active and By around age 35, reality starts to set in. Even if we exer-
healthy, you have plenty of lean mass. Your fertility and cise faithfully and eat well, we notice changes. It’s harder
hormone production is likely at its peak. to lose fat, gain muscle, or get stronger. And we have to
be more careful about how we exercise.
If you’re older than 30, you may have started noticing a
few changes. If you started out with an RMR of 1500 kcal at age 25, by
35 it’ll be around 1400 kcal. By 55, it’ll be down around
Maybe your digestion is a little slower. 1200 kcal. And so on.
Maybe you can’t drink as much alcohol as you used to. We lose lean mass too. On average, people lose about 5
lb of lean mass per decade between the ages of 25 and 65.
Maybe some foods now upset your stomach.
So, in addition to dropping around 300 kcal of metabolic
Maybe you don’t recover from tough workouts quite as power by the age of 65, most folks also lose about 20 lb of
well as you did before. Or you need more warm-up time. lean mass.
Maybe your periods or fertility aren’t as reliable, if you’re Because lean tissue such as muscle and bone is so meta-
a woman. (And if you’re a man, you may have occasion- bolically active, this loss is probably directly responsible
ally noticed a little less mojo.) for much of the metabolic losses.
And hey… where did that extra little bit of squish This suggests that metabolic decline isn’t about chrono-
around your middle come from? logical age. Rather, it’s about “body age” and our lifestyle

Aerobic and Anaerobic Metabolism | 139
choices. What we think of as “normal” aging may, in

fact, result from inactivity and poor nutrition.
Bad news: We can’t turn the clock back. Good news: We

can control, to some degree, our biological aging pro-
cess. If we focus on smart nutrition and preserving that
Metabolism
valuable muscle, we’ll age well and healthily.
How exercise affects

metabolism
0 1 2 3 4 5
We are meant to move. Movement makes our bodies and
brains work better. Time (days)
For instance, after surgery, nurses get us up and moving

Figure 5.1 Change in metabolism after intense resistance
as soon as possible. The more we sit at desks, the more training
we risk chronic disease. Emotions are really just strong
movement cues (for instance, to move towards a loved
one or away from a threat). The more we move, the better begins to contract their muscles during exercise. Let’s
we think, learn and remember. review that quickly now.
Movement is the engine of health, wellness, and a long Imagine yourself bursting into a sprint, running as fast
vibrant life. as possible. Here’s what happens in your body.
Why? The secret lies in movement’s metabolic effects, 1. Within 3 seconds, muscle cells use up most of their
particularly the effects of exercise. available ATP.
Whether it’s skateboarding, canoeing, or trampolining, 2. You need more ATP to keep running. The ATP-PCr
purposeful exercise of any kind contracts the skeletal system then kicks in. This lasts for about 10 seconds.
muscles over and over. Our lungs work harder and our Because ATP regeneration takes time, you start to
heart beats faster. Our brain needs fuel for the ev- slow down a bit.
er-changing motor and cognitive demands of movement,
such as balance, body positioning, muscular coordina- 3. As you keep running, and you deplete your ATP-PCr
tion, and decision making. stores, the glycolytic system starts providing most of
the energy transfer for ATP regeneration. This lasts
Muscles use energy when they contract. The more for about 90 -120 seconds or so, depending on the
intense the exercise, the more energy used with every intensity. As the glycolytic system generates ATP
passing minute. more slowly than the ATP-PCr system, you have to
slow down a bit more.
For example, a Tour de France cycling pace burns four
times as much energy per minute as a leisurely cycle on 4. If you keep running, the oxidative phosphorylation
a beach cruiser bike. Likewise, sprinting at a 100 m dash system will then provide most of the energy transfer
pace, or up a hill, burns more kcals per minute than run- for ATP regeneration. Because the oxidative systems
ning at a slow, shuffling jog. are slower than the anaerobic systems, you’ll have
to slow down again. In fact, if you slow your pace
As we discussed in the previous unit, high-intensity ac- enough, you can keep running (or walking) for quite
tivity not only demands more energy while we’re doing a long time.
it, but also afterwards, when the body needs more energy
for recovery and repair. Figure 5.1 shows how metabolic Now, let’s consider another scenario.
activity can go up after intense physical exercise.
What if you blast into a sprint… but only run for about
In Unit 3, we looked at what happens when a person 30 meters? Then, you slow down, stop, and stroll back.

140 | Unit 5
a quick jogging pace or a few sets of squats is an easy

ATP Store warm-up.
% of maximum rate of energy production
ATP-PCr System
• For a couch potato or older person, a moderate jog, a
Lactic Acid System
few jumping jacks, or even a brisk walk may count as
Overall Performance
high intensity at first.
Aerobic System
So what counts as “high intensity” varies from person to

person because our body must adapt to the demands of
exercise.
In a moment, we’ll look more closely at what actually

happens when muscles do their work. But think gener-
ally now about what might happen in your body during
high-intensity exercise… and what the metabolic effects
could be.
2 sec Th 10 sec Th 1 min 2 hrs
• We damage our muscles a little bit, which means we
Time Th = Threshold Point have to repair them later.
• We ask our cells to produce more energy.
Figure 5.2 Contribution of each energy system to total en- • We challenge our body’s defenses and immunity.
ergy use during prolonged exercise
• We must circulate more oxygen and nutrients around
our body.
You wait 5 minutes. Then burst into another 30-meter • We put stress on our skeleton and connective tissues.
sprint. Stop. Wait. Repeat.
• We might even have more brain activity as our motor
What happens in this case? As you might guess, the gly- cortex and senses are called on to process a lot of
colytic and oxidative phosphorylation systems won’t play incoming signals.
such big roles. Waiting between short sprints lets your
ATP-PCr system quickly replenish the available ATP so You can imagine what the body might need to do to
you can blast off again. deal with these demands, as well as to repair and re-
cover itself afterwards. And, as we’ll see, nutrition is an
Would the metabolic effects of these two different types essential part of these processes.
of exercise be different? Yes.
Because of these different fuel pathways, different exer- Muscle and metabolism
cise intensities and types affect our physiology differ-
ently. This is especially true when it comes to preserving Did you know that the stronger your grip, the healthier
muscle and metabolism with age. Intense exercise seems you’ll probably be as you age? Yep. The hand-grip test,
to prevent muscle loss and preserve our RMR most which tests how well you can crush a handshake, is one
effectively. Lower-intensity activity — while nevertheless of the best indicators of longevity and robust aging.
important — doesn’t seem to do this much at all.
Does this mean you should run out and start tearing
You might wonder what qualifies as “high-intensity exer- phone books? Or take up arm wrestling?
cise.” We’d say you’ll know it when you do it. Anything
Well, those are fun hobbies. But the relationship between
that gets your heart pounding, sucks your oxygen, gets
your grip strength and your senior citizen shenanigans
your whole body working, and maybe even lights your
doesn’t mean that a hearty grip causes healthy aging.
muscles on fire a little is high-intensity exercise.
It means that if your grip is strong, you’re probably
High intensity is relative.
strong. If you’re strong, you probably have lots of lean
• For a top middle-distance runner or CrossFit athlete, body mass, strong connective tissues, a good dense

Epimysium
Tendon
Perimysium
Fascicle
e
Bon
Muscle Fiber Myofibril
Thin
Troponin
(actin)
Tropomyosin filament
Sarcomere
Z-disk
Myosin head Actin
Thick
(myocin) Myosin/actin
filament cross bridge
Figure 5.3 Skeletal muscle structure
skeleton, and the motor control to recruit all these things. If all that stuff is work-
ing well, the rest of your systems are probably working well too.
Interestingly, the hand-grip test is a better predictor of healthy aging than your
cardiovascular function (VO2 max), your flexibility, and your balance — al-
though, of course, you want all that other stuff working well too.
To understand why this is, and why muscle is so essential to a healthy metabo-
lism, you need to understand muscle structure and function.
Muscle structure and function

Skeletal muscles contain long, slender fibers, known as muscle cells, that are myofibrils: One of the threadlike
components of a muscle fiber
bundled together. These bundles merge with tendons that are in turn attached to
bone. When a muscle contracts (or gets smaller), its tendon ends (or attachments) myosin: Thick fibrous muscle
protein that can split ATP and bind
pull on the bones, and the bones move. with actin
Muscle cells are formed from smaller bundles of myofibrils. These consist of actin: Thin fibrous muscle protein
thick and thin filaments called myosin and actin. When muscles contract, actin that is necessary for cell shape and
can bind to myosin
and myosin form cross-bridges that slide across each other, pulling the ends
of the muscle together. (You might say they “interact to contract.”) Myosin and cross-bridges: Formed when
the head of myosin temporarily
actin are thus known as contractile proteins. attaches to actin
Sarcomeres are made of strands of actin and myosin attached to natural breaks sarcomeres: Repeating structural
in the muscle, called Z-discs. If you look at muscle under a microscope, you’ll see units of striated muscle fibers
that it looks striated. That characteristic appearance comes from the Z-discs. See Z-discs: Region of the sarcomere
Figure 5.3. into which actin is inserted

142 | Unit 5
When called upon to contract, the actin and myo- Sarcoplasmic reticulum
sin are pulled together, shortening the space between
the Z-discs. ATP is needed for the ongoing cycle of The sarcoplasmic reticulum is the network of tubules
actin-myosin binding and release during muscle and sacs in the muscle cell, similar to the endoplasmic
contraction. reticulum. It uses a significant amount of ATP during
exercise. And it contains calcium that when released
Most cells have only one nucleus. Skeletal muscle cells
allows for muscle contraction.
can have several nuclei, just under the muscle cell mem-
brane. Like nuclei in other cells of the body, muscle cell
nuclei control protein synthesis in the muscle. Myofibrils
Muscle organelles Myofibrils are the bundles of very fine fibers made up of
actin and myosin.
In Unit 1, you learned about cell organelles. Muscles
have many of the same organelles as other cells, along
Sarcomere
with some specialized ones, including:
A sarcomere is the segment of a myofibril between two
Sarcolemma successive Z-discs.
This is the plasma membrane of a muscle fiber.

T-tubules (transverse tubules)
Sarcoplasm These tubes extend into the sarcoplasm. Imagine some-
thing like deep divots on the surface of the sarcolemma,
This is the cytoplasm of the muscle cell, which contains which plunge down and cut into the sarcoplasm.
nuclei and mitochondria.
T-tubules let nerve impulses travel along the sarcolem-
Since muscle cells need a lot of energy, they have a lot of ma, deep inside the cell, to tell the muscles to fire and
sarcoplasmic mitochondria. contract.
Figure 5.4 Microanatomy of skeletal muscle

Muscle fiber types

Humans have three general types of muscle fibers:
1. slow-twitch (or type I);
2. fast-twitch A (or type IIA); and
3. fast-twitch B (or type IIB).
These three fiber types differ in:

• how fast they contract;
• how well they resist fatigue;
• their fiber diameter;
• their capillary and mitochondrial density; and
• their myoglobin content. myoglobin: Oxygen-carrying

and storage protein of muscle.
Slow-twitch fibers are dark, while fast-twitch fibers are lighter. This signals that Similar to hemoglobin
each has a unique makeup of contractile proteins, muscle cell organelles, and
myoglobin.
(You can think of light or dark meat in chicken or turkey. Breast meat is lighter
than leg meat, because these birds walk instead of fly.)
Next, let’s look at how this applies to different types of exercise.
Energy demands of muscle

In the previous unit, you learned about how we can measure the energy that our
body uses. Metabolic testing, which measures how much oxygen we consume metabolic testing: Tests that
during a given activity, can tell us about how much exercise “costs.” measure metabolic functions
(e.g., digestion and energy
production)
The more intense the exercise, and the more muscles we use, the more oxygen we
take in. And the more oxygen we take in, the more energy we use.
Let’s say you’re lying in bed, sleeping.
At that moment, you consume about 3.5 mL of oxygen per kilogram per minute.
You weigh 70 kg (154 lb). So, you’ll be taking in 70 x 3.5 mL, or about 245 mL, of
oxygen per minute.
That formula of 3.5 mL / kg / minute is equivalent to 1 MET (short for metabolic MET: Oxygen cost of energy
equivalent). 1 MET represents 1 unit of metabolic rate, or the amount of oxygen expenditure measured at rest,
equal to 3.5 mL of oxygen per
consumed during 1 minute of rest. When you’re sleeping, you’re using 1 MET. kilogram of bodyweight per
minute
Then, let’s say you wake up, get out of bed, and decide to walk briskly to the cof-
fee shop for a morning brew.
Your brisk walk requires five times the amount of oxygen you used while sleep-
ing — 5 x 245 mL, or 1.225 L. Now you’re using 5 METs.
Before you can get to the coffee shop, you hear barking and growling. Your

144 | Unit 5
Table 5.1 Metabolic equivalents (METs) of Oxygen consumption

selected daily activities Muscle activity generally matches how much oxygen you
Daily Activity METs consume.
Sexual intercourse with established partner But when you start moving, there’s a bit of a lag. Your
Lower range (normal) 2-3 oxygen consumption doesn’t immediately match your
new level of muscle energy demands. Your muscles will
Lower range orgasm 3-4
need more oxygen than you’re taking in. This is known
Upper range (vigorous activity) 5-6 as oxygen deficit.
Lifting and carrying objects (9-20 kg) 4-5 During this time, your movement will be powered by
anaerobic energy transfer from the ATP-PCr and the
Walking 1.6 km (1 mile) on the level in 20 glycolytic systems. Thus, even if you’re just going for a
3-4
minutes
slow stroll that would normally use the oxidative phos-
Golf 4-5 phorylation system, that walk will be fueled by anaerobic
Gardening (digging) 3-5 energy production at first.
Do-it-yourself, wallpapering, etc. 4-5
Imagine a new company — a startup. It doesn’t have
Light housework, e.g., ironing, polishing 2-4 money to run its business at first, so it borrows cash to
get going.
Heavy housework, e.g., making beds, scrub-
3-6
bing floors, cleaning windows • If the startup is relatively small and doesn’t have a lot
of overhead costs, it won’t need much money. It won’t
Each 1 MET is achieved at rest and is equivalent to 3.5
mL of oxygen consumption per kg of bodyweight per have a lot of debt. And soon it can stand on its own.
minute. To determine energy expenditure per hour of • If the startup has big dreams and needs a lot of ma-
exercise, multiply MET values by bodyweight in kg.
chinery, and if it wants to expand quickly, it’ll need
more money. It’ll have a lot of debt before it breaks
neighbor’s angry, crazy guard dog has snapped its leash even. And it’ll take a while to pay down that debt.
and is coming right for you. You break into an all-out
The same idea applies here.
survival sprint, running the few final meters uphill to
the coffee shop, where you dive inside and slam the door • If you’re going to continue to do low-intensity work,
against Cujo. you don’t need to borrow much energy from the oth-
er energy systems to get started. Your oxygen deficit
That uphill sprint to safety, fueled by primal fear, put you will be small.
at 10 METs, a near-maximal effort. Now you’re sucking
in 2.45 L of oxygen per minute. • If you’re going for broke with a high-rep squat set, a
round of Ultimate Fighting, or skating like heck for the
You can use METs to estimate how much energy you use last few crucial moments of a hockey game, you’re
during exercise. By multiplying the MET intensity by going to incur a lot of energy and oxygen debt.
bodyweight in kilograms, you can easily calculate your
energy expenditure per hour of activity. The higher the intensity, the greater the deficit.
For example, if you’re 70 kg and cycling at 10 METs Eventually, once you slow down or find a steady pace
(which is very high-intensity activity), you’d be expend- you can do for a long time, your oxygen consumption
ing about 700 kcal per hour (10 METs x 70 kg). will catch up. But you still owe oxygen. Once you stop
exercising, you still keep consuming oxygen to pay that
Now of course, different people will take in differ- debt back.
ent amounts of oxygen, and have different metabolic
demands. METs are just one way to estimate energy This period of increased oxygen consumption and
expenditure.

3.0
2.7
O2
Oxygen Consumption
2.4
deficit
2.1
1.8
1.5
1.2
0.9 oxygen deficit: Difference
O2
0.6 between oxygen uptake of the
Resting oxygen uptake debt
0.3 body during early exercise and
during a similar duration of steady
0 state exercise
0 1 2 3 4 5 6 7 8
Time (minutes)
Figure 5.5 Oxygen deficit and debt with exercise
250
ax
225 2 m
VO
200
0%
175 10 ax
2m
VO
150 %
90
EPOC (ml/kg)
125 x
VO 2ma
100 80%
75
50 70% VO2max
60% VO2max
25
0
5 10 15 20 25 30 35 40 45 50 55 60
Time (minutes)
Figure 5.6 Relative EPOC after exercise of different intensities and durations
energy demand has been called the period of “oxygen debt” or EPOC (excess oxygen debt: Extra oxygen
post-exercise oxygen consumption). It can last for a few minutes, or even a few required above basal needs after a
period of intense exercise
hours. (If someone is training REALLY intensely, EPOC can last from several
hours up to two days!) EPOC: Increased rate of oxygen
uptake following strenuous
To see how it might look when charted on a graph, check out Figures 5.5 and 5.6. activity
Our body needs to repay the oxygen debt for three important jobs:
• metabolizing additional nutrients;
• replenishing the energy stores that have been used up; and
• reloading the depleted oxygen stores in the muscle and blood.

146 | Unit 5
Anaerobic Aerobic
16%
29% 34%
71% 57% 43%
48% 66% 84%
200m run 400m run 800m run 1500m run
Figure 5.7 Comparison of aerobic and anaerobic energy contribution to total energy expenditure across track events
In addition to these recovery-type activities, the follow- However, in practical terms, most clients do best with
ing also contribute to EPOC: a mix of higher- and lower-intensity exercise. As lower
intensity exercise can help facilitate recovery from high-
• a higher body temperature after exercise
er-intensity exercise, while still expending energy and
• harder working heart and respiratory muscles maintaining fitness.
• more metabolism-boosting hormones
• converting energy transfer products such as lactate Anaerobic versus aerobic

into other things exercise
• more protein synthesis
In Unit 3, you learned about the three main energy
• helping stressed and damaged muscles recover systems:
The more intense the exercise, the bigger and longer-last- 1. The ATP-PCr system
ing the EPOC values. Check out the figure below for
more detail. 2. The glycolytic pathway
Thus: 3. The oxidative phosphorylative pathway
• When exercise intensity is higher, we consume more You may also remember that all systems are well-coor-
oxygen and use more energy for each minute of dinated and work together. During exercise, all three
exercise we do. We also use more oxygen and energy systems are activated. How active they are, and how
afterwards. And we stimulate muscle mass to grow. much ATP they contribute, defines activities as either
anaerobic (without oxygen) or aerobic (with oxygen).
• When exercise intensity is lower, we take in less oxy-
gen and use less energy for the same amount of time. The first two systems, the ATP-PCr and glycolytic
There is a small oxygen debt afterwards, and this gets systems, are anaerobic systems. They supply most of the
smaller and smaller with training adaptations. And ATP that we need during high-intensity exercise. Oxygen
we don’t really stimulate muscle mass to grow (unless uptake and oxidative metabolism simply can’t keep up.
we’re very deconditioned).

indicates end of test

25
400m track race,
Blood lactate concentration (mmol/L)
excellent performance (50s)
20
400m track race,
average performance (60s)
15
10
10K race
5
fast running
easy running
0
0 5 10 15 20 25 30
Time (minutes)
Figure 5.8 Lactate accumulation during runs of different intensities and durations
The third system, the oxidative system, as its name implies, is an aerobic system.
It uses oxygen.
Figure 5.7 shows how much anaerobic versus aerobic systems contribute to ener-
gy expenditure for varying track and field events.
You may recall that as exercise intensity increases and the glycolytic energy
system is working full force, mitochondria can’t keep up with the amount of
pyruvate being produced. This leads to the conversion of pyruvate to lactate (ie.
about 10-90 seconds into high intensity exercise) and significantly increased
levels of H+ (hydrogen ions) that spill into the bloodstream. When we’ve reached
this level of exercise intensity, the body can’t keep up for long and it’s referred to
as the anaerobic threshold (AT). anaerobic threshold: The point
above which the muscles derive
If we lower our intensity below the AT, we can exercise more or less indefinitely. their energy from non-oxygenic
This is due to the aerobic pathway of ATP supply and our ability to efficiently use rather than oxygenic sources
during exercise
lactate as an energy substrate, keeping H+ levels low. However if we stay about
the AT (perhaps through Herculean willpower, or running from that angry dog),
exercise will be so anaerobic that we’ll only be able to do it for a short while lon-
ger. The body just can’t keep up.
Figure 5.8 shows how lactate accumulation (a market of hydrogen ion build
up) occurs during runs of different intensities and durations.

148 | Unit 5
Can we buffer lactate?
If chemistry is your thing, you may be wondering why bonate solutions do seem to improve performance in
we don’t somehow buffer lactic acid and hydrogen ions various medium-duration events, such as rowing, swim-
with something alkaline. In fact, our body has natural ming, or middle-distance running.
buffering systems, including:
Unfortunately, baking soda also leads to lots of unpleas-
• sodium bicarbonate ant gastrointestinal side effects such as diarrhea. Which,
• phosphate as far as we know, does not improve athletic perfor-
• carnosine in muscle tissue mance.
You might recognize sodium bicarbonate as household ß-alanine and carnosine supplements may be more
baking soda. Indeed, many athletes have tried eating promising and less intestinally explosive. So far, it seems
baking soda as a way to avoid lactate and hydrogen ion that ß-alanine may provide minor performance im-
buildup. And in some cases, it worked. Sodium bicar- provement during higher-intensity exercises.
How we adapt to exercise

Our body is always adapting and adjusting — to the food For instance:
we eat, to what’s around us, to ever-changing physiologi-
• Our muscles store more ATP and PCr.
cal processes, and of course, to exercise and movement.
• Our muscles store more glycogen (intramuscular
Fundamentally, our body tries to adapt to exercise storage).
by making us stronger and better at it. This includes
breaking down and removing damaged tissues, building • We improve the activity of ATP-PCr system enzymes
new structures, and improving cell function so that we (such as creatine kinase and myokinase).
become more effective and efficient. • We improve the activity of glycolytic system en-
zymes (such as glycogen phosphorylase and
Exercise is a stressor — normally a good one, but a
phosphofructokinase).
stressor nonetheless. The higher the intensity of exercise,
the greater the stress. This is one key reason we should These adaptations help us use fuel more effectively the
balance high- with low-intensity exercise, and why we next time we do anaerobic exercise.
need to support athletic training or other high-intensity
exercise with enough energy from a nutrient-rich diet. Anaerobic exercise, particularly short-duration, high-in-
tensity strength and / or power training, also makes
Muscular adaptation muscles bigger. This is known as muscle hypertrophy.
You’ve learned about muscle fiber types. Our body Muscle fibers can increase their size. And we can make
prefers to activate different fiber types depending on the more contractile proteins (actin and myosin), which
type of exercise we are doing. make muscles stronger. This is known as myofibrillar
hypertrophy.
Anaerobic exercise
We can also increase fluid and fuel storage in the muscle
During anaerobic exercise, type IIA (aka fast oxidative cells. This is known as sarcoplasmic hypertrophy.
glycolytic) and type IIB (aka fast glycolytic) muscle fibers
Five other factors can contribute to muscle hypertrophy.
are still recruited, but contribute very little), as they con-
tract more quickly. Over time, this will lead to particular • We can make more, and bigger mitochondria.
metabolic adaptations as the body repairs and rebuilds • We can make more myoglobin.
damaged muscle tissue.

• We can improve our muscles’ intracellular storage capacity.
• We can store more intracellular glycogen.
• Increasing cytosol volume (this is another way creatine works, by increasing

intra-myofiber volume).
While exercise provides the stimulus for all of this to happen, we need the raw
materials to rebuild structures and replenish fuel. So if we don’t get enough en-
ergy, enough protein for building blocks, enough carbohydrates for glycogen, or
enough micronutrients to help the process, we can’t recover and get stronger.
Aerobic exercise
During aerobic exercise, oxidative type I (aka oxidative) and type IIA muscle
fibers do most of the work. Though they contract more slowly and with less force,
they can last longer.
As with type II fibers, activity in type I fibers will lead to particular metabolic
adaptations.
• We improve oxidative (or mitochondrial) enzyme activity. muscle hypertrophy: Increase
in the size of muscle cells
• We store more fuel such as intramuscular glycogen and triglycerides.
myofibrillar hypertrophy:
These adaptations help us do better the next time we do aerobic exercise. Enlargement of a muscle fiber as it
gains myofibrils
Aerobic exercise, of course, depends on oxygen. So adapting to aerobic training sarcoplasmic hypertrophy:
involves supporting oxygen transport and delivery in these fibers. Increase in the volume of the
sarcoplasmic fluid in the muscle
For example, in response to regular aerobic exercise: cell with no concurrent increase in
strength
• We make more red blood cells, which carry oxygen bound to their hemoglo-
hemoglobin: Oxygen-carrying
bin. More red blood cells means more oxygen transport. and storage protein in blood
• We make more and bigger blood vessels through increased capillarization capillarization: Development of
(i.e., developing more capillaries per unit of muscle). This helps deliver oxygen a capillary network
and fuel to muscle cells, remove CO2 and waste products, and transfer heat
away from the muscle.
• We make more myoglobin, another protein that can bind and carry oxygen.
While more capillarization gives us more oxygen transport, more myoglobin
means more muscle oxygen uptake.
• We make more and bigger mitochondria, which let us put that oxygen to work
through the Krebs cycle and electron transport chain.
Structural adaptation
It’s not just our muscles that need to recover. Our bones and connective tissues
also need to get stronger.
Movement and mechanical loading are essential stimuli for our skeleton and
joints. Receptors in bone and connective tissues (such as ligaments, tendons, and
joint cartilage) respond to changes in position and force being placed on them,
sending cell signals to increase protein turnover.

150 | Unit 5
Hormonal adaptation elevated cortisol from training or other stressors can

also suppress sex hormone production.
Our hormones, too, need to adapt to exercise.
But temporarily elevated cortisol, when balanced with
Catecholamines lowered cortisol from low-intensity or other relaxing and
recovery activities, is good. It gives us a healthy stressor
that stimulates repair and regeneration, without over-
As we saw in previous units, high-intensity exercise can
whelming our ability to rebuild.
stimulate catecholamines such as epinephrine (adrena-
line) and norepinephrine (noradrenaline).
Anabolic hormones
This can change fuel use as well as post-exercise appetite
(although how each person’s appetite and hunger signals Exercise can change the levels of anabolic hormones,
respond to exercise will vary). which tell our body to build things up.
Catabolic hormones Two of the major anabolic hormones are testosterone

and growth hormone. Both of these hormones increase
protein synthesis and stimulate the growth and rebuild-
Exercise can change the levels of catabolic hormones, which
ing of lean mass.
tell our body to break things down.
Growth hormone increases blood glucose and free fatty
One of the major catabolic hormones is cortisol. Cortisol
acids, and promotes gluconeogenesis in the liver.
is a steroid hormone (which you may remember is made
from cholesterol, like our sex hormones) and one of the Though women have some testosterone, men have much
major regulators of our blood sugar. more. This is why, on average, men have more muscle
and denser bones than women.
In its breaking-down role, cortisol helps break down stored
macronutrients for energy. It temporarily suppresses the High-intensity exercise stimulates anabolic hormone
immune system as well as rebuilding of bone and connec- production. As always, there is a “sweet spot.” The right
tive tissues. And it affects our electrolyte balance, making amount of resistance training or sprinting will prompt
us retain sodium but excrete potassium and water. us to release anabolic hormones. Too much, too intense-
ly, too often, will suppress them.
Cortisol release depends on how intense the exercise is.
• High-intensity exercise raises cortisol during and Growth hormone, interestingly, is considered a stress
afterwards. hormone. So it will be released with exercise (a good
stressor), fasting (potentially good or bad, depending),
• Low-intensity exercise, such as gentle walking or and low blood sugar.
yoga, tends to lower cortisol.
Anabolic hormones go down with age, which makes it
Changes in cortisol can affect our immune system and harder to rebuild and repair as we get older.
how we use fuel for energy.
Sleep also improves the secretion of anabolic hormones
Too much cortisol too often (i.e., with lots of high-inten- — just one more reason recovery is so important.
sity training) is a problem. Eventually we stop recov-
ering. And our body keeps getting the signal to break
Insulin
down stored fuel for energy, which can keep our blood
sugar constantly high. Thus, chronically high cortisol
can also change where body fat is deposited. (An easy Insulin is an anabolic hormone, but it deserves its own
tip-off is body fat on the upper back.) You may see clients listing.
with disrupted cortisol from chronic stress. We often think of insulin as a hormone related to
Since our body may prefer to use cholesterol to make glucose. But like other anabolic hormones, insulin also
cortisol rather than our sex hormones, chronically helps stimulate protein synthesis, prevent protein break-
down, and promote a positive nitrogen balance (in other

words, excreting less nitrogen than we’re using, which The bigger picture
means we’re using protein effectively).
There are many good reasons to exercise. Our metabolic
Our insulin is most available and effective when we’re and structural adaptations to both anaerobic and aerobic
well fed and have enough energy. For most people, activities can make us stronger, fitter, and healthier, as
ensuring carbohydrates around workout times helps well as give us a better quality of life for longer.
insulin do its job.
High-intensity (anaerobic) and low-intensity (aerobic)
Other factors exercise can have different metabolic effects. These are
important to understand if you are programming exer-
Protein synthesis and exercise adaptation are also affect-
cise for your clients, as well as if you are thinking about
ed by:
how to support this exercise with a nutrition plan.
• the amount of mRNA in cells;
As you develop your practice, always keep the bigger
• ribosomal number; picture in mind. Think of the body as a dynamic, ev-
• ribosomal activity; er-changing system. Nothing happens in isolation, and
we rarely do just one type of activity. The metabolic and
• amino acid availability;
structural effects of one kind of training can influence
• other hormones and cell signals; and the other.
• our native genetic code and epigenetic state. Both regular anaerobic and aerobic exercise, as well as
daily-life activity and movement, can have other effects.
When we’re young, protein synthesis and exercise adapta-
tions happen quickly. We can easily recover from a tough For instance, both types of exercise can help you:
workout in a couple of days, or perhaps even train twice
daily. When we’re older, these processes slow down. • Calm the sympathetic nervous system, lowering the
perceived stress of exercise over time. This means
Figure 5.9 shows how combining proper nutrition with that if you want the same amount of adaptation, you
a proper physical activity stimulus can lead to healthy have to increase the workload.
adaptations.
Systemic Hours
Essential amino acids and energy Storage
+ Full adaptation without amino

acid or energy restrictions
Local Day
Mechanical or energetic stress Adaptive potential
Figure 5.9 How exercise stress and nutritional inputs influence human adaptation

152 | Unit 5
Aerobic Resistance
exercise Variable exercise
Glucose metabolism:
Glucose tolerance
Insulin sensitivity
Serum lipids:
HDL cholesterol increased values
LDL cholesterol
decreased values
Blood pressure in rest: unchanged values
Systolic
Diastolic or small effect
or intermediate effect
Body composition:
% of fat or large effect
Fat free body mass
Basal metabolism
Muscular strength
Aerobic capacity:
VO2max
Time of maximal or submaximal aerobic exercise
Figure 5.10 Typical changes with exercise
• Improve insulin sensitivity. With regular activity and We need energy not only to do exercise itself, but for two
muscular contraction, insulin works as it should, thus jobs after exercise:
nutrients go where they should: into the cells for use
• paying back the oxygen debt; and
and storage.
• repairing and rebuilding.
• Get fatty acids out of storage, transport them, and
use them effectively for energy. Thus, when thinking about how exercise relates to TDEE,
make sure to consider the big picture.
• Utilize / tolerate lactate better. You get more blood
flow to the liver plus better uptake of lactate by other Each activity type will have its own unique profile of ad-
organs and skeletal muscles to be used as an energy aptation. The more often and consistently you exercise,
substrate and keep hydrogen ion levels low. the faster you’ll adapt.
See Figure 5.10 for more. Most adaptations begin within days of beginning a new
exercise routine. However, some adaptations continue
Interestingly, even the process of recovering and adapt-
indefinitely. For example, Krebs cycle enzymes keep in-
ing to our exercise training demands is metabolically
creasing even after two years of intense aerobic training,
costly. Breaking down and building up proteins takes
while the cross-sectional area of muscle fibers continual-
energy. Protein turnover accounts for between 10 and
ly fluctuate.
25% of resting energy expenditure.
And of course, we must use it or lose it. Each of these ad-
aptations depends on constant protein turnover. So each
depends on regular activity for a stimulus, and good
nutrition for the raw materials.

Case study
It should be clear by now that exercise has wide-ranging We then changed his nutrition plan.
effects in our body.
We asked him to drink a protein-carbohydrate drink
Both anaerobic and aerobic activities can help us get (with added creatine) during each training session.
stronger, fitter and healthier by stimulating metabol-
The carbohydrates would help fuel his high-intensity
ic and structural adaptations. They can also help us
glycolytic efforts.
prevent the metabolic decline of aging and improve our
quality of life. The protein would help promote muscle protein syn-
thesis, helping him build muscle mass and strength,
Yet training and nutrition are somewhat energy sys-
improve his enzyme quality, and a host of other positive
tem-specific. In other words:
exercise adaptations.
If an athlete does an anaerobic sport, their training and
The creatine would help build up his muscle Cr stores to
nutrition should support the particular demands of the
support ATP-PCr system energy transfer.
ATP-PCr and glycolytic pathways.
With this new regime, this athlete consumed 15 g
If an athlete does an aerobic sport, their training and
protein, 30 g carbohydrate, and 1 g creatine per hour of
nutrition should support the particular demands of the
exercise. Thus:
oxidative pathways.
If his training lasted an hour, he consumed 15 g of pro-
(Of course, if athletes do both, then you support both.)
tein, 30 g of carbs, and 1 g of creatine.
Here’s an example that illustrates this important princi-
If his training lasted two hours, he consumed 30 g of
ple.
protein, 60 g of carbs, and 2 g of creatine.
Lacrosse, like hockey or soccer, involves brief bursts of
And so on.
fast movement (such as running down the field) as well
as power (such as checking and throwing). While there’s We also added another meal to his daily menu. This
a component of aerobic endurance to it, it’s mostly an well-balanced meal gave him more energy and more
anaerobic sport. important nutrients.
A 17-year-old lacrosse athlete came to us complaining During tournaments and multiple event weekends, he
of early fatigue. His energy levels would fade midway kept a cooler well stocked with between / after game
through games and his performance would drop off foods and drinks to ensure recovery and energy for the
fairly dramatically. next event.
We reviewed what he was doing. It became clear that he We tracked his results carefully and saw big improve-
was training like an endurance athlete, and eating like ments right away. Within one month:
an average person. Even though his growing male body
plus his athletic training demanded more energy and The athlete gained lean mass and lost body fat.
high-quality nutrition, he wasn’t getting it. He couldn’t He had lots of day-to-day energy.
repair his muscles nor replenish his fuel stores.
He also had lots of energy for training: Now he was
Our first step was to adjust his training program, just as strong toward the end of his games or training
weighting it much more towards anaerobic activities sessions as he was at the beginning.
such as sprinting, plyometric drills, and full-body resis-
tance training. The lesson here: Help your clients get the right kind
of training, and the right kind of fuel, for their specific
activities.

154 | Unit 5
Summary
Resting metabolic rate (RMR) changes as we age. On intimate link with the nervous system (T-tubules), and
average, after age 25 we lose 2-4% of our RMR every an extensive network of energy transfer (large, numer-
decade. ous mitochondria).
This decline is not inevitable. Good nutrition and regu- Oxygen consumption goes up both during and after
lar activity, especially high-intensity anaerobic activity, exercise. How much and how long it goes up for depends
help build lean mass that slow the aging process and on exercise intensity and duration.
keep us fit, healthy, and functional for life.
The intensity of energy demand determines the fate
Exercise requires energy, both during the activity itself, of our macronutrients both during and after exercise.
and — in the case of anaerobic activity — for hours or Aerobic exercise uses mostly fatty acids, glycogen, and
even days afterwards. a small amount of protein through the slower-burning
oxidative pathways. Anaerobic exercise uses mostly ATP
We can measure this energy cost by looking at oxygen and PCr, glucose, and glycogen through the fast-burning
consumption using METs. 1 MET = 3.5 mL of oxygen ATP-PCr and glycolytic pathways.
consumed per kilogram of bodyweight per minute. To
determine the hourly energy cost of an exercise bout, you Both types of exercise, as well as daily-life movement,
can multiply the MET intensity by bodyweight in kg. lead to beneficial metabolic adaptations. But for best
results, make sure you match exercise and nutrition
Our skeletal muscles help us move with an efficient programming to client needs and activities.
network of contractile proteins (actin, myosin, etc.), an

UNIT 6
Macronutrients
156 | Unit 6
Unit Outline
1. Macronutrients 4. Macronutrient 3: Protein
2. Macronutrient 1: Carbohydrate 5. Case study
3. Macronutrient 2: Fat 6. Summary
Objectives
In this unit, you’ll learn all about the three major macronu- our ability to do work, our recovery from exercise, chronic
trients (carbohydrate, fat, and protein), their chemical com- disease risk, body composition, and much more.
position, and why they’re important to health. Different
You’ll also learn how each of the energy systems discussed
macronutrients can significantly affect our energy levels,
in previous units depends on our dietary intake of the
macronutrients.
Macronutrients Macronutrient 1: Carbohydrate

In previous units, you learned about macronutrients: Carbohydrate structure
carbohydrate, fat, and protein.
We typically classify carbohydrates by their general
These three macronutrients, for the most part, make up chemical structure, and divide them into three general
our food. (Of course, remember that food also contains groups of saccharides (from the Latin saccharum, or
micronutrients, which we’ll look at in the next unit, sugar) based on their level of complexity (for examples of
and food is more than just a “macronutrient delivery each, see Table 6.1): monosaccharides, oligosaccharides,
system.”) and polysaccharides.
Macronutrients can affect many processes in our body, You can think of saccharides as looking like links in a
including: chain.
• our ability to digest our food and absorb nutrients;
Monosaccharides are the simplest form of carbohy-
• our hormone production; drates, since they contain only one (“mono”) sugar
group, or chain link.
• our immune system health;
• our cells’ structure and function; Oligosaccharides are short chains of monosaccharide
units linked together in the form of disaccharides (“two
• our body composition (i.e., how much lean mass and sugars”), trisaccharides (“three sugars”), etc. The most
body fat we have); common oligosaccharides are the disaccharides, includ-
• our metabolic function; and ing maltose, sucrose, and lactose.
• much more. Maltose = glucose + glucose
In this unit, we’ll look at some of these processes, and Sucrose = glucose + fructose
how each macronutrient plays an important role in them. Lactose = glucose + galactose

Macronutrients | 157
Table 6.1 Carbohydrate Classification

Monosaccharides Oligosaccharides Polysaccharides
Glucose Sucrose Digestible
Fructose Maltose Starch and dextrins
Glycogen
Galactose Lactose
Mannose Trehalose Partially digestible
Ribose Inulin
Raffinose monosaccharides: The simplest
form of carbohydrate
Indigestible
Cellulose oligosaccharides: Saccharide
Pectin composed of a small number of
monosaccharides
Polysaccharides have many (“poly”) saccharides. They are long, complex chains polysaccharides: More than
about 10 linked monosaccharides
of linked monosaccharide units, which can be either straight or branched. that form a polymer
Typically, when we refer to starches, glycogen, or fiber, we’re referring to
glucose: A monosaccharide
polysaccharides. found in foods and blood; the
end product of carbohydrate
Different carbohydrate structures affect not only how the carbohydrates behave metabolism and the major source
when they are cooked, but also how we digest and absorb them. of energy for humans
fructose: A monosaccharide that
Plant cells make starches by joining glucose monosaccharides together. Amylose is very sweet; possesses a ketone
and amylopectin are the two main forms of starch. The links are connected with rather than an aldehyde, which
glycosidic bonds, which join monosaccharide molecules. distinguishes it from glucose
galactose: A monosaccharide;
Amylose is a linear polysaccharide. This means it looks like a single long chain. less soluble and sweet than
glucose
amylose: A component of starch
characterized by straight chains of
glucose units
Hydrogen
amylopectin: A component of
Oxygen starch characterized by its highly
Carbon branched structure and fast
digestion
CHO
H – C – OH
HO – C – H
3D model of Glucose
H – C – OH
H – C – OH
C6H12O6 CH2OH
Molecular formula for Glucose Fischer projection
(2D representation)
of Glucose
Figure 6.1 Structure of glucose

158 | Unit 6
Amylopectin is a highly branched polysaccharide. This means it looks like sever-

al chains hooked together.
Glycogen is like starch, but made by animal cells from glucose monosaccharides
in the process of glycogenesis.
Cellulose, which gives plants their rigid cell walls, is another polysaccharide
similar to amylose. We know it as fiber. But unlike starch, fiber’s chemical bonds
resist human digestive enzymes. We can’t break fiber down well in our GI tract.
So we don’t digest or absorb it, although it can be broken down and used a bit
by the bacteria in our GI tract. Animals that live on high-cellulose plants (such
as cows that eat grass, or termites that eat wood) have bacteria in their stomachs
that can digest it and extract the energy from it.
Which potatoes should you choose?
You may have noticed that particular potato recipes call for specific kind of pota-
toes. This is because potatoes differ by their content of amylose and amylopec-
tin.
Potato types high in amylose are fluffy and floury. They’re best for mashing,
frying, or baking.
Potato types high in amylopectin are waxy. They’re best for boiling, and tend
to hold their shape rather than falling apart. If you try to mash them, they’ll go
gluey.
Waxy-type potatoes are also higher in resistant starch. When they’re cooked,
then cooled, their molecules align to trap water and resist digestion.
Carbohydrate digestion, absorption, transport and

metabolism
We can’t absorb larger carbohydrate molecules (polysaccharides). We need to
break them down into monosaccharides (glucose, fructose, and galactose) and
eventually release them into the bloodstream as glucose.
This process occurs throughout the GI tract, and begins the moment we put
carbohydrate in our mouth.
The mouth
salivary amylase: Enzyme As soon as we take a bite of carbohydrate, salivary amylases help to hydrolyze,
found in saliva that catalyzes the or break down, these polysaccharides into smaller carbohydrate chains.
hydrolysis of starch
Salivary amylase, however, can only help with about 20% of carbohydrate
breakdown, depending on how long food stays in our mouth. The less we chew,
the faster we swallow, and the less salivary amylase has a chance to work on our

food. Conversely, if we eat slowly and chew well, we digest our food better with
the help of these salivary enzymes. (A good reason to eat mindfully.)
The stomach
After the carbohydrate food is swallowed, it travels down the esophagus to the
stomach. In the stomach, carbohydrates (and all other swallowed food) get mixed
into a homogenous mixture known as chyme. There is no further digestion of
carbohydrates here, as the job of the acidic environment of the stomach is to
destroy potential harmful pathogens. And it stops the action of salivary amylase.
The small intestine
Once the carbohydrate is passed on to the small intestine, pancreatic amylases

take over, turning these smaller carbohydrate chains into disaccharides.
• The enzyme maltase breaks down maltose into two monosaccharide units of
glucose.
• The enzyme lactase breaks down lactose (milk sugar) into glucose and galac-
tose monosaccharides.
• The enzyme sucrase breaks down sucrose (table sugar) into glucose and fruc-
tose monosaccharides.
Remember, starch is made up exclusively of glucose molecules joined together

into long chains. Thus, the end products of starch digestion are always glucose
monosaccharides.
All of these monosaccharide end products pass through the intestinal cells into
blood vessels that take them to the liver (via the portal vein) before they enter
general circulation.
The liver
The liver takes what it needs for energy transfer and glycogen storage and then
ships the rest out as glucose monosaccharides.
You may have noticed that we can absorb galactose and fructose from our diet,
but they don’t usually end up in the bloodstream. Why not?
First, they’re both mostly converted to glucose by the liver. If there’s any
leftover glucose that the liver doesn’t think we need, it’ll turn that into tri-
glycerides (especially in times of caloric excess).
Second, our liver actually prefers to use fructose rather than glucose for energy
and liver glycogen replenishment (though it can use glucose too). Again, once the
liver takes what it needs and does the appropriate chemical alchemy, the glucose
units released into circulation work their way through the blood until they’re
taken up into our cells.

160 | Unit 6
Is fructose “bad for us”?
One of the most important things to understand about drink sweetened beverages. Combine that with oth-
sweeteners is that their chemical structure affects the er sweetened foods, and the sugar adds up fast. For
way the body processes and stores them. instance, let’s look at what our average North American
might eat in a day:
The word “fructose” comes from the Latin fructus, or
fruit. Fructose is mostly found naturally in fruit, but also Meal Foods eaten Sugar
in other sweeteners such as honey… and more impor- content
tantly, in high-fructose corn syrup and table sugar.
Breakfast Honey Nut Cheerios with 45 g
Some experts think that over-consuming fructose will sweetened soy milk
lead to Type 2 diabetes and other types of metabolic
Glass of orange juice
disruption and diseases. The more we consume, the
worse it is. Many people even claim we shouldn’t eat On the way to work Starbucks Grande Frap- 39 g
fruit at all. puccino (Vanilla Light)
What does the research say? Mid-morning snack Nutrition bar 25 g

Lunch Chicken wrap 46 g
Based on the most current studies, most people should
get no more than 50 g of added fructose per day. Added 15 oz can of sweetened
fructose includes things like sugar, high fructose corn iced tea
syrup (HFCS), juice, honey, and other sweeteners. Mid-afternoon snack Can of Slim-Fast 18 g
Whole foods like fruit don’t seem to contribute to the Dinner Stir-fry with sweet and 21 g
sugar problem because of their fiber, water, and phyto- sour sauce
nutrient content. Salad with bottled
More than 50 g of added fructose, and we start to see French dressing
problems. Less than that, especially if we’re otherwise Dessert Bowl of low-fat ice cream 30 g
healthy and active, and we’re fine. (Some active and or frozen yogurt
healthy people can have more than 50 g daily; usually
sedentary people are more at risk for metabolic disrup-
tion.)
That’s 224 g of sugar. If most of that is table sugar, then
But what does that mean in reality? about half of it (112 g) is fructose.
First, the average North American adult gets 20% of And that’s definitely not an outrageous day of eating
their daily energy intake as added sweeteners. That in North America. Some people might even consider it
means they’re eating a lot of processed foods with lots healthy. (After all, they chose the Light Frappuccino and
of extra sugar in them. the low-fat ice cream.)
Second, let’s translate 50 g of fructose to real foods and However, with whole, minimally processed foods, it’s
drinks. a lot tougher to get that much fructose, or sugar in
general.
For instance:
For instance, you’d have to eat about 11 apples to get
• A 32 fl ounce soda sweetened with either high that much fructose… or an unimaginably intestinally
fructose corn syrup (HFCS) or sugar has about 50 distressing quantity of red beets.
g of fructose.
No matter which sweetener you choose, the real issue is
• A 32 fl ounce sports drink has about 22 g of quantity.
fructose. 1 bag of Skittles would provide another
24 g. If sweeteners — from any source — regularly make up
more than 5 to 10% of your diet, that’s probably bad
It’s especially easy to rack up sugar grams when you news for your health.

The bloodstream
On average, we move about 20 g of glucose through our blood every hour. Our
body prefers to keep this more or less stable.
If our blood sugar drops too low, the body will immediately use the new glucose
supply for preserving blood glucose levels and for immediate energy.
If our blood sugar goes too high, the liver and muscles will take up what they can.
The liver can store about 80-100 g of glycogen before it’s full. And the muscles can
store between 300-600 g of glycogen before they’re full (this obviously depends on
the amount of muscle mass someone has, as well as their training status).
If blood sugar is still too high after liver and muscle storage, extra glucose can be
converted into body fat, though that’s not as common. Instead the body oxidiz-
es more glucose (because there’s more available) and less dietary fat, leading to
more of our dietary fat being stored as body fat.
The glycemic index
Many of you are probably familiar with the glycemic index (GI), a measure of glycemic index (GI): Measure of
how quickly and significantly a given food can raise our blood sugar. the rate of which an ingested food
causes the level of glucose in the
blood to rise
The GI tells us how much blood sugar goes up when we consume 50 g of usable
carbohydrate from a particular food. It’s a relative measure, determined against
a specific reference food — 50 g of carbohydrate from pure glucose — which is
given a GI value of 100. Each food’s GI score is then calculated relative to this
value of 100.
In general, the less processed and higher-fiber a food is, the more complex its
carbohydrate molecules usually are. Because of this, those foods will usually take
longer to digest and have a lower GI. See Figure 6.2.
8
Blood glucose (mmol/l)
High GI
7
(glucose)
Low GI
5
(beans)
0 50 100 150
Time after intake (minutes)
Figure 6.2 Glycemic index

162 | Unit 6
For instance, high glycemic foods include sugar, candy, breakfast cereal and
bagels. Lower glycemic foods include legumes, whole grains, and vegetables.
When blood glucose goes up quickly, insulin usually responds quickly. The
amount of insulin released usually matches the amount of glucose present.
This has led some people to suggest that a low-GI diet is a healthy one.
While an interesting measure of the physiological response to carbohydrate in

the diet, the GI doesn’t tell the whole story.
First, we don’t eat most foods by themselves. (When was the last time you ate a
plain slice of bread as a meal?) Since protein, fat, and fiber all change GI, eating
food as part of a meal will change the GI.
Second, many other factors can affect how quickly a food is converted to glucose,
including when we eat that meal during the day, whether we’ve been active, and
so forth. GI measurements vary from person to person, and from day to day and
meal to meal in the same person.
Third, the score can be easily manipulated by the type of sugar in the food.
Foods with large amounts of fructose tend to have low GI scores, simply because
fructose does not immediately raise blood glucose levels. But this doesn’t make
these foods any healthier.
Finally, the glycemic index is based on a standardized amount of carbohydrate,

not a standardized amount of food. In order to calculate the GI of 50 g of car-
bohydrate, we’d only need a small amount of sugar, but quite a lot of carrots, for
example.
Although it’s very easy to get 50 g of sugar in one sitting (for instance, a chocolate
bar plus a can of cola amounts to about 75 g of sugar), it would take about five
cups of carrots to get the same amount. Few people would eat this many carrots
in one sitting. This makes for an unfair and unrealistic comparison.
Glycemic load (GL)
glycemic load: Equal to the Researchers often use the glycemic load (GL) as another, more realistic measure.
glycemic index of a food times the The glycemic load of a food is based on the glycemic index multiplied by the serv-
number of grams of carbohydrates
in the serving
ing size of the food.
While this gives a better picture of how fast or significantly blood sugar may
go up after a meal, GL still has some of the same problems as GI. And it too
doesn’t take into account the other elements the food may have to offer (fiber,
micronutrient, and phytonutrient / zoonutrient content).
Insulin index (II)
While GI and glycemic load are somewhat useful in determining overall glucose
insulin index (II): Measure of load, they aren’t the best predictors of insulin response to a meal, which is the
the rate of which an ingested food measure most closely correlated with health.
causes the level of insulin in the
blood to rise Another index, the insulin index (II), measures the amount of insulin the body
produces in response to a particular food.

Interestingly, the II does not always match the GI. You may be surprised to
know, in fact, that high-protein and high-fat foods can stimulate greater insulin
responses than you’d expect, while some high GI foods produce surprisingly low
insulin responses.
In addition, when people with underlying insulin resistance eat moderate and
high GI foods, their bodies produce more insulin than a healthy person’s.
Choosing carbohydrates wisely
The bottom line is that GI, GL, and II don’t give us the whole story. Most clients
probably shouldn’t be “eating by numbers.” Nor should these theoretical mea-
sures dictate what kinds of carbohydrates we eat and enjoy as part of normal
daily life.
We’ll discuss other, easier, and more effective methods for choosing foods later in
this unit.
Our cells
Let’s now look at what our cells do when glucose is available to them in the
blood.
Glucose transport
Cells take glucose from the blood using facilitated diffusion (and active trans-
port), which you’ll hopefully remember from previous units. In this process,
transport proteins on the cell membrane grab the glucose monosaccharides and
transfer them into the cells.
In muscle and fat tissue, glucose uptake is stimulated primarily by the hormone
glucose
Binding
glucose
Recovery Transport
glucose
Dissociation
glucose
glucose =
chair representation
of glucose
Figure 6.3 Insulin dependent glucose transport

164 | Unit 6
GLUT family: Group of insulin. Insulin tells glucose transport proteins (members of the GLUT trans-
membrane proteins that transport porter family) to move to the cell membrane so that they can pick up glucose
glucose from the blood into cells
floating past and bring it into the cell.
Muscle contraction also brings glucose into cells, even without insulin. This is
why insulin sensitivity and glucose uptake are usually better after exercise, and
why exercise helps keep us metabolically healthy.
isoforms: Any of the proteins Fourteen isoforms, or related types, of GLUT have been described (GLUT1
with the same function and similar — GLUT14). All cells have at least one of these on the plasma membrane. But
amino acid sequence, encoded by
different genes
generally, GLUT transporters like to live in particular tissues.
GLUT1 — GLUT3 live in red blood cells, at the blood brain barrier, in the pla-
centa, in fetal tissues, in the liver, in pancreatic beta cells, in the kidneys, in the
brain, in muscle tissue, and in the small intestine. They are responsible for basal
glucose uptake and don’t depend on insulin.
GLUT4 however, is sensitive to insulin (and muscle contractions). It lives in adi-

pose cells, and heart / skeletal muscle. GLUT12 also appears to be sensitive to in-
sulin. It was originally cloned from human breast cancer cells, and appears to be
expressed more in ductal cell carcinomas. This may tell us that glucose uptake in
breast cancer tissue is significant. Of course, we need further research to be sure.
Figure 6.4 Summary of carbohydrate-related metabolic pathways

Table 6.2 Summary of the properties of facilitative glucose transporter family members
Protein Major sites of expression Proposed function
GLUT1 Ubiquitous distribution in tissues Basal glucose uptake; transport across blood tissue barriers
and culture cells
GLUT2 Liver, islets, kidney, small intestine High-capacity low-affinity transport
GLUT3 Brain and nerves cells Neuronal transport
GLUT4 Muscle, fat, heart Insulin-regulated transport in muscle and fat
GLUT5 Intestine, kidney, testis Transport of fructose
GLUT6 Spleen, leukocytes, brain Not determined
GLUT7 Small intestine, colon, testis Transport of fructose
GLUT8 Testis, blastocyst, brain, muscle, Fuel supply of mature spermatozoa; Insulin-responsive transport in
adipocytes blastocyst
GLUT9 Liver, kidney Urate / glucose antiporter (transports urate out and glucose in, and both
have to happen for the transporter to work); glucose transport
GLUT10 Liver, pancreas 2-deoxy-glucose and galactose transport
GLUT11 Heart, muscle Muscle-specific; fructose transporter
GLUT12 Heart, prostate, mammary gland Insulin-responsive glucose transporter
GLUT13 Neurons and glial cells Transport of myo-inositol
GLUT14 Testis Not yet known
After glucose enters most cells, it becomes phosphorylat- Carbohydrates: The big picture
ed via ATP to become glucose 6-phosphate. This process
activates glucose for entry into the metabolic pathways of By now, we hope it’s clear, but we’ll reiterate:
the body (including glycogenesis, glycogenolysis, and gly-
colysis) while preventing the glucose from leaving the cell. There is no single “best” diet.
You can refer back to previous units for a reminder of There is no “correct” amount of carbohydrates that is
the specifics of how glucose is used for energy. the same for everyone, all the time.
Carbohydrates in the diet Carbohydrate intake will depend on factors such as:
• how big or small someone is;
We need glucose to live. As we saw in previous units,
energy transfer depends on it. Tissues such as our brain • how much lean mass or body fat they have;
and red blood cells, which can’t make their own glucose,
• how active they are;
need a continuously available supply of it.
• how intense, long-lasting, and / or frequent that
Our brain needs about 130 g of glucose a day. We can activity is;
get this from our diet. Or, when carbohydrate intake is
low (or we’re fasting), gluconeogenesis and ketosis can • how old they are, and what stage of life they are at;
provide what we need, assuming we have enough protein • intake levels of other macronutrients;
and fat to process.
• genetics;
This is important to understand: While our body needs • what foods they like, tolerate, and prefer to eat; and
a certain amount of glucose, that glucose can come from
several sources. • what they want to do.

166 | Unit 6
Same as others
SD = Standard deviation
Probably more Probably less

than others than others
Definitely more Definitely less

-2 -1 Mean +1 +2
SD SD score SD SD
2% 14% 34% 34% 14% 2%

Percentage of people
Figure 6.5 How much carbohydrate do people likely need?
For example, a muscular young male athlete who While it’s important to learn about the specific fea-
competes in heavyweight-class boxing and trains twice tures of each carbohydrate type, keep the big picture
daily will probably do best with more total energy and in mind.
carbohydrates in his diet. A sedentary 68-year-old
woman who does Tai Chi once a week will need less Focus on these key points:
overall energy and relatively fewer carbohydrates. When • Humans evolved eating a varied and seasonal diet.
it comes to carbohydrate intake, there is a distribution of We thrive best on a mix of carbohydrate types that
how intake will vary. A small percentage of people will occur naturally in different types of foods.
function best with more carbohydrates than average; an-
other small percentage will function best with less than • Most of the time, we want relatively slower-digesting,
average. And most people are somewhere in the middle, higher-fiber carbohydrates.
doing best with a moderate portion of carbohydrates (es- • We easily get these types of carbohydrates if we
pecially from higher-fiber, nutrient-rich, slow-digesting
choose a wide selection of diverse, whole, less-pro-
sources such as vegetables, fruits, legumes, and whole
cessed foods such as:
grains). See Figure 6.5.
• fruits and root vegetables
We’ll look at some types of carbohydrate next. • whole grains
• beans and legumes

• Occasionally, faster-digesting, lower-fiber carbo- Fiber

hydrates can be helpful, particularly for athletes or
people looking to gain weight. Fiber comes in two different forms: soluble and
• Match your nutrition plan to each client’s unique insoluble.
body, preferences, and needs. We can’t digest these, but they have important jobs.
Our GI bacteria love to ferment them, producing short-
We’ll give you some more specific recommendations in
chain fatty acids like acetate, propionate, and butyrate.
Section 2.
Emerging evidence shows these fatty acids can provide
various health benefits.
Carbohydrate type
Soluble fiber is so called because its carbohydrate
“Carbs” are not all created equal. While they all meet molecules are water soluble. It will often turn to a gel in
more or less the same fate in the body, the process by water (for example, think of the pectin that gives jelly
which they end up as glucose (and then, perhaps, glyco- its structure).
gen or triglycerides), will differ. This will create different
effects in the body. Soluble fiber is found in oats and oat bran, dried beans
and peas, nuts, barley, flax, chia, fruits like oranges,
For instance, compare: bananas, blueberries, and apples, and vegetables such
as artichokes, tomatoes, and carrots. You can also
• Cellulose, technically a carbohydrate, isn’t used for
find it in supplements such as glucomannan or konjac
energy at all. Our GI bacteria munch on it a little bit,
(which is often used in East Asian cuisine for jellies or
and then we excrete most of it. As fiber, it can bind shirataki noodles).
to other things in our GI tract, such as fat-soluble
hormones or other dietary fats. Soluble fibers can decrease enterohepatic recycling of bile
acids (instead of bile acids being recycled, they will be
• A highly branched chain of amylopectin must be bro-
excreted in the stool), which can decrease serum cholesterol
ken down slowly in our small intestine. It will release
levels. They can also help excrete other fat-soluble substanc-
its glucose gradually. es such as sex hormone metabolites (byproducts).
• A spoonful of table sugar in our coffee will be easily
Insoluble fiber is found primarily in the structures that
broken into glucose and fructose for quick disposal in
make up plants’ rigid cell walls. This includes vegetables
our liver and possibly bloodstream.
such as celery, root vegetables, dark green leafy vegeta-
These differences are important. bles, fruit and vegetable skins, whole-grain seed hulls,
seeds, and nuts.
Complex carbohydrates that come from whole-food
sources like vegetables, fruits, legumes, and whole Insoluble fibers will add bulk to stools and help to ensure
grains tend to keep us feeling full longer. They also regular bowel movements.
travel with passengers: micronutrients, phytonutrients,
Thus, fiber can:
fiber and water — perhaps even some protein and
healthy fats. They keep our blood sugar and insulin • help us feel full longer;
levels stable, releasing their energy gradually. • lower our blood lipids and cholesterol;
Simple, refined and highly processed carbohydrates • lower our risk of colon cancer;
digest quickly but tend to leave us unsatisfied.
• keep things moving through our GI tract; and
They’ve been stripped of nutrients. Their passen-
gers are often high amounts of sodium along with • boost our overall gut health.
industrial chemicals such as flavorings, trans fats or
preservatives. They stimulate our appetite and leave Although the minimal recommended intake for fiber is
us wanting more. They can cause fluctuations in our 25 g / day, the optimal amount seems to be closer to 35 g
blood sugar and insulin levels. / day for women and 48 g / day for men.
In general, we should try to eat mostly complex carbohy- Not every client will do well with this amount of fiber.
drates from whole-food sources. Some clients with inflammatory bowel disease (IBD) or
colitis may feel better with less during flare-ups.

168 | Unit 6
Keep complex carbs simple
When it comes to the actual carbohydrates, we sug- 3. Why are they eating each day?
gest making things complex — at least, in terms of the Are they eating when they’re truly physically hungry?
carbohydrates themselves. As often as possible, choose
less-processed, whole foods with slow-digesting carbo- 4. What are they eating each day?
hydrates such as complex starches and fiber. Are they eating mostly whole, fresh, minimally pro-
cessed foods, such as fruits, vegetables, lean proteins,
But when it comes to nutrition programming, keep it healthy fats, whole grains, and / or beans and legumes?
simple.
5. Are they doing #1 to #4 properly and con-
In other words, don’t get lost in GI lists or nutrient tim- sistently?
ing if your clients aren’t eating their vegetables. STOP here until your client can do the above at least
Instead, start with the real priorities: Making sure your 75% of the time. (For best results, we prefer to get closer
clients are eating the right foods, in the right amounts, to 90%, depending on their goals.) And wait a little
for the right reasons. while to make sure they can keep doing it.
Use this list as a checklist. And only then, if they really need it, and their goals dic-
tate it, should they consider timing of specific carbohy-
1. How much food are they eating each day? drates after workouts.
Are they eating the right amounts for their goals? We’ll
look more at portion sizing later. We’ll give you some more specific recommendations in
Section 2.
2. How are they eating each day?
Are they slowing down to taste and enjoy their food
mindfully?
Resistant starch
As its name implies, resistant starch resists digestion. You competition, especially if they have multiple events in one
can think of it almost as a third kind of dietary fiber. day. In those situations:
Some types occur naturally in foods such as green ba- • Insulin sensitivity is high.
nanas or beans. • Liver and muscle glucose uptake is rapid.
Another type is starch that has been cooked then cooled. • Carbohydrates will go to replenishment and oxida-
When cooled, this starch arranges its molecules in a tion, rather than storage.
different configuration. This can include cold cooked • The athlete needs this process to happen quickly and
potatoes, cold cooked oats, cold cooked pasta, or sushi
easily. (Especially since they may not want to train or
rice. (See? Leftovers are good for you.)
compete with lots of food in their stomachs.)
Like dietary fiber, we can’t fully break down or absorb
In this case, simple processed food sources of carbo-
the nutrients from resistant starch. Rather, our intestinal
hydrates around training or competition times are an
bacteria turn it into short-chain fatty acids.
appropriate choice.
Special considerations Second, simple processed carbohydrates can help people

who are underweight and having trouble eating enough.
Simple, fast-digesting carbohydrates can be useful in a These types of carbohydrates can help people get enough
couple of situations. energy when needs are very high (e.g,. endurance ath-
letes). They can also help replenish fuel stores after train-
First, these types of carbohydrates can help higher-lev- ing, which can help people gain weight if needed.
el athletes who need rapid refueling around training /

Thus:
• Carbohydrate amount, along with total energy, is important.
• Carbohydrate type, along with the other nutrients in a given food, is
important.
• Carbohydrate sensitivity matters: Active people need and use carbohydrates
most effectively.
• Carbohydrate timing can matter for higher-level athletes who are already
following a good-quality basic diet consistently, and who are looking for the
“extra edge” for their training or competitions.
For more on individualizing carbohydrate intake, see Section 2.
Macronutrient 2: Fat
Fat structure
Fats are organic molecules made up of carbon and hydrogen elements joined
together in long groups called hydrocarbons. The arrangement of these hydro- hydrocarbons: Organic
carbon chains, and their interaction with each other, determines fat type. compounds that contain only
carbon and hydrogen
The simplest unit of fat, analogous to a carbohydrate monosaccharide, is the fat- fatty acid: Chain of carbon
ty acid. Fatty acids are made of simple hydrocarbon chains with special chemical atoms with a carboxylic acid and
groups at each end: aliphatic tail
• a methyl group (CH3) on one end; and

• a carboxyl group (COOH) at the other.
methyl group carboxyl group
Figure 6.6 Differences in fatty acid structure. Saturated fats contain no double bonds between carbons. Monounsaturated fats
contain one carbon-to-carbon double bond. Polyunsaturated fats contain multiple carbon-to-carbon double bonds.

170 | Unit 6
Hydrogen atoms can bond to the hydrocarbon chain. This is known as satura-
tion. The more hydrogens bonded, the more saturated the fat is.
If hydrogens have filled up all the available bonding spots on the chain, the fat
saturated fatty acids: A fatty is saturated. Because of this chemical structure, saturated fats (such as butter,
acid with no double bonds in the coconut oil, or cocoa butter) are usually solid or semi-solid at room temperature.
chain
unsaturated fatty acids: If only some hydrogens have bonded, the fat is unsaturated. Unsaturated fats
Having double bonds between are usually liquid at room temperature. The less saturated the fat, the more fluid
carbons in the fatty acid chain it is. (Indeed, omega-3 fatty acids act like “natural antifreeze” for cold water fish,
preventing their cells from stiffening up in icy temperatures.)
Unsaturated fatty acids can be broken down into;

• monounsaturated fatty acids (in which only one carbon is unsaturated); and
• polyunsaturated fatty acids (in which more than one carbon is unsaturated).
The often-discussed omega-3 and omega-6 fats are both polyunsaturated fatty
acids. Their names come from the location of their double bonds.
Alpha-linolenic acid (ALA): polyunsaturated, essential fatty acid
Figure 6.7 Determining the location of double bonds

Table 6.3 Foods highest in saturated, monounsaturated, and polyunsaturated fats

Highest in saturated fats Highest in monounsaturated fats Highest in polyunsaturated fats
Butter Almonds (almond butter) Chia seeds (chia oil)
Coconut (coconut oil, coconut milk, Avocado (guacamole) Cod liver oil
shredded coconut)
Brazil nuts Corn oil
Cream (half & half, heavy whipping,
sour) Canola oil Fish (fish oil)
Dark chocolate (70%+ cacao) Cashews (cashew butter) Flaxseeds (flaxseed oil)
Fatty beef, lamb / mutton and pork Egg yolk Grapeseed oil
Palm and palm kernel oil Hazelnuts (hazelnut butter) Hemp seeds (hemp oil)
Whole fat milk, cheese, and yogurt Lard Mayonnaise
Macadamia nuts (macadamia butter, Pine nuts

macadamia oil)
Sesame seeds (tahini, sesame oil)
Olives (olive oil)
Soybean oil
Peanuts (peanut butter, peanut oil)
Sunflower seeds (sunflower seed
Pecans (pecan butter) butter)
Pistachios (pistachio butter) Walnuts (walnut butter)
Safflower oil (this oil can be altered, so

check label)
Sunflower oil (this oil can be altered, so

check label)
Chicken and duck fat
To determine where the double bonds in fatty acids are located, simply count
from the terminal methyl carbon toward the carbonyl carbon (Figure 6.7). Ome-
ga-3 would mean a double bond on the third carbon.
As you may remember from Unit 3, fatty acids can be joined together to form
triglycerides. As the name implies, three (“tri”) fatty acids join together with a triglycerides: Compound with
glycerol molecule to make up a triglyceride. Triglycerides are the major form of three molecules of fatty acids
bound with one molecule of
fat found in the diet, and the major storage form of fat found in the body. glycerol; the storage form of fat in
humans
Fat digestion, absorption, and transport
You’ll hopefully recall that to digest fat, the body breaks down triglycerides into
fatty acids and glycerol, which are repackaged in various ways before entering glycerol: Sugar alcohol that is the
the bloodstream. backbone of a triglyceride
This takes place mostly in the small intestine, where bile emulsifies tri-
glycerides in the food we’ve eaten. Emulsification divides the fat into small
droplets that offer more surface area to digestive enzymes than the original
larger triglyceride droplet. pancreatic lipase: Enzyme
secreted from the pancreas that
The pancreas secretes pancreatic lipase, the major enzyme of triglyceride hydrolyzes fat

172 | Unit 6
H
Triglyceride
H
H C OH O
H C
H C OH
H C O O
H C OH
H C
O
O
H
H
Glycerol O
O-
Free fatty acid
Figure 6.8 Triglyceride structure
digestion, into the small intestine where it hydrolyzes the triglycerides and re-
moves the fatty acids from their glycerol backbone.
After they are broken down, fatty acids can diffuse across the intestinal cell layer
(mucosa). Intestinal cells repackage them into large lipoprotein particles called
chylomicron: A lipoprotein chylomicrons. Chylomicrons are released into the lymphatic system, which slow-
that transports cholesterol ly empties into general circulation through the thoracic duct (via the left subcla-
and triglyceride from the small
vian vein, if you’re interested).
intestine to tissues of the body
Because it takes a long time to break down and transport, fat enters the blood
several hours after we’ve eaten it. See Figure 6.9 for more.
Packaged in chylomicron
5. H
Triglyceride H C
O
reassembled
H C O O
H C
O
O
Cells of small intestine
Triglyceride
hydrolyzed 1.
4.
2.
3.
Triglyceride
Figure 6.9 Triglyceride absorption

You’ll remember from previous units that these packaged triglycerides circu-
lating in the blood (carried by chylomicrons) are again broken down into free
fatty acids and glycerol with the help of an enzyme called lipoprotein lipase. This
occurs so they can pass through yet another cell membrane and into the tissues
of our body.
Once through the membrane, they’re either:

• oxidized (through the process of ß-oxidation) and used to transfer energy in
skeletal muscle or other tissues; or
• converted back (again) into triglycerides for storage in adipose tissue, skeletal
muscle, etc.
The role of lipoproteins
As we’ve seen, because fat doesn’t dissolve in water, it can’t travel in the blood on
its own. To get around the body, fat (such as triglycerides and cholesterol) must be
carried in a lipoprotein.
This is where phospholipids (which you may remember make up cell membranes)
come in handy. The phosphate “head” is hydrophilic: It can hang out in water. hydrophilic: Denoting the
The lipid “tail” is hydrophobic: It doesn’t like water. But it sure likes other fats. property of attracting or
associating with water molecules
See Figure 6.10.
Lipoproteins’ coats are studded with apolipoproteins, which act as receptors that apolipoproteins: Proteins
can bind to other things and help control what a specific lipoprotein does. that assist in the transport and
regulation of lipids.
You’ll remember from Unit 3 that there are several kinds of lipoproteins (in fact,
there are over a dozen when including sub-classes, but for our purposes, we’ll just
focus on a handful).
Figure 6.10 Basic lipoprotein structure

174 | Unit 6
Classification of Lipoproteins
Chylomicron VLDL LDL HDL

and (Very low (Low density (High density
Chylomicron remnant density lipoprotein) lipoprotein) lipoprotein)
99% lipid 92% lipid 80% lipid 50% lipid
1% protein 8% protein 20% protein 50% protein
Figure 6.11 Classification of lipoproteins
Chylomicrons are the biggest. They carry triglycerides (fat) from the intestines to
the liver, to skeletal muscle, and to adipose tissue.
lipoprotein lipase: An enzyme Very-low-density lipoproteins (VLDL) carry newly created and packaged tri-
found in endothelial cells lining the glycerides from the liver to adipose tissue.
capillaries; hydrolyzes lipids into
fatty acids and glycerol Low-density lipoproteins (LDL) carry cholesterol to all cells in the body, and
come in two general types:
• large buoyant LDL (lb LDL) particles (which indicates good health); and
• small dense LDL (sd LDL) particles (which indicates poor health).
High-density lipoproteins (HDL) bring fat and cholesterol from the body’s
cells back to the liver. This is an important process known as reverse cholesterol
transport.
You may also see Lipoprotein (a) (LpA) listed on a client’s lab work. Scientists
aren’t totally sure what it does yet, but high LpA is linked to cardiovascular
disease. Its levels are genetically determined, and are not affected by cholester-
ol-lowering drugs. Niacin (vitamin B3) therapy seems to help. L-carnitine may
also lower LpA.
The total amount of each type of lipoprotein, and how much of each type we
have, can affect our health.

HDLs are considered heart healthy lipoproteins The Total Cholesterol to HDL Cholesterol ratio is a good
because of their role in reverse cholesterol trans- marker. The goal for males is 5:1 or lower, with 3.5:1
port — the removal of excess cholesterol from cells, or lower being optimal. The goal for females is 4.4:1 or
including arteries, and transportation back to the lower, with 3.4:1 or lower being optimal.
liver. In general, we want the cholesterol content of
HDL particles to be higher. This usually indicates a Another ratio, Triglycerides to HDL Cholesterol, was re-
well-functioning reverse cholesterol transport system cently determined to be the best predictor of risk among
and lower cardiovascular disease risk. the commonly available blood lipid tests. The goal is 4:1
or lower, with 2:1 or lower being optimal.
LDLs are often considered dangerous lipoproteins
because of their role in depositing cholesterol into Fortunately, eating an appropriate amount of less-pro-
our arteries. Recent research seems to indicate that cessed, whole plant and animal foods significantly im-
the total number of LDL particles may be the most proves blood lipids. Maintaining a healthy bodyweight
important risk factor, even more important than the and body composition, and engaging in regular physical
cholesterol content of the LDL particles, which is the activity also significantly improve blood lipids. But keep
number seen on most blood lipid panels. In general, in mind that our lipoprotein makeup is highly genetic.
we still want the cholesterol content of LDL parti-
A full discussion of lipoproteins and their effects is
cles to be lower, as well as the total number of LDL
beyond the scope of this textbook. Just remember some
particles.
basic ideas:
Now, as you can see, the world of lipoproteins can be a bit • We have a range of lipoprotein types, which have
hard to grasp. Let’s try an analogy. different physical structures and different jobs.
Your bloodstream is like a highway. Lipoproteins are • The total and relative amounts of each lipoprotein
like cars (LDL) and ambulances (HDL). Cholesterol can affect our health.
and fats are like passengers in those cars and ambu-
• When talking about “cholesterol”, be sure you are
lances. The guardrails on the highway are like the
clear on what you mean. Most of the time, when
lining of your vessels.
doctors or news articles talk about “cholesterol”, they
If there are too many cars (LDL), there are likely to be usually mean the cholesterol content of various lipo-
more crashes into the guardrails. When an LDL par- proteins. Not the size or the number of lipoproteins
ticle crashes into the lining of the vessel, it can initiate (which are both important).
the process of plaque formation on an artery. HDL
particles would be like the ambulance who comes to Fat in the diet
the scene of the crash and takes passengers back to the
hospital (the liver). Dietary fat has six major roles:
• It provides us with energy (in fact, it’s the most ener-
As you can see, it’s not the passengers (cholesterol) that
gy-dense macronutrient).
are the main concern, it’s the number of cars on the road
(LDL). Someone who goes to the doctor to get general • It helps make and balance hormones, particularly our
blood work will likely get a test for total cholesterol steroid hormones (such as sex hormones and cortico-
(measuring the number of passengers). We also want to steroid hormones).
know the number of cars (the number of LDL particles)
and ambulances (the number of HDL particles). • It forms our cell membranes.
• It forms our brains and nervous systems.

Unfortunately, most general blood work won’t provide
you with the number of LDL particles or apolipoproteins • It helps transport the fat-soluble vitamins A, D, E, and
(another way to measure LDL particles). But there are K.
still some good markers for measuring cardiovascular • It gives us two fatty acids that we can’t make on our
disease risk.
own:

176 | Unit 6
100
39% 66% 9% 47% 22% 17%
90
Saturated fat
80 19%
Monounsaturated fat
70
60 Polyunsaturated fat
Fat content (%)
43% 31% 37%

50
40
30 27% 49%
20
18% 72% 47% 46%
10
4% 4%
0
gs r s ef fu on
Eg tte ed Be To
Bu se lm
ax Sa
Fl
Figure 6.13 How foods differ in fat content
linoleic acid: Unsaturated • linoleic acid (an omega-6 fatty acid), and
omega-6 fatty acid considered
essential to the human diet • linolenic acid (an omega-3 fatty acid).
linolenic acid: Unsaturated As you’ll remember, most dietary fat comes in the form of triglycerides: three
omega-3 fatty acid considered
essential to the human diet fatty acids attached to one glycerol backbone. Also remember that the glycerol
backbone doesn’t care what fatty acids attach to it. So most dietary fat sources are
made up of some combination of saturated, polyunsaturated, and monounsatu-
rated fatty acids.
For example, while most people consider eggs to be foods rich in saturated fat,
eggs actually contain more monounsaturated fatty acids than saturated fatty
acids. Indeed, 39% of the fat in eggs is saturated while 43% comes from monoun-
saturated fat and 18% from polyunsaturated fat. See Figure 6.12.
Fat: The big picture
We’ll look at some types of fat next.
While it’s important to learn about the specific features of each fat type, keep
the big picture in mind.
Focus on these key points:

• Humans evolved eating a varied and seasonal diet. We thrive best on a mix

of fat types that occur naturally in different types of Importantly, this saturation happens naturally, unlike
foods. artificially created “hydrogenated” fats, which we’ll look
at in a moment.
• We want a relatively equally balanced mix of fat
types. Because of this hydrogen bonding, saturated fats are
• This balance comes naturally if we choose a wide chemically stable. They don’t oxidize, or degrade easily,
selection of diverse, whole, less-processed foods, because there are no spaces for any other molecule to
such as:
stick to. (In fact, recently a farmer in Ireland uncovered
a 22 lb (10 kg), 2,000-year-old chunk of butter that had
• nuts and seeds • poultry been preserved in a peat bog. It’s said to smell like a
• avocados • wild game strong cheese. “You could eat some”, said a researcher,
“but we don’t advise it.”)
• dairy • beef, pork, and lamb
• eggs • olives and extra-virgin olive oil

We find saturated fats in such foods as:
• beef, pork, and lamb (although the animals’ diet will
• fatty fish
significantly change their fat type and content)
• When feasible, getting fish and animal products that • eggs
are wild-caught or pasture-raised provides improved
• full-fat dairy (such as butter or cheese)
fatty acid profiles (balanced against availability, goals,
and cost). • coconut
• Try to minimize or eliminate refined and processed • cacao (chocolate)

foods containing industrially produced fats and artifi-
As you may have noticed when cooking with some of
cially hydrogenated fats. these, saturated fats tend to be solid at room temperature
• At times, it may be useful to supplement particular (think of the fat on a steak or a lump of butter). Again,
fat types, especially omega-3s (e.g., fish, krill, or algae this comes from their chemical structure. With all the
oil). hydrogens packed in there, there’s not much room to be
liquid. (We’ll come back to this idea later when we look
• Match your nutrition plan to each client’s unique at hydrogenation.)
body, preferences, and needs.
Saturated fats sometimes get a bad rap for causing heart
We’ll give you some more specific recommendations in disease. (See “Is saturated fat ‘bad for us’?” on the next
Section 2. page.) The relationship seems simple and logical:
• If we eat saturated fat, then it should raise our choles-
Saturated fats
terol levels.
Saturated fats, as you’ll hopefully remember, are hydro- • Foods high in saturated fat are also often rich in
carbon chains that are “saturated”, or filled with hydro- cholesterol.
gens. There are no empty spaces on the chain for any • If we eat cholesterol, then it will also raise our choles-
other hydrogens to bond.
terol levels.
methyl group carboxyl group

178 | Unit 6
Is saturated fat “bad for us”?
If you remember the 1980s and 90s, you’ll remember What really occurred was that:
the “low-fat” craze. Fat (especially saturated fat) became
• People ended up eating a lot more processed
Public Health Enemy #1.
foods.
People tossed out their butter, bacon, and eggs, and
• People focused on the “badness” of a particular
replaced these with margarine, “low-fat” turkey bacon,
nutrient, rather than on eating high-quality, deli-
and cartons of egg whites. They bought “fat free” com-
cious food mindfully.
mercial salad dressings and baked goods.
• People often felt less satisfied with their meals
Ironically, we didn’t really get any healthier. Or slimmer.
(because, as you’ll remember, eating fat releases
Or fitter. (And actually, when you crunch the numbers,
satiety hormones), and ended up eating more
we also didn’t actually lower our TOTAL fat intake, just
overall.
the percentage of total energy from fat).
• People ate more processed sugars and salt to
Meanwhile…
make up for the missing fat, not to mention plen-
• Folks like the French, Greeks, and Scandinavians ty of industrial chemicals that reproduced fat’s
kept eating olive oil, fatty sardines, butter, cream, viscosity and mouthfeel.
fatty meats, full-fat yogurt and cheese… but they
• People focused on the nutrient itself, instead of
seemed perfectly fine.
considering their whole diet in a broader context.
• In many Southern Hemisphere countries like
This last point is perhaps the most important one.
Costa Rica and Vanuatu, they chowed down on
avocado and coconut (not to mention starchy Always look at the big picture.
tubers), and still managed to live healthy lives Always look at a diet as a whole-life pattern — a set of
relatively free of cardiovascular disease. choices we make against a background of social and
• Ethiopians and Mongolians put butter in their cultural norms and environmental conditions.
coffee and tea. In other words, don’t just look at some small part of
• Arctic indigenous peoples like the Inuit ate whale what we eat.
and seal blubber. While Arctic people now have Look at how we eat, why we eat, and with whom
many health issues thanks to modern processed we eat.
foods, they do not seem to have chronic meta-
bolic diseases if they live on their traditionally • Continental Europeans were living it up with
foraged diet. small portions, eaten slowly and joyfully with
others around a table.
• Traditional East African cattle herders like the
Masai drank full-fat milk straight from the cow, • Indigenous, foraging, and / or farming people
not to mention living mostly on meat, milk, and were moving around all day hunting that blub-
blood. ber, herding those cows, or churning that butter.
During the low-fat years, this drove researchers nuts (so • Healthy, long-lived populations were eating a
to speak) in North America. variety of fresh, seasonal foods — often foods they
grew or raised themselves.
How could people around the world eat that “bad stuff”
and stay so lean and healthy? We, on the other hand, were snarfing fat-free Snack-
wells in our cars, spreading industrially created fats on
Scientists even started calling this the “French paradox.” our white bread, and eating second helpings of fat-free
Of course, there are no paradoxes in nature. A “paradox” ice cream for dessert because the first portion didn’t do
means we don’t fully understand what’s happening. the job.
Think about it.

• Raised cholesterol levels will then cause cholesterol to For instance, a 2013 article in the British Medical Journal
be deposited into our arteries. points out that “Now two thirds of people admitted to
hospital with a diagnosis of acute myocardial infarction
• If we deposit it into our arteries, we will then form
[heart attack] really have metabolic syndrome — but
arterial plaques that lead to cardiovascular disease
75% of these patients have completely normal total
(CVD) and coronary heart disease (CHD).
cholesterol concentrations.” It concluded that “high total
As usual, human physiology is more complex than this. cholesterol is not a risk factor in a healthy population.”
In previous units, you learned that: Here’s what we know about saturated fat and health.
• Our own liver (and other bodily tissues) make most of A lot of saturated fat combined with a lot of sugar and
the cholesterol in our body. / or processed / refined carbohydrate (in other words,
methyl group
a low-quality dietcarboxyl
with group
lots of processed foods) is
• Our liver tightly controls the relationship between the
unhealthy.
cholesterol we eat and the cholesterol we make.
• We need cholesterol for many important jobs in our

Saturated fat should be balanced with other fat types
(monounsaturated and polyunsaturated fats).
body.
• Our steroid hormones — i.e., our sex hormones (such Our body seems to know what to do with naturally oc-
as testosterone and estrogen) and mineral or glu- curring saturated fats (for instance, stearic acid, found
cocorticoid hormones (such as cortisol) — are made
in cocoa butter and beef). Many naturally occurring
saturated fats can even make us healthier.
from cholesterol.
But this doesn’t mean, as some types of diets claim, that
So cholesterol is not “bad.” We need it to live. Indeed, ar-
it can be “all bacon, all the time.” Fats are still ener-
tificially decreasing our liver’s cholesterol synthesis (for
gy-dense. And an unchecked intake of saturated fat is
instance, with statin drugs) can cause dangerous side
not the answer.
effects (though it can be a life-saving measure for many).
A recent meta-analysis (a type of study that looks at a Omega-3 and omega-6 fatty acids
bunch of other studies and puts all the findings together)
found that “there is no significant evidence for con- You’ll hopefully remember that
cluding that dietary saturated fat is associated with an we need to get omega-3 and
increased risk of CHD or CVD.” omega-6 unsaturated fatty acids
from our diet.
Other meta-analyses have found that:
• We can’t predict a food’s disease risk by how much Omega-3 fatty acids
saturated fat it has.
• Different saturated fats have different health effects. The most important omega-3 fats are alpha-linolenic
Some, such as the stearic acid that naturally occurs in acid (ALA), docosahexaenoic acid (DHA), and eicos-
apentaenoic acid (EPA).
beef and cacao, may even be good for us.
• Plant sources such as flax, chia, hemp, and walnuts
• Foods that contain saturated fats, especially if they
are rich in ALA.
are processed, have other things in them (such as
sugar and sodium) that probably affect CHD and CVD • Marine sources such as fish (and fish oil) and algae
risk as much or more (especially since that combina- (the original omega-3 sources for fish) are rich in EPA
tion often leads to over-eating). and DHA, which are widely recognized as the most
beneficial omega-3 fats.
• The biggest culprit in many chronic diseases, includ-
ing cardiovascular disease, is excess body fat, which Recall also that we don’t convert ALA to EPA / DHA
leads to systemic inflammation and metabolic disrup- very well, so wherever possible, look for direct dietary
tion from things like insulin resistance. sources of EPA / DHA.

180 | Unit 6
As we’ve seen, cell membranes are fat-based. One reason omega-3 fats are so im-
stearic acid: An 18-carbon portant is that they keep our cells’ membranes more “fluid”, which provides several
saturated fatty acid
benefits. For example:
docosahexaenoic acid (DHA):
An omega-3, polyunsaturated • When brain cell membranes are relatively fluid, messages from neurochemicals
fatty acid, found mainly in fish and such as serotonin can be transmitted more easily. Getting enough EPA / DHA
algae; can be formed from ALA
early in life helps with brain development; getting it later in life helps prevent
eicosapentaenoic acid (EPA): or slow neurodegenerative disorders.
An omega-3, polyunsaturated fatty
acid, found mainly in fish and algae • When muscle cell membranes are more fluid, it increases insulin sensitivity.
These essential fats also play a role in many other areas, including cardiovascular
function, nervous system function, and immune health.
eicosanoids: Signaling molecules Eicosanoids are signaling molecules that help regulate processes such as immu-
of the body that control many nity or inflammation. Both omega-3 and omega-6 intake can affect eicosanoid
systems
production.
Omega-3 fats are considered anti-inflammatory. They tend to promote eicosa-

noids that do things like:
• dilate (open up) our blood vessels;
• lower inflammation;
• prevent blood coagulation and clumping;
• decrease pain; and
• dilate our airway.
Omega-6 fatty acids
Three key omega-6 fatty acids are:

• linoleic acid (LA);
• gamma-linolenic acid (GLA); and
• arachidonic acid (AA).
Omega-6s are considered pro-inflammatory. They promote eicosanoids that do

the opposite of omega-3 eicosanoids, such as:
• constricting blood vessels;
• increasing inflammation;
• causing blood clotting;
• increasing pain; and
• constricting our airway.
These processes may sound unhealthy, but we need them. Without them, we
couldn’t heal from injuries or recover from training sessions.
We mentioned that lipoprotein makeup has a genetic component. Genes may

also affect metabolism of polyunsaturated fats too.
Because of variants in key genes, people from some ethnic groups (particularly

folks with some types of African ancestry) may synthesize more AA and thus
potentially pro-inflammatory eicosanoids. This means that people carrying these
genes can have a higher rate of chronic diseases such as cardiovascular disease,
especially if they eat a lot of omega-6s.
Balancing omega-3s and omega-6s
As you can see, omega-3s effects oppose omega-6s effects. We need them both.
Indeed, fat balance is crucial.
As we’ve emphasized, humans evolved eating diverse diets that included

• marine life (fish, seafood, and seaweed),
• small and large wild game (including insects and reptiles)
• eggs
• nuts and seeds
• various types of plants
Early humans would also eat as much of the animals they caught as possible,
including:
• bone marrow and soft bones
• organs
• brains
• connective tissues such as cartilage
• eyes
• the eggs of fish
• skin and blubber
Not only did this give them abundant micronutrients (such as the minerals
and iron from bone marrow), it also gave them a relatively balanced omega-6 / omega-6 / omega-3 fatty acid
omega-3 ratio. Researchers studying indigenous diets estimate that this would ratio: Balance of dietary fat intake;
critical to overall health
have been around 2:1 to 8:1 in favor of omega-6.
Currently, in North America and western Europe, that ratio is now more like
10:1 to 20:1. We eat fewer foods that naturally contain omega-3s, and more foods
with omega-6s, particularly from oils in processed foods, especially soybean oil.
To improve the omega-3 to omega-6 ratio for yourself and your clients:
1. Eat fewer industrially processed and refined foods and fats (such as corn and
soybean oil).
2. Eat more varied plant and animal foods, especially fatty fish and wild game.
3. Once you’ve addressed the two most important steps above, consider whether
supplementing omega-3s (in the form of fish, krill, or algae oil) might be a
good idea.
We’ll look more closely at specific meal recommendations and supplementation

in Section 2.

182 | Unit 6
Trans fats
trans fat: Unsaturated fat with The trans fats are another group of fats. Their name — trans — is based on the
a trans- isomer fatty acid; created chemical configuration of the double bond in unsaturated fats.
through hydrogenation
Wherever a carbon-carbon double bond exists, there’s an opportunity for either
a “cis” or “trans” configuration. See Figure 6.15. Almost all naturally occurring
unsaturated fatty acids have a cis configuration, although there are a few natural-
ly occurring trans fats.
Most trans fats come from industrial fat processing. This takes an unsaturated fat
(soft or liquid at room temperature) and bubbles hydrogen ions through it until
it’s solid at room temperature. This is known as “hydrogenation.”
There are two types of hydrogenation: full and partial.

• Full hydrogenation makes a saturated fatty acid from a polyunsaturated fatty
acid.
• Partial hydrogenation makes a trans-fatty acid from a polyunsaturated fatty

acid.
You may remember we mentioned earlier that saturated fats are chemically sta-
ble, because all of their hydrogen “parking spots” are full.
Polyunsaturated fats are normally reactive — they quickly oxidize and go rancid,
because other things such as oxygen can bond to their hydrocarbons. But since
hydrogenated fats are polyunsaturated fats that have been artificially “filled up”
with hydrogens, these fats now have a longer shelf life.
Figure 6.15 Trans versus cis fat

While hydrogenation is good for commercial food production, it’s not so good
for our body. Especially the partially hydrogenated trans-fatty acids. Trans fats
don’t kink, or fold upon themselves like cis fats do. They pack into the cell mem-
brane of our body very tightly.
This physical configuration changes how fats are processed in our body. For
instance, eating a lot of trans fats can:
• lower HDL;
• suppress the excretion of bile acids;
• increase our own cholesterol production;
• compete with essential fats for transport into the cells; and thus
• create and worsen essential fatty acid deficiencies.
Over time, this can add up to a higher risk of many chronic diseases. Even
one meal with a high trans fat content can diminish blood vessel function and
elasticity.
In 2015, the FDA concluded that artificial trans fats in processed foods are not
GRAS (generally recognized as safe) and partially hydrogenated oils will need to
be phased out of all food products.
Importantly, the few naturally occurring trans fats, such as conjugated linole-
ic acid (CLA), which is formed in the rumen of cows and sheep, don’t seem to
harm us. They may even help us. As always, eating whole, less-processed foods is
usually best.
Macronutrient 3: Protein
Protein structure
Like carbohydrates and fats, proteins are made up of carbon and hydrogen mol-
ecules. Unlike carbohydrates and fats, proteins also contain nitrogen as part of
their amino groups. α: Alpha; the first letter in the
Greek alphabet.
The smallest unit of protein (similar to the monosaccharide or the fatty acid) is peptides: A molecular chain
the amino acid. All amino acids have four main characteristics (as seen in the composed of two or more amino
Figure 6.16): acids linked by the carboxyl group
of one amino acid and the amino
• an amino group (NH2) on one end; group of another
• a carboxyl group (COOH) on the other end; secondary: Pertains to the folding
of a polypeptide chain, resulting
• a central carbon (called the alpha, α, carbon); and in an alpha helix, beta sheet, or
random coil structure
• a side chain (R group), which differentiates one amino acid from another.
tertiary: Refers to a protein’s
three-dimensional structure by
When amino acids are joined together, they form what are called peptides or complete folding of the sheets and
peptide chains. These peptide chains, or groupings of amino acids, make up the helices of a secondary structure
primary protein structure. held in position by hydrophobic
and hydrophilic interactions
But most proteins aren’t just long chains of amino acids. Rather, these chains quaternary: Refers to the
form secondary, tertiary, and quaternary structures. assembly of multiple folded
protein molecules in a multi-
A protein’s secondary structure is formed as amino acids bind to their neighbor subunit complex

184 | Unit 6
as well as to other amino acids further down the

chain. These secondary structures give proteins
strength and stiffness.
Many enzymes, transport proteins, and immuno-

proteins in the body have tertiary structures, which
are formed when the protein, in secondary structure
formation, loops together to form globular shapes.
When one or more proteins in tertiary structure join

together, we get quaternary structures. Each protein
is considered a separate sub-unit but we need the
entire protein, including this new shape, for optimal
function within the body.
Molecules’ chemical structures are important, but so

are their physical structures and shapes, which can
affect how they behave and fit together with other
Figure 6.16 Basic chemical structure of amino acids
molecules. This is particularly true for proteins,
which can be very large and complex molecules.
You’ve also gotten a sense of how this might work for trans and cis fat molecules.
Within our body’s own structures, and within the foods we eat, most proteins are
found in complex secondary, tertiary, and quaternary forms. But when we digest
complex proteins, we break them down into small peptides and amino acids. We
also judge protein quality based on amino acid content, not structural formations,
since we can then use those broken-down amino acids to build new things.
See Figure 6.17.
Protein digestion, absorption, metabolism, and transport
The stomach
The process of digesting complex proteins down into small peptides and individ-
ual amino acids starts in the acidic environment of the stomach.
gastric hydrochloric acid: Here, gastric hydrochloric acid denatures (breaks apart) the secondary, tertia-
Produced by parietal cells in ry, and quaternary structures of the ingested proteins, while the enzyme pepsin
the stomach, this acid liquid is
necessary for digestion
begins to break down peptide bonds.
Then, the resulting polypeptides and single amino acids are passed along to the
small intestine.
The small intestine
proenzyme: Inactive enzyme In the small intestine, proenzymes (aka zymogens) secreted by the pancreas
precursor that requires a now enter the picture. These chemicals include trypsinogen, chymotrypsinogen,
biochemical change to become
active
procarboxypeptidases, proelastase, and collagenase.
Normally inactive, these proenzymes must be activated (by other enzymes and
chemicals also released into the small intestine) in order to form the enzymes
necessary for carrying out further peptide digestion.

Protein structures
Level Description Stabilized by
Primary The sequence of amino acids in a polypeptide Peptide bonds
Secondary Formation of a-helices and ß-pleated sheets Hydrogen bonding between groups along the pep-
in a polypeptide tide-bonded backbone
Tertiary Overall three-dimensional shape of a Bonds and other interactions between R-group, or between
polypeptide R-groups and the peptide-bonded backbone
Quaternary Shape produced by combinations of Bonds and other interactions between R-groups, and be-
polypeptides tween peptide backbones of different polypeptides
Figure 6.17 Four structures in which proteins are found in the body
This breaks down proteins further to produce small di- peptides are actually absorbed more quickly than free
and tripeptides as well as free amino acids. form amino acids. This is important to note, since large
dietary intakes of free amino acids (usually in supple-
Intestinal absorption ment form) may create a “traffic jam” as these amino
acids “pile up” waiting for transportation. This means
Different amino acids and peptides are absorbed in they get into the bloodstream more slowly.
different ways through the cells of the intestinal brush Once absorbed, these amino acids and peptides can
border. All need ATP for active transport, using carriers. experience one of a few fates.
Amino acids compete for transport by common car- First, in the intestinal cells, some of these amino acids
riers in the small intestine. As di- and tripeptides use can be used for energy or to synthesize new proteins
different carriers than individual amino acids do, short such as hormones, and new digestive enzymes.

186 | Unit 6
Figure 6.18 Protein absorption in the GI tract
glutamine: An amino acid that’s For example, our intestinal cells use the amino acid glutamine for energy. Gluta-
only essential under certain mine also promotes gastrointestinal cell growth. Thus, much of the glutamine we
conditions (certain illnesses and
physical trauma)
eat goes to intestinal cells. If we don’t get enough glutamine from our food, our
body will get it from the plasma amino acid pool and from muscle cells to meet
plasma amino acid pool:
our intestinal cells’ demands.
Reserve of amino acids found in
blood plasma
Ingested amino acids and peptides can also be delivered to the liver (via hepatic
portal circulation) for processing and distribution to other cells of the body. See
Figure 6.18 for the process of protein absorption.
The liver
Most amino acids go to the liver. For every 100 g of amino acids taken in:
• About 20 g will be used for protein synthesis in the liver.
• About 60 g will be catabolized in the liver.
• About 20 g will go into systemic circulation.

For every 100 g

of amino acids Liver 80 g
ingested:
Catabolized 60 g
Protein synthesis 20 g
Remains in liver 14 g
Exported to plasma 6 g
Systemic circulation 20 g
Figure 6.19 On average, this is how 100 grams of ingested amino acids are distributed in the body
Protein synthesized in the liver
Of the 20 g of protein synthesized in the liver: energy, glucose, ketone bodies, cholesterol or fatty acids.
• 14 g of this protein will remain in the liver; and
Exactly what happens here will depend on factors like:
• which amino acid is being broken down (e.g., some
• 6 g of this protein will be exported to the plasma
amino acids can only be used to make glucose);
in the form of plasma proteins (albumin, globulins,
lipoproteins, etc.), glutathione, carnitine, creatine, • what other nutrients are available;
and more.
• how much energy is available (i.e., are we fasted or
Within the liver, proteins can be turned into enzymes fed?); and
and nitrogen-containing chemicals for the liver to use. • what our body needs.
Protein broken down in the liver If our liver needs to make other amino acids, it can
transaminate them (which we covered in Unit 3). After
deamination and transamination you are left with am-
The liver will remove the amino group to produce
monia, which is used for urea synthesis and excreted.

188 | Unit 6
Figure 6.20 Importance of the amino acid pool in maintaining homeostasis
Proteins exported from the liver
Whatever the liver doesn’t use, it sends out to feed the plasma amino acid pool and
other cells of the body. (Review Unit 3 for more on the plasma amino acid pool.)
Of the 20 g of amino acids that pass through the liver to the bloodstream, about
branched chain amino acid 14 g of these are the branched chain amino acids (BCAAs). See Figure 6.20 for
(BCAA): Amino acid with more on the amino acid pool.
aliphatic side chain that is non-
linear
Our body’s cells can then extract amino acids from the plasma for various tasks
such as synthesizing:
• muscle proteins
• skeletal and connective tissues (e.g., bones, tendons, ligaments, cartilage),
• neurotransmitters
• enzymes
cytokine: Hormone-like • immune system chemicals (e.g., immunoglobulins, antibodies, cytokines)

substance secreted by various cells
that regulate immune response • transport proteins (e.g., carrier proteins, lipoproteins)
Where new proteins end up is controlled by genetic signaling and depends on

which amino acids and how much energy is available in the body.

Protein in the diet

As you can imagine from even the brief list of protein’s jobs above, we need
dietary protein to survive and thrive.
As you saw in Unit 3, we are always breaking down and building up new pro-
teins. While we can store carbohydrate and fat, we can’t store protein in the same
way. We’re always losing little bits of aminos along the way, so we need to get
enough protein from our diet to keep the process of protein turnover happening.
Protein: The big picture
We’ll look at some types of protein and amino acids next.
While it’s important to learn about the specific features of each protein type,
keep the big picture in mind.
Focus on these key points:

• Humans evolved eating a varied and seasonal diet. We thrive best on a mix of
amino acids that occur naturally in different types of foods.
• In particular, our body needs a range of essential amino acids.
• This balanced range comes naturally if we choose a wide selection of diverse,

whole, less-processed foods.
• At times, it may be useful to supplement with protein powders, especially for

clients who have trouble eating whole-food protein sources. You may also
want fast-digesting proteins (such as whey or rice) for clients who need quick
replenishment, such as athletes.
• Match your nutrition plan to each client’s unique body, preferences, and
needs.
We’ll give you some more specific recommendations in Section 2.
Amino acids and protein quality
Amino acids are grouped into three general categories.

• We can make 12 amino acids in our body. These are known as non-essential non-essential amino acids:
amino acids. We don’t need to eat them. Amino acid that does not need to
be included in the diet
• We do need to get 8 other essential amino acids from food. We can’t make essential amino acids: Amino
these ourselves. acid that must be included in the
diet
• We may also need to eat extra conditionally essential amino acids
conditionally essential amino
sometimes, particularly when under physical stress (such as from hard athletic
acids: Essential under specific
training, or when we’re sick). We can synthesize these aminos, but not always conditions, for example childhood,
effectively. Or having extras around helps us rebuild tissues when those tissues stress, aging, etc
are damaged.
Almost all foods contain some protein.

190 | Unit 6
Table 6.5 Amino Acids

8 Essential 4 Additional Essential Amino 8 Conditionally Essential Amino
Amino Acids Acids Acids
Cannot be made by the body, must be Required for infants and growing Necessary in special populations with-
obtained from the diet. children. out adequate synthesis.
Isoleucine (BCAA) Arginine Arginine
Leucine (BCAA) Cysteine Cysteine
Lysine Histidine Glycine
Methionine Tyrosine Glutamine
Phenylalanine Histidine
Threonine Proline
Tryptophan Serine
Valine (BCAA) Tyrosine
For instance: All protein adds up. So eating, for instance, beef chili
with beans and guacamole will give you the accumulat-
• A fist-size portion of broccoli has about 3 g of protein.
ed protein from meat, beans, and avocado together.
• A thumb-size portion of peanut butter has about 3 g
of protein. This is important to remember for nutrition coaching:
Your clients can get protein from many sources.
• The average baked potato has about 4 g.
Yet you may have wondered whether some protein
• The average avocado has about 4 g.
sources are better than others. Helpfully, there are
• A cupped handful of quinoa has about 5 g. protein quality indices that measure how well a given
protein source provides the amino acids we need. We’ll
And of course, you may already have a roster of foods look at those in a moment.
that are considered high in protein:
• Lean meat such as beef, pork, wild game None of the measures are perfect. And most are not
important unless you are dealing with clients who are
• Poultry such as chicken, turkey, or duck malnourished. For instance, the Food and Agricul-
• Fish and seafood ture Organization of the UN (FAO-UN) recommends
the Protein Digestibility Corrected Amino Acid Score
• Eggs (PDCAAS). But remember that the FAO-UN is largely
• Dairy such as cottage cheese or strained plain Greek concerned with ensuring adequate nutrition in poorer
yogurt areas of the globe.
• Protein powder such as whey, egg, vegetarian blends Additionally, many protein indices are calculated for
animal feed. Farmers want to know how much their
• Beans and legumes
animals need to eat for optimal growth. So a measure of
• Tempeh or tofu protein quality may not account for human health needs.

So, as always, remember the big picture. Protein Digestibility Corrected Amino Acid Score
• Few people in affluent Western countries will be truly (PDCAAS)
protein-deficient or living on a single food source
such as rice and have to worry about the specifics of
The Protein Digestibility Corrected Amino Acid Score
their protein quality. (Though they may be getting
sub-optimal amounts of protein for performance or (PDCAAS) is the current “gold standard” of determin-
body composition purposes.) ing protein quality, because unlike PER, BV, and NPU,
• For our purposes, protein scores must apply to real
it’s based on human amino acid requirements.
humans in the real world, and represent how we
actually eat, digest, and use proteins in our body.
PDCAAS also accounts for the number of limiting
amino acids in a protein. A limiting amino acid is the
essential amino acid found in the smallest quantity in a
Protein efficiency ratio (PER) particular food.
Protein efficiency ratios (PER) are determined using Once the limiting amino acid is calculated, the PD-
mice or rats rather than humans. CAAS compares the amount of this amino acid in the
test protein versus the amount of this amino acid in a
PER studies look at the relationship between what specif- high-quality reference protein. Then, this value is multi-
ic protein is in the animals’ feed and how big and healthy plied by how truly digestible the protein is.
they get. The PER value is calculated as the growth of the
animal (in grams of bodyweight) per gram of ingested This gives a measure of protein quality that takes several
protein. factors into account.
So the PER is a measure of “feed efficiency” and is re-

Meeting protein needs
ported in comparison to casein as a reference protein.
The “average person” baseline
Biological value (BV)
The average person eating a standard Western diet is
The biological value (BV) of a protein, like the PER val- probably not protein deficient. This is because most of
ue, is determined using studies on rats and mice. The BV these eaters are relatively sedentary omnivores, which
is calculated as a percentage: how much nitrogen goes to means:
tissue building, divided by the amount of nitrogen ab- • They don’t need much protein for repair or
sorbed from the food. In other words, how much protein rebuilding.
did the animal get, and how much of that did it use?
• They are probably including animal products and
Along with the problem of applying rodent data to hu- dairy, both of which are common sources of protein.
mans, BV doesn’t take into account certain factors that
influence protein digestion. It measures how good a pro- Yet “not deficient” does not mean optimal. It just means
tein could possibly be at its best, rather than how useful it people have enough to get enough protein turnover and
is when consumed as part of a normal diet. prevent malnutrition.
For sedentary, generally healthy adults, about 0.8 g of

Net protein utilization (NPU) protein per kg of body mass is enough to cover basic
daily requirements. This translates to about:
Net protein utilization (NPU) was developed to improve
on BV measures. NPU calculations are based on the • 55 g of protein per day for a 150 lb (68 kg) person;
product of biological value and true digestibility, which and
corrects one of the problems of BV measures. In other • 72 g of protein per day for a 200 lb (90 kg) person.
words, NPU looks at not only how good a protein could
be, but how well it’s actually used.

192 | Unit 6
Table 6.6 Protein recommendations

Source Recommended What this means What this means for a
amount for a 150 lb (68 kg) 200 lb (90 kg) person
person
American College of Sports Medicine 1.2-1.7 g of protein per 82-116 g of protein daily 108-153 g of protein daily
kg of body mass
Academy of Nutrition and Dietetics
International Society of Sports Nutrition 1.4-2.0 g of protein per 95-136 g of protein 126-180 g of protein daily
kg of body mass daily
Some other recent research reviews 1.2-2.2 g of protein per 82-150 g of protein 108-200 g of protein daily
kg of body mass daily
Adjusting intake upwards
Remember that protein is involved in repair and rebuild- Recommendations for athletic protein intakes vary. See
ing of tissues, hormones, and our immune system. Table 6.6.
So our protein needs can go up if: We probably don’t need more than 2.2 g of protein per
kg of body mass per day. For most people, even this rela-
• we are training hard frequently (e.g., as athletes) or
tively higher intake appears to be safe, but not necessari-
have a heavy physical job;
ly advisable on a regular basis (the exception might be in
• we are injured or sick, or are recovering from surgery; very rare situations when lean athletes with high levels
and / or of muscle mass are undergoing a calorically restricted
diet).
• we are losing protein for some other reason (e.g.,
chronic physical stress or poor digestion). Indeed, the upper limit (translation: you don’t want to
spend much time in this range) of what healthy livers and
We may also need more protein if we are trying to lose kidneys can handle is around 3.5-4.5 g per kg daily. (Thus,
weight, and thus in a negative energy balance. Protein our 150 lb, or 68 kg, person could theoretically metabolize
helps keep us feeling full longer. around 238-306 g of protein daily.)
What rabbits can teach us about protein metabolism
Protein is pretty important. It can do almost anything: Unfortunately, free-living game is usually very lean, espe-
repair stuff, build stuff, give us energy… cially during the winter. Many Europeans were also not
accustomed to eating animals’ organ meats, brains, bone
You might think that given protein’s powers, an
marrow, and / or eyes, which might have contained some
all-protein diet might be extra-healthy.
valuable fatty acids. So they threw them away.
In fact, we always need some carbohydrate and / or
Thus, many hapless explorers became ill or even died of
fat in our diet to metabolize protein properly. And our
hunger even though they were eating.
liver and kidneys can only process so much protein per
day, although they can adjust over time to changes in This sickness and death from an all-lean-protein diet, a
protein intake. phenomenon well-known to North American indig-
enous groups, has become known as “rabbit starva-
Early European explorers in North America found this out
tion.” (This is also why you should always listen to the
the hard way. When conditions were tough and food was
locals when it comes to regional cuisine.)
scarce, they tried living on wild game such as rabbits.

Adjusting intake downwards • avoid building their diet around cereals, grains and
processed foods, which are often lower in amino
While most clients will do best with slightly more acids or have important nutrients processed out; and
protein, some clients may have health conditions that • be taking a plant-based protein supplement if they
require a lower-protein diet.
are having trouble meeting their protein require-
These can include: ments, and/or are taking in less energy.
• kidney disease
Supplementation
• certain metabolic diseases (e.g., PKU)
• liver disease
Our approach is “Real food first.” Always start with
• problems with gastric emptying real, whole, less-processed foods to give clients the
• homocystinuria nutrients they need.
Remember that you cannot provide medical nutrition Yet many clients struggle to get enough protein. For
therapy. But you can suggest a meal plan that suits their instance:
doctor-prescribed needs (and / or collaborate with their • They may be busy and find it hard to make good
health care team on helping clients implement any spe- protein choices on the go.
cific care providers’ recommendations). • They may be ill or not able to get around easily to
cook and prep whole foods.
Plant-based eaters • They may be athletes who are on the road, traveling
from game to game or training session to train-
ing session (or to work / school between training
People choose plant-based diets for many reasons, sessions).
including the sustainability of their protein sources.
• They may be students who don’t have kitchens in
It takes a lot more energy and resources to produce a
their dorms.
kilogram of beef than it does to produce a kilogram of,
say, kidney beans. These types of clients can get the protein they need by
(By the way, many people are looking to “micro-farm- supplementing with protein powders such as:
ing” — raising “mini-livestock” such as insects — as a • whey
solution to global nutrition and sustainability. Insect • casein
protein is a cheap, easy, and relatively more sustainable • milk protein blend
alternative to other animal protein. Commercial cricket
• egg white
and other insect flours and protein powders are already
available. We predict you’ll see a lot more of this in the • plant-based proteins (e.g., pea, hemp, rice, sacha
inchi proteins)
upcoming decades.)
For your clients who eat a plant-based diet, review the Other supplement possibilities include:
following checklist with them. They should: • Branched-chain (BCAA) supplements (particular-
ly leucine) are good options for clients restricting
• be eating enough energy to meet their needs; energy intake, training fasted, and / or needing some
extra peri-workout and / or post-workout recovery.
• be eating as much variety as possible. This includes a
• Glutamine supplementation can improve immunity
wide range of fruits, vegetables, beans and legumes,
and gastrointestinal health.
nuts and seeds, and tubers;
• Arginine supplementation can improve wound
• include at least a 1 cup of beans / legumes each day. healing.
Legumes are a rich source of lysine, which can be • Lysine supplementation can reduce cold sore severity,
low in plant-based diets. We need 30-45 mg / kg of frequency, and healing time.
lysine per day. This translates into 2-3 grams for a
However, individual amino acids can be effective only
150 pound (68 kg) adult. 1 cup of legumes usually
when there’s a specific need for that amino acid. In
contains about 1 gram of lysine;
Section 2, we’ll discuss this idea more in depth, covering
specific needs-based supplement recommendations.

194 | Unit 6
Case study
About halfway through the year while working with a it was getting a takeout burger for himself and a
Coaching group, we got this frantic email: veggie burger for his wife.
“Coach, • He wanted to support his spouse (and cut down

on dinnertime arguments).
My wife and I eat dinner together each night. It’s a
good chance for us to connect. And lately we’ve been • He wanted to eat healthy foods that met his nutri-
alternating food preparation duties. tional needs, made him feel satisfied, and tasted
good.
About two years ago my wife started eating a plant-
based diet. So, dinners often don’t include meat for • They both wanted meals that were easy to pre-
her. pare and cost-effective.
I’m trying to eat more plant-based meals at dinner as We can work with this.
well (mainly so I don’t have to prepare two dinners). First, we introduced him to a broader variety of foods,
But I’m also a bit worried that I’ll be missing out on and showed him how to build some basic (yet delicious)
important nutrients if I don’t eat meat (mainly protein). meals around beans and legumes, fruits and vegetables,
I’m not quite sure how to prepare a meal that is plant- and nuts and seeds along with a wider range of grains
based and offers balanced nutrition for both me and (such as brown, red, and wild rice; quinoa; millet; ama-
my wife. ranth; buckwheat).
Can you help? Here were the first few recipes we encouraged him to try:
Client” • Falafel with hummus and tahini sauce, veggie

kebabs, and brown rice.
For anyone who grew up in a culture building meals
around animal products, starting to eat meals with less • Lentil / pumpkin seed / quinoa burgers, roasted
of them (or none at all) can be intimidating, even scary. potato wedges, and salad
This is particularly true if people aren’t sure how to make • Black bean chili (including black beans, veggies,
meals that are nutritious, convenient, and — dare we say cashews, and topped with avocado), and corn-
it — actually taste good. bread made with 50% almond meal and 50%
As nutrition coaches, you always look to understand whole grain flours.
your clients first, before making any recommendations. As you can see, these kinds of meals provide plenty of
So before we suggested anything to our client, we asked protein, fat, and other nutrients, mostly from whole
him to tell us more. What did he want out of this arrange- foods. And if our client still wanted to include smaller
ment, and what was he concerned about? amounts of animal protein with those dinners, he could
always cook some on the side and add it only to his
Here’s what we discovered.
plate.
• When his wife cooked, the meal was bland and
The next step was to talk with him about basic protein
boring. It usually revolved around a processed
and fat needs.
starchy food such as pasta, with little else.
We broke down the meals above and showed him their
• When he cooked, it wasn’t so much “cooking” as
nutrient composition. He could see that he was getting

what he needed (not to mention lots of other good stuff And they both felt better financially because they often
from the whole foods). He felt reassured. had leftovers to use later in the week.
Over time, as they both got better at cooking and trying As you can see, being a coach doesn’t just mean know-
new foods, our client and his wife discovered that they ing about “nutrients” (although, of course, that’s a
both enjoyed them. good start). It also means that you’re able to understand
clients’ needs, wants, lifestyles, and most important
He felt better (and more satisfied) after eating
priorities, and work with those to create a real-life action
a nutritionally balanced meal. His wife felt better be-
plan that they can do…and feel good about.
cause he wasn’t getting fast food burgers
and takeout.
Summary
The three macronutrients are carbohydrates, fat, and Most fats in our diet are triglycerides, which is made up
protein. of three fatty acids bound to glycerol. Any type of fatty
acid (saturated, monounsaturated, or polyunsaturated)
Carbohydrates, fat, and protein come in many forms can be part of a triglyceride.
ranging from very simple to very complex molecules.
The makeup of these molecules determines how they All fats are broken down into fatty acids, then reassem-
will be processed in our body. bled into triglycerides.
Simpler molecules are digested relatively quickly. To travel to our cells, triglycerides (and other lipids such
More complicated molecules, such as polysaccharides, as cholesterol) must be transported using lipoproteins.
triglycerides, and quaternary proteins, must be broken When we refer to “cholesterol levels”, we usually mean
down into their most basic components so that we can lipoproteins.
absorb, transport, and use them.
Different fat types have different effects in our body.
All digestible carbohydrates are broken down into Contrary to popular opinion, naturally occurring satu-
glucose, fructose, and galactose monosaccharides. Most rated fats are not harmful.
cells use glucose. The liver can also use fructose.
We must get omega-3 and omega-6 fatty acids from
All indigestible carbohydrates (such as soluble and food. They have opposite effects in our body: omega-3s
insoluble fiber and resistant starch) are either partially lower inflammation, while omega-6s stimulate it. Thus,
digested by our GI bacteria and converted to short-chain getting enough omega-3 to omega-6 is important.
fatty acids, or excreted. They may bind to lipids in the
intestines and help to remove them. Minimize or avoid processed foods, which contain
industrially produced trans fats and seed oils along

196 | Unit 6
with other unwanted things such as refined sugars and leave the liver are used to make up the body’s plasma
sodium. amino acid pool.
We need protein for nearly every metabolic activity. Protein deficiency is rare in industrialized countries.
Because we lose small amounts of amino acids every day, However, many groups of people (such as athletes) need
we need to eat enough protein to keep protein turnover more protein to thrive and optimize key metabolic pro-
healthy. cesses such as recovery and repair. Protein also helps us
feel full longer, which helps people trying to lose weight.
All proteins are broken down into very small peptides or
individual amino acids. Some of this protein is used in Most foods have some protein. Protein adds up from all
the intestinal cells themselves. The rest goes to the liver the foods that we eat.
for processing.
Don’t “eat by numbers.” While each nutrient has specific
Of the amino acids that reach the liver, about 20% (most types and qualities, take a holistic perspective. Treat
of which are BCAAs) are shipped out. An equivalent the body as a system and encourage your clients to eat a
amount (20%) is used to make proteins in the liver and wide range of whole, less-processed foods.
the majority (60%) is catabolized. The amino acids that

UNIT 7
Micronutrients
198 | Unit 7
Unit Outline
1. Micronutrients 6. Phytonutrients and myconutrients
2. Vitamins 7. Zoonutrients
3. Minerals 8. Case study
4. Getting vitamins and minerals right 9. Summary
5. Vitamin and mineral overview
Objectives
Micronutrients are vitamins, minerals, and other com-
• how to recognize the symptoms of micronutrient
pounds such as phytonutrients. We need them — in appro-
deficiencies;
priate amounts — for many metabolic and physiological
processes. • how to recognize the symptoms of micronutrient excess
In this unit, you’ll learn • strategies to correct both of these
• what micronutrients do in our body; You’ll also learn why you should choose whole-food sourc-
es of micronutrients as often as possible.
Micronutrients
We need vitamins, minerals, and other compounds such as phytonutrients (plant
chemicals) to be healthy. But we need much less of them than protein, carbohy-
micronutrient: A chemical drates, and fats. Thus, we call these compounds micronutrients.
element or substance required in
trace amounts for normal growth We also need them in the right amounts.
If we don’t get enough micronutrients, we won’t function properly. We may get

sick, and key processes can break down.
If we get too much (usually from supplements, but occasionally from foods too),
we may also get sick, or disrupt other key processes.
In this unit, we’ll cover:

• the main micronutrients
• their effects
• what you might see when someone is deficient in them, or getting too much of
them
The big picture

When learning about micronutrients, it’s easy to get overwhelmed with details.
Remember that you can always come back to this unit and use it as a reference.

Micronutrients | 199
Indeed, this unit is just an introductory overview. Nature’s biochemistry is vast

and complex — scientists still don’t know all the compounds in food, or what
they do in our body. And even the most common and well-known micronutri-
ents (such as, say, vitamin A or calcium) come in many forms and we sometimes
discover new functions they have.
As you go through this unit, think about the underlying patterns and big picture.
For instance, here are some common themes:

• Eating a wide range of whole, less-processed plant and animal foods can help us
get abundant micronutrients easily and naturally.
• Some foods in particular (such as colorful fruits and vegetables) are treasure
troves of vitamins, minerals, and other phytonutrients. Build your clients’ diets
around these.
• Often, supplementing a particular micronutrient will not have the same effect as
eating a food that contains that micronutrient (but not always).
• Micronutrients often work together.
• Getting a lot of one particular micronutrient can sometimes disrupt the balance
of another.
• Deficiency symptoms (or symptoms of excess) can often seem like other things.
Micronutrient deficiencies and excesses can contribute to nagging, chronic,
often-puzzling health problems.
• Different people will have different micronutrient needs. While “real food” is the
first and most important tool in your nutrition coaching toolbox, some people
will benefit from specific micronutrient supplementation.
Vitamins
The word “vitamin” comes from the Latin vita, or “life.” This is the same word
root as “vitality.” Indeed, vitamins are organic compounds that we need to live organic compounds: Molecules
and thrive. with a carbon component
Vitamins participate in all metabolic processes such as growth, repair, digestion,

energy transfer, nervous system function, and immunity.
One of their most important jobs is as co-factors for enzymes. For instance, you
might recall that vitamin B3 (niacin) is a co-enzyme involved in the formation of co-enzyme: Non-protein
NAD, an electron transporter important to the energy transfer process. However, compound that forms the active
portion of an enzyme system
vitamins don’t give us energy directly, as, say, carbohydrates or fats do.
We need vitamins in our diet, because we can’t make most of them ourselves. fat soluble: Able to be dissolved
Luckily, vitamins are naturally found in food. in fat
water soluble: Able to be
dissolved in water
Vitamin digestion and absorption
bioavailability: The proportion
of a substance that enters
Vitamins are generally categorized as either fat-soluble or water-soluble. This circulation when introduced into
chemical makeup affects how we digest, absorb, use, and excrete them, and thus the body and so is able to have an
particular vitamins’ bioavailability. active effect

200 | Unit 7
For micronutrients, cooking matters
Different methods of food preparation can affect that (or less) available when cooked and / or eaten with other
food’s vitamin content and bioavailability. foods. For example:
• Some micronutrients are most available, and best • We need to eat fat to absorb fat-soluble vitamins.
absorbed, when foods are eaten raw. So put some olive oil, avocado, and / or nuts on
your salad.
• Some micronutrients are most available, and best
absorbed, when foods are cooked. • We need vitamin C to best absorb iron from leafy
greens, so add some fresh-squeezed lemon to
your kale.
absorbed, when foods are eaten with other foods.
• Some micronutrients (e.g. polyphenols) in
grapefruit can enhance the absorption of some
absorbed, when their structures are broken down
minerals (such as calcium, magnesium, phospho-
first (e.g., by cutting or crushing).
rus, copper, and zinc) yet inhibit the absorption
of other substances (such as iron).
For instance… • Chopping or crushing garlic, then letting it sit for

a few minutes before cooking with it, will release
We digest anthocyanins (the blue-red compounds in
allicin, a powerful disease-fighting chemical.
foods such as plums or eggplant skins) relatively quickly,
often even starting in the stomach. Many types of an- You’ll notice here that, as always, people don’t eat “nu-
thocyanins, such as those in berries, are readily available trients.” They eat foods and meals.
when eaten raw. Often, traditional or ancestral diets have figured out
Water-soluble vitamins can be lost in water during how to make the most of micronutrients. For instance:
cooking and storage. This means the best methods to • The famed Mediterranean diet includes both
preserve vitamins include blanching, steaming, sautée- crushed garlic and cooked tomatoes, not to men-
ing, roasting, and microwaving. tion the antimicrobial powers of the phytonutri-
Boiling in water, and then discarding the water, will usu- ents in fresh herbs.
ally mean you lose nutrients. (However, if you keep the • South Asian cuisine does the same and throws in
liquid for something like soup stock, you’ll retain many of some anti-inflammatory turmeric and ginger plus
those nutrients. And again, keep the big picture in mind. painkilling hot peppers for good measure.
Boiled and mashed potatoes are still far superior to fries.)
• Arctic cultures such as Scandinavians and Inuit
Some micronutrients, such as the lycopene in tomatoes make sure to eat fish liver to give them enough
or many carotenoids in yellow / orange / red plants, are vitamin D during the long, sunless winters. (The
often better absorbed when cooked. famous Icelandic sheep’s head dish, or svið, offers
Some micronutrients, such as the minerals in dark phosphorus and vitamin A to brave eaters who
greens or bones, or fat-soluble vitamins, become more consume the eyes.)
As you learn more about nutrition, look at world
cuisines and notice what foods they traditionally put
together in dishes and meals. There may be a reason
beyond just taste!

Fat-soluble vitamins bioavailability. For instance, our body uses retinol more
readily from food than beta-carotene. See Table 7.1. A
Fat-soluble vitamins are mostly absorbed passively in provitamin will need to be converted into a vitamin;
the GI tract. They usually travel bound to dietary fat. this conversion process may limit how much of that end
This means that if we don’t eat enough fat, we may not product we can absorb.
get these key vitamins, let alone effectively transport,
absorb, or use them. Table 7.1
Retinol equivalents for various carotenoids
Once in our body, fat-soluble vitamins snuggle into
Vitamin A source Micrograms of retinol
lipid-based structures, such as our cell membranes, our equivalent per micro-
eyes, and lipid droplets in adipose cells. gram of the substance
Because fat-soluble vitamins live in fatty tissues, we Retinol 1

don’t need to eat them every day. Indeed, they can Carotenoids commonly found in food
accumulate and cause toxicity (for instance, if we beta-carotene 1/12
over-consume particular supplements, or go on a liv-
alpha-carotene 1/24
er-eating spree). Like other lipids, we can also excrete
fat-soluble vitamins through our feces. gamma-carotene 1/24
beta-cryptoxanthin 1/24
Vitamins A, D, E, and K are classified as fat-soluble
vitamins. Literally hundreds of compounds thus fall into the cate-
gory of “micronutrients.”
Water-soluble vitamins
Of course, you needn’t memorize exactly how much of
These vitamins are absorbed by both passive and active any vitamin or its relatives we absorb. Just get the gener-
mechanisms in the GI tract, using carrier proteins for al idea:
active transport.
• Vitamins come in different molecular forms.
Because we’re always taking in and excreting water, we • Those molecular differences affect how that particular
don’t store large amounts of water-soluble vitamins. vitamin form behaves in our body — how we digest,
Thus, we need to get these more often. absorb, use, and / or excrete it.
The B vitamins and vitamin C are water soluble. • Different foods have different vitamin forms. Thus, get-
ting a wide range of foods is important.
Complex compounds
We tend to think of vitamins (and minerals) as single Minerals
things. For instance, we tend to think of vitamin A as
just one type of substance. We pluck minerals from the earth’s skin. Soil and water
contain minerals that plants absorb and use. Animals eat
In fact, many vitamins are more like groups of related the plants. Humans may eat both the plants and the an-
chemical cousins. “vitamin A” covers several molecules, imals. Thus, the health of our environment (particularly
such as retinol, retinal, retinoic acid, and many carot- our soil) determines the quality of our food.
enoids — the chemicals that make foods such as carrots
or peppers yellow, orange, and red. Some of these (i.e., Like vitamins, minerals don’t give us energy directly.
the carotenoids) are “provitamins”, which means that Yet we still need them. They help build body structures
they are converted in our body to vitamins. such as teeth and bones. They help regulate our body
fluids. And they are co-factors in enzymatic reactions, or
A vitamin’s specific molecular form can also affect its perhaps even enzymes themselves.

202 | Unit 7
macrominerals: Minerals We can classify minerals as macrominerals (minerals the body requires in larger
required in larger amounts amounts) or microminerals (minerals the body requires in trace amounts).
microminerals: Minerals
required in trace amounts
Mineral digestion and absorption
We absorb most minerals in our small intestine, either through passive or active
transport. Minerals are already in the simplest form possible: elements. We don’t
need to break them down before absorbing them. Nor will minerals break down
when heated. So unlike often-fragile vitamins or phytonutrients, minerals in
food easily survive storage and cooking.
Factors affecting absorption
Compound type
Usually minerals must bind to other things, such as amino acids, for us to absorb
and use them most effectively. (For instance, we can’t just eat straight-up calci-
um… unless we’re looking for a fiery fiesta upon contact with the water in our
mouth.)
Luckily, Mother Nature has cleverly done this compounding pharmacology

for us. Minerals are best absorbed and used when we eat — you guessed it — a
variety of whole, less-processed foods that contain minerals in their naturally
occurring format, along with other foods that help us extract those minerals.
For example, some foods contain minerals bound to oxalic acid (a compound
known as oxalate) or phytic acid (known as phytate). These forms make it harder
for us to absorb minerals. Yet this is only a problem when those high-oxalate and
high-phytate forms are all we eat — for instance, isolated and poor regions of the
world where the main menu item is rice or corn; or urban and affluent regions
where the main menu item is green smoothies. With a mixed diet, oxalate and
phytate rarely pose problems (and even seem to have health benefits).
On the other hand, many minerals are better absorbed when they work with other
micronutrient “partners.” For instance, phosphate likes to trade places with sodi-
um using the same transporter, and vitamin D enhances phosphate’s absorption.
Fluid balance
electrolyte: Compound that
when placed in solution becomes As biological organisms, we are a chemical soup driven by electrical motors.
an ion; regulates flow in and out
of cells
Thus, we need substances that can help generate and regulate electrochemical
impulses. These substances are known as electrolytes.
ionic state: A given ion’s charge:
positive, negative or neutral We need mineral-based electrolytes such as sodium and potassium to contract
concentration gradient: and relax our muscles, balance our body fluids, and shoot signals across our
Difference in the concentration nerve cells.
of solutes in a solution between
two areas
We can absorb electrolytes from food in an electrically charged state (or an “ionic
hemochromatosis: Hereditary state”). Either the minerals are missing an electron (positive charge) or have extra
disorder that causes the body electrons (negative charge). This lets minerals bond readily with water. In our body,
to retain excessive amounts of
iron, leading to serious health this charged state helps create concentration gradients across cell membranes,
consequences which then lets electrolytes do their jobs.

Imbalances As you read these, remember a few key points:

• There is no one best diet.
As with vitamins, mineral balance is important. You can
have too much or not enough. • Not every person needs the same micronutrients in the
same amounts.
For example:
• Many factors can influence vitamin requirements.
• Eating too little sodium while drinking too much water
can lead to hyponatremia, a dangerous and potentially These factors can include:
fatal condition.
• biological sex;
• If calcium is too high and magnesium too low, you’ll
• age (especially being very young or old);
often get muscle cramps.
• medications;
• If you supplement too much potassium, you risk heart
arrhythmias. • food choices and energy intake;
• stress;
We’ll learn about electrolyte and fluid balance more in
the next unit. • activity levels and intensity;
• pregnancy or menstruation; and / or

This concept can also be important for people who are
taking mineral supplements and want to maximize • illness or injury.
absorption.
For example, when it comes to iron:
For example:
• Women still menstruating should probably include
• Tannins and polyphenols in tea and coffee can inhibit plenty of iron in their diet, especially if they are athletes.
iron absorption. A person taking an iron supplement is
• Yet for men, excess iron can be a problem, since they
usually told to avoid taking it with those drinks.
don’t lose it as readily.
• Conversely, the acidity of vitamin C can change iron
• Too much iron may actually be dangerous for someone
from ferric (3+) to ferrous (2+) form, which we absorb
with primary or secondary hemochromatosis, lead-
better.
ing to overload and organ damage.
Supplements are usually sketchy shadows of real food. • Plant-based eaters may not get enough iron from their
Mineral supplements are no exception. Micronutrients food, since plant-based or fortified food (non-heme)
in whole foods are a symphony of compounds that make
iron is not as well absorbed as animal-based (heme)
beautiful biological music together. It’s hard to duplicate
iron.
that with an isolated supplement.
Indeed, researchers stopped a few large-scale studies Plant-based diets

when they found that certain supplements had the oppo-
site effect than that of food: while the micronutrients in As the example above suggests, plant-based eaters may
food were helpful, the same isolated micronutrients in need extra supplementation. Plant sources of some
supplements were harmful. micronutrients may not be as bioavailable as animal
sources. 100% plant-based eaters may also avoid particu-
larly rich sources of micronutrients, such as dairy, organ
Getting vitamins and meats, or eggs.
minerals right We’ll cover supplementation and special considerations
In the next section, you’ll learn about what each vitamin for plant-based eaters in later units.
and mineral does in the body, and what happens when
we get too much or too little.

204 | Unit 7
Athletes
In general, athletes will need more micronutrients than sedentary people, espe-
cially if they are training hard while trying to lose fat or weight.
Medications
Ask about any medications or other supplements your clients may be taking, as
these can interfere with proper micronutrient absorption.
For instance, oral contraceptives (which many female clients will be taking) can
interfere with vitamin B2 absorption.
Work with your clients’ doctors and pharmacists to check for any potential mi-
cronutrient deficiencies or excesses.
Disordered eating and restriction

Longtime dieters, food restrictors, and clients with various forms of disordered
eating will probably have micronutrient deficiencies.
Indeed, some have speculated that dieting, restriction, and disordered eating
behaviors (such as purging) actually make the deficiencies worse.
The more people do these behaviors, the more micronutrient-deficient they

become. The deficiencies then cause people to keep doing the exact behaviors that
caused the problem, since deficiency symptoms can include:
• anxiety / OCD / controlling behaviors;
• GI upset or loss of function;
• loss of appetite;
• mood disorders (e.g., depression); and
• problems with thinking and reasoning.
It becomes a vicious cycle. The more they do, the worse it gets.
You can’t treat clinical disordered eating within your scope of practice. But
you can consider basic multivitamin / multimineral supplementation as part
of an overall nutrition plan for clients with a history of dieting and disordered
behaviors.
Malabsorption syndromes
Malabsorption syndromes: Malabsorption syndromes occur when our body can’t properly absorb the
A group of disorders marked by micronutrients we eat.
suboptimal absorption of dietary
constituents
This is common with many diseases, particularly those that involve damage to the
ostomies: Artificial opening GI tract, such as Crohn’s disease, ulcerative colitis, celiac disease, or pancreatitis.
created for the discharge of body It’s also a major risk of bariatric or other abdominal surgeries such as ostomies.
wastes
Some other chronic health problems, such as HIV, severe anorexia, cancer, or
alcoholism, can also create malabsorption.

In the case of vitamin D, which we can get from sunlight, deficiency can happen
if we don’t get enough exposure, such as:
• when we spend most of our time indoors;
• when we live in non-tropical regions;
• when we’re extra-diligent with the sunscreen; and / or
• when our skin is dark.
Again, health doesn’t just come from how many micronutrients we eat; it comes
from the micronutrients we absorb and use safely, appropriately, and effectively.
Assessing vitamin and mineral status

Next we’ll look at some common symptoms of vitamin and mineral deficiency.
But never assume anything. Symptoms are just a starting point.
If you’re concerned about deficiencies in your clients, suggest that they get vita-
min and mineral lab tests. This will give you a clear and accurate picture of your
clients’ needs (and potentially allow you to test improvement over time).
Use evidence. If you’re not assessing, you’re guessing.
And, again, if you find deficiencies, work with your clients’ doctors and pharma-
cists to explore potential causes and solutions.
Vitamin and mineral overview

Vitamins
Vitamin A (and carotenoids)
As we touched on earlier, the vitamin A family includes:
• Animal sources: retinol, retinal, retinoic acid; and
• Plant sources: carotenoids — the chemicals that make foods such as carrots or
peppers yellow, orange, and red.
Some of these (i.e., the carotenoids) are “provitamins”, which means that they are
converted in our body to vitamins.
Hypervitaminosis is caused by consuming excessive amounts of preformed hypervitaminosis: Vitamin

vitamin A (retinyl palmitate), not the plant carotenoids. Preformed vitamin A toxicity from excess
is absorbed rapidly but excreted slowly.
It’s involved in:

• Forming pigments in the eye
• Synthesizing proteins
• Immune function and wound healing
• Embryonic development

206 | Unit 7
• Stem cell differentiation We get it from:

• Red blood cell development • Beans and legumes
• Sunflower seeds and tahini (seed paste)

We get it from:
• Marmite
• Red / orange / yellow vegetables and fruits such as car-
rots, pumpkin or winter squash, orange sweet potatoes, • Nutritional yeast
beets, orange melons • Whole grains such as oats and barley (many cereals will
• Dark leafy greens such as spinach, collards, kale, mus- also be fortified)
tard greens
Not getting enough can result in:
• Liver (polar bear liver provides toxic levels of vitamin A,
as it can have 20,000 IU of retinyl palmitate per gram of • B1 deficiency (known as beriberi) which can cause
liver) burning feet, weakness in extremities, rapid heart rate,
swelling, loss of appetite, nausea, fatigue, GI distress,
• Egg yolks
nystagmus (eye twitching).
Not getting enough can result in: • Chronic B1 deficiency in alcoholics, which can lead to
Wernicke-Korsakoff syndrome, with confusion and mem-
• Difficulty seeing in dim light
ory loss. (Alcohol makes it difficult for the body to absorb
• Dry eyes B1 from food).
• Rough / dry skin • B1 deficiency isn’t common today, as many foods are
• Acne fortified. But B1 deficiency is common with malnutrition
and may contribute to symptoms of anorexia (especially
Getting too much can result in: over time, as nutrient intake dwindles).
• Nausea Vitamin B2 (riboflavin)

• Headache B2 helps regulate levels of other B vitamins.
• Fatigue
B2 is only somewhat water-soluble, so it’s not well ab-
• Loss of appetite sorbed. We tend to excrete the excess as bright yellow
• Dizziness urine (which is harmless but potentially entertaining,
especially for clients who may be new to taking vitamin
• Dry skin supplements).
• Birth defects when pregnant (thus prenatal vitamins
Some medications such as oral contraceptives can inter-
contain less vitamin A)
fere with B2 uptake.
Vitamin B1 (thiamin) B2 deficiency (known as ariboflavinosis) isn’t common
Vitamin B1 is found in many foods, so deficiencies are today, as many foods are fortified.
rare. It’s water-soluble and easily excreted, so there’s no However, B2 deficiency is common with malnutrition
known excess or toxicity. and may contribute to symptoms of anorexia (especially
over time, as nutrient intake dwindles).
It’s involved in:
• Producing energy (as a co-enzyme) It’s involved in:
• Synthesizing DNA and RNA • Being part of the electron transporter FAD
• Potentially treating diabetic retinopathy and • Metabolizing drugs and toxins in the liver
nephropathy • Neutralizing hydroperoxides (antioxidant)

• Red blood cell production
• Maintaining health of skin, nervous system, and GI tract
• Purine metabolism Purine: Compound that is the

nucleus of adenine and guanine.
• Iron metabolism Can be synthesized in the body or
consumed in diet
• Red blood cell production
We get it from:
• Soybeans
• Mushrooms
• Spinach
• Whole grains, especially wheat
• Almonds
• Eggs
• Shrimp
• Beef liver
• Dairy (there will be seasonal variations due to what the animals are eating)
• Nutritional yeast

• Damage to mucous and skin membranes, such as mouth inflammation or rashes
• Conjunctivitis
• Light sensitivity (photophobia)
• Anxiety
• Loss of appetite
• Anemia and fatigue
Vitamin B3 (niacin)
A deficiency of Vitamin B3 (known as pellagra) is rare in industrialized regions,
but can happen to people who live in poor regions with limited diets, such as
rural people in South America who may live mostly on a corn-based menu. It can
also happen to people with chronic diseases such as HIV or alcoholism.
Niacin from foods is safe. Toxicity generally comes from supplementing

excessively.
Niacin can be created from tryptophan in the human body.
It’s involved in:

• Making up the electron transporter NAD
• DNA repair

208 | Unit 7
• Maintaining health of skin, digestive system, and nerves • Liver toxicity
• Cellular signaling • Insulin resistance
• Controlling cholesterol levels by influencing lipid syn- • Flushing of the skin (this can also happen when getting
thesis in the liver a normal amount)
We get it from: Vitamin B5 (pantothenic acid)

• Whole grains such as whole wheat and buckwheat Our gut bacteria may produce a little B5 on their own.
• Mushrooms Deficiency is very rare, and excess / toxicity only hap-
• Canned tomato products (such as tomato paste) pens with supplementation in very high doses.
• Beef It may be a helpful supplement for treating acne.

• Fish The name “pantothenic acid” inspired Pantene shampoo.
• Pork
• Chicken It’s involved in:

• Liver from any source • Forming acetyl-CoA. See Figure 7.1.
• Synthesizing cholesterol, steroid hormones, and

Not getting enough can result in: neurotransmitters
• Damage to mucous and skin membranes, such as • Drug metabolism

mouth inflammation or rashes • Maintaining skin health
• Diarrhea
• Dementia We get it from:

• Mushrooms
Getting too much can result in: • Corn
• Nausea • Avocado
• Headache • Peas
• Diarrhea
O- O-
O NH
Pantothenic acid O P CH2
O P O
(vitamin B5)
CH3 C S O O
Acetyl ß-mercapto-
group ethylamine
O
-O P O
3’,5’-ADP
Figure 7.1 Structure of Acetyl-CoA, which includes vitamin B5

• Lentils • Poultry • Fish and seafood
• Egg yolk • Yogurt • Potatoes and sweet potatoes
• Beef liver

• Tingling feet (only in severe malnutrition)
Getting too much can result in:

• Nausea • Diarrhea
• Heartburn
Vitamin B6 (pyridoxine)
It’s involved in:

• Working as a co-enzyme to form PLP, • Red blood cell metabolism
which is needed for more than 100 en- • Nervous and immune system
zymes involved in protein metabolism function
• Glycogen breakdown • Forming neurotransmitters
and steroid hormones
We get it from:
• Potatoes and • Sunflower seeds • Pork
sweet potatoes
• Chickpeas • Beef
• Bananas and
• Spinach • Poultry
plantains
• Fish

• Damage to mucous and skin • Nervous system disorders • Confusion
membranes, such as mouth
• Anxiety, sleeplessness, • Depression
inflammation or rashes
irritability
• Anemia

• Painful neurological symptoms (look for excess B6 from supplementation in people
with things like carpal tunnel syndrome or tennis elbow)
Vitamin B7 (biotin)
Intestinal bacteria can produce biotin.
avidin: A compound found in
Eating a lot of raw egg whites, which contain avidin, can create a biotin deficiency. raw egg albumen that inactivates
Avidin can bind up to four molecules of biotin and carry them out of the body. biotin

210 | Unit 7
It’s involved in: We get it from:

• Forming four vital enzymes known as carboxylases, • Beans and legumes
which are involved in gluconeogenesis, leucine metabo-
• Leafy greens such as spinach, and other greens such as
lism, energy production, and the synthesis of fats
asparagus or broccoli
• DNA replication and transcription
• Chicken liver
We get it from: Not getting enough can involve:

• Nuts and peanuts • Beans and legumes • Anemia
• Sweet potatoes • Egg yolks • Low white blood cells (leukopenia) and platelets
• Onions • Dairy (thrombocytopenia)
• Mushrooms • Liver • Weakness and weight loss
• Cacao (chocolate) • Fish • Cracking / redness of tongue and mouth
• Tomatoes • Pork • Diarrhea
• Whole grains, especially oats • Low birth weight and preterm delivery in pregnancy,
neural tube defects in newborns
• Dry or rashy skin
• Masking Vitamin B12 deficiency (beyond 1,000 mcg of
• Nausea and loss of appetite
supplemental folic acid)
• Hair loss / thinning hair
Vitamin B12 (cobalamin)
• Conjunctivitis
• Depression We can store literally decades’ worth of B12 in our liver.

This is good, because as we age, we often absorb less
Vitamin B9 (folate) B12. In particular, low intrinsic factor (IF) can result in
a Vitamin B12 deficiency. (Folks on antacids or proton
“Folate” is found in foods while “folic acid” is a synthetic pump inhibitors will likely have problems absorbing
supplement. vitamin B12 in the gut and may benefit from a sublingual
supplement).
Folate deficiency is one of the more common in the US.
Folate is particularly important for pregnant women, as This relationship between low IF and low B12 is known
it helps prevent neural tube defects. as pernicious anemia. A symptom is large, immature,
red blood cells with nuclei (mature red blood cells don’t
It’s involved in: normally have nuclei) called megaloblasts.
• Metabolism of nucleic and amino acids as a co-enzyme Only bacteria can produce B12. Yet it’s only found in ani-
• Breaking down and using vitamins B12 and C mal products (thanks to bacterial symbiosis). So plant-
based eaters will need a B12 supplement.
• Forming new proteins
It’s very hard to get too much B12, so there are no real
• Red blood cell formation and circulation
toxicity symptoms.
• Fetal development

It’s involved in:

• Forming and maintaining healthy nerve cells and red blood cells
• DNA synthesis
We get it from:
• Fish and shellfish • Dairy
• Beef (especially liver)
• Neurological problems (including • Loss of appetite and weight loss

poor memory, mania, dementia, and
• Fatigue / weakness
psychosis)
• Depression
• Megaloblastic anemia (a symptom of
pernicious anemia) • Mouth inflammation
Choline
Choline is a water-soluble nutrient that’s often grouped together with the other B
vitamins.
Choline metabolism can vary widely from person to person. Up to half of people
in North America may carry gene variants that make them susceptible to choline
deficiency. Our body’s regulation of choline may also be regulated by estrogen.
Toxicity / excess is rare without supplementation.

intrinsic factor (IF):
However, some people have a genetic condition known as trimethylaminuria, in Glycoprotein secreted by the
which they over-excrete trimethylamine, a byproduct of choline. This will give stomach that enables the body to
absorb vitamin B12.
them a fishy smell, even when eating normal amounts of choline.
It’s involved in:

• Building cell membranes and neurotransmitters (e.g., it’s used in synthesizing
acetylcholine, an essential neurotransmitter for muscle impulses)
• Liver metabolism
• Nutrient transport
• Controlling homocysteine levels in fetus during pregnancy
• Possibly lowering inflammation
We get it from:
• Shellfish • Salmon • Legumes and beans
• Beef and beef liver • Pork • Tomato products
• Eggs • Chicken

212 | Unit 7

• Problems metabolizing fats • Muscle and nervous tissue damage
• Liver disease • Cognitive and memory problems
• Kidney disease

• Hypotension
Vitamin C (ascorbic acid)
It’s involved in:

• Protecting cells from free radicals • Building collagen, an important struc-
(antioxidant) tural protein throughout the body
• Improving iron absorption • Synthesizing norepinephrine and

carnitine
• Regenerating vitamin E supplies
• Metabolizing cholesterol to bile acids
We get it from:
• Most colorful fruits and vegetables • Organ meats (such as thymus)

• Poor wound healing and structural repair (e.g., bruising, slow collagen
rebuilding)
• Poor dental health

• Diarrhea
• A higher risk of kidney stones
Vitamin D (ergocalciferol / cholecalciferol)

Most of our vitamin D can and should come from the sun. (Take note: If you live
north of the line that connects Philadelphia, San Francisco, Athens, and Beijing,
there is a good chance you don’t get enough vitamin D from the sun, especially
in winter). We can’t overdose on sun-based vitamin D, so any excess will come
from supplementation (however, you can get skin damage, so be reasonable).
prohormones: Precursor to a Vitamin D is really a group of prohormones. Vitamin D must be metabolized to

hormone(s) its biologically active form in the body.
• After it is consumed or synthesized in the skin, it enters the bloodstream and goes
to the liver.
• There, it’s hydroxylated to form 25-hydroxyvitamin D.

Major
Source
Minor Source
Dietary intake
Skin
Vitamin D3 (fish, meat)

Vitamin D2 (vitamin supplements)
7-Dehydrocholesterol
Cholecalciferol 25-dihydroxyvitamin D3
Liver
(Vitamin D3)
K
id
ney
1,25-dihydroxyvitamin D3
Increases calcium absorption (small intestine)

Increases calcium reabsorption (kidney)
Increases bone mineralization
Maintains calcium balance in the body
Figure 7.2 Pathways of vitamin D production and its influence on calcium absorption
• In the kidney, a second hydroxylation results in calciferol, or 1,25-dihydroxyvi- calciferol: Vitamin D

tamin D – the most potent form. cholecalciferol: Vitamin D3
• In animals, this forms cholecalciferol, or vitamin D3.
• In plants, this forms ergocalciferol, or vitamin D2.

214 | Unit 7
It’s involved in:

• Maintaining serum calcium levels
• Modulating gene transcription
• Cell differentiation
• Immune system function
• Regulating glucose tolerance
• Regulating the renin-angiotensin cascade and blood pressure
Note: vitamin D can interact with certain prescription drugs
We get it from:
• Fish • Shrimp
• Egg yolks • Beef liver
• Mushrooms • Fortified dairy products such as milk

• In children: Rickets, deformed bones, retarded growth, and soft teeth
• In adults: Low bone density, tooth decay

• Elevated blood calcium • Itching
• Loss of appetite • Muscle weakness and joint pain
• Nausea and / or vomiting • Disorientation
• Fluid imbalance • Calcification of soft tissues
Vitamin E (tocopherol / tocotrienol)

tocopherols: Fat-soluble alcohols The vitamin E family contains eight antioxidants: four tocopherols and four
with vitamin E tocotrienols. Alpha-tocopherol is the chief form found in blood and tissues.
tocotrienols: Vitamin E
compounds Deficiency is rare unless someone is very malnourished.
It’s involved in:

• Scavenging free radicals (antioxidant)
• Cell signaling
• Expression of immune and inflammatory cells
We get it from:
• Nuts and seeds; peanuts
• Dark leafy greens such as spinach, Swiss chard, turnip greens
• Avocado

Not getting enough can result in: • Egg yolks
• Muscle weakness • Grass-fed butter
• Damage to red blood cells (hemolysis) • Chicken, duck, goose liver
• Movement coordination problems (ataxia) • Beef
• Impaired vision • Dairy
• Acne
Getting too much can result in: • Tendency to bleed or hemorrhage; bruising
• Impaired blood clotting (as vitamin E interferes with • Anemia

vitamin K metabolism) • Calcium going to the wrong places: not enough in
bones, but too much in blood vessels
Vitamin K1 (phylloquinone) and
Vitamin K2 (menaquinone)
Vitamin K is a family of fat-soluble vitamins. Two of the • Negating anti-clotting effects from blood-thinning
main forms are: drugs (which work as vitamin K inhibitors).
• Vitamin K1 (plant-based)
Note: As far as we know, there’s no upper limit to K1 or K 2.
• Vitamin K 2 (animal-based) Do not supplement with the artificial form of K3.
In plants, K1 helps with photosynthesis, which is why it’s

found most often in dark leafy greens. Minerals
We can convert K1 to K 2, mostly with our GI bacteria. Calcium
But some other tissues such as testes, pancreas, and arte-
rial walls can convert K1 to K 2 as well. Calcium is the most common mineral in our body. Cal-
cium levels are regulated by complex systems that involve
Synthetic forms of Vitamin K (such as K3) may be toxic. the interplay of parathyroid hormone, calcitonin, vitamin
D, and bone cells such as osteoblasts and osteoclasts.
It’s involved in:
It’s involved in:
• Blood clotting (K1 and K 2)
• Transmitting nerve impulses
• Amino acid metabolism co-factor (K 2)
• Muscle contraction
• Cell signaling in bone tissue (K 2)
• Hormone secretion
We get it from: • Forming teeth and bone
K1: • Acting as a co-factor for enzymes
• Leafy greens such as kale, collards, spinach, turnip

greens, beet greens, dandelion greens, Swiss chard
We get it from:
• Dairy • Rhubarb
• Cruciferous greens such as Brussels sprouts and broccoli
• Dark green vegetables • Fish
• Asparagus
• Beans • Calcium-fortified foods
K 2:
• Nuts and seeds
• Cheese
• Natto (fermented soybeans)

216 | Unit 7
Not getting enough can result in: It’s involved in:

• Poor bone metabolism (e.g., low bone density, rickets • Glucose and fat metabolism; supporting the effects of
in children) insulin
• Muscle stiffness / cramps • Lipoprotein metabolism and oxidation of

macronutrients
• Low blood pressure
Getting too much can result in: We get it from:

• Broccoli
• Nausea and / or vomiting
• Mushrooms
• Constipation
• Potatoes
• Dry mouth and thirst
• Oats
• Kidney problems
• Prunes
• Calcium deposits in the wrong places (e.g., in soft
tissues) • Nutritional yeast
• Beer / red wine

Chloride
• Aged cheese
Almost every whole food (e.g., fruits and vegetables, lean
meats) has some chloride. And processed foods generally • Beef / organ meats
have a lot of sodium chloride (salt).
Copper
Thus, chloride deficiency is rare and only occurs as a re-
sult of excessive fluid loss (e.g., through severe diarrhea You may have heard that wearing copper helps prevent
or vomiting). arthritis. Unfortunately, there’s no evidence that that’s
true.
It’s involved in: Indeed, copper deficiency is relatively rare.
• Maintaining an electrochemical gradient across cell
However, supplementing with high doses of zinc can
membranes (membrane potential) result in copper deficiency by increasing intestinal
• Digestion and absorption of many nutrients (part of proteins that bind and prevent certain metals from being
hydrochloric acid in stomach) absorbed. Also, a high intake of vitamin C supplements
may impair copper absorption. (Note that some herbal
Chromium cold remedies include both zinc and vitamin C, and
people may take high doses of these.)
High-sugar diets can increase chromium excretion
in the urine, which means people may need more
It’s involved in:
chromium.
• Oxidation-reduction reactions and free radical scaveng-
Vitamin C can improve chromium absorption; antacids ing (antioxidant)
and NSAIDs can decrease it.
• Cellular energy production
Although chromium is important for glucose and fat • Collagen and elastin cross-linking
metabolism; and low chromium may increase risk for
chronic diseases, there’s still not enough evidence to • Synthesis and metabolism of neurotransmitters and
support chromium supplementation for health problems myelin
like Type 2 diabetes. True chromium deficiency is rare. • Regulating protein synthesis
Chromium toxicity is generally limited to industrial
exposure. However, long-term supplement use may
increase DNA damage.

We get it from:
• Cacao (dark chocolate) • Beans and legumes
• Mushrooms • Beef liver
• Nuts and seeds • Seafood, especially oysters

• Anemia that doesn’t respond to iron therapy
• Low white blood cell count
• Loss of skin and hair color (hypopigmentation)

• Nausea and / or vomiting • Diarrhea
• Abdominal pain • Liver damage
Iodine
Between iodized salt and fish and seafood consumption (along with seaweed
in some regions), iodine deficiencies are rare in industrialized countries (as is
iodine excess). Yet, iodine deficiencies are amongst the most common worldwide.
Low iodine is possible, especially given that some plant foods contain goitro- goitrogens: Substances that
gens. When iodine is too low, the thyroid swells and tries to harness more iodine, disrupt the production of thyroid
hormones by interfering with
leading to a goiter. iodine uptake in the thyroid
gland
Equipment used to process dairy may be sanitized with chemicals containing
iodine. Thus, higher levels of iodine can make their way into dairy products.
It’s involved in:

• Forming T3 and T4 thyroid hormones
We get it from:
• Saltwater fish and seafood • Dairy
• Seaweed • Eggs
• Iodized salt

• Impaired growth and neurological development
• Decreased production of thyroid hormones, enlarged thyroid

• Burning mouth / throat / stomach, fever
• Diarrhea
• Enlarged thyroid

218 | Unit 7
Iron
Hemoglobin and myoglobin are two proteins that bind with oxygen to move it
around the body. Iron forms an essential part of hemoglobin and myoglobin.
heme iron: Form of iron bound Dietary iron comes in two forms: heme iron and non-heme iron.
with carrier proteins found in
animal products Heme iron comes mainly from the hemoglobin and myoglobin in red meat
non-heme iron: Form of iron (which includes dark-fleshed fish such as tuna, and poultry such as ostrich and
not bound with carrier proteins; duck). Heme is better absorbed than non-heme.
found mainly in plant foods
Non-heme iron is found in plant sources and iron salts. (The story that Guinness
beer is highly nutritious and a good source of iron is, sadly, a myth.)
Vitamin C, organic acids, and meats enhance iron absorption.
On the other hand, zinc, calcium, phytates and polyphenols inhibit iron
absorption.
Iron deficiency is the most common nutritional deficiency worldwide.
This has many causes:

• Plant-based eaters or people whose diet depends heavily on grains may eat iron-
rich plant foods, but not absorb much of that iron.
• Vitamin A deficiency can intensify iron-deficiency anemia, and we need enough

copper to metabolize iron properly and form red blood cells.
• Women need more iron to support menstruation and pregnancy. Yet they
often eat fewer iron-rich foods (and are more likely than men to be plant-based
eaters, or restrict their food intake).
However, iron overload can also be a problem.
Iron can poison children who over-eat vitamin pills. And excess iron is a partic-
ular problem for men. Some people have speculated that our less-active lifestyle
(in which we are less likely to lose blood, bruise, or do hard physical work) may
be out of sync with our evolutionary past, and thus lead to iron overload. Luckily,
men can lower their risk by regularly donating blood.
It’s involved in:

• Forming hemoglobin (which stores about 2/3 of the body’s iron) and myoglobin;
oxygen transport and storage
• Forming red blood cells and blood vessels
• Producing anaerobic energy
• Forming cytochromes involved with cellular energy production and drug

metabolism
• Making up hundreds of proteins and enzymes

We get it from:
• Non-heme food sources • Seeds, especially pump- • Prune juice
kin seeds, sunflower
• Beans and legumes • Heme food sources
seeds, sesame seeds
• Dark leafy greens and tahini • Fish
• Molasses • Whole grains, especial- • Shellfish
• Olives ly brown rice, whole • Organ meats

wheat, teff, amaranth,
• Jerusalem artichokes • Potatoes
and quinoa
• Raisins • Red meats (e.g., beef,
• Dark poultry (e.g.,
pork, wild game)
• Seaweed chicken and turkey dark
• Peppers meat, duck, ostrich)

• Anemia
• Behavioral abnormalities (in children)
• Spoon-shaped nails that curl upwards (Koilonychia) Koilonychia: Dystrophy of the

nails in which they are abnormally
• Low immunity thin and concave from side to
side, with the edges turned up.
• Nausea and vomiting
• Shock; potentially death
• Increased risk of CVD, cancer, neurodegenerative diseases
Magnesium
Magnesium is found mostly in the skeleton, but also in skeletal muscle and
inside / outside of cells.
We need magnesium for many processes. Yet most Americans don’t get the basic
dietary requirements for magnesium. Low-level magnesium deficiency might
play a role in hypertension and Type 2 diabetes. Magnesium also seems to have a
calming effect, making it useful for helping muscle cramps, anxiety, and sleep.
It’s involved in:

• Carbohydrate and fat metabolism
• DNA and protein synthesis
• Active transport of ions across cell membranes
• Phosphorylation of second messengers
• Cell migration and wound healing
• More than 300 enzymatic reactions

220 | Unit 7
We get it from:
• Beans and legumes • Cacao (dark chocolate)
• Dark leafy greens • Potatoes
• Nuts and seeds • Whole grains, especially quinoa, buckwheat,

brown rice, and barley
• Muscle cramps and twitching • Abnormal heart rhythms
• Nausea and loss of appetite • Problems with thinking, moods, and memory

• Diarrhea • Very low blood pressure
• Weakness or sleepiness • Shortness of breath
Manganese
Manganese is found widely in many foods.
Phytates found in many foods can decrease manganese absorption, as can iron,
magnesium, and calcium supplementation.
Manganese excess is rare and limited mostly to industrial exposure (e.g., in

miners).
It’s involved in:

• Carbohydrate, amino acid, and cholesterol
• Antioxidation
metabolism
Proteoglycan: A compound • Proteoglycan synthesis
consisting of a protein bonded
to glycosaminoglycan groups,
present especially in connective We get it from:
tissue
• Tea • Beans and legumes
• Nuts • Dark leafy greens, especially spinach and kale
• Cacao (dark chocolate) • Whole grains, especially teff, oats, and barley
• Seaweed • Okra
• Peppers • Berries
• Garlic and onions • Pineapple
• Mushrooms

Molybdenum
The active form of molybdenum is called molybdenum co-factor.
Since molybdenum helps to get rid of purines, molybdenum deficiency can lead
to increased uric acid in the body and gouty arthritis.
Both molybdenum deficiency and excess are rare.
It’s involved in:

• Carbon, nitrogen and sulfur metabolism
• Nucleotide breakdown
• Metabolism of drugs / toxins (e.g., purines, nitrosamines) nitrosamines: A class of organic

compounds present in certain
foods and products, appear to be
We get it from: carcinogenic
• Legumes • Potatoes
• Almonds and peanuts • Bread
• Oats • Green vegetables
• Yogurt
Phosphorus
Remember ATP? Phosphorus is the P, in the form of phosphate. Every cell in the
body needs phosphorus to function.
Both phosphorus deficiency and excess are rare, except in cases such as severe
malnutrition.
Phosphoanhydride bonds
- O- O-
Phosphoester
O bond adenine
-O P O P O P O CH2
O O O
ribose
Adenosine (ribose + adenine)
Adenosine monophosphate (AMP)
Adenosine diphosphate (ADP)
Adenosine triphosphate (ATP)
Figure 7.3 Phosphorus and ATP

222 | Unit 7
It’s involved in: It’s involved in:

• Bone formation • Maintaining an electrochemical gradient across cell
membranes
• Energy transfer (see image of ATP in Figure 7.3)
• Enzyme activity (ATPase and pyruvate kinase)
• Hormone production
• Enzyme production
We get it from:
• Cell signaling
• Vegetables • Dairy
• Buffering acidity
• Potatoes • Fish
• Helps regulate oxygen delivery from hemoglobin
• Beans and legumes • Whole grains
• Fruits
We get it from:
• Beans and legumes
• Nuts and seeds; peanuts
• Cardiac arrhythmia • High blood pressure
• Cheese (especially ricotta)
(possibly leading to
• Glucose intolerance
• Fish cardiac arrest)
• Kidney stones
• Beef and beef liver • Muscle cramps
• Bone loss
• Eggs
Potassium Getting too much can result in:

• Tingling of extremities
Potassium is the principal cation (positively charged
ion) of the intracellular fluid. (Sodium is the main cation • Muscle weakness
of the extracellular fluid.) • Nausea and / or vomiting
Sodium and potassium are both essential for maintain- • Diarrhea

ing an electrochemical gradient across cell membranes.
• Cardiac arrhythmia
This gradient must be tightly regulated to have healthy
nerve impulse transmission, cardiac function and mus- Selenium
cle contraction.
Selenium is a powerful antioxidant, but it’s easy to get
Potassium works to balance sodium. In fact, some too much. Just six Brazil nuts can contain as much as
estimate that our ancestors ate 10 times more potas- 800 mcg of selenium, exceeding the upper limit of rec-
sium than sodium in their hunter-gatherer diets. This ommended intake. Excess selenium can be a risk factor
balance helps regulate blood pressure. for Type 2 diabetes.
Potassium deficiencies are usually caused by pro- Since selenium appears in a wide range of animal foods,
tein-wasting conditions, severe diarrhea, or the use of selenium deficiency is rarely seen in industrialized
some diuretics. The USDA states that the average Ameri- countries.
can consumes around 60% of their potassium needs.
Potassium excess happens when there is more potassium It’s involved in:
than the kidneys can excrete. This often happens with • Working with selenoproteins, selenium-dependent
kidney failure and potassium sparing diuretics, or with enzymes
potassium supplementation.
• Antioxidation
Excess potassium can be quite dangerous, given potas-
• Deiodination of T4
sium’s role in regulating some of the body’s essential
activities such as heart function.

We get it from: cations: Positively charged ion
• Brazil nuts • Sunflower seeds
• Whole grains (especially whole • Poultry

wheat and brown rice)
• Red meat (including beef and pork)
• Fish and seafood (especially tuna,
• Eggs
shrimp, and salmon)

• Excess oxidation / free radical production
• Juvenile cardiomyopathy (also known as Keshan disease) Keshan disease:

Cardiomyopathy due to the
• Problems in skeletal and connective tissue metabolism and growth deficiency of selenium
• Inflammatory arthritis (Kashin-Beck disease) Kashin-Beck disease:
Degenerative disease of bone,
• Acne (possibly) believed to be caused by
ingestion of cereal grains infected
with a fungus
• Skin problems • Fatigue
• Brittle hair and nails • Nervous system abnormalities
• GI upset • Garlic odor on skin / breath
Sodium
Sodium is the principal cation (positively charged ion) of the extracellular fluid.
(Potassium is the main cation of the intracellular fluid.)
We need both sodium and potassium to maintain an electrochemical gradient

across cell membranes. This gradient must be tightly regulated to have healthy
nerve impulse transmission, cardiac function and muscle contraction.
Thus, our body controls sodium carefully with the renin-angiotensin-aldoste- renin-angiotensin-
rone system and antidiuretic hormone (arginine vasopressin). aldosterone system: A hormone
system that regulates blood
pressure and fluid balance
Most foods have some sodium. Processed foods generally have a lot. Clients eat-
ing a lot of processed foods will almost certainly be getting much more sodium antidiuretic hormone
than they need. (arginine vasopressin):
Pituitary hormone that acts to
promote the retention of water by
In the next unit, we’ll look at what happens when sodium levels drop too low, a the kidneys; and increases blood
condition known as hyponatremia. But in general, high blood sodium usually pressure
results from excessive water loss; low blood sodium usually comes from more
fluid retention.
It’s involved in:

• Absorbing chloride, amino acids, glucose, and water
• Regulating extracellular fluid status, blood volume, and blood pressure
• Maintaining the electrochemical gradient

224 | Unit 7
Not getting enough can result in: iron, dietary calcium, and dietary phytates can impair
zinc absorption.
• Nausea and vomiting
• Headache It’s involved in:

• Cramps • Growth and development
• Fatigue • Neurological function
• Disorientation • Reproduction
• Immunity
• Apoptosis (programmed cell death)
• Increased fluid volume and edema
• Acting as a catalyst in chemical reactions
• Nausea and / or vomiting
• Cell structure and health
• Diarrhea and / or abdominal cramps
• Gene expression
Sulfur
• Cellular signaling and hormone release
Sulfur is the third most abundant mineral element found • Nerve impulse transmission
in our body, and is part of three important amino acids:
cysteine, methionine, and taurine.
We get it from:
Since we get sulfur from foods containing protein, defi- • Beans and legumes • Beef
ciency is rare unless someone is following a very strict, (including peanuts)
low-protein, plant-based diet or has some type of malab- • Lamb
sorption syndrome. • Nuts and seeds
• Pork
• Whole grains (especially
• Poultry (especially dark
It’s involved in: quinoa, rye, and wild
meat)
• Acid-base balance rice)
• Eggs
• Antioxidant • Seafood (especially
oysters) • Wild game
• Liver detoxification
• Mushrooms
• Collagen synthesis
We get it from:
• Delayed growth and • Night blindness
• Protein-dense foods (e.g., meat, seafood, eggs)
sexual maturation
• Hair loss
• Garlic and onions
• Poor wound healing
• Loss of appetite
• Cruciferous vegetables
• Low immunity
• Acne (possibly)
Zinc • Skeletal abnormalities
• Dry eyes
Zinc in animal sources is usually more bioavailable than
that from plant sources. Plant sources may contain zinc Getting too much can result in:
compounds that are not easily broken down, or that
interfere with zinc absorption. • Nausea and / or vomiting
• Abdominal pain
Taking too much zinc can result in copper deficiency.
• Diarrhea
The amino acids cysteine and methionine can improve
zinc absorption. Excessive dietary folate, supplemental • Blocking copper absorption

Table 7.1 Symptoms by body part

If you have... You may be or have... If you have... You may be or have...
Ankles Hands
Swollen ankles Sodium excess Tingling / burning hands Vitamin B6 or potassium toxicity.
Phosphorus deficiency
Pitting edema Vitamin C deficiency
Numbness Magnesium deficiency
Bones
Head
Soft / weak bones Vitamin D, C, calcium, phosphorus,
or fluoride deficiency Headache Vitamin A or B3 toxicity. Sodium
deficiency
Joint pain Vitamin D toxicity. Sulfur deficiency
Dizziness Vitamin A toxicity
Gout Molybdenum deficiency or toxicity
Fever Iodine toxicity
Growth problems Zinc, vitamin D, or iodine deficiency
Heart
Brain
Rapid heart rate Vitamin B1 deficiency
Memory problems, dis- Vitamin B3, B6, B12, choline, or sodi-
orientation or dementia um deficiency Arrhythmia Potassium or magnesium deficiency.
Potassium toxicity
Sleeplessness Vitamin B6 deficiency
Lips
Sleepiness Magnesium toxicity
Cracked lips Vitamin B2 or B6 deficiency
Depression Vitamin B7 or B12 deficiency
Lungs
Eyes
Shortness of breath Magnesium toxicity
Dry eyes Vitamin C, A, or zinc deficiency
Mouth and mucous membranes
Dry eyes with gray spots Vitamin A deficiency
Dry mucous membranes Calcium deficiency
Red or difficult-to-control Vitamin B1 or B2 deficiency
eyes Numbness around Calcium deficiency
mouth
Difficulty seeing in dim Vitamin A or zinc deficiency
light Sore / burning mouth Iodine toxicity
Impaired vision Vitamin E deficiency Excessive thirst Vitamin D toxicity. Calcium deficiency
Sensitivity to light Vitamin B2 deficiency Cracking / redness of Vitamin B9 deficiency
mouth
Conjunctivitis Vitamin B7 deficiency
Increased salivation Choline toxicity
Ears
Taste changes Zinc deficiency
Hearing loss Manganese deficiency
Muscles / tendons
Face
Muscle spasms Calcium, magnesium, or vitamin D
Acne Vitamin C, E, A, zinc, or selenium
deficiency
deficiency
Muscle cramps Calcium, sodium, potassium, or mag-
Feet
nesium deficiency
Tingling / burning feet Vitamin B1, B5, or phosphorus
Muscle weakness Vitamin B9 or B12 deficiency. Potassi-
deficiency. Vitamin B6 or potassium
um or magnesium toxicity
toxicity.
Weak tendons / Vitamin B1 or manganese deficiency
Numbness Magnesium deficiency
ligaments
Gums
Neurological problems Vitamin B12, choline, chromium, or
Sore and spongy or red Vitamin C deficiency manganese deficiency. Molybdenum,
and swollen selenium, or fluoride toxicity
Hair Nails
Hair loss Vitamin B7, C, or zinc deficiency Brittle, thin nails Selenium toxicity
Dry hair Vitamin C deficiency Spoon-shaped nails Iron deficiency
Brittle hair Selenium toxicity Whitened nail beds Selenium deficiency
Hypopigmentation Copper deficiency

226 | Unit 7
Table 7.1 Symptoms by body part (cont)

If you have... You may be or have... If you have... You may be or have...
Neck Stomach
Enlarged thyroid Iodine deficiency or toxicity Nausea Vitamin A, D, B3, B5, calcium, sodi-
um, potassium, zinc, fluoride, iron,
Nose
or copper toxicity. Vitamin B1, B7,
Sensitivity to smell Molybdenum deficiency sodium, or magnesium deficiency.
Skin Diarrhea Vitamin B3 or B9 deficiency. Vita-
min B3, B5, C, sodium, potassium,
Dry, scaly, pale or bruises Vitamin B7 or C deficiency
magnesium, zinc, iodine, or copper
easily
toxicity
Hypopigmentation Copper deficiency
Loss of appetite Vitamin A or D toxicity. Vitamin B1,
Red spots under the Vitamin C deficiency B2, B7, B12, phosphorus, magnesium,
skin’s surface or zinc deficiency.
Scaly, greasy skin Vitamin A or B2 deficiency GI distress Vitamin B1 deficiency. Sodium
excess. Zinc, selenium, fluoride, or
Itchy Vitamin D toxicity
copper toxicity
Tendency to bleed Vitamin K deficiency or vitamin E
Heartburn Vitamin B5 toxicity
toxicity
Constipation Calcium toxicity
Dermatitis Vitamin B2, B3, B6, or B7 deficiency
Teeth
Flushing Vitamin B3 excess
Cavities Vitamin C or fluoride deficiency
Unusual fishy body odor Choline toxicity
Soft teeth, decay Vitamin D deficiency
Unusual garlic body odor Selenium toxicity
Tongue
Increased sweating Choline toxicity
Purple, white, or smooth Vitamin B2 or B6 deficiency
Lesions Selenium toxicity
and slick; painful
Rash Selenium toxicity
Sore tongue Vitamin B6 or B12 deficiency
Jaundice Copper toxicity
Cracking / redness of Vitamin B9 deficiency
tongue
Urine
Excessive urination Vitamin D or calcium toxicity
Brightly colored urine Vitamin B2 excess
Kidney stones Calcium or vitamin C toxicity. Potassi-
um deficiency
Phytonutrients and myconutrients

Plants and fungi are cool. They’re the original chemical • chemicals that fight diseases;
masters, turning soil, water, and (in the case of plants) • chemicals that attract helpful animals such as bees;
sunlight into thousands of organic compounds.
• chemicals that protect against environmental damage;
Over millions of years, plants and fungi have evolved
• chemicals to store nutrients; and even
things like:
• chemicals that help them communicate with each
• pigments that turn them all shades of the rainbow;
other (yes, plants and fungi do communicate… though
• chemicals that repel pests and pathogens; they’re not exactly philosophers).

Many of these chemicals have potential nutritional benefits for us. (And some are
potent poisons.)
Phytonutrients are found in plants (the prefix “phyto” comes from the ancient
Greek phyton or plant).
Myconutrients are found in fungi such as mushrooms (the prefix “myco” comes
from the ancient Greek mykes, or mushroom). Some traditional Northern diets
also include lichen, which is a symbiotic organism made up of algae / bacteria
and fungi. Lichen is now used as a vegan source of vitamin D3.
Like vitamins and minerals, phytonutrients and myconutrients don’t directly

give us energy. Yet they do help keep us healthy and thriving.
We know of over 10,000 phytonutrients and myconutrients so far, and discover

new ones all the time. We don’t know what all of them do. But we do know that
eating a lot of different plants and certain kinds of fungi is good for us.
Phytonutrients and myconutrients do many different things.

• They scavange free radicals as antioxidants.
• They influence hormonal function. For instance, isoflavones in soy and lignans
in flax can mimic estrogen in the body. Liver enzymes that block estrogen action
can be upregulated by indoles, a phytochemical found in cruciferous vegetables.
If you use progesterone cream, it may have come from wild yam.
• They help with DNA repair.
• They help fight bacteria, viruses, and other pathogens, as well as preventing
them from getting a foothold (e.g., the proanthocyanidins found in cranberries
can actually inhibit certain pathogens from adhering to cell walls, potentially
preventing urinary tract infections). Some chemicals in plants may also help repel
pests such as mosquitos.
• They lower inflammation.
• They lower blood clotting and coagulation.
• The inhibit fat synthesis and storage.
This is just a brief overview. We have yet to discover many of the wonders of
nature’s medicine pharmacy.
Phytonutrients and myconutrients work in complex ways. For example, some

work by mildly stressing cells in the body, ultimately making them stronger by
building internal defense mechanisms (this is called hormesis). Given this com- hormesis: Phenomenon of
plexity and how little we still understand, the best sources of phytonutrients and dose-response relationships in
which something (such as a heavy
myconutrients are, as always, whole foods rather than supplements. metal or ionizing radiation) that
produces harmful biological
effects at moderate to high doses
Zoonutrients may produce beneficial effects at
low doses
Zoonutrients are the cousins of phytonutrients and myconutrients. As their
name implies, they’re found in animal foods.

228 | Unit 7
These include compounds such as: As with phytonutrients and myconutrients, zoonutrient
substances can be complex, and interact in many ways
• carnitine
in our body. Often, zoonutrients in whole foods (such as
• creatine meat or dairy) act quite differently than similar nutrients
• carnosine
in supplements.
• conjugated linoleic acid (CLA) Zoonutrients will depend significantly on the animal’s
diet, environment, and age. The healthiest animals raised
These and other zoonutrients can do many things, such in the best conditions (such as pastured beef or chickens,
as: or wild-caught fish) will usually have the most nutrients.
• suppress tumor growth;
As you can probably guess by now, nature is quite the
• lower our risk of heart disease; biochemistry whiz. We’ve just scratched the surface of
what there is to know about vitamins, minerals, and the
• support healthy brain function;
vast array of chemical compounds in plant, fungi, and
• help us build stronger, more powerful muscles; animal foods. And, as you’ll note, a diverse, varied diet
• lower oxidation; and
of whole foods is the best way to get these incredible
compounds. In upcoming units, we’ll teach you how to
• prevent glycation of blood cells. help your clients eat more of these nutrient-rich foods.
Case study
Many people struggle for years with dieting. They try Ensure or nutrition bars) to meet her energy needs.
this diet and that diet, restricting their food intake and
So: She was not only eating less food overall, she was
hoping for the best. At times, they may feel desperate
eating far fewer micronutrients than she needed.
and try more extreme measures.
This led us to a second hypothesis: that the client was
Unfortunately, they often end up disappointed, as
not consuming enough vitamin B12 and her limited
stringent diet plans are not sustainable. And the weight
stores were becoming exhausted. Vitamin B12 deficien-
comes back on.
cy can result in neurological changes and a tingling
But disappointment, regaining weight, and having to sensation in the hands and feet. As our liver stores some
buy one more darn diet book aren’t the only problems vitamin B12, these symptoms might not show up right
serial dieters can have. away.
A woman in her 50s, who’d been diligently working to Since she was in her 50s, it was also likely that she
lose weight for several months, came to see us. wasn’t digesting her food well, and that her stomach
was producing less intrinsic factor (IF). Even if she had
She felt tired. More unsettlingly, her fingers and toes
been supplementing with a vitamin supplement, she
tingled. At first, the tingling was just occasional. Now, it
might not have absorbed B12 properly anyway.
happened more and more.
We proposed our hypothesis: Low vitamin B12 from
We put on our nutritional detective hats and got to
lower energy and micronutrient intake, along with older
work. As all good coaches do, we gathered data and
age. We sent her to her doctor to confirm and collabo-
looked for clues.
rate with our nutritional recommendations.
Was she supplementing too much Vitamin B6? As you’ve
The doctor agreed with our suggestion, and the client
learned, this can result in neurological damage and simi-
began taking a sublingual B12 supplement. Her “tin-
lar “tingling” symptoms in hands and feet.
gling” symptoms quickly disappeared, and she started
No. Our assessment showed that she wasn’t taking to feel more energetic.
any vitamin or mineral supplements besides a calcium
Over time, we kept working with her to help her keep
supplement.
losing weight while eating nutrient-rich whole foods, to
Hmm. ensure she was getting all the micronutrients she need-
ed. Bonus: Since whole fresh foods taste much better
We looked at what she had been eating. Which was not than packaged “diet” foods, she also enjoyed her daily
much. She wanted to lose weight, of course. She also menu much more!
relied on processed calorie-controlled snacks (such as

Summary
Micronutrients are vitamins, minerals, and other Minerals support biochemical processes. Some are elec-
compounds such as phytonutrients, myconutrients, and trolytes that maintain electrochemical gradients across
zoonutrients. cell membranes. Other minerals can act as co-factors and
enzymes.
Vitamins, minerals, and other micronutrients do not
give us energy directly. However, they are involved in People vary widely in their needs for dietary micronu-
almost all biological processes and keep us healthy and trients. Many factors, including health conditions and
thriving. So we need to get them from our diet. medications, can affect how well people absorb and use
micronutrients.
If we don’t get enough micronutrients, we won’t function
properly. We may get sick, and key processes can break If you suspect micronutrient excess or deficiencies in
down. If we get too much (usually from supplements, your clients, get them tested to know for sure. Work with
but occasionally from foods too), we may also get sick, or their doctors and / or pharmacists if you recommend
disrupt other key processes. any supplementation, or want to know how their health
status or medications may interfere with micronutrient
Micronutrients often work together synergistically. Get- absorption and use.
ting a lot of one particular micronutrient can sometimes
disrupt the balance of another. As much as possible, recommend whole foods that are
micronutrient-rich. These include:
Vitamins, minerals and other micronutrients are com-
plex compounds that come in many forms. They are best • colorful fruits and vegetables
absorbed from whole foods, although different foods and • mushrooms
forms of the compounds will be differently absorbed.
• herbs and spices
Thus, what is in our food (or supplements) may not be
what our body actually uses. • lean proteins such as red meat (particularly organ
meats), wild game, poultry, fish, seafood, and eggs
Vitamins are generally categorized as either fat-soluble
or water-soluble because they dissolve well in either • beans and legumes
lipids or water, respectively. Fat-soluble vitamins are • whole grains
stored in fatty tissues and may accumulate, while most
water-soluble vitamins are less well stored and easily • dairy
excreted.

UNIT 8
Water and Fluid Balance

Water and Fluid Balance | 231
Unit Outline
1. The importance of body water
6. Case study
2. Fluid balance
7. Summary
3. Body water imbalances
4. Body water regulation

Objectives
We need water to live. Yet we lose it through many
5. Hydration strategies
processes: respiration, sweating, excretion and, of course,

exercise.
balance to work with specific types of athletes and recre-
In this unit, you’ll learn all about hydration and how our
ational exercisers.
body regulates and balances our fluids. You’ll also learn
how you can use the principles of fluid and electrolyte
The importance of body water
Evolutionarily speaking, we came from the ocean.

Table 8.1 Intracellular and extracellular fluid
Mineral-rich fluid gave us life, let us move around, and
regulated our biological functions. We still carry that Intracellular Extracellular fluid
fluid (ICF) (ECF)
ocean with us.
Found Enclosed within Outside of cell
All of our cells soak in water. Water makes up over half — cell membranes membranes
around 55 to 60% — of who we are. • 25% within vascular
system, makes up
If you are 200 lb (91 kg) and male, you are about 120 lb plasma portion of
(54 kg) of water. blood volume
• 75% known as inter-
If you are 130 lb (59 kg) and female, you are about 72 lb
stitial fluid, which
(33 kg) of water. (And some days, depending on your surrounds cells and
menstrual cycle, it probably feels like more than that.) connective tissues
If you’re a baby, you’re about 75% water. (Congratula-

Makes up About 2/3 of the About 1/3 of the body’s
tions on learning to read so early in life. However, please body’s water water
get a grownup’s help with your nutrition coaching.)
Water is on the inside of our cells as intracellular fluid Higher in Potassium and Sodium and chloride
magnesium
(ICF), and on the outside of our cells as extracellular
fluid (ECF). See Table 8.1.
Lower in Sodium and Potassium and
chloride magnesium

232 | Unit 8
Different cells contain different amounts of water. For moves them around the body. Water brings nutrients to
example: cells and carries waste products away from them. Thus,
we need water to synthesize proteins, glycogen, and
• Bone is about 22% water.
other macromolecules.
• Adipose tissue is about 25% water.
Water as a catalyst
• Muscle and brain tissue are about 75% water.
• Blood is about 83% water. Dissolved chemicals spend much of their time hanging
out in water. Thus, water is the arena for many intra-
• Eyes are about 95% water. cellular metabolic reactions. Indeed, many chemical
reactions need water to happen. Water is a catalyst that
Thus, our body composition (along with other things
speeds up enzymatic interactions with other chemicals.
such as hormones) determine how much water we carry
around. Water as a lubricant
Water has important jobs. As anyone who’s slipped on a wet floor knows, water
• It dissolves other substances. decreases friction. Water lubricates joints and acts as a
shock absorber for the eyes and spinal cord.
• It transports substances.
• It catalyzes (starts) chemical reactions. Amniotic fluid, which is mostly water, protects a grow-
ing fetus from bumping around inside its mother.
• It lubricates tissues.
• It regulates our temperature. Water as a temperature regulator

• It provides minerals. When our body temperature goes up, we sweat. As sweat
evaporates, it cools us.
Let’s look at each one of these now.
Water as a source of minerals
Water as a solvent and transporter
Both seawater and naturally occurring fresh water are
A solvent is a liquid that can dissolve other solids, full of dissolved minerals.
liquids, or gases. You’ll soon see how this is important
when we get to fluid balance. As our drinking water is processed, pollutants are
removed and fluoride and minerals are added. Many
Water dissolves proteins (including enzymes, DNA) and bottled waters add extra minerals.
How can you measure body fat with water?
You’ve probably seen the scales that estimate your body Fat has much less water and fewer electrolytes. Current
fat percentage along with your weight. does not flow well through it. (This is also why our
nerve cells are insulated with a fatty sheath, much like
These scales are based on the bioelectrical impedance
the plastic or rubber on electrical cords.)
analysis (BIA) method, which sends an imperceptible
electrical current through the body. The BIA device then measures your body fat based on
how quickly the current moves through your body.
This current travels differently through water or other
cellular materials. Because they depend on water and electrolyte balance,
BIA scales can be thrown off by how hydrated or dehy-
Muscle contains lots of water and electrolytes. Electrical
drated you are, or your unique mix of fat to lean tissue.
current flows through easily.
So they are not very accurate for many people.

The big picture Fluid balance

In this section, we’ll look at how much fluid we need and Fluid balance is the relationship between fluid coming in
lose. We’ll also look at what things can change our fluid and fluid going out.
balance.
• We take in fluid from food and drinks. We can also ab-
While there are formulas to calculate fluid needs and sorb a little water through our skin, although it stays
losses (which we’ll give you at the end of this unit), don’t there and doesn’t go into the rest of the body.
get too caught up in the numbers. Most of the time, this • We lose water through sweating and the air we
doesn’t need to be an exact science. breathe, and excrete it in urine and feces (plus, if
Just understand the general ideas of fluid balance: we’re ill, vomiting).
• Fluid balance is a dynamic equilibrium between On average, we get around 1 L (4 cups) of water from our
what’s coming in and going out. food each day. This depends on what we eat (see Figure
8.1). For instance:
• Many factors can affect fluid input and output.
• Raw fruits and vegetables are mostly water.
• Some people might need to drink more water than
others. • Cooked whole grains and legumes, since they absorb
cooking liquid, also have some water.
• Our biological cues may differ from actual fluid needs
(at least temporarily). High-fat foods like nuts, seeds, oils, butter, and lard have
• You may sometimes need to drink more, even if very little water.
you’re not very thirsty.
100%
80%
Percentage of water
60%
40%
20%
0%
e
s
gs
s
se
ts
ge
r
in
ea
be
rro
ee
eg
r
an
ga
br
um
ch
ca
or
ar
c
rd
m
cu
ha
Figure 8.1 Water content of various foods

234 | Unit 8
How much fluid do we need? • Thus, if you weigh 50 kg (110 lb), you’d need 1.5-2 L
of water per day.
Of course, along with food, fluid also comes from • If you’re 100 kg (220 lb), you’d need 3-4 L of water
drinks. Our body regulates our thirst so that we take in
per day.
more fluid when we need it.
We get thirstier when: How much fluid do we lose?

• it’s warmer;
Our daily fluid loss balances our fluid intake. We can
• the air is drier; lose water in many ways.
• we’ve eaten something salty;
Breathing and skin evaporation
• we’ve drunk alcohol; and / or
Our nasal passages and lungs moisten the air we breathe.
• we’ve been sweating. Our skin is always losing water through evaporation. We
We are less thirsty when: can’t usually feel this if we aren’t actively sweating, but
it’s happening.
• it’s cooler;
We lose about 0.4-0.5 mL of water per kilogram of body-
• it’s humid; and / or
weight per hour this way. Thus, a 70 kg person would
• we haven’t sweated much. lose about 650-850 mL every 24 hours.
There may be a bit of a “lag time” between losing fluid Sweating

and being thirsty. Even slight dehydration can mean that
we think, focus, and perform worse. We don’t sweat much when we’re comfortable and / or
not moving around. But during intense exercise, espe-
While this is only a minor problem for a person sitting cially in hot climates, we can lose quite a lot of water. The
at a desk in a comfortable room, it can be dangerous for sweatiest exerciser on record is distance runner Alberto
people exercising in extreme conditions, such as heat, Salazar, who sprayed a sweat-soaked trail of 3.7 L — 8
desert climates, and / or high altitude. pounds! — of fluid per hour as he prepared for the 1984
Summer Olympics.
So how much should you drink? Obviously, it depends.
• Most adults need around 3 L (12 cups) of fluid each
Interestingly, scientists have recorded even more fluid
loss — up to 5 L per hour and 11 lb (5 kg) of bodyweight
day as a baseline. Since 1 L (4 cups) comes from
—in hot environments with no exercise. You might won-
our food, this means that 2 L (8 cups) comes from
der how this could be. Some suggest that we can actually
drinking.
lose more water this way, because blood is going mostly
• Bigger people usually need more fluid than smaller to our skin rather than to working muscles.
ones (although babies and children can dehydrate
In general, we sweat out around 0.5-2.0 L per hour of
quickly).
activity.
• People who are sick and losing water through diar-
rhea and / or vomiting will need fluid and electrolyte Excretion
replenishment.
We lose fluid through both feces and urine.
• If it’s warmer and / or drier, you might need 500 mL
(2 cups) more. An average healthy adult needs about 400-500 mL of
water per day for kidney function. This is an absolute
• If you’re exercising hard, you might need up to 6 L minimum. At this fluid intake, our urine becomes
(24 cups) per day. highly concentrated, and we risk kidney stones and
other problems.
Calculating basic fluid needs
If we don’t get enough water, we also tend to become
If you enjoy math, you can estimate fluid needs by body- constipated. Conversely, we may lose a lot of fluid if we
weight. For every kilogram of bodyweight, ingest 30-40 have severe diarrhea (and / or vomiting).
mL of water.

The “magic secret” to fast weight loss?
Later in this unit, we’ll talk about how athletes can purposely and quickly
change their body weights by manipulating fluid levels.
The same trick can be used by low-carb diet promoters.
If you are used to eating a lot of carbohydrates, and you suddenly go low-carb,
you’ll probably lose a few pounds of water in a few days.
This can make it seem like a low-carb diet is the “magic secret” to fast weight
loss.
Unfortunately for dieters, they haven’t lost fat. But fortunately for athletes such
as wrestlers or boxers, they can “make weight” without losing too much lean
tissue.
Conversely, if you aren’t used to eating a lot of carbohydrates, and you have
a high-carb meal or two, you’ll also often notice yourself being thirstier after-
wards (plus retaining water).
Bodybuilders and physique athletes about to go on stage use this water reten-
tion effect to “fluff up” their fluid-depleted muscles at the last minute. If they
time it right, extracellular fluid will stay relatively low but intracellular fluid in
muscles will go up. This makes them look both more muscular and leaner.
Many people losing weight notice that weight loss is not linear. Instead, it often
seems to happen in bursts. People can often be surprised by sudden weight loss
the day after a big meal. Some refer to this as “the whoosh.”
“Whooshes” can seem like a paradox. How can we lose weight after eating
more?
One possible explanation is that energy restriction can cause fluid retention, in
part from changes in hormone levels (such as increased cortisol) or the different
osmolarity of dissolved proteins and electrolytes.
Briefly eating more after a period of eating much less changes the osmotic bal-
ance. Our body rebalances our fluids.
End result: We lose water… and weight.
Thus: Weight fluctuation from changes in fluid balance is one reason the bath-
room scale doesn’t always give us the whole picture.
Body water imbalances

Fluid in versus fluid out is only part of the picture of fluid balance. The other part
is what is dissolved in that fluid, such as electrolytes. Substances dissolved in a
solvent are known as solutes. solute: The minor component in a
solution, dissolved in the solvent
If you understand the basic idea that fluid balance is about fluid in versus fluid
out, as well as the relationship between a solute and its solvent, you can see that
imbalances can happen in two ways:
• Dehydration means there is not enough water, and too much solute. We are
losing more water than we are taking in.

236 | Unit 8
Losses through sweating

(minimal with no exercise)
~100 mL
Losses through feces

~100 mL
Insensible losses through

Losses through urine the skin and respiration
(assuming no excess intake) ~800 mL
~500 mL
Total: ~1500 mL
Figure 8.2 Daily water losses without exercise
• Hyponatremia means there is too much water rela- However, more severe and potentially dangerous de-
tive to solute (in this case, sodium). We are taking in hydration can result from such serious physiological
more water than we are losing (or the water-sodium problems as:
solution is becoming too dilute). • vomiting
We can also have problems with fluid regulation for • diarrhea

other medical reasons (for instance, if the systems that
• fever and sweating
transport fluid break down). If the medical problem
results in water retention, we usually call this edema. • dialysis
• burns
Dehydration • trauma
Dehydration can simply mean that we’re healthy, but • kidney failure
don’t drink enough fluid as we go about our daily-life • diuretics
activities. This type of dehydration is usually mild.

Table 8.2 Percentage of body water loss and consequences

0.5% Increased strain on heart
1% Reduced aerobic endurance
3% Reduced muscular endurance
4% Reduced muscle strength, reduced motor skills, heat cramps
5% Heat exhaustion, cramping, fatigue, reduced mental capacity
6% Physical exhaustion, heatstroke, coma
10-20% Death
• disordered eating
• diabetes mellitus with ketoacidosis
• hypoaldosteronism
• diabetes insipidus (caused by a lack of antidiuretic hormone [ADH])
• and more
Exercise and sweating

We lose both water and salts when sweating. But since we lose more water than salts,
we risk electrolyte imbalance when exercising hard for a long time. Losing even small
amounts of water can affect our athletic performance and energy. See Table 8.2.
Because blood plasma is mostly water, losing water through sweating will lower
blood volume. Our heart must work harder to pump blood through our body.
Heart rate must go up to deliver the same cardiac output. This is a particular
problem for endurance athletes, since their performance depends on an efficient
heart rate.
Our body can, to some degree, control the effects of dehydration. For example,
as we lose more water than sodium, sodium concentrations in the extracellular
fluid go up.
This change in blood osmolarity sends signals to receptors in the hypothalamus osmolarity: Concentration of
(called osmoreceptors), which then triggers thirst. osmotically active particles in a
solution
Symptoms of dehydration osmoreceptor: Sensory receptor
that detects changes in osmotic
We don’t usually notice thirst until we’ve lost about 1-2% of our body water. pressure
Unfortunately, at this point, our performance has already started to suffer. Be-
yond a 2% loss, we can start to see some more serious symptoms of dehydration,
including:
• headache • nausea
• fatigue • flushing
• low blood pressure • rapid heart rate
• dizziness and / or fainting
If this sounds like a hangover to you, you’d be right. Alcohol can suppress hor-
mones that control thirst and body water regulation.

238 | Unit 8
10%
body weight percentage
8%
Water loss as
6%
4% Severe heat
Reduced muscle cramps, heat
2% strength, reduced exhaustion,
Reduced muscular endurance time, heatstroke,
endurance time heat cramps coma, death
0%
Impaired
thermoregulation
Effects of water loss
Figure 8.3 Effects of dehydration on physical performance
If we keep losing fluid without replenishing, these symp- Hyponatremia occurs when the plasma sodium concen-
toms can become more dire. In the worst case, we can tration drops below 135 mEq / L.
die. See Figure 8.3.
There are three common types of hyponatremia.
Unlike many biological stimuli, we don’t “adapt” to • low blood volume
dehydration. We can’t “train” to become better at being
dehydrated. There is no “cure” or “adaptation” to fluid • high blood volume
loss. We must replenish those lost fluids. • normal blood volume
Athletes and exercisers should thus be careful to drink Symptoms of hyponatremia

regularly and expect that they may need more fluid than
they anticipate. Initial symptoms of hyponatremia include:
• GI discomfort (including nausea and / or vomiting);
Hyponatremia • headache;
Hyponatremia means having too much water relative to • swollen hands and feet;
sodium content.
• confusion; and / or
“Hypo” means “low.” The elemental symbol for sodium • restlessness.
is Na. Thus, hyponatremia equals low sodium.
Note that some of these are similar to dehydration
(You may also see hypokalemia, or low potassium symptoms. This mix-up can lead to giving people more
[which has the elemental symbol of K]. The Arabic root water, which makes the problem worse.
of al-qily, which originally referred to ashes, also gives us
the word alkaline.) As brain cell water increases, the brain swells (cerebral
edema). In advanced stages, hyponatremia is a very seri-
Our body prefers to keep blood sodium (and all electro- ous, potentially deadly condition.
lytes) in a narrow range, generally between 136-145 mEq /
L (milliequivalents of solute per liter of solvent).

Table 8.3 Three common types of hyponatremia

Blood Total body
volume water Total body sodium Caused by
 Vomiting, diarrhea, pancreatitis, peritonitis,

Low blood
volume
  Goes down (outpacing burns, rhabdomyolysis, diuretics, osmotic
diuresis, mineralocorticoid deficiency and
Goes down Goes down blood volume and
TBW decrease) salt-losing kidney diseases
Diuretic use, hypothyroidism, glucocor-

Normal blood
volume
   ticoid deficiency, increased antidiuretic
hormone (ADH) and excessive thirst / water
Stays normal Stays normal Goes down
consumption
 Congestive heart failure, liver cirrhosis, var-

High blood
volume
  Goes up (less than ious kidney disorders, and excessive water
Goes up Goes up blood volume and consumption.
TBW
Exercise and hyponatremia

Athletes are particularly at risk for hyponatremia. In their zeal to replace lost
fluids, or perhaps because they feel thirsty during intense exercise, they may
drink too much by mistake. They may also drink too much plain water, rather
than balancing their electrolytes (with, for instance, a sports drink that contains
sodium and potassium).
Other people, too, have died from hyponatremia after drinking too much water.
Notable examples include:
• The university student who died from drinking too much water during a frater-
nity hazing.
• The woman who died from drinking too much water during a water-drinking
contest.
• Several people who died from drinking too much water after taking the drug
Ecstasy, which affects thirst, body fluid balance, and sodium balance.
Thus:
• While fluid replenishment is crucial, don’t over-drink or guzzle a lot of water at
once.
• Plain water is usually fine for normal people under normal conditions, and
when exercise bouts are short or not very intense.
• When replacing a lot of fluid, consider an electrolyte solution (such as a sports

drink or something like Pedialyte) instead of plain water.
Edema
Edema occurs when fluid builds up where it normally shouldn’t, such as in the edema: Swelling from fluid
extracellular space of tissues. This can happen in any body part, such as: accumulation

240 | Unit 8
anasarca: Massive edema in • system-wide edema (sometimes known as anasarca);

subcutaneous space
• our hands, feet, and legs (known as peripheral edema or pitting edema);
• around our heart and lungs (known as pulmonary edema); and / or
• our brain (known as cerebral edema).
Edema is also common in the later stages of pregnancy.
Edema may be related to electrolyte imbalances, but more often it’s a result of
a variety of health problems. While most medical conditions that cause edema
(such as kidney disease or heart failure) are beyond your scope of practice as a
nutrition coach, there is one interesting case that is relevant: nutritional edema.
Nutritional edema
Starvation and malnutrition can cause edema, or water retention. As hunger
and famine have always been with us, humans have known this for thousands of
years.
In 700 BCE, for instance, the Greek poet Hesiod described the stark contrast
between lean faces and swollen hands of starving people. Originally known as
“dropsy”, edema appears anywhere there is hunger: famine, crop failures, malnu-
trition, and among people just barely surviving on meager, nutritionally limited
diets.
Orthorexia: Obsessiveness Sometimes it was called “war dropsy” to describe what happened to soldiers
about the quality of the food
and civilians whose food supplies were cut off. A report on the defeated French
being ingested, ensuring that
it’s the most healthy, organic, etc. army at Naples in 1528 described starving soldiers with “swollen legs and bloated
bellies.” A 1917 medical article describes the phenomena among POWs captured
by the Germans, who called it Kriegsoedem (war edema).
A post-WWI medical article from 1920 notes that “war dropsy” often goes
with “emaciation, muscular weakness, depression, anemia, and very frequently
gastro-intestinal disturbances.” While most of us are not living in war zones or
famine-blighted regions, we can recognize these symptoms in restrictive dieters,
people missing key food groups in their diets, and people with disordered eating.
In the 21st century, we typically call this nutritional edema. It can have many
causes. Here are a few.
Not enough protein

Kwashiorkor, or severe protein deficiency, is a common problem of childhood
malnutrition.
A Jamaican pediatrician who first described the phenomena in the 1930s sug-
gested the name should come from a Ghanaian term: “the sickness the baby gets
when the new baby comes.” In other words, the malnutrition that results when
an older baby is weaned off nutrient-rich breast milk to accommodate a new ar-
rival, and then must subsist on a high-carbohydrate diet without enough protein.

Kwashiorkor doesn’t just happen in poorer regions of the

globe. In the United States, there have been dozens of cas-
Body water regulation
es of well-meaning parents who have placed their children Body water and electrolyte levels are regulated by the bal-
on “special” diets, with disastrous results. (Mineral-defi- ance between water intake and water excretion through
cient diets can have similar edematic effects.) the kidneys. Both thirst and kidney excretion are, in turn,
influenced by:
One of kwashiorkor’s most distinctive symptoms is a
distended belly. • pituitary hormones such as ADH;
• adrenal hormones such as aldosterone; and

Proteins dissolved in water create what is known as the
colloid osmotic pressure. This balances the osmotic pres- • concentrations of blood osmolytes (soluble substanc-
sure of dissolved electrolytes, and helps regulate fluid es that can affect osmosis, such as ions, proteins, or
movement and absorption. With no protein to balance other molecules).
the osmotic gradient and pull water back into the blood-
stream, fluids pool in tissues. These mechanisms stimulate thirst when body water vol-
ume is low or solute concentrations are high. In addition,
Malabsorption they may slow down urinary excretion to conserve water.
Many malabsorption syndromes, such as Crohn’s They also stimulate urinary excretion (and decrease
disease, IBD or celiac disease, can interfere with proper thirst) when body water volume is high or solute concen-
nutrient absorption. This can result in edema. trations are low.
Restrictive dieting Generally, when we are healthy and these systems are
working well, we regulate our body fluids and electro-
The restrictive dieting of lifetime yo-yo dieters, severe lytes effectively.
orthorexics, physique athletes such as bodybuilders,
people doing intermittent fasting, and other forms of
disordered eating can also create nutritional edema. Antidiuretic hormone (ADH)
In some cases (for instance, physique athletes), protein Ever wonder why bars serve salty snacks? More salt
deficiency may not be the main problem. means more thirst, which means buying more drinks.
In others (for instance, extreme “raw” vegans), protein Here’s how the process works.
deficiency may play a role.
1. When blood levels of sodium go up (for instance,
What to do with nutritional edema after having a few handfuls of pretzels at your local
pub), this creates higher blood osmolarity. Our blood
Many causes of nutritional edema are outside of your becomes “salty.”
scope of practice unless you are licensed or otherwise
certified to treat them. 2. This triggers osmoreceptors in the hypothalamus,
which stimulate thirst while also stimulating the
However, if a client complains of water retention, puffi- release of ADH.
ness, swollen ankles, etc., pay attention. At the very least,
you can: 3. ADH reduces fluid output through the kidneys.
• help your client understand that chronic water reten- 4. Thus, we bring in more fluid (because we’re thirsty)
tion may be a symptoms of a more serious problem; but excrete less fluid (thanks to ADH’s effects on the
and kidneys).
• suggest that your client discuss this (and any other 5. More fluid coming in + less fluid going out = less
possibly related symptoms) with their doctor. salty blood. Body is happy.
ADH, also referred to as arginine vasopressin or AVP,

242 | Unit 8
Low water and/or high sweat

triggers the posterior
pituitary to produce ADH.
ADH
Aldosterone
High blood potassium,
low blood volume, and
low blood pressure
stimulate the adrenal
gland to secrete
aldosterone.
Kidney conserves
and reabsorbs water.
Figure 8.4 Mechanisms of body water conservation
is a powerful controller of water and salt levels in the rennin, the enzyme in rennet, a substance derived from
body. Anything that lowers body water or increases cow stomachs that is used in the production of cheese.)
relative sodium levels (such as sweating) can stimulate
ADH release. Then, the release of renin will eventually lead to the
release of angiotensin II, which constricts blood vessels
(aka vasoconstriction) and thus increases blood pressure.
Renin-angiotensin system Angiotensin II can also interact with the central nervous
system to stimulate thirst and to reduce fluid excretion.
As ADH slows kidney flow, this activates the renin-an-
giotensin system. Aldosterone, which is also part of the renin-angiotensin
system, is a hormone secreted by the cortex of the adrenal
First, the kidneys secrete renin. The prefix “ren” comes glands (which sit atop the kidneys). Its job is to help the
from ren, the Latin word for “kidney.” This also gives us body retain sodium by increasing how much sodium our
words like “renal.” “Angio”, derived from the Greek word kidneys re-absorb. Since sodium pulls water in the direc-
for “vessel”, typically refers to the circulatory system. tion it’s headed, aldosterone helps to conserve body water.
(Note: Renin, with one n, should not be confused with

Aldosterone is released in response to: All of these signal that our body needs more fluid. Al-
dosterone is also generated in response to high levels of
• low blood volume, and / or
angiotensin II. See Figure 8.4.
• low blood pressure, and / or
• a high potassium concentration in extracellular fluid.
Should hypertensives eat less salt?
Because angiotensin II raises blood pressure in response so by inhibiting the formation of angiotensin II. Angio-
to high sodium concentrations, you may have heard tensin II is formed from angiotensin I when angiotensin
that people with high blood pressure should lower their converting enzyme (ACE) acts on it. Drugs known as
sodium intake. This is one possible method of keeping ACE inhibitors can thus prevent angiotensin II formation
angiotensin II under control. by blocking the action of ACE that’s required to convert
angiotensin I to II.
Indeed, some people have speculated that high blood
pressure is exacerbated by the availability of processed Since angiotensin II helps to preserve water in the
food, much of which is high in sodium. body, including maintaining plasma volume, prevent-
ing the formation of angiotensin II reduces this fluid re-
Drugs are another method of lowering blood pressure.
tention, getting rid of body water and plasma volume,
One of the medications that lowers blood pressure does and thus reducing blood pressure.
Why don’t I have to pee as often in the middle of the night?
Like many hormones, aldosterone has a natural ebb and Shift workers sometimes note that they have to go to
flow. It’s pulsatile, which means it’s released in small the bathroom more often during a night shift. This is,
bursts. perhaps, because they aren’t getting their normal noc-
turnal aldosterone pulses.
Likewise, our blood pressure naturally goes down at
night, with circadian changes in the renin-angiontensin If your evening involves some alcoholic drinks, you’ll
system. Indeed, slow-wave sleep can actually predict also probably notice a few runs to the bathroom. Alco-
hypertension: The less deep sleep we get, the higher hol briefly suppresses aldosterone. This means you’ll
our blood pressure will likely be during the day. urinate more for a while, then (if you haven’t replaced
your fluids) become dehydrated. Result: hangover.
Aldosterone pulses also correlate with sleep, especially
deep sleep. As we sleep through the night, we drop in We all know sleep is important. But because of its pow-
and out of deeper sleep cycles. As we enter a deep sleep erful effects on the renin-angiotensin and aldosterone
cycle, we also release a pulse of aldosterone. systems, getting Zs can also affect our fluid balance and
healthy blood pressure.
This helps ensure that our deep sleep periods don’t get
interrupted by having to go to the bathroom.

244 | Unit 8
Fluid and the menstrual cycle
As most women know from experience, menstrual In theory, this should mean that women lose water
cycles (and pregnancy) can significantly affect fluid when progesterone goes up. And in fact, this does hap-
balance. pen in women who supplement extra progesterone.
Because they have the same chemical origin and similar In contrast, when progesterone goes up endogenously
structures, our sex hormones interact with aldosterone, (i.e., is only secreted by women’s bodies, rather than
and can often even act on aldosterone receptors. (This being supplemented exogenously), women’s bodies
includes many hormonal contraceptives and hormone may compensate with increased aldosterone. In other
replacement.) words, since the body knows that progesterone will
be blocking aldosterone, it makes more aldosterone to
Aldosterone levels and progesterone levels go up during
balance things out.
the luteal phase of the menstrual cycle (the period after
ovulation, before menstruation begins). The result, once again: Feeling sloshy, craving salt, failed
attempts to zip up jeans, and avoiding the bathroom
Indeed, many women complain of feeling bloated or
scale.
puffy, or gaining weight, during this time as aldosterone
decreases urinary output (leading to fluid retention). During their reproductive years, women are much less
You may already have heard this from many of your likely than men to have high blood pressure, thanks to
female clients or noticed this in yourself, if you’re female the regulating and possibly protective effects of ovarian
and cycling — a premenstrual weigh-in is not always a hormones such as estradiol.
happy event.
But after menopause, these hormones go down and
However, progesterone (which goes up after ovulation, renin activity goes up. Thus after menopause, women’s
in the second half of the cycle) inhibits aldosterone hypertension risk is nearly the same as men’s. And older
binding to the mineralocorticoid receptor. women may also notice more water retention overall.
Macronutrients Electrolytes
Dietary carbohydrate and protein also affect fluid Electrolytes are minerals such as sodium, potassium,
balance. chloride, calcium and magnesium that carry an electri-
cal charge (positive or negative) when dissolved in water.
Carbohydrate These charged ions conduct electrical currents that let
fluid pass through cellular membranes. Essentially,
As we briefly mentioned, carbohydrate storage increases
they’re electrical transporters.
water storage in the body. (Ever noticed that the word
“carbohydrate” contains the word “hydrate”?) Every process in our body depends on electrolytes. We
need them, and we need them in the proper balance. As
For every gram of stored carbohydrate (glycogen), we
with energy balance or water balance, electrolyte balance
also store 3-4 grams of water.
is about input versus output.
Thus, again:
• On higher-carbohydrate diets, we store more water. We take in electrolytes in our food and drinks.
• On lower-carbohydrate diets, we store less water. We can lose electrolytes in our urine and sweat, but not
as much as we lose water. But if we sweat a lot, we lose
We also store less water when we eat more protein, enough electrolytes for it to matter. Urinary excretion of
because our body must remove urea, a byproduct of electrolytes depends on intake: The more electrolytes we
protein / amino acid deamination. See Unit 3 for more consume, the more we lose through urine.
on deamination.

1 2 3 4 5 6 7 8 A urine chart such as this can

help you assess a client's
hydration status (level of
dehydration) in extreme
slightly yellowish
environments.
gold brown
light brown
dark brown
colorless to
soft yellow
dark gold
pale gold
If the urine sample matches
#1, #2, or #3 on the chart,
gold
they are well hydrated. If
their urine color is #7 or
darker, they are dehydrated
and should consume fluids.
Figure 8.5 Urine color and hydration status
Thus, again, if we are sweating a lot, we will need to

replace both fluid and electrolytes. (You will hopefully
Hydration strategies
remember that over-consuming fluid without electro- Match the plan to the client
lytes can throw off the fluid balance.) Yet here again, we
needn’t be overzealous. As a nutrition coach, you’ll see all different kinds of
clients.
Replenishing electrolytes for exercisers
You’ll have endurance athletes pushing their limits
Athletes and exercisers who need fluid and electrolyte outdoors in hot, dry climates and / or high altitudes.
replacement can simply drink a diluted carbohydrate
drink that also contains electrolytes. You’ll also have beginners who have never done any-
thing physically active, who start their exercise program
Taking in carbohydrates during and after exercise can: by walking slowly on an indoor treadmill for 5 minutes
• improve how quickly fluid is absorbed; per day. And, of course, you’ll probably have everyone in
between. So: Match the hydration plan to the client.
• enhance endurance;
Remind the treadmill walker to have a glass of water
• increase blood glucose and glycogen synthesis;
with their meals, and / or whenever they feel thirsty.
• lower the stress response and inflammatory damage
of training; For the elite endurance athlete, you may want to cal-
culate their hydration needs based on bodyweight, and
• improve immunity; make sure they get carbohydrates, electrolytes, and
• enhance whole body hydration; and protein in all their recovery drinks.
• improve muscle and liver glycogen synthesis. Safe hydration and proper fluid-electrolyte balance is
important. In extreme cases, your client’s life could
However, this drink should be dilute, ideally less than depend on it. Thus, if you’re ever unsure about a hydra-
10% concentration. More concentrated solutions will not tion situation, or feel it’s outside your knowledge base
only absorb slowly, they’ll likely cause GI upset. (Not (for instance, IV-rehydrating a pro MMAer), refer out to
something you want during a hard training session or a specialist.
competition!)
You can make an informed guess about someone’s
If appropriate, you can also add protein to carbohy- hydration status by using simple color charts like the one
drate-electrolyte drinks. This will do many of the same in Figure 8.5.
things as a carbohydrate drink, with the added bene-
fits of more muscle protein synthesis and less protein
breakdown.

246 | Unit 8
Factors affecting hydration types General hydration requirements

The baseline For moderate-intensity activity under 2 hours
For normal people who aren’t exercising, and who are and / or high-intensity activity under 1 hour
spending their time in comfortably temperate environ-
Step 1: Consume 0.5-1 liter (2-4 cups) of water during
ments: About 2 L (8 cups) of water per day along with
activity.
water-rich whole foods (such as fruits and vegetables)
should be enough. Step 2: Consume 0.5-1 liter (2-4 cups) of water after
workouts.
Step 3: Consume 0.25-0.5 liter (1-2 cups) of water at
When to consider sports drinks
each meal.
For average people, plain water is just fine.
But in some situations, sports drinks that contain glu- Add-ons

cose and electrolytes can help exercisers replenish and For recreational exercisers who want a little extra re-
recover, including: covery boost: Add 10-15 g of BCAAs to Step 1 or 2.
• hot, dry, and / or high-altitude climates, which in- For clients who need to gain weight or who want to
crease fluid needs and electrolyte losses; gain a lot of muscle mass: Add a protein + carbohydrate
• repeated bouts of training (e.g., multiple daily train- drink during workouts. The general formula: 30-45 g
ing sessions or competition rounds); carb + 15 g protein in 500 mL-600 mL water every hour
during training. (You don’t have to get it perfect, but
• endurance training; if the drink is too concentrated it can upset the stom-
• high intensity training; and ach, and if it isn’t concentrated enough it won’t be as
effective).
• professional / elite athletes (who train more and hard-
er, and need more recovery).
For moderate-intensity activity lasting longer
Keep the big picture in mind than 2 hours and / or high-intensity activity
lasting longer than 1 hour
Next, we’ll give you some specific guidelines for particular
Step 1: Consume 0.25-0.5 liters (1-2 cups) of water 30-
types of clients in particular situations.
60 minutes before activity.
Remember that most of these are higher-level strat- Step 2: Consume 30-45 g carb + 15 g protein + elec-
egies. Most beginner clients, or clients who struggle trolytes (sodium & potassium) in 600 mL water
with consistency, will not need these strategies. Nor every hour during activity.
will they need this level of detail. Step 3: Consume 30-45 g carb + 15 g protein +
electrolytes (sodium & potassium) in 600 mL
One easy and simple way to both remind your clients to afterwards.
drink enough and to advertise your services is to get a Step 4: Consume 0.25-0.5 liters (1-2 cups) of water at
large refillable water bottle with your name or coaching each meal.
practice logo on it. As one of their regular habits, ask
them to fill up the bottle once or twice during the day, Implementation tips
then keep it near them. They’ll drink more, and remem-
ber you as well. Most clients won’t need this type of strategy, which
applies mostly to:
Or you can just start by asking your beginner clients • clients who are training or competing in multiple
to drink a glass or two of water with each meal. Start
bouts (such as a day-long tournament); and
simply. You can always make things more complex
later. You want your clients to succeed immediately and • clients who are training relatively harder and / or
consistently. longer, such as triathletes and long-distance adven-
ture racers.

Advise them to sip, not chug. First, their GI tract will get sick when trying to rehydrate, as their stressed GI
thank them. Second, we can only absorb about 1.5 L (6 tract rejects the fluid, carbohydrates, and electrolytes.
cups) of liquid per hour.
The most successful water manipulation and weight
They don’t have to get the numbers perfect. They should cutting practices use the physiology of fluid balance.
try to get close, though. Err on the side of more dilute. Athletes can drop water weight quickly and effectively
If a hydration drink is too concentrated, it might cause for competition by manipulating their fluid, carbohy-
stomach upset. drate, and sodium intakes.
You can find recipes to create your own formula for The big picture
these recovery drinks, or advise your clients to buy a
preformulated drink. The general guidelines below give you a starting point,
which you can then customize to meet the needs of dif-
Endurance athletes who will be sweating a lot need more ferent athletes, different goals, and different bodies.
electrolytes. This is one of the reasons many companies
have an “endurance” line of supplements. As you read through these guidelines, make sure you
understand why and how they might work.
Body water manipulation for For instance: Why does drinking a lot of water for a
physique contests, weigh-ins, and few days, then drinking much less, cause an athlete to
lose weight? What homeostatic mechanisms might be
photo shoots operating here?
Bodybuilders, fitness athletes, models, and weight- Also remember: This type of water manipulation is rel-
classed athletes are masterful manipulators of fluid atively safe… but not without risks. As we’ve seen, fluid
balance in the body. balance affects every process in the body. If you suggest
these protocols to clients, make sure to monitor them
For physique athletes, water manipulation creates the il-
closely and stop the process if any symptoms of fluid
lusion of leanness plus muscularity. When water balance
imbalance become serious. No competition or fight is
is just right, paper-thin skin stretches across bulging
worth serious physical damage.
muscles.
Weight-classed athletes such as powerlifters or grap- Sex differences

plers play with body size and strength. A heavier body A quick note: You may see sex differences in water ma-
is a stronger, denser, and more muscular one. This puts nipulation and weight cutting.
naturally lighter opponents at a disadvantage.
• Women’s normal hormonal changes may cause
Thus, the trick here is to be as heavy as possible in real them to retain or release water at different times in
life (known as “walking-around weight”) while weighing their cycles.
in as light as possible for the few moments it takes to step
• Women tend to have more body fat than men, which
on a tournament’s weigh scale.
does not hold as much water as muscle. This, along
And many weight-classed athletes like to push their with an average smaller body size, will usually mean
boundaries. 10-15 lb is considered a relatively easy that the average woman cannot cut as much weight
weight cut. Many male athletes in particular are proud as the average man can.
of their ability to “make weight” by dropping 20 or even
30 lb of water rapidly. • Women’s hormonal systems are much more sensi-
tive to disrupted energy balance than men’s. Weight
Unfortunately, of course, there are costs to this. Some cutting can fall into this. Repeated weight cutting
water manipulation and weight cutting practices are and / or water manipulation may cause hormonal
dangerous, even potentially deadly. Even if an athlete problems for women.
survives a drastic cut, they may then perform poorly. Or

248 | Unit 8
Physique competitors 3. Finally, lower your sodium intake as much as you

can. Cut all extra salt out of your diet and avoid foods
8 days before the contest higher in sodium. Just like with the water manipu-
lation above, the body has gotten used to excreting a
1. Double your water intake. For example, if you’re lot of sodium. It will keep doing this for a little while,
drinking 2 L (8 cups) per day, start drinking 4 L (16 even when salt intake drops. For a brief period, more
cups) per day. Drinking a lot more water means you’ll sodium will leave the body than enter it; as it goes,
be urinating a lot more. For now, this will be matched this sodium will draw additional water from the body.
by the increased water intake, so net water balance
remains fairly constant. 4. Continue until one day out from the contest (i.e.,
about 24 hours).
2. Do this for two days.
1 day before the contest
6 days before the contest
1. Drop your water intake again by 50%. For example, if
1. Double your water intake again. Now you’ll drink you’re now drinking 2 L (8 cups) per day, drop down
four times your normal water intake. If you started to 1 L (4 cups) per day. This second drop will ensure
with 2 L (8 cups) per day, you’ll now drink 8 L (32 that additional water is lost from the body as excre-
cups). Again, you’re telling your body to get rid of tion rates should still be high.
water.
2. Keep your increased carbohydrate intake the same.
2. Lower your carbohydrate intake. For most people, this This will keep filling up muscle glycogen and
means eating around 50-100 g of carbohydrate per drawing any remaining extracellular fluid into your
day. By doing this, you’ll begin to lose muscle glyco- intracellular spaces.
gen as well as 3-4 g of water per gram of glycogen lost.
3. Keep your sodium low. This will continue to draw
3. Increase sodium intake: Add lots of salt to meals and sodium and additional extracellular fluid out of the
/ or even small amounts of salt to your drinking wa- body.
ter. This will tell your system to start actively excret-
ing lots of both salt and water. 4. Keep doing this for about 24 hours, until the contest
day.
4. Do this for four days, until you’re two days out from
the contest.
Contest day
2 days before the contest 1. Avoid water until the contest.
1. Drop your water intake down fourfold. For example, 2. Keep carbohydrate intake high.
if you’re now taking in 8 L (32 cups) per day, drop
back to 2 L (8 cups). Since your body’s gotten used to 3. Keep sodium intake low.
excreting a lot of fluid, and adjustments take a few
4. Be sure to rehydrate carefully after your event. You
days to catch up, this sudden drop means a nega-
may want to have an electrolyte solution close at
tive water balance. In essence, you’ll be temporarily
hand.
dehydrating the body by forcing it to lose more water
than it takes in.
Weight-classed athletes
2. Increase your carbohydrate intake. For most people,
Weight-classed athletes, such as strength athletes, wres-
this means eating two to four times what they’ve
tlers, and / or fighters, often weigh in and compete on
been eating for the last few days. So, if you’ve been
different days.
eating 50-100 g of carbohydrate per day, increase
your intake up to 200-400 g. By doing this, your body Below is an example program for an athlete, such as an
will supercompensate muscle glycogen stores, filling MMA athlete, who needs to weigh-in 24 hours before
out the muscles with stored glycogen as well as draw- their competition.
ing some water into the intracellular spaces. This
means that you’ll look more muscular and leaner at
the same time.

8 days before the contest 3 days before the contest

1. Double your water intake. For example, if you’re 1. Cut your water intake in half again. So, if you started
drinking 2 L (8 cups) per day, start drinking 4 L (16 with 2 L (8 cups) per day, you’d be down to 0.5 L (2
cups) per day. Drinking a lot more water means you’ll cups) now.
be urinating a lot more. For now, this will be matched
by the increased water intake, so net water balance 2. Keep carbohydrate intake low.
remains fairly constant.
3. Keep sodium intake low.
2. Increase sodium intake: Add lots of salt to meals and
4. Do a short sauna session (15-20 minutes) in the
/ or even small amounts of salt to your drinking wa-
evening.
ter. This will tell your system to start actively excret-
ing lots of both salt and water. 5. Do this for one day.
6 days before the contest 1. Cut your water intake in half again. So, if you started
with 2 L (8 cups) per day, you’d be down to 0.25 L (1
1. Cut your water intake back to normal. So, if you
cup) now.
started with 2 L (8 cups) per day, go back to 2 L now.
2. Keep carbohydrate intake low.
2. Lower your carbohydrate intake. For most people, this
means eating around 50-100 g of carbohydrate per day. 3. Keep sodium intake low.
By doing this, you’ll begin to lose muscle glycogen as
well as 3-4 g of water per gram of glycogen lost. 4. Do two short sauna sessions (15-20 minutes) in the
morning and evening.
3. Decrease sodium intake. Cut all extra salt out of your
diet and avoid foods higher in sodium. Just like with 5. Do this for one day.
the water manipulation above, the body has gotten
used to excreting a lot of sodium. It will keep doing Until weigh-in
this for a little while, even when salt intake drops. For
a brief period, more sodium will leave the body than 1. No water until after weigh-in.
enter it; as it goes, this sodium will draw additional 2. Keep carbohydrate intake low.
water from the body.
4. Do this for about 24 hours, until five days out from
the competition. 4. Eat 1-2 very small meals until weigh-in.
5 days before the contest 5. Use a sauna as needed to make weight. (Be sure to
have someone keep an eye on you during this time, as
1. Cut your water intake in half again. So, if you started you’re in the danger zone for fluid balance.)
with 2 L (8 cups) per day, you’d be down to 1 L (4
cups) now.
After weigh-in
2. Keep carbohydrate intake low. 1. Start re-hydrating immediately.
3. Keep sodium intake low. 2. Keep it as gradual as possible to avoid GI upset.
Aim for no more than 1.5 L (6 cups) of fluid rehy-
4. Do this for 2 days, until 3 days out from the dration per hour (using carbohydrate, protein, and
competition. electrolytes).
3. Continue until bodyweight is back up to normal.

250 | Unit 8
For weight-classed athletes who might have less time Our experiments have shown that athletes who deplete
between weigh-in and competition (e.g., with a morn- more than 5-10% of their body weight can lose tremen-
ing weigh-in combined with an afternoon competition, dous amounts of muscle strength, anaerobic power, and
or even a ringside weigh-in where they weigh in then endurance. And while a full day of rehydration generally
immediately compete) we generally recommend avoid- gets them with a few percentage points of their original
ing extreme water manipulation. This means making performance capacity, ringside weigh-ins don’t leave
sure your “walking around weight” is very close to your enough time for this sort of recovery.
“competition weight.”
Case study
Perplexed. That’s how we felt after working with a pa- lousy diets. It’s pretty rare to find a dedicated drinker
tient admitted to the medical center. who alternates vodka coolers with kale smoothies. This
means they aren’t getting a lot of vitamins, minerals,
He was diagnosed with hyponatremia and muscle wast-
protein, and / or valuable electrolytes.
ing. But standard medical tests and labs showed noth-
ing unusual. Where did his hyponatremia come from? Second, beer (and most alcohol) is a poor source of
electrolytes, particularly sodium.
Good coaches are curious and look for clues. So we
asked more questions about his nutrition. What was Low salt intake and low protein intake, combined with
he eating? What supplements or medications was he about 2 L of daily liquid from the beer equaled hypona-
taking? What was he drinking? And so on. tremia.
After about 20 minutes of discussion, he mentioned that We immediately treated him with an IV solution of iso-
he consumed an occasional alcoholic beverage. tonic sodium chloride. This raised his sodium concentra-
tions to normal levels and triggered the normal, healthy
Aha.
clearance of both water and solute.
We asked him to define “occasional.”
However, that was a temporary fix. To prevent this in the
Well, “occasional” wasn’t so occasional. He was drinking future, we suggested he scale back on the beer intake
a six-pack of beer every night. That’s about 2 L of beer… while increasing his intake of healthy foods.
every night.
Fortunately, he took our advice.
And thus, a potential cause of his mystery condition
But let’s say he didn’t. Luckily, there’s another easy (if
was revealed: severe hyponatremia secondary to beer
imperfect) fix: salty snacks. At the very least, the added
potomania, or the regular consumption of high volumes
sodium would help regulate the fluids. And if he chose
of beer.
foods like beef jerky or roasted / salted edamame, he’d
This situation was created by two factors. get a little protein in there too. It’s not perfect… but at
least it’ll keep him off the IV bag.
First, most people who drink a lot regularly usually have

Summary
We need water to live. All our cells soak in it, though While these can have different causes, and many are
some tissues (such as muscle) have higher water contents outside your scope of practice, you can understand the
than others (such as body fat). basic principle behind them: Somehow, fluid input is out
of sync with fluid output; and / or fluid is in the wrong
Water is a solvent, catalyst, lubricant, temperature regu- place in the wrong amounts.
lator, mineral source and regulator of growth.
Edema can be a sign of malnutrition and / or restrictive
Fluid balance is the relationship between fluid input dieting.
(from foods and drinks) and output (from processes like
respiration, sweating, and excretion). For most average people under normal conditions,
drinking about 2 L (8 cups) of water per day along with
Electrolytes are minerals that, when dissolved in water, water intake from food is enough.
become electrically charged. Like fluid, we get them
from foods and drinks, and lose them as part of normal Athletes and recreational exercisers should be careful
physiological processes. to replace fluids lost through respiration and sweating,
especially in hot, dry, and / or high-altitude conditions,
Normally, our body tightly regulates body water and and / or when activity lasts a long time.
electrolytes with complex, interconnected systems of
sensors and hormones. We need proper fluid balance Normal changes in women’s hormones with menstru-
and electrolyte balance to be healthy. ation, pregnancy, and / or menopause can significantly
affect their fluid balance.
However, fluids can get out of balance. As a nutri-
tion coach, you will typically see three types of fluid You can use the principles of fluid and electrolyte bal-
imbalance: ance to help clients such as physique athletes or weight-
classed athletes.
• dehydration (too much water out; too little water in)
• hyponatremia (too much water; not enough sodium)
• edema (fluid building up where it shouldn’t)

SECTION TWO
NUTRITIONAL PRACTICE
9 What It Means To Be a Good Coach, p253
10 The ISSA Nutrition Coaching Methodology , p270
11 Nutritional Levels, p300
15 Special Scenarios, p431
16 Business 101 for Fitness and Nutrition Pros, p479
17 Continuing Ed for the Coach, p493

UNIT 9
What It Means To Be a Good Coach

254 | Unit 9
Unit Outline
1. Why talk about coaching? 5. Mental skills
2. What’s your story? 6. Communication skills
3. What do great coaches do? 7. Case study
4. Understanding clients 8. Summary
Objectives
In this unit, we’ll give you the “big picture” of coaching. • what skills are part of coaching
You’ll start to learn: • how a coach shares information with clients
• how a coach thinks and makes decisions
• what a coach is
• what a coach does
Why talk about coaching? What kinds of things do you need to

Nutrition coaching isn’t just about nutrition.
know?
In fact, the more you work with clients, the more you’ll Here’s a brief list of the kinds of stuff you’ll need to con-
realize: Helping people change food behaviors and sider in your coaching.
choices is almost never just about the food. • What enables people to make changes?
Because coaching is about people. About how they • Why do people resist change, or have mixed feelings
think. How they feel. How they live. Why they act the about it?
way they do. • What do people think they need… and what do they
Coaching is also about being a working professional. really need? (And why are these two things often so
Yes, coaching is a calling for many people. It’s also a job. different?)
Maybe even a lifelong career. • What stories are your clients telling themselves about
who they are as people, and how does that affect
That means you have to show up every day in the real
their choices?
world, with real people, to deal with real situations. And
real struggles with change. • How do you know what level of difficulty and com-
plexity is appropriate for each client?
Thus, effective nutrition coaching has a lot more to do
with psychology and interpersonal skills than knowing • How do you properly assess clients and track their
the specifics of macronutrients. progress?
Sure, nutrition coaches need to know about nutrition. • How can you help people set realistic goals?
You should probably know, for instance, that a green • How can you help people understand the trade-offs
vegetable is healthier than cotton candy. required to get to those goals?
But there’s a lot more to nutrition coaching than carb • How can you figure out what’s standing in the way of
grams and sodium. those goals?

What It Means To Be a Good Coach | 255
• How can you work with special populations, such as athletes, older clients, or
clients with food sensitivities?
• If we can’t make people change, how can we at least create the conditions that
will support change?
Over the coming units, we’ll look at all of these. First, let’s start with Ground
Zero of coaching: You.
What’s your story?

Why do you want to be a coach? You likely have many reasons.
Maybe you want to help other people. That’s a great motivation.
But here’s a funny paradox about helping other people: You help them best when
you know more about yourself.
This includes things like:

• what you think is important, and what you value most;
• what you prioritize;
• your unique coaching style;
• your life experiences;
• how you learn and communicate;
• what work environment suits you best; and
• your coaching “super powers” (Yes! You have them.) coaching super powers:
Coaching skills you are
In this unit, we’ll look at some of what you bring to the table as a coach. Know- particularly good at, or coaching
ing this is essential. skills that come more naturally
to you
For instance:
• When you have a clear goal, you can stay focused on it.
• When you recognize your own patterns and tendencies, you can take advan-
tage of your known and proven “success strategies.” You can also avoid or
defuse situations that might trigger you into unproductive habits.
• When you know why you’re doing something, you stick to it when times get
tough. (This may be a good time to mention that it’s pretty hard to become a
millionaire doing nutrition coaching.)
• When you know exactly what you hope to get out of coaching, and how you
prefer to work, you can choose the workplace and the coaching support team
that you think will fit you best.
• When you know what “fills your tank” and keeps you going, you can build a
career for life, rather than burning out or looking for short-term gains at the
expense of long-term, sustainable growth.
This is an opportunity to get to know yourself as a person, as a coach, and as a

professional working in the field of nutrition.
The more you know YOU, the better your coaching will be.

256 | Unit 9
to whip up tasty healthy snacks in 10 minutes, to how to

What is a coach? rehydrate a weight-cutting athlete.
“Coaching” others in nutrition can mean many different But when you step back and look at the big picture,
things. You might work with all kinds of people, in all coaches have four key tasks:
kinds of settings, helping them do all kinds of stuff.
1. Define clearly what to do, and why.
So let’s think about the general job description of a 2. Develop a plan to do that thing (in collaboration
“coach.” with the client).
It can include: 3. Help the client become able to do that thing.
• teaching • directing 4. Build relationships that make this possible.
• knowing information • helping
In the coming units we’ll help you start to develop these
• knowing how to do things • planning four key areas.
• communicating • problem-solving For now, let’s start with the “why” of coaching.
• learning • troubleshooting
• analyzing • brainstorming Why coach?

• motivating • guiding Whether it’s a client’s nutrition habit or your own career
choices, it’s important to understand why you’re doing
Some of what coaches do is cognitive, like planning and something. As much as possible, your coaching decisions
reasoning. Some of it is emotional, like empathizing or should be deliberate and purpose-driven.
building relationships. Some is plain old “gut feeling”
and instinct. Of course, you won’t always know why you’re doing
something. Nor will your clients.
It’s a harmonious blend of science and art.
So here’s a little thought exercise: The 5 Whys.
Coaches give clients information, perspective, tools, and
strategies. Coaches can push when a client has become The idea is that you ask a “why” question, like:
too comfortable. Or pull back when a client has been
pushing too hard. Why do you want to be a nutrition coach?
Coaches are not best friends, drill sergeants, or You answer that question as best you can. For instance,
all-knowing gurus. They’re more like facilitators, naviga- you might answer:
tors, or guides.
I want to help people.
Indeed, one of our favorite definitions of a coach is:
Then, you ask “why” again. Like this:
A coach is like a tour guide to a place where you already
Why is helping people important to me?
live.
You answer that question as best you can. Maybe you
In other words, a coach can help a client explore their own
might say:
potential and resources — potential and resources the
client already has, but doesn’t recognize or trust. And a I believe that helping people is an essential value.
coach can help clients translate knowledge into action.
Then, you ask “why” again, like this:
The four jobs of coaching
But why is helping people an essential value for me?
As you might guess, a coach’s job can involve a wide
range of abilities, skills, and daily-life tasks. Nutrition And you answer that question.
coaches in particular need all kinds of stuff in their
Well, because...
toolbox, ranging from how to feed picky eaters, to how

And so on, five times in total. (Or as many times you as

• If part of your identity is as an athlete, you might look
want.)
for a role that challenges you and helps you keep
Each “why” builds on the previous answer. pushing your own limits.
By the time you’ve gotten to the fifth “why”, you should Now, notice we say “part of your identity.” Because we
have a pretty good idea of some of your core values and are all a collection of “identities”, plural. For instance,
motivators. the same person can be:
After all, you didn’t just put on a blindfold and point to a • a husband • a mountain biker
random list of careers, winding up on “nutrition coach.” • a father • someone with a knee injury
Something happened in your life that made you want to
coach other people in nutrition. • a son • a lover of Scrabble
• a brother • a nutrition coach

If possible, figure out what that reason is. Because when
you can harness this reason, you’ll be able to come back And in fact, all of these parts of yourself can come in
to it when business finances are tight, when you have a handy in nutrition coaching.
5 AM client, and / or when you’re feeling symptoms of
burnout. You never know when a teenage athlete may walk
through your door… and need some wise-dad-style in-
Or maybe right now you don’t have a strong “why” for sight. Or when a mountain biker might ask for trail tips.
your coaching. That’s okay too. And that’s useful to Or when you might need to spell out “GLYCOGEN” for
know. That can also help you make career decisions. an epic Scrabble win.
For instance: So don’t limit yourself. And don’t feel like you can only
be a “nutrition nut” to be a good coach. Instead, think
• If nutrition coaching is a deep passion for you, you
about all the things you bring to nutrition coaching as
might decide to take a more difficult but more per-
a complete human being with all kinds of interests, life
sonally rewarding coaching job. skills and experiences.
• If nutrition coaching is just a way to pay the bills, you
Your sense of identity can also shape who you choose to
might decide to take a position that’s less personally
work with.
rewarding, but more steady and financially secure.
For instance, think about what kinds of clients you con-
Either way, the more you know, the stronger your strate-
nect with the best.
gic position can be.
If part of your identity is being a competitive “go-getter”,
Your coaching identity you might seek out high-performance clients who chal-
lenge you and themselves.
Identity is who we think we are. Who we want to be.
If part of your identity is being older and wiser, you
And who we want others to see us as. It’s almost like
might want to mentor younger clients… or work with
we’re characters in a story.
other older people who are on the same wavelength.
Our values and priorities — what we think is truly
If part of your identity is as a caregiver, you might seek out
important, and put first — flow from our identity.
vulnerable clients who need a lot of love and compassion,
For instance: such as obese clients considering bariatric surgery.
• If part of your identity is “yoga instructor”, you may You might already have a strong identity as a nutri-
think it’s important to offer clients a calm, restful tion coach. You might even have a niche market (e.g.,
space. bodybuilders, CrossFitters, vegetarian eaters, endurance
athletes). Or maybe this is a second or third career for
• If part of your identity is as a parent, you might make
you and your identity has been deeply rooted in account-
certain decisions about work hours or traveling.
ing or parenting.

258 | Unit 9
Although there are skills that all coaches should have What really matters as a coach?
(such as communicating clearly), there is no “right”
identity to have as a coach. Now, maybe you can answer those easily. Most folks
can’t. At least not right away.
All kinds of people can coach effectively.
So let’s break it down into something more practical.
The trick is to know who YOU are, what YOU need, How do you think different coaches would handle these
and where you fit best. coaching situations?
To get a better sense of what your coaching identity is, My client keeps over-eating. I’m the type of coach
try a little thought exercise. who will approach it like this… because…
What kind of person are you? Another kind of coach might… because…
Grab a pen and paper and write out as many answers as My client is late for each appointment. I’m the
possible to the following: type of coach who will approach it like this…
because…
“I’m the kind of person who _____.”
Another kind of coach might… because…
“I want to be the kind of person who ____.”
My client is following along with everything I’ve
“I would never be the kind of person who outlined for them. I’m the type of coach who will
____.” praise them like this... because…
“People who know and love me would say I’m Another kind of coach might… because…
the kind of person who ____.”
The “because” part here tells you about your values and
“If I were a movie character, I’d be ____.” priorities. There’s a reason you choose to do what you do.
No right responses here. Just play around and see what Your identities, values, and priorities are like your “inner
pops for you as you brainstorm. compass” that helps direct you and navigate through
life’s tricky situations. If you’re business-minded, you
Then go back and change “person” to “coach.” For might also think of your identities, values, and priorities
instance: as your personal “brand.”
“I’m the kind of coach who _____.” When you know who you are, what you stand for, what’s
“I want to be the kind of coach who ____.” most important, and what you have to offer coaching,
you don’t wonder and worry about doing a good job.
And so on. Again, no right answers. Simply see where
your pen and paper take you. You can feel when you’re on track and aligned with what
truly matters to you. And you can see it in strong client
(For fun, check your answers with a friend or family relationships that get results.
members. Ask them how they think you’d fill in those
blanks.) Of course, this takes time to figure out. Which is why
you’re here.
What do you value? • You might have to try different work situations
(such as a small boutique gym, a large chain, or
The identity game isn’t just a pointless existential ex-
ercise. Again, our values and priorities flow from our self-employment).
identity. And our values and priorities shape what we do • You might have to try different kinds of clients (such
in coaching. as endurance athletes or seniors).
For instance, consider the following Big Questions: • You might have to try different coaching styles.
• You might have to ask yourself, “What the heck am I

Who do you want to be as a coach?
doing here, anyway?”
What is “right” as a coach?

That’s okay. Keep experimenting until you find what • How did they do it?
matches who YOU are as a unique individual. And then • What made working with them such a great
consider how you can apply that to working with clients
experience?
during a coaching career.
There are lots of ways to be a great educator, trainer,
You don’t have to figure out any of this now. Just think
and coach, but generally they all have some things in
about it a little bit. This process of becoming a better
common.
coach is a lifelong journey.
In this section, we’ll show you some of those things, and
Congratulations: You’ve already taken the first few steps.
suggest how you can put them into practice for your-
self… so that maybe someone will remember you as the
What do great coaches do? most awesome coach they ever had.
Take a moment and think of the most awesome teacher, (If after you’re done this program, you want to learn
professor, instructor, or coach you’ve ever had. more about great coaching, check out our Level 2
Master Class. It’s the year-long nutrition coaching
• What was that person like?
mentorship we use to train our own in-house super
• What did they do? coaches. Yep, we’re finally making it available for Level
1 students and graduates too.)
Table 9.1 The principles of great coaching

Principle Description What it might look like
1 Unconditional This is a fancy way of saying you Smile and say hello to every single person that comes
positive regard treat all clients with respect and into your gym.
compassion. You see their poten-
tial and value. Even though you’re Treat klutzy adolescent or unsure beginners with the
helping them change, you accept same professional courtesy as you would treat elite
them as they are. athletes.
Make everyone feel valued and welcome.

2 Client-centeredness Helping the client meet their Ask your client: “Tell me about what’s most import-
and humility goals, not yours. ant to you here. What are your goals? What’s a priori-
ty for you to do first? How would you like me to work
Looking for what’s important and with you and help you?”
meaningful to them.
When working with a client one on one, give them
Being a guide, not a guru. your full attention. Don’t talk on your cell phone or
send emails or texts. Make them feel like they’re the
most important thing in the world right now.
3 Observation Looking, listening and learning. Watch your client’s non-verbal cues and body
language.
Paying attention to cues and all
information. Listen to them carefully.
Being curious. Look at their behaviors.
Notice their tendencies and patterns.

4 Assessment and Learning as much about your Ask questions.
information clients as possible.
gathering Learn about clients’ lives, and what they’re doing.
Trying to get a big picture. (You obviously don’t have to know every detail, but
try to get a broad understanding.)
Collecting data in different forms.
Use many types of input: assessment forms, lab work,
body measurements (if appropriate), photos, consis-
tency checklists, journals, etc.
Keep careful records.

260 | Unit 9

5 Understanding As much as possible, you under- You are curious about each of your clients.
standing what makes your clients
tick. When you chat with them, ask questions to help
explore their sense of identity, values, and priorities,
Grasping their motivations, limit- such as, “Given X or Y, which one matters most to
ing factors, and worldviews. you right now? Why?”
Seeing their starting points and Explore their motivations: “What’s driving this? Why
how far they’ve come. does this goal feel urgent or important for you right
now?”
You “get” them.
6 Monitoring and Deciding what counts as “prog- Collaborate with your client on what they would con-
measuring ress” and how to measure it. sider “progress” (e.g., weight loss, better blood work,
better recovery from training).
Then measuring it, consis-
tently, looking for change and Then, periodically, collect data on those progress
improvement. indicators and see what has changed.
Have a regular schedule and system for “check-ins.”

7 Solution- and Looking for what is going right, Reframe a client’s mindset (for example, from “I’m a
strengths-focused and where your client is stron- busy parent” to “I can be a healthy role model for my
mindset gest. Then you want to do more kids”).
of the good stuff.
Point out every success and victory a client has, no
Not focusing on “flaws” or “weak- matter how small or silly.
nesses.” Instead, you play to each
client’s strengths and assume Look for how a client may already have tried to solve
all problems have some kind of their problems (even if imperfectly), then just build-
solution… which your client has ing on what already works.
probably already tried without
realizing it.
8 Skill building Teaching clients how to do Show clients how to book food prep or exercise
the stuff they need to do, sessions as appointments in their calendar, and set
consistently. reminders.
Breaking complex tasks down into Show clients how to grocery shop effectively and
smaller, simpler pieces, so clients efficiently.
can learn and practice without
getting overwhelmed.
9 Appropriate Keeping the client in their optimal Introduce a new task that is relatively easy. When the
progression “growth zone.” client gets it, you make it a little harder. Repeat.
Over time, continuing to chal- Monitor closely and know your clients well enough
lenge the client appropriately — to understand where each person’s optimal “zone of
enough to keep them engaged, challenge” lies.
improving, and pushing their
boundaries a little, but not so
much that it’s overwhelming or
damaging.
10 Appropriate Scaling back where necessary. If a client can’t do a new habit consistently, make the
regression habit easier to execute (e.g., do 10 minutes of daily
Understanding when you need to exercise instead of 20).
make things easier.
Noticing if clients are tired, stressed, overwhelmed or
Focusing on “what is”, rather than burned out, and giving them a smaller task (or some
“what should be.” active recovery) while their attention and energy is
elsewhere.


11 Analysis and insight Looking for patterns and rela- Looking at a food journal to see that most over-eating
tionships in what your client is happens in the evenings.
thinking, feeling, and doing.
Noticing that food intolerance symptoms occur after
eating a certain food.
12 Outcome-based Deciding what to do next based After taking client measurements and tracking prog-
decision making on the data you’ve collected. ress in the gym, you decide that the current nutrition
program may need some adjustment.
As much as possible, making
choices based on known evi- After implementing a new habit and tracking con-
dence, rather than speculation or sistency, you notice that your client has successfully
what you think “should” happen. done this habit 95% of the time, and loves doing it.
Although you were thinking about a different habit
for the next step, you change course: Further refine
and improve this proven success habit.
13 Collaboration Building a strong support team. Leave your brochures at a local physiotherapy clinic
or doctor’s office. Ask them to refer clients for you,
Having a solid network to whom and you can refer clients back to them.
you can refer (e.g., doctors, phys-
iotherapists, counselors). Be a good team member. Play well with others. Be
courteous, professional, and interested in the work
Treating other coaches as col- that other coaches and practitioners are doing.
leagues and potential collabora-
tors, rather than as competition.
14 Rewarding Improving your client’s mastery Ask your clients: “What would make it easier for you
behaviors, not of process, skills, and consisten- to do Habit X consistently? If we look at all the steps it
outcomes” cy. The results will take care of takes to get to doing Habit X, where do you need the
themselves. most help?”
Success comes from what we do, High-five your clients for eating 2 servings of vege-
over and over and over. tables every day this past week. Then see if they can
try 3 servings. Look at what they might need to do in
order to make that possible.
With more experienced clients, seek mastery and

consistency. Whatever they’re doing, help them do it
better, more often.
When you praise progress, praise hard work, effort,

determination, and consistency. “You lost 5 lb over
the last 2 weeks. You can see how working on that
‘eating slowly’ habit really makes a big difference.
Congratulations on sticking to that habit; it’s a tough
one… but it paid off.”
15 Lifelong learning Committing to a practice of Read books.
lifetime self-development and ed-
ucation. Looking for information, Listen to podcasts.
ideas, and insight everywhere. Make PubMed and Google Scholar your friends.
Talk to people in the field whom you admire.
Go to professional conferences.
Take continuing education or professional certifica-

tion courses.

262 | Unit 9

16 Practice what you Speaking, acting and working If you tell clients to get more sleep, go to bed on time
preach with integrity. yourself. If you tell clients to eat their vegetables, put
some green leafy stuff in your own mouth too. If you
If you give a client something tell clients to get active, you’d better be lacing up
to do, you should have at least those sneakers regularly too.
tried it yourself. Take your own
medicine. Block time off each day to stay active, make nutritious
food choices, and do other healthy behaviors, even if
Prioritizing your own fitness, nu- it means taking fewer clients at first.
trition, and health even over that
of your clients. Get your own coach. This helps you experience what
your clients experience, and helps you stay on track.
17 Communication Being able to communicate effec- Write simple, clear, professional-looking emails. Spell
tively in various formats, whether words correctly.
in writing or in conversation.
Be polite, courteous, and enunciate clearly. Make eye
Expressing yourself clearly, accu- contact.
rately and respectfully.
When explaining things, use plain language and
everyday concepts rather than technical language
(unless you’re talking to other experts). Say “get in
shape” rather than “body recomposition.”
18 Humor Having a sense of humor. You’ll Laugh. Joke.
need it.
Celebrate successes joyfully.1
Making coaching fun. It’s not
supposed to be serious.
1. Mark Fisher Fitness in New York has made a brand out of silly, fun stuff like ninjas, glitter, goofy dancing, and unicorn
outfits. Their tagline is “Ridiculous Humans. Serious Fitness.” Check out markfisherfitness.com.”
Understanding clients
If you look at the table above, you’ll see that good coach- • what they can do; and perhaps most importantly
es do a lot of listening, learning, observing, and careful • what they can do consistently.
analysis.
And of course, just like coaches, clients will have
To help your clients succeed, you need to understand different:
them as individuals. Each person is coming to you with:
• identities; • priorities
• different life experiences;
• values; • goals
• different needs and wants;
• different personalities;
Thus each person will need a different coaching style.
• different problem-solving abilities; and
• different attitudes about change and trying new This can change from client to client, or even for the
things. same client on different days. For instance, the day your
client shows up after their favorite pet goldfish dies is
In upcoming units, we’ll look at three different levels of probably not the day to get on their case about why they
clients. Each client can be sorted into these three nutri- aren’t eating their vegetables, even if normally that client
tional levels based on: loves a challenge and being pushed.
• what they want and need; Luckily, you don’t have to come up with a completely
• what they know; new approach each time.

Along with three nutritional levels (which we’ll look at • What level of motivation do they have?
in an upcoming unit), most people’s coaching needs can • What level of skill do they have?
be sorted into four general categories depending on two
criteria: motivation and skill, as Table 9.2 shows. While each client is a unique individual, there will also
be common themes in their experiences, and in your
As you work with your clients, think about how to filter approach.
and prioritize.
• What nutritional level are they?
Table 9.2 Four types of clients and how to approach them

Client type Coaching Description
style
High-motivation, Delegate High-motivation, high-skill clients are typically people who are good at everything and
high-skill motivated to get better.
Keep these clients constantly involved and in tune with your process by making them
active drivers rather than passive passengers. For example, with this type of client you
should give them assignments and research to do on their own. You should explain to
them that the truest measure of the most successful clients is their ability to learn, under-
stand, and become sensitive to what works best for them.
Offer ideas and generalized concepts that you want this client to think about or research,
or give them a problem to solve. Let them know that during the next session, you want
to have a spirited conversation with them about their findings. Follow up by having these
discussions.
Low-motivation, Inspire To be good at something but lose zeal for it is often the result of overwhelming internal or
high-skill external pressure. These characteristics describe the low-motivation, high-skill client.
Clients with this temperament do not respond well to overly critical feedback or overly
hyped rhetoric. To coach this type of client, you must find the glimmers of wisdom that
inspire them to reclaim their drive for improvement.
Coaching this type of individual isn’t easy, and common coaching styles just don’t work.
To the low-motivation, high-skill client, “rah, rah” strategies and training or nutrition
strategy pitches sound like more work that they don’t have the time or energy for.
You will need to take the pressure off and find ways to ease them back into the coaching
process through subtle inspiration.
High-motivation, Guide “More enthusiasm than skill” describes this type of client, who often suffers from too
low-skill much motivation rather than too little.
This type of client may be so motivated (and yet so unskilled) that they risk making too
many corrections or lifestyle transformations all at once, which can be both dangerous
and limit potential long-term success.
You will need to guide them through well-staged and progressive steps so that they get
it, but don’t let them try to get it all at once!
Low-motivation, Direct This type of client is typically quiet, shy, and introverted. Respect that personality, and
low-skill don’t become their cheerleader. They aren’t looking for the loud, motivational coach
who constantly tells them “YOU CAN DO IT!” They are looking for someone to provide
direction and develop a relationship at a pace that doesn’t make them feel uncomfortable
or want to push back.
Even positive reinforcement offered too hastily can have negative consequences with a
low-motivation, low-skill client.
(Adapted from Grasso 2007)

264 | Unit 9
Mental skills
You’re probably getting a good idea about what nutrition skills you might need in
your work as a coach. For instance, you will probably need stuff like:
• recipe reading skills;
• nutrition planning skills;
• shopping skills;
• food preparation skills; and
• dietary modification skills.
But as we’ve emphasized, the game of nutrition coaching isn’t just about the food.
Coaching is mostly a mind game.
mental skills: Skills for Thus, both coaches and clients will also need mental skills. These are skills for
managing your impulses and thinking, reasoning, problem-solving, self-awareness, and self-regulating (in
emotions
other words, managing your impulses and emotions).
For instance, at some point in the coaching process, both you and your clients
will need to:
• deal with the discomfort and anxiety of trying new things;
• focus on realistic goals (and let go of unrealistic goals);
• negotiate with other people (like spouses or family members);
• stay resilient, adaptable, and optimistic in the face of setbacks;
• allow your beliefs about who you are and how things work to evolve; and
• manage stress.
Are you squirming yet?
The challenge of stress

For instance, consider the problem of stress. Coaches feel stress. Clients feel
stress. All of us feel stress sometimes.
High levels of stress can make us crummy coaches.
We may feel snappish, rushed, distracted, or overwhelmed. We may forget

things, or get burned out.
High levels of stress can affect your clients’ ability to change too.
Think about the last time you were overbooked and / or overstressed. Now imag-
ine that someone suggested you make some major life changes, including putting
time and effort into meal prep, exercise, sleep, meditation, and so forth.
What’s your response?
Probably: No way.
When you’re in day-to-day survival mode, you aren’t open to learning Turkish
get-ups and / or stir-fry combinations.

When we feel stressed, we all try to cope as best we can. • rebound quickly from setbacks; and
But without mental skills, we usually choose badly — • have a “growth mindset” — that all events and out-
maybe even self-destructively. We eat too much (usually
comes are just information that can help them learn
stuff that makes us feel rotten afterwards). We drink
and develop (rather than “failures” or commentary
too much. We shop too much. We binge-watch TV. We
on their “goodness” as a human being).
smoke. Or we do a variety of other unwanted habits.
Much of what you’ll see in clients is simply a normal All of these mental skills will:
reaction to being stressed. It’s not stupid or lazy or crazy. • lower clients’ overall stress (and yours);
It’s just a way to get through a busy day or a difficult
• help clients make better, more thoughtful choices;
time.
and
Stress isn’t going away. • enable clients to stay “in the game”, moving forward.
It’s part of being human. We can’t change many stressors

(such as the weather, or random life events). Mental skills
But we can change how we deal with it. Table 9.3 is a brief overview of some types of mental
skills, and how they might help both you and your
And we can change how much stress we create for our-
clients.
selves (for instance, with taking on more and more work,
or not getting enough sleep). Like any skills, mental skills can be learned, practiced,
and improved.
As a coach, you can help your clients:
• You can practice and develop these skills to build
• deal with stress more effectively and thoughtfully;
your “inner game” of coaching.
• calm themselves and plan ahead;
• And you can help your clients practice and develop
• set clear priorities; these skills to get better results from their nutrition
programs.
Table 9.3 Mental skills

What it might look like for What it might look like for
Mental focus Description
a coach a client
Focus Deciding on a course of Giving clients your full atten- Sticking to a single eating plan
action and then stay- tion during sessions. rather than jumping from diet
ing true to it. Ignoring Focusing on your clients’ goals fad to diet fad.
distractions. and priorities, even if other Doing one habit at a time.
options seem more appealing.
Re-focusing Getting back on track after Having a way to “switch gears” Scheduling a session with
getting distracted or “fall- between clients so that each coach immediately after the
ing off the wagon.” client gets a “fresh coach.” holidays.
Showing up to each coaching Having a plan to get back
session as your “best self”, into normal routine after a
no matter what happened disruption.
previously.
Setting goals Having a clear idea where Working as a team with your Asking: “Where do I want to be
you want to go. Adjusting client to set clear objectives at the end of 4 weeks? Why is
as needed, when things that are meaningful to them. that important?”
change. “What specifically will I work
on this week?”

266 | Unit 9
Table 9.3 Mental skills

What it might look like for What it might look like for
Mental focus Description
a coach a client
Following the “inner Knowing and living your Coaching with integrity Saying things like: “I value
compass” core values and priorities. despite temptations to “sell my family and being there for
out” or take the path of easy my children. So I want to get
reward. healthy to be a role model for
Deciding purposefully how your kids.”
you want to “show up” as a “I value confronting life’s chal-
coach — what kind of coach lenges. So I’m going to push
you want to be, and what’s my limits a bit, on purpose, as
important to you. part of growth.”
Self-awareness Noticing and naming Staying “checked in” with Asking “How might my emo-
thoughts, feelings, behav- your own thoughts, feelings, tions affect my eating behav-
iors, and how all of these responses and actions as you ior?”
things are related. work with clients. “How does my 7 AM breakfast
Noticing which clients or affect my 9 AM workout?”
situations “trigger” you into
feeling annoyed, frustrated,
etc. Choosing to act maturely.
Reframing and rewrit- Noticing when we are You reframe “I don’t know Reframing “I hate cooking” to
ing stories and scripts writing scripts and enough” to “I’m always learn- “I prefer simple food prepara-
stories for ourselves to ing and growing.” tion strategies.”
explain the facts of our You reframe “I don’t want to Reframing “I fail every diet” to
lives. Then, consciously make mistakes” to “It’s import- “I have fallen down a lot but
reframing and rewriting ant to me to do a good job. I’ll always picked myself back up
the endings. try my best.” and tried something else.”
Confronting anxieties, Dealing directly with anx- Focusing on what you are Speaking openly with your
fears, or worries ieties, fears, and worries learning and doing well as a coach about what you’re wor-
rather than avoiding them coach. ried about.
or trying to make them go Taking risks. Experimenting. Focusing on what can be
away. Allowing “failure” Treating all setbacks as oppor- learned from setbacks so that
to be an option, so that it tunities to learn and grow. “failure” is not paralyzing.
becomes less of a threat.
Recognizing and Identifying the things that You think about what is work- Thinking about what is work-
changing limiting hold you back or block ing and how to do more of ing and how to do more of
factors you from moving forward, it. Or how to remove or work it. Or how to remove or work
then either removing around blocks. around blocks.
them or working around Sample limiting factors can Sample limiting factors can
them. include a heavy client load or include a stressful job or not
a tough work schedule that having cooking skills.
makes it hard for you to take
care of yourself, or spend time
learning.
Self-regulation Being aware of and Noticing when a client interac- Noticing when you may eat
managing emotions and tion is frustrating or annoying impulsively or emotionally.
impulses. you. Having techniques to help
Having techniques to calm and yourself pause and choose
refocus yourself. more thoughtfully.
Discomfort tolerance “Sitting with” uncom- Allowing a few moments of “Sitting with” urges to over-eat
fortable sensations or silence in a client conversation or make a poor food choice.
thoughts, without rushing to let a client share an idea. Learning a new habit.
to respond. Allowing a client to progress “Feeling silly” while learning a
more slowly than you would new movement.
like, because it’s better for
them.

Communication skills As a coach, you need to know a wide range of nutrition

(and coaching) concepts, theories, methods, and termi-
Your ideas may be awesome. Your expertise may be stel- nology. You may use technical language like “oxidative
lar. Your care for your clients may be all-encompassing. phosphorylation” or “cognitive dissonance.”
But if you can’t communicate these things effectively, Your clients don’t need to know this stuff. And they talk
nobody will ever know. in plain everyday language, not jargon. (Many of your
clients may also be younger athletes, and / or not even
Good coaches communicate well. This includes: speak English as a first language.)
• listening actively to what clients say (and don’t say);
All your clients need to know is: What they should be
• speaking clearly, courteously, and thoughtfully; doing, right now.
• writing clearly and professionally; They need to know just enough of the “what” and “how”
• observing non-verbal cues and being aware of your to take action. The details and the “why” are mostly up
own; and to you.
• filtering and prioritizing information for your clients. In Table 9.4 you’ll find some examples of technical mes-
sages that you should know along with some practical,
We cover these topics in greater depth in our Level 2 teachable, take-home messages your clients should know.
program, and to some degree in upcoming units. But,
for now, let’s look at the last point: Filtering and priori- Notice here how you transform and translate more
tizing information. complicated, theoretical information into practical
information that your clients can understand and act on
What you should know versus what your immediately. You can also combine this with handouts
clients should know and other resources (such as shopping lists or instruc-
tional videos) that clients can use right away.
What you should know and what your clients need to
know are two different things.
Case study
Learning about fitness and nutrition is cool. It’s easy to ever written, and was fairly advanced. She simply want-
get wrapped up in it and forget to apply what you’re ed to take her fitness to the next level.
learning. This is true whether you’re a coach or a client.
Impressive. So we scheduled her first appointment.
After all, most of us know what we should be doing. But
Given her expertise and interest, we imagined that she
are most of us doing what we should be doing?
would look, operate, and perform like an athlete.
Acquiring knowledge and applying that knowledge are
When we met this client in person, we discovered that
two different things.
this client’s reality did not match her self-assessment.
As a coach, you want to help your clients get better at
She was at least 50 lb overweight, and we determined
doing.
that she was over 35% body fat. She could not do basic
A long time ago, a client called us to ask about our movements well, and had multiple muscle imbalances.
coaching services. We asked her to tell us more about
Now, there’s nothing inherently wrong with this. Many
herself.
clients start out exactly this way. The problem here
The client told us that she had been working out for is that this client considered herself “advanced” even
about 10 years, had read every article and book we’d though she was not even doing the basics consistently.

268 | Unit 9
Table 9.4 Technical messages and how to translate them for clients
Technical message (what you should know) Translation (what your client should know)
To optimize protein turnover, protein synthesis, thermic See your hand? We’ll use your palm for a serving size.
effect of feeding, and muscle recovery, most clients should
be getting around 0.7-1.0 g protein per lb of bodyweight. Eat 1-2 palms of higher-protein foods at most meals. This
includes things like chicken, fish, beef, lentils, and tofu.
Here’s a list of foods high in protein. Just pick from the list
each time you eat.
To stabilize hormone and blood glucose levels, assist recov- Cup your hand. That’s what we’ll use for a serving size.
ery, and fuel training, emphasize consuming carbohydrates
with more complex structures, fiber, and resistant starch. At most meals, eat about 1-2 cupped handfuls of minimally
processed carbohydrate-dense foods.
Here’s a list to give you some ideas. We’ve got fruits, whole
grains, beans, root vegetables, potatoes, etc. Just pick from
the list each time you eat.
To optimize the dietary fat profile, your clients should be Look at your thumb. That’s a fat serving.
getting roughly 1/3 of their dietary fat from polyunsatu-
rates, 1/3 from monounsaturates, and 1/3 from saturates. At most meals, eat about 1-2 thumbs of healthy-fat foods.
This balance helps create a favorable hormonal environ- Here’s a list to give you some ideas. You can see that it in-
ment in the body, helps to manage inflammation, and cludes stuff like olives, olive oil, avocado, coconut, coconut
helps support healthy immune function. oil, nuts and seeds. Oily fish like salmon or herring are also
good.
If you like, you can take a fish oil or algae oil supplement
regularly.
The phytonutrients present in veggies (and fruits) have Think about all the different colors of vegetables: Red
been shown to influence genetic expression, reduce can- peppers, green broccoli or spinach, purple cabbage, white
cer, heart disease, and diabetes risk. onions, orange pumpkin, etc.
Now, go to the grocery store and pick out all the colorful
vegetables you like.
Here’s a list to give you some ideas.
At every meal, try to eat about 1-2 fist-size servings of a color-

ful vegetable. Eat the rainbow!
Someone who is trying to reduce body fat will have less Since you’re trying to lose weight, let’s work towards reduc-
kcal flexibility. So, decreasing carbohydrate and / or fat ing your number of portion. Here’s an easy way to start: Re-
intake can help to repartition intake and control overall move 1-2 handfuls of carbs and / or 1-2 thumbs of fats from
kcal consumption. your daily intake. You can also try eating with smaller dishes.
Someone trying to gain muscle mass should increase Since you’re trying to gain some muscle, let’s work towards
carbohydrate and / or fat intake to increase overall kcal getting you to eat a bit more. Here’s an easy way to start:
consumption, and create a more optimal metabolic and Let’s add another small meal to your roster. Do you know
hormonal profile for weight gain. how to make a Super Shake?
Research is equivocal on the optimal macronutrient profile What’s the best diet? Well, it depends. I can give you some
for metabolic improvement and reducing chronic disease general principles to follow. But what’s most important is
risk. A number of systematic research reviews have con- that we find something that you enjoy, and can realistically
cluded that a vast array of nutritional profiles can result in stick to.
weight loss, metabolic improvements, and overall health.
Adherence is the most salient factor in determining optimal
outcome.

She simply didn’t see the difference between knowledge ing and what they should be doing. This client always
and application. She had an extensive fitness library at wanted to know why we were doing something before
home. She had read every single article and book we’d we actually did it. This can become a real challenge.
ever written. And she was familiar with most of the popu-
Focusing too much on acquiring information or under-
lar strength training and nutrition theories of the time.
standing (which is otherwise good) can prevent people
In her mind, her knowledge made her an advanced ath- from acting.
lete, even though the evidence said otherwise.
Over time, we had some success with this client in the
How does this apply to your clients? gym and in the kitchen.
Here are some things to look for. We were able to show her the evidence of gaps between
her knowledge and application.
First, the more intelligent and cerebral the client, the
more likely it is that they will have trouble applying We also included her in the decision-making process,
knowledge. and discussed ideas with her before implementing them.
This helped her feel engaged and recognized her prior
For example, the client in this example was a PhD student
learning.
who always excelled in school, and had been in school
her entire life, but had never had a non-academic job or This client needed a mix of action, evidence, and careful
played a sport. Her entire existence was cognitive (think- coaching to change her perspective and start moving
ing and reasoning) so it was a real challenge for her to be forward.
kinesthetic (moving and physically experiencing).
Remember that helping your clients improve is only part-
Second, clients who want to know the “whys” will often ly about physiology. The other part is psychology.
have trouble distinguishing between what they’re learn-
In upcoming units (and in our Level 2 course), we’ll
show you how to shift clients from cognition to action.
Summary
Being a nutrition coach is as much about the art and Self-knowledge and self-awareness can guide you to-
science of coaching as it is about the nuts and bolts of wards a coaching practice that fits YOU, and serves your
nutrition. This is especially true if nutrition coaching is a clients in the best way possible.
long-term career path for you.
While each coach and client are unique individuals,
Effective nutrition coaching includes nutritional knowl- there are principles that guide good coaching and create
edge along with an understanding of psychology and a sustainable coaching practice. These include having
interpersonal skills. (and teaching) good mental and communications skills.
• Good coaching starts with YOU. What you need to know and what your clients need to
• Know yourself. know are different things. Part of your role is to filter
and prioritize information for clients. Speak in plain,
• Know your motivations.
everyday language, not jargon.
• Know who you are.
• Know what matters to you.

UNIT 10
The ISSA Nutrition

Coaching Methodology
The ISSA Nutrition Coaching Methodology | 271
Unit Outline
1. The process of change 6. Choosing a direction for coaching and building an
early action plan
2. The 6 steps of coaching
7. Working through normal client ambivalence
3. The early stages of the change process
8. How to communicate effectively
4. Assessment and triage
9. Putting it into practice: What’s ahead
5. Identifying and clarifying values, priorities, and goals
10. Case study
11. Summary
Objectives
In this unit, we’ll introduce you to the ISSA coaching system decision making. We’ll also look at how to communicate
and method. We’ll take you through the general process effectively and address clients’ natural and normal resistance
we use, from assessment, to action step, to outcome-based to change.
The process of change

There’s a lot more to coaching than making meal plans or portioning out calories
and percentages of macronutrients.
Fundamentally, nutrition coaching is about two things:
1. Helping people change.
2. Helping them take meaningful action in their own lives.
It’s not just about nutrition. In fact, ironically, nutrition coaching often has very
little to do with actual nutrition. Nutrition coaching often involves understand-
ing clients’ psychology, worldview, lifestyle, environments, and a host of other
factors that shape food and eating.
Nutrition coaching is iterative. That means you try things. Learn. Gather
data. Change. And adapt.
There are no “rules.” No formulas. Only general principles, which you must then
tailor to each client’s unique situation, and revise over time.
At ISSA we’re recognized for being world-class at nutrition coaching. Yet even we
keep experimenting, evolving, and improving our practice. We observe our clients
carefully, noting what works and doesn’t work. We constantly learn and revise.
And so should you.

272 | Unit 10
Coaching for change You’ll notice that most of these are collaborative tasks.
You’re not the “expert” or “authority” telling your clients
Nutrition coaching is about facilitating and supporting what to do. You’re a guide and a facilitator, working with
change, and guiding your clients towards doing some- your clients to help them move forward with their goals.
thing different and better.
Sure, you have opinions, knowledge, and insight to
But what does that mean, exactly? share. And you should share them.
Here are some of the general coaching tasks you’ll do But remember: This is a team approach. You and your
with clients. We’ll look at how to organize these into a client are working together to advance the client’s
process a bit later. agenda.
Your coaching tasks

The 6 steps of coaching
1. Assess and gather data about your clients.
Let’s look more closely now at the coaching system from
2. Organize that data into a coherent, meaningful start to finish.
story. Step 1: Assess and gather data; identify client goals.
3. Use data to make informed decisions, and to help Step 2: Understand the client and “build the story.”
your clients understand their situation. Step 3: Create an action plan and possible “next steps.”
4. Observe and monitor your clients over time, looking Step 4: Choose one next action step and test it.
for change, progress, opportunities for relation- Step 5: Observe and monitor what happens.
ship-building, and “learning moments.”
Step 6: Use outcome-based decision making.
5. Seek to understand your clients’ values, priorities,
As you’ll see from Figure 10.1, the process of coaching is
goals, mindset, and underlying motivations. iterative and cyclical. It loops back on itself.
6. Help clients understand basic nutrition / exercise So, for instance, you’ll probably do Step 1 (data gath-
/ behavior change material (and answer questions ering) on your first day with a new client, but you’ll
when needed). also probably do it periodically as the client’s situation
evolves and you track their progress. Step 5 also looks
7. Help clients reflect on insights, ambivalence, resis- a lot like Step 1. And as you gather more data and learn
tance, and shifts in perspective that come up. more about your client, you’ll revisit Step 2, building
understanding.
8. Provide clear, concrete, immediately usable feed-
back (e.g., connecting the dots between how clients
are living and what results they’re getting). Step 1: Assess and gather data;
identify client goals
9. Be “present” with clients on their journey.
As a coach, you are almost always gathering data in
10. Help clients self-regulate, focus, and manage the some form.
normal feelings that come with change.
For instance, you may notice that one day your client
11. Help them plan, anticipate, strategize, and decide seems full of energy; the next session they seem listless
on a course of action. and tired. This may be a clue about how well your nu-
trition plan is meeting their needs, or how well they are
12. Help them execute that action plan. recovering from their exercise.

ASSESS & OBSERVE BUILD UNDERSTANDING PLAN & STRATEGIZE TAKE ACTION
STEP 1 STEP 2 STEP 3 STEP 4

Assess & gather data. Understand the client Create an action plan Choose next action
Identify goals. and ‘build the story’. and possible ‘next step and test it.
steps’.
STEP 5
Observe and monitor
what happens.
STEP 6 STEP 7
Use outcome-based Choose new next action
decision making. based on Step 6.
Figure 10.1 6-step coaching process
In other words, you’re always paying attention to what • environment and lifestyle, e.g., social support,
your client is up to. family, work hours and demands, travel;
However, you’ll probably start with an initial assess- • goals and desired outcomes, e.g., a specific goal
ment, and periodically gather data to track progress. weight or body composition change, decreased
medication usage, improved performance measures,
This can include data about your client’s:
improved relationship with food.
• physiological indicators, e.g., blood work, other
lab tests, digestive function, immunity, heart rate What to do at Step 1
variability, genome, microbiome;
At this stage, you’re mostly collecting information,
• body composition and measurements, e.g., including:
height, weight, body girths, lean mass, body fat, • Objective indicators (e.g., heart rate, measurements,
bone density; other numeric data)
• other health needs, e.g., known allergies or food • Subjective indicators (e.g., how your client feels, their
intolerances, medication use, other health problems, quality of life)
the other health care providers they work with;
• Descriptions of what is happening right now, or
• function and physical capability, e.g., mobility, recently happened (e.g., food journals)
daily-life tasks, athletic performance;
• Identifying and clarifying your client’s values, priori-
• psychological state and mindset, e.g., readiness ties, and goals
for change, resilience, problem-solving;

274 | Unit 10
active listening: To fully You’re also doing a lot of “active listening”, observing, and asking questions.
concentrate on what is being said,
not just passively hearing what We give you assessment forms that you can use to gather these types of data in
the person is saying
the forms package.
Step 2: Understand the client and “build the story”

Data doesn’t stand alone. You have to make sense of it, and put it together into a
“story” that starts to explain your client’s situation and needs.
For instance, high triglycerides, poor glucose tolerance, a demanding job, crum-
my sleep, and family stress aren’t just randomly unrelated data points. When you
put them together, they start to “build a story” of a client who is dealing with
physical and psychological stressors that are creating a variety of problems.
As a coach, you are also seeking to clarify and understand each client’s values,
priorities, motivations, goals, and perspectives. In particular:
• You want to know what matters most to them right now.
• You want to know how ready, willing, and able they are to make change.
• You want to look for any ambivalence or tension they might feel about chang-
ing their behaviors. (For example, “I want to take time for myself” can conflict
with “My family needs me” or “I’m so busy with work.”)
If you like, you can even create a little template of “client stories” by filling in the
blanks:
“As a ____, I want to ____ so that I can ____.”
For instance:
“As a working parent, I want to find quick and easy nutrition solutions so that I
can help my whole family eat better without a lot of disruption to our routine.”
“As an older recreational athlete, I want my nutrition to improve my recovery and

support my training so that I can stay injury-free, boost my immunity, have lots of
energy, and keep doing the sports I love for life.”
We’ll talk more about client stories later in the unit.
What to do at Step 2
At this stage, you will:
• put data together; analyzing and synthesizing it; drawing conclusions about what
it means
• try to understand what makes your client tick; and what’s most important to
them right now
• identify where their roadblocks are and what might be holding them back
from change
bright spots: Things that are
already going well • identify “bright spots” — things that are already working, or abilities that

OUTCOME:
End goal
Today This month

I will: I will:
This week
I will:
Figure 10.2 The 4-circle exercise
you can apply (e.g., client is very organized or follows At this stage, you will:
instructions well)
• hypothesize what might work most effectively for
• identify what they’re capable of doing and your client.
understanding
• map out a course of action that works towards the
• identify their nutritional level (more on this later in client’s goals; and / or a roster of possible tasks that
the unit) the client might do.
• break this larger course of action or “to do list” into

Step 3: Create an action plan and smaller steps that your client could potentially do
possible “next steps” immediately. You can use the Make It a Habit
Worksheet found in the forms package.
For instance, here’s one way of thinking about moving
In Step 3, you apply what you discovered and digested in from goal to next action steps. We illustrate this ap-
Steps 1 and 2. proach in Figure 10.2.

276 | Unit 10
Make It a Habit Worksheet C Ready, Willing and Able Worksheet
NAME DATE NAME DATE
PROPOSED TASK
How to make goals into habits: a quick reference
1. Start with the awesome. How ready are you to do this task?
2. Let the client choose the direction.
3. Set the right kind of goal. LET’S GO
NOT AT ALL 1 2 3 4 5 6 7 8 9 10 NOW!
4. Break the goal down.
5. Choose ONE small piece. What might make you more ready to do the task?
6. Shrink the task even further.
7. Confirm the fit.
8. Set up an accountability system.
9. Use outcome-based decision making to assess how well the habit worked and plan next steps.
How willing are you to do this task?
Step 1: Start with the awesome NOT WILLING DYING TO

AT ALL 1 2 3 4 5 6 7 8 9 10 DO IT
What are your client’s existing: To ask your client: What might make you more willing to do the task?
• skills • Where / how are you already successful? How can you do
• solutions to other problems more of that?
• successes • In what situations do you tend to be successful? How can we
reproduce that for you in the service of a new nutrition-related
• strengths task?
• superpowers How able are you to do this task?
• Where do you feel strongest? How can we build on those
strengths? 100%
CAN’T DO IT
AT ALL 1 2 3 4 5 6 7 8 9 10 CONFIDENT
I CAN DO IT
What might make you more able to do the task?
What’s awesome about your client?

Revised task
REVISED TASK
Revised task score
 Ready  Willing  Able
© 2018 ISSA issaonline.edu © 2018 ISSA issaonline.edu
Find the Make It A Habit worksheet; Ready, Willing, and Able worksheet, and others in your forms package
1. Start with the end result. What does the client You probably have some good ideas, but you won’t know
want to do, be, feel, and / or see at the end of their which action step works best until you try it.
coaching process?
Here’s what this means.
2. Work backwards. In order to get to the goal, what
might the client need to do:
a. This month? At this stage, you will:
b. This week? • Offer the client your expert suggestions on 1-3 po-
tential next action steps, or general areas to work on.
c. Today?
(For instance, “Given what you’ve mentioned about
Note that at this stage, you’re still mostly guessing about having trouble in the mornings, I’m thinking we
what could work for your client. They’re informed guess- could either tackle your breakfast menu, or your sleep
es — aka hypotheses — but you’ll still need to test them. habits. Which would you prefer?”)
• Allow the client to choose what they’re willing to

Step 4: Choose one next action step work on, and / or what they think is most important.
and test it • Make sure this action is meaningful to the client and
not just “some random thing coach says I should do.”
Once you have some possible next actions in mind,
you’ll need to pick one and make sure it matches what • Break each step down into the easiest, most consis-
your client is ready, willing, and able to do. tently do-able format.

• Ensure that the client clearly understands what the with regular check-ins that are less frequent and
task involves. more of a casual conversation, perhaps even with the
distance of email.
• Get full confidence and buy-in from the client.
Decide together in advance how often you will check in,
Important: monitor and follow up, and how you’ll do it.
1. do only ONE thing at a time. You can and should also schedule regular progress
updates, where you gather and update specific types of
2. Make sure that the client is completely con- information, such as:
fident about this task, and ready, willing,
• body measurements and photos
and able to do it. To do this, try out our Ready,
Willing, and Able Worksheet. You can find that • athletic performance indicators (e.g., strength,
in the forms package. mobility)
• other wellness indicators (e.g., sleep, energy,

3. Collaborate on the next action. Don’t just tell
recovery)
your client what they “should” do. Remember that
you and your client are a team who decides on tasks Your initial assessment and ongoing conversations with
together. your client should tell you what is important to track.
If you aren’t sure, talk to your client about what “prog-

Step 5: Observe and monitor what ress” means to them.
happens
Don’t assume your idea of “progress” is the same as
Once you’ve assigned the action step to your client, and theirs.
you’ve both agreed on what constitutes “doing the task”,
track how often and well the task gets done. We recommend you use something like this:
• Daily: Client tracks their assigned task (a simple yes /
At this stage, you’re experimenting. There is no failure, no checklist is fine)
only feedback.
• Weekly or biweekly: Reviewing together with your cli-
This stage is much like Step 1. You’re gathering data ent how well and consistently they did their assigned
again. task
• How often / consistently did your client do the as- • Monthly: Assess overall progress indicators
signed task?
• Quarterly: Assess goals and overall strategic direction
• How well did your client do the assigned task? of coaching program
• Did any challenges or questions come up?
• Was there anything that went particularly well? (Use
this to shape your decision making. As often as possi- At this stage, you will:
ble, play to your clients’ strengths.) • track how often and well the client’s assigned task
got done
You’re also monitoring your client and staying in rela-
tively regular contact. • agree on what measures you will track, based on the
client’s goals and definition of “progress”
How, and how often you do this will depend on the
client’s needs and preferences. For instance: • gather any additional data that might be useful. Ob-
serve your client carefully
• Some clients do best when you’re “on their case”
with frequent text messages, emails, and / or phone • agree on regular scheduled check-ins, monitoring
calls. They may like a lot of in-person contact and and follow-ups
“hand holding.” • agree on how, and how often, these check-ins / fol-
• Other clients may prefer a more “hands-off” style, low-up sessions will occur

278 | Unit 10
outcome-based decision
making (OBDM): Deciding what
Step 6: Use outcome-based decision making
to do next based on the outcomes
of what someone just experienced After you observe how well your client did their assigned action, decide what to do
next, based on the results of your experiment. This is known as outcome-based
decision making (OBDM).
Remember: What you choose to do next should be based on the data you collect-
ed. Don’t stick to dogma, rules or plans rigidly when the data tell you otherwise.
There are no “shoulds” in coaching — only what is.
Your regular schedule of checking in and monitoring your client should eventu-
ally give you some data about how well things are working.
At this stage, you will:
• review and analyze the data you gathered from Step 5.
• based on your analysis, assess whether you are moving in the right direction.
Are you getting the results you seek?
• look for trends, patterns, and relationships between things (e.g., every time
your client does A, it leads to B)
• choose the next task and / or strategic direction of the coaching program
based on the results of your experiment. This can include:
• assigning the client a completely new task, or deciding to go in a new direction;
• changing the original task;
• shrinking the original task so that it’s easier or more manageable (if the client
struggled with it initially); and / or
• making the original task more challenging (if the client found it too easy).
The early stages of the change process

In the rest of this unit, we’ll look at the early stages of coaching clients through
the change process.
This includes:
triage: Assigning degrees of • assessment and triage (including sorting clients into nutritional Level 1, 2,
urgency
and 3)
• identifying and clarifying clients’ values, priorities, and goals
• setting realistic expectations and negotiating trade-offs
• choosing a direction for coaching and building an early action plan
• identifying “small wins” and bright spots
• identifying limiting factors
• working through normal client ambivalence and testing client confidence
• communicating and giving feedback clearly

Assessment and triage • Go slowly, step by step. Don’t overwhelm new cli-
ents with documentation in the beginning. And don’t
try to fix everything at once.
The value of assessment
• Set priorities. Look for the most important things
Good coaches are always gathering, analyzing, and using to focus on.
data to make informed, outcome-based decisions about
what to do next. How to assess your clients
This means you need to do some comprehensive initial
Assess new clients immediately, or as soon as possible.
assessments of your client, and have an ongoing system
Then, schedule ongoing assessments regularly.
of “checking in” to update the data you’re collecting.
You can ask a new client to start filling out your forms
You also need to triage — to understand what’s most
in advance, and / or you can work through the forms
important, right now, for each unique client. This helps
together. We recommend you do both.
you figure out “first things first” and set priorities.
Filling out forms in advance gives your client time to
A good initial assessment helps you match your coach-
think and remember details. Then, going through the
ing plan to what the client can actually understand,
forms together and discussing them in your first consul-
manage, and do. This ensures that your clients go steadi-
tation gives you both an opportunity to fill in any gaps
ly from success to success, rather than swinging wildly
and make sure you’re on the same page.
from resistance to anxiety to failure.
A very small, simple plan that a client can do — and Using the ISSA Certified Nutrition
feel good about — every day beats an awesome plan Specialist assessment forms
that a client can’t do consistently.
Assessment forms and data gathering
The initial assessment will:
We suggest you start with the ISSA Initial Assessment
• help you give your client an objective appraisal of
& Triage Questionnaire. Ask the client to fill it out
what and how they’re doing;
beforehand if possible, and bring it to your first session
• help you identify whether your client is at risk for together. Then, discuss their responses and look for ad-
illness and / or injury; ditional information and understanding where required.
• determine if you need to refer the client out, either Using the Initial Assessment & Triage Questionnaire,
because they fall outside your scope of practice or you’ll cover:
because the relationship would be a mismatch (re-
• the client’s perspective, such as expectations,
member, referring out is an important and valuable
goals, self-identified limiting factors, willingness to
option);
change, and what behaviors they’d like to focus on or
• help you focus on what matters to your client; change
• give you vital information on what your client’s limit- • social factors such as social support, stress, and
ing factors may be; and relationships
• provide you with information that serves as a baseline • health indicators and conditions such as injuries,
for comparison when monitoring progress in the medication use, and digestion
future.
• lifestyle factors such as how often they see the
doctor, whether they smoke, how they spend their
What to focus on time, and how their kitchen is set up
At the assessment stage: Once you review the initial questionnaire together, you
as the coach can also assess your client’s nutritional
• Keep it simple. Use only the forms and informa-
level.
tion-gathering tools you need.

280 | Unit 10
Identifying nutritional level

Initial Assessment & Triage Questionnaire C As part of your initial assessment, we suggest you place
each client into one of three nutritional levels, based on
NAME DATE
four questions:
Coaching tips
• You can use this form both for an initial baseline assessment and to track progress periodically.
1. What does this client know?
• Client responses to questions can suggest what areas to work on and track.
• You can also use questions such as the 1-10 numeric scores to track objective progress in particular areas (e.g., “Right now,
how would you rank your overall eating / nutrition habits?”). 2. What can this client do right now?
Tell me more about yourself. 3. What does this client want to do? (In other words,
what are their goals?)
By learning more about your lifestyle and your habits, I can take better care of you and make sure coaching is a good fit for your goals
and individual needs.
DATE OF BIRTH GENDER

4. What can this client do consistently?
Staying in touch
Please print clearly. In the next unit, we’ll give you a breakdown of Level 1, 2,
EMAIL MOBILE PHONE HOME PHONE
and 3 clients, and how to properly categorize them.
How do you prefer me to contact you?


Email
Phone
Emergency contact name:
Review and follow up
 Skype or other video chat


Text
Other (please specify):

Emergency contact phone number:
As you go through the Initial Assessment & Triage
Questionnaire with your new client, don’t make any de-
Coaching tips cisions or commit to any next actions. At this point, just
gather information and seek to understand.
• Ensure that all contact information is complete and correct.
• Confirm with client how they would like to be contacted, and how often.
© 2018 ISSA issaonline.edu

Afterwards:
• Take some time to review what you learned.
Find the Initial Assessment & Triage Questionnaire in your forms • Decide what level the client is at. (Hint: It’ll almost
package always be Level 1.)
• Start to identify potential pathways for coaching

After the first session, if you feel like the Initial Assess- them.
ment & Triage Questionnaire raises some questions that
you’d like to immediately answer, you can also use any of • Establish if you’ll need to give them additional forms.
the worksheets listed in Table 10.1, which may help you: Then:
• identify what is most important to your client right
• Set up a second meeting with your client to discuss
now
next steps and programming. (For convenience, you
• identify what “progress” means to your client, and can also book this at the end of the first session.)
track it
During this follow-up meeting, you can also discuss
• collaborate on next actions together things like:
• ensure that your client is able to execute any tasks • what counts as “progress” and a schedule for moni-
you give them toring it;
• troubleshoot as needed • adjusting the next step to make it do-able;
Keep in mind that you don’t have to use any of these • how your client would like to work with you (e.g., by
worksheets. We recommend you try one at a time. Feel email / phone, in person); and
free to use these throughout the coaching process, and
• what to expect in your work together.
only if you find them useful in your coaching decisions.

Table 10.1 Index of forms

Worksheet, assessment, or
What it’s used for Versions
questionnaire
Initial Assessment and Triage Helps you match your coaching plan to what the client can Coach version1
Questionnaire actually understand, manage, and do. Also helps you to give
clients an objective appraisal of what and how they’re doing, Client version2
helps you identify clients who are at risk for illness and / or
injury, and helps you determine if you need to refer a client
out.
4 Crazy Questions Worksheet For helping clients think through the benefits of the status Client version
quo and what they’ll have to give up to change.
A-B-C Worksheet For negotiating which specific exercises and / or foods clients Coach version
can / will do or eat. (At least right now.)
Client version
All-or-None Worksheet For helping clients see choices as a continuum versus all or Coach version
nothing.
Client version
Athletic Nutrition Needs For understanding a client’s training goals, training volume, Coach version
Questionnaire current recovery practices, and current nutrition practices.
Client version
Baseline Blood Chemistry For coaches who find blood work useful in the decision-mak- Coach version
Assessment ing process.
Behavior Awareness Worksheet For helping clients change unwanted habits and behaviors Client version
(such as stress eating).
Body Measurements Form For tracking body composition in clients who might benefit Coach version
from regular measures.
Eating Habits Questionnaire For learning more about a client’s eating patterns. Coach version
Client version
Food journals
3-Day Diet Record For recording exactly what a client is eating; most often for Client version
Level 2 eaters.
80% Full Meal Journal For helping clients learn how to eat until satisfied versus Client version
stuffed and tracking progress in this area.
Athletic Performance Indicators & For correlating mood, energy, and motivation with dietary Client version
Athlete Nutrition Journal intake in hard-training athletes. Includes Athletic Perfor-
mance Indicators worksheet.
Eating Behaviors Journal For capturing a client’s urges, cravings, and behaviors Client version
around meals.
Eating Slowly Meal Journal and For tracking a client’s meal speed and whether they’re Client version
Meal Duration Journal consistently eating slowly and mindfully. Use Eating Slowly
for subjective self-assessment or Meal Duration for objective
self-assessment.
Emotional Eating Journal For capturing a client’s emotions and thoughts and how they Client version
might lead to different food choices.
How Food Feels Journal For capturing a client’s physical sensations (like allergies or Client version
intolerances) related to food.
Hand-Sized Portion Guide A simple guide to calorie control without calorie tracking. Coach version
Client version

282 | Unit 10
Table 10.1 Index of forms

Worksheet, assessment, or
What it’s used for Versions
questionnaire
Ideas for Movement Suggestions for daily movement outside of scheduled Coach version
“exercise.”
Client version
Kitchen Set-up Assessment For helping highlight the relationship between a client’s Coach version
environment and their food habits.
Client version
Limiting Factors, Advantages, and For identifying a client’s struggles, their advantages, and Coach version
Behavior Goals Log how to turn them into a plan for change.
Make It A Habit Worksheet For moving from vague idea or outcome goal to specific Coach version
habit and behavior goal.
Meal Consistency Worksheet For tracking a client’s consistency with agreed-upon behav- Coach version
iors and practices.
Client version
Medical History and Present Medi- Provides more detailed information about the client’s overall Coach version
cal Condition Questionnaire3 health.
Client version
Planning & Time Use Worksheet For clients who have problems with time management. Client version
Fitness Nutrition Plate A simple way to structure each meal the ISSA way. Client version
Push-Pull-Habit-Anxiety Worksheet For identifying what’s pushing clients away from old ways of Coach version
doing things and pulling them towards new things.
Ready, Willing, and Able Worksheet For helping establish how ready, willing, and able a client Client version
is to make a given change. Also helps coaches “shrink the
change” to make it more manageable.
Sleep & Recovery Ideas For helping coaches discuss sleep rituals and stress Coach version
management.
Client version
Social Support Form For showing how social support influences a client’s eating Coach version
and movement decisions.
Client version
Sphere of Control Worksheet For helping clients identify what they have control over… and Coach version
don’t.
Client version
Stress & Recovery Questionnaire For showing patterns of sleep, stress, and recovery. Coach version
Client version
The Hunger Game For helping clients better tune into hunger and appetite Client version
cues.
Want-Willing-Won’t Worksheet For negotiating what clients want, and what they’re willing Coach version
to do (or not do) for that goal right now.
Client version
1 Coach versions contain scripts or background information that you can use to either explain the form to your clients, or to understand why we’ve asked certain questions.
It’s like a “Teacher’s guide” for school teachers.
2 Client versions of forms are for the clients to take home and fill out themselves.
3 Remember that Medical Nutrition Therapy is off limits unless you’re a registered dietitian. We include this form so you can have access to the client’s medical history in
case that needs to inform your advice.

Identifying and clarifying values, priorities, and goals

Ultimately, coaching is about helping clients further Each client’s situation will be unique. What they want
their agendas. will be unique. Assume nothing.
You’re a champion for your clients. An advocate. An ally. Of course, you’ll hear some common things, like “lose
weight” or “get in shape.” But as a coach, you have to
You help them get where they want to go. dig a little deeper than that to truly understand what
matters to each individual client, and why.
But first, you have to figure out where exactly that is.
You should start talking to your clients about these
This involves exploring questions like:
things during your first session together. Each session
• What does your client want to do? after that is to learn more, understand more, and clarify
more about what matters most to your client (and how
• What do they really want to do?
that may change over time).
• Why do they want to do that? Why is this goal mean-
ingful to them?
Clarifying goals
• What’s realistic for your client? Do they understand
that? Work towards figuring out a clear “what” and “why.”
• What’s most important to your client? 1. What does your client want to do? (What are their
• What should come first? What does your client want goals?)
to prioritize?
2. Why do they want to do it? (What motivates them?)
• What do they need in order to move towards their
goals? The more specific, concrete and well-defined a goal is,
the more it can become “real” for the client.
• What’s holding them back or blocking them from
those goals? (In other words, why haven’t they al- The more meaningful and resonant a motivator is, the
ready achieved those goals?) more it’ll keep your client on track when things get
tough. (Which they will.)
• What do their goals mean in the context of their lives?
(For instance, wanting to lose weight in the face of Table 10.2 offers some examples of clear and unclear
a health scare will be different than wanting to lose “whats” and “whys.”
weight to look good at the beach on a honeymoon.)
Notice here how unclear goals and motivators often in-
As you think about these questions, and work through clude unclear terms like “eat better”, “tone up”, or “better
them with your clients, notice how there are no “rules”, shape.” It’s hard to track “tone up” as a coach.
buzzwords, or slogans.
So your role here is, in part, to help clients get more con-
crete and specific. Here are some exercises you can try.
Table 10.2 Clear versus unclear “whats” and “whys”

Clear Unclear
Why I want to get my blood lipids back into the normal I want to learn to eat better.
range.
Goals I want to tone up.
I want to run a 5K in April.
I want to add some muscle.
I want to bench press 200 lb.
What My father just died of a heart attack, and I’ve decided I dunno, I just feel like I should be in better shape.
that I don’t want to go out like that.
Motivators Ummm… I’m not sure...
I need to gain / lose weight to compete in X weight-
class division in my sport.

284 | Unit 10
5 Whys
5 Whys: Asking someone The 5 Whys is an exercise that helps get at a client’s deeper motivations.
“why” at least five times to
elicit introspection and deeper Deeper motivations help you tailor the coaching plan to the client. And they
motivations
keep your client on track when the going gets tough.
The concept is simple: Ask why five times, building on the previous answer, until
you arrive at a deeper understanding of what drives the client, or what meaning
this goal has to them.
Here’s an example.
Client: I want to lose weight.
Coach: Why do you want to lose weight?
Client: Well, I just don’t feel very attractive at this weight.
Coach: Why don’t you feel attractive at that weight?
Client: I can’t wear my old clothes, or dress up and go out.
Coach: And why is wearing those clothes or going out important to you?
Client: My wife and I used to go out a lot when we were first dating. But now…
we just… don’t.
Coach: So why is that an issue for you?
Client: It sorta seems like a lot of the magic is gone. You know?
Coach: And why does that bother you?
Client: Well, I really miss those times. With the kids… you know how it is…
being so busy and over-scheduled… And I worry that my wife doesn’t think I’m
attractive any more. So I guess it’s about just wanting some of that back.
You went from a vague “lose weight” to a pretty good understanding of this
client’s deeper motivators and lifestyle challenges in under one minute of
conversation.
Now you know that their goals involve feeling more attractive but also possibly
managing their time more effectively and having more fun in their life again.
Nice work, coach.
Of course, be sure to use a diplomatic, curious, interested tone rather than a

judgmental or interrogating one.
What will be different?

Ask your client:
“If you get what you want, how will you know? What specific things will be differ-
ent? Once you get what you want, how specifically will you feel? What specifically
will you be doing, or able to do?”

Table 10.3 Behaviors as goals

Step 1: Show how behav- Step 2: Help the client Step 3: Identify possible Step 4: Assign a small
iors lead to outcomes understand what they behavior goals specific task as the goal
can control
“You’ve said you’d like to “Now, just to be clear: We “From your list of possible “What seems easiest? Using
lose X lb. Tell me what you can’t set a timeline on this. behaviors, it looks like por- plate size? Okay, cool. So
think needs to happen to get Everyone’s body is different. tion control is an important let’s start simply: How about
there. I have some ideas, but But what we can control is part of losing weight. Would for this week, you’ll eat din-
I’d like to hear yours first.” what you choose to eat, and you like to start working on ner off this smaller plate?”
how much.” some basic portion control
“Let me ask you a question. as our first goal together?” “Given what you’ve suggest-
What do you think fit people “So obviously a fit body ed, do you think booking
do? How do you think they doesn’t happen by accident. “Okay, you said fit people 10 minutes of walking every
live? What choices do you Fitness is something we have make time for exercise every day would be do-able as a
think they make day to day? to prioritize every day, right? day. What would that look first behavior goal for this
If you had to imagine those And for most people, that like for you? How could week?”
things… what might you usually means scheduling you work towards that
say? Fit people do _____.” some time in advance.” behavior?”
For instance, a client might talk about: Help your client move from the outcomes they want to the
behaviors that will get them there.
• feeling more confident;
Step 1: Show how behaviors lead to outcomes.
• fitting into a certain clothing size;
Outcomes don’t “just happen.” There is a process for how
• doing a new activity; or to get there.
• doing an everyday activity more comfortably and Step 2: Help the client understand what they can
easily. control, and what they can’t. Focus on changing what
they can control (e.g., what they eat), and steer them away
This helps you get a better idea of what the client’s goals
mean to them. from thinking about what they can’t (e.g., how fast they
will lose weight).
Outcome versus behavior goals Step 3: Identify some possible behaviors that lead
Help your client distinguish between outcome and to the outcome the client wants. Together with your
behavior goals. client, you can “reverse engineer” the behaviors that will
have to happen to get to their goals. Start with the end,
Outcome goals specify what will happen at the end of and work backwards.
things — the outcome.
Step 4: Choose one behavior and set it as a goal.
Behavior goals specify what actions must be taken to get
there — the processes, actions, steps, and behaviors that See Table 10.3 for a couple of examples.
must occur in order to progress toward the outcome.
Expectations and trade-offs
Outcomes are usually out of our control. Behavior goals
are usually fully within our control. Asking what matters most to your clients, why it matters
to them, and what they can reasonably manage, can also
For example:
help you talk about realistic expectations and trade-offs.
• We can’t control our hormones and activity of fat
cells. But we can control what we eat. Many of your clients have never lived in a lean, muscular,
athletic, and / or healthy body. Thus, many of them will
• We can’t control how effectively our muscle cells grow. have no idea what type of daily behaviors it takes to get
But we can hit the gym regularly and work hard. those outcomes.

286 | Unit 10
Explore trade-offs Set realistic expectations

As part of your assessment and ongoing monitoring, Clients may also not know there is a “middle ground”
explore the “Want-willing-won’t” questions with your between “extremely unfit” and “fitness magazine model.”
clients: To them, the only way to “be in shape” or “be healthy”
may be a Photoshopped image, a grueling workout reg-
1. What do you want? imen, and / or a very restrictive eating plan. They may
2. What are you willing to do for that goal right now? also think that major changes will happen very quickly
(e.g., the “6-week beach body plan” mentality).
3. What won’t you do for that goal right now?
So, part of your job as a coach is to help them see a range
Some clients might start to realize that they don’t want of possible options, particularly those that are achievable
to make certain trade-offs. and realistic.
Some clients might be willing to make trade-offs, but For example:
based on where they currently stand (e.g., a certain per-
centage of body fat, a certain body type, a certain age, a “Research is showing that even losing 5-10 lb can help
certain history with disordered eating), it might be unre- improve health. You don’t necessarily have to lose 50 to
alistic (or unhealthy) for them to pursue a certain goal. feel better or improve your blood work.”
As the coach, part of your job will be to help your clients “I know you’re worried about the health effects of sitting
stay safe and sane about their trade-offs. all the time. The good news is that even quick movement
breaks throughout the day, maybe a 15 or 20 minute walk
Use the Want-Willing-Won’t Worksheet to help facili- at lunch, can make a big difference.”
tate this discussion.
Want-Willing-Won’t Worksheet C A-B-C List Worksheet
NAME DATE NAME DATE
Take a few minutes to fill out the lists below. It doesn’t have to be an exhaustive list. Just do the best you can.
How to explain this form to your clients

Here’s a sample script you can use to introduce this form to your clients. FOODS A FOODS B FOODS C
“I’d like to understand more about your current goals, limitations, and priorities. When we are trying to change our body and Like Might eat Not right now
health, we have to make certain trade-offs. In order for X to happen, you may have to change Y. And not everyone is ready to
take certain actions. That’s okay.
I just want us to get clear on what you are willing — and not willing — to do right now. Of course, this can change. We can re-
visit this discussion any time you like.
Please be honest. There are no right or wrong answers. The more truthful you are, the more I can match your coaching
program to your unique situation. I just want to help you stay safe and sane about your trade-offs.”
Please answer the questions as honestly as you can. There are no right or wrong answers.
1. What do you want?
2. What are you willing to do for that goal right now?
ACTIVITIES A ACTIVITIES B ACTIVITIES C
Can do easily Maybe Not right now
3. What won’t you do for that goal right now?
Find Want-Willing-Won’t, the A-B-C worksheet, and others in your forms package

List A List B List C
Like Might Eat Not right now
Apples Spinach Broccoli

Oranges Watermelon Olives
Bananas Shrimp F ish
Grapes Brown rice Quinoa
Chicken Carrots Lentils
Celery Corn Brussels sprouts
Peas Protein powder
Hamburgers
Can do easily Maybe, sort of Not right now
Walking Running (up to 15 min) Sprinting

Squats Pullups (assisted) or Running over 15 min
pulldowns
Lunges Pressing, pushups
Deadlifts (light)
Rows
Hip hinge (light)
Most mobility work
A-B-C worksheet examples
“In my experience, it takes longer than that for most clients

to bounce back from that type of surgery. The good news is
Choosing a direction for
that we can focus on other things while you heal.” coaching and building an
You can also ask your client what they think is realistic early action plan
versus ideal. Direct their attention to “a little bit better” As you work with your client to understand their
or “a small step forward.” motivations, values, priorities, and goals, your overall
“Of course, most of us would like to be Superman / Super- coaching strategy should start to become clearer.
woman. Let’s set that aside for a minute and talk about Sometimes, you’ll have an intuitive sense of what to do
what you think is most realistic for you, given your lifestyle, next and why, and how that fits into the bigger pic-
abilities, and everything else we’ve discussed. What would ture. Other times, it won’t be as clear. You can then ask
a small step towards your goals look like?” yourself:
As part of this, you can use the A-B-C Worksheet, which • What are they already doing well, and how can I help
helps clients see what is on their “A” (for sure, no prob- them do more of that? (Otherwise known as small
lem), “B” (maybe), and “C” (no way) lists respectively. wins and bright spots.)

288 | Unit 10
• What is holding them back? Why haven’t they already part of that? The part that makes you feel the most
changed? (Otherwise known as limiting factors.) stuck or frustrated?” (This question helps you figure
out what you could tackle first. It also helps the client
• What are some small actions that can start moving
clarify what exactly is bothering them most, rather
my client in the right direction?
than giving you just a vague “feeling bad.”)
• What can my client reasonably and realistically do?
The client may have a long list of limiting factors. Don’t
get bogged down. Don’t get freaked out. You’re going to
Identifying small wins and “bright work through these systematically, one by one.
spots”
Once you’ve brainstormed your list of limiting factors,
One easy (and often motivating) way to keep clients help your client then choose the one they’d like to work
motivated and moving towards their goals is simply to on.
ask them:
Have them pick either the biggest boulder in their path,
• “What have you already tried that seemed to help?” or the tiniest, easiest-to-grab pebble.
• “What is already working well for you?”
“Okay, out of this entire list, think about two things. Ei-
• “What could work in your favor here?” (For instance, ther: What’s the biggest blockage — the thing that would
client already knows how to cook; client is organized; make the biggest difference if we fixed it right now? Or:
client lives near the gym) What’s the easiest thing to do? … Uh huh. Great. Okay, so
which one would you like to work on first?”
• “You’ve mentioned struggling with X. Are there times
when X doesn’t happen? Times when dealing with X Sometimes, we like the “documentary film crew”
is actually a little bit easier?” (For instance, client can question.
eat a healthy breakfast and lunch but has trouble with
dinner.) “Let’s say a documentary film crew is making a movie of
your life. They follow you around all the time, filming ev-
• “It sounds like you had some motivation to start erything you do. What you ate. When you ate it. How you
working with me. What was that motivation? What ate it. Where you ate it. And so on. If we were to sit down
pushed you to come here today, and not wait, say, together this evening and review this footage, what do you
another few months?” think would stand out? If you imagine your life as this
kind of movie, what might we see as some of the behaviors
As a next action, you can then just suggest that the client that are blocking you from getting what you want?”
build on what is already going well (i.e., small wins and
“bright spots”). You can also help them strengthen their In fact, you’ll see this question appear on the Initial
initial motivation. Assessment & Triage Questionnaire.
We’ll look more at specific limiting factors and potential

Identifying limiting factors solutions in upcoming units.
Another way to keep clients rolling along is to remove
whatever is in their way and preventing them from mov- Figuring out the right type of action
ing forward (i.e., limiting factors).
Once you identify bright spots and limiting factors, and
• “Why haven’t you already done what you’d like to think about them in the context of your client’s lifestyle,
do?” (Make sure to ask this in a friendly, neutral way.) values, priorities, and goals, you’ll probably have some
• “What’s blocking you from doing X?” ideas for next actions.
• “Sometimes, there are good reasons for not chang- Ask the client to choose first
ing. What would you say is the advantage for you of
not changing right now?” Clients believe what they hear themselves say. Instead of
telling a client what to do, ask questions that get them
• “You mention struggling with X. What’s the worst generating their own solutions.

“So, given all this, what do you think you’ll do next?” Start very, very, very small
“You say now might be a time to consider cutting back Always start small. Smaller than you think or want.
on sugar. How would you go about it if you were ready? (Even if you choose a Big Kahuna option — tackling the
What steps do you need to take to get started?” massive life-altering change.)
“You mentioned that you want to start eating more Here are four guiding principles for establishing small
vegetables each day. Where do you think you could start next actions:
building more vegetables in right now?”
1. Your client must be 95-100% on board with what
You can also ask your client what they might want to do you’re proposing. (We allow 5% wiggle room be-
next, while combining it with the assurance that you’ll cause some tasks may be new, and your client may
provide expert guidance if they get stuck. be willing to try them, but not entirely certain about
“After reviewing all of these, I have some ideas, but I’d like them.)
to hear yours first. Knowing yourself and what you want
2. Your client must score 9/10 or more on ready, will-
to do, what might you like to work on first? What seems
most urgent for you?” ing, and able to do the task. (More on this below.)
3. Your client must fully understand what they are

Start big / start small
being asked to do.
If you’re stuck for ideas, you can try this quick triage for
deciding which direction to pursue. 4. The task must be very clear, specific, and concrete.
“Eat healthy” is no good. “Eat an orange with break-
With your client, choose one of these two options. fast” is what you want.
1. The Big Kahuna — the piece or action which, if To facilitate this, try the Make It A Habit Worksheet.
altered, would yield the most benefit. Changing this
will be hard, but will yield massive payoffs. Test ready, willing, and able
2. The Low-hanging Fruit — the piece or action that Ask your client:
the client feels is easiest and least troublesome to • “On a scale of 1 to 10, how ready are you to do this
change. Changing this will be simple and make the task?”
client feel immediately successful.
• “On a scale of 1 to 10, how willing are you to do this
With each proposed change, check which path the client task?”
would prefer: Big Kahuna or Low-Hanging Fruit. • “On a scale of 1 to 10, how able are you to do this
task?”
Use the 80/20 rule
In the forms package, we’ve given you a Ready, Willing,
We suggest you apply the 80/20 rule to choosing next
and Able Worksheet.
actions:
• 80% of the time, focus on expanding and im- You want 9/10 or higher on each of these.
proving bright spots. If your client already walks
If you don’t get it, make the task smaller / easier. Then
for 15 minutes a day, get them walking for 20. Then
ask again.
offer them praise of an affirmation.
• 20% of the time, focus on removing limiting

Keep asking until you get 9/10 ready, willing, and able or
higher.
factors. If your client can’t walk more than 20 min-
utes without knee pain, get them to physio. You can also simply ask:
Focusing on what your client already does well, and • “On a scale of 1 to 10, how confident are you that
making use of their existing strengths, will keep them you could absolutely, for sure, no matter what, do
feeling motivated, capable, and successful. this task every day?”

290 | Unit 10
Again, adjust and scale back the proposed task until the client tells you they are
at least 9/10 confident they can do it each day.
No task is too small to start with. Set aside your grand dreams and get that 9/10.
Set realistic expectations (again)

Your client may want to DO ALL THE THINGS all at once. Your job is to stop
them from doing that. (Or, assign it as a one-week experiment where they must
take notes, and then ask them to tell you how it went.)
Clients will often seek a solution that befits the scale of change they want to
make. They want to get magazine-cover-ready by next week so they look for the
“one week magazine cover model diet.”
Or they may want big changes right now. They may be anxious, or worried about
failure. This may feel like their “last chance.” So change may feel urgent to them.
They may be angry about going too slowly.
Big solutions and overnight results are fantasy. Call out “magical thinking” when
it occurs (diplomatically, of course).
“I know, I know. It would be awesome if we could just do X and get completely

ripped. I hear ya. Unfortunately, that’s not how it works. Here’s what you can
actually expect…”
“Yeah, losing X pounds in Y weeks isn’t realistic for most people. But there is hope.
I had another client similar to you and s/he got great results like this [showing
photo]. However, it actually took about Z months. The good news is, s/he was able
to maintain this rather than rebounding.”
Help them scale accordingly and be realistic.
Working through normal client

ambivalence
ambivalence: Having mixed Change naturally involves mixed emotions and ambivalence.
feelings or contradictory ideas
about something or someone Even if we really want to change, we may feel “stuck” or attached to something
that keeps us from changing. We may feel pulled between different things,
such as taking care of others versus taking care of ourselves; or wanting to lose
weight but not wanting to give up comfort eating.
This ambivalence is absolutely normal.
Ambivalence and mixed feelings (or contradictory behavior) don’t mean your
clients don’t want to change. Neither do they mean your clients are dumb, illogical,
“difficult”, and / or “not motivated.”
Change always involves competing drives and forces.
Unless you have a very specific, advanced / elite client population, most clients
will feel at least a bit “stuck” or conflicted. Many people will come to you having

had some kind of recent painful confrontation with “needing to change”, but
they still may not be “ready, willing, and able.” And this can happen to all clients,
even if your client is an educated expert in the field of health / nutrition.
In fact, clients may not know why they are doing certain things. (“I start out
trying to eat healthy, and then… I dunno… it just kind of goes off the rails.”)
As a coach, you can help them:

• normalize this ambivalence and understand that it’s okay — all part of the process
of change;
• talk through this ambivalence, clarifying what’s actually going on and why the
ambivalence might be there;
• identify the resistance, i.e., the forces that are acting against change;
• understand that they might be invested in not changing right now, or attached
to ways of coping that might be working against their goals (e.g., emotional
eating, over-training, restricting food or rigidly controlling their diets).
Here are a couple of sample coaching scripts:
“Don’t worry, it’s pretty normal to have mixed feelings about changing. It happens
to everyone. In fact, most of the time, there are good reasons for not changing. I’d
be curious to hear about yours. If you want to make Change X, why haven’t you
made that change already? What do you think is blocking you from that?”
“It’s pretty common to want to change, then get blocked somehow. I’m here to help
get you un-blocked. Tell me more about where you seem to get stuck in particular.
You have great intentions, and want to do better, and then…? What happens? Talk
me through that.”
Talking through ambivalence

Coaching isn’t about always telling people what to do. In this case, coaching is
about collaborating with your clients to help them make changes.
Coaching is a dialogue — a conversation.
There are many ways to facilitate change through discussion. One that we
strongly recommend is Motivational Interviewing (MI). This style of dialogue Motivational Interviewing
provides clients with a safe place to contemplate change. (MI): A directive, client-centered
counseling style for eliciting
behavior change by helping
A full description of MI is beyond the scope of this book. However, we strongly
clients to explore and resolve
recommend you check out William Miller and Stephen Rollnick’s classic text- ambivalence
book Motivational Interviewing: Helping People Change (3rd ed.), and / or even
look for an MI training workshop near you.
However, here are a few small MI-style exercises you can try immediately. These
are designed to simply highlight ambivalence for clients, and get them thinking
about their dilemma in new ways.
If you’re interested in learning more about practical application of MI tech-

niques, our Level 2 Master Class course covers MI in great detail.

292 | Unit 10
Use the ambivalence 4-square. • What HABITS might they have to change to try this
new thing?
In the forms package, you’ll see two worksheets that
• What ANXIETY does potential change create?
you can download and fill out with your clients.
The 4 Crazy Questions Worksheet: Simply ask your Show how two things are happening at
clients four questions: the same time.
1. What is GOOD about NOT changing? Subtle changes in language can affect how your client
thinks about their situation.
2. What might be BAD about changing?
Point out that this thing and that thing are both happen-
3. What is GOOD about changing? ing for your client simultaneously.
4. What might be BAD about NOT changing? “On the one hand, you say you want to eat better. On the
other hand, you’re finding yourself getting a lot of takeout
The Push-Pull Habit Anxiety Worksheet: With your food because you’re so busy.”
client, identify:
“So it sounds like you’d like to get back into ‘pre-baby
• What is pushing them AWAY from their old ways of shape’ with healthy eating and regular workouts. At the
doing things? same time, you’re finding that raising a new baby is taking
• What is pulling them TOWARDS trying something all your energy, and your eating is inconsistent.”
different?
“You’re trying to work towards X, and you feel like Y is
blocking you.” (Notice here how “and” is used instead of
“but.” Small but important difference.)
4 Crazy Questions Worksheet Push-Pull-Habit-Anxiety Worksheet C
NAME DATE NAME DATE
(Adapted from Jobs To Be Done)
1. What is GOOD about NOT changing?
Push
What is working for you with the status quo? What are the benefits of staying the same? What is pushing you AWAY from your old ways of doing things?
What feels uncomfortable, annoying, and / or unworkable about your previous routine?
2. What would be BAD about changing?
Pull
If you changed, what might you have to give up or lose? How would your regular routine be disrupted? What is pulling you TOWARDS new ways of doing things?
What’s appealing about this potential change? What seems valuable, fun, useful, helpful, etc. about your goals?
3. What might be GOOD about changing?
Habit
If you changed, how would that be helpful or beneficial? What new opportunities or possibilities could open up? To try something new, what old habits and routines would you have to change?
Thinking about how you normally do things, what would have to be different if you tried this new path?
4. What might be BAD about NOT changing?
Anxiety
If you didn’t change, what bad things could happen? If you keep going the way you’re going, what might things look like in the future When you think about changing or doing something new, what do you worry about?
(say, 10 years from now)? What are your concerns and / or questions about changing?
Find 4 Crazy Questions, Push-Pull-Habit-Anxiety, and other worksheets in your forms package

Develop discrepancy.
In MI, “discrepancy is the engine of change.” discrepancy: Enables someone
to see that their present situation
To develop discrepancy, point out the gap between where the client is and where does not fit with their values
they say they want to be.
For instance:
“Hmmm. Help me figure this out. You’ve mentioned that you want to be around
a long time for your kids and grandkids. It’s something you really value. So I’m
wondering — how does your current eating fit in with this?”
“Okay, so on your assessment form you say you eat ‘pretty healthy’, and that’s
definitely a priority for you. Now, when I look at the food journal, I’m noticing that
five evenings out of seven involved a fair bit of alcohol. Tell me about how you see
those two things matching up?”
Be careful to be neutral and non-judgmental here. You’re just observing the mis-
match and being curious about it, not telling the client what they should be doing.
Don’t fight their resistance

Just roll with it. Be patient. Clients always have the option not to change. Para-
doxically, often just knowing this makes them more willing to change.
“Okay, so it sounds like you’re not willing to do X right now. That’s totally cool. You
never have to do X if you don’t want to. We can try Y instead.”
You can also try negotiating and exploring. It may not be a solid “no”, but rather
a “no right now” or “no, but I didn’t realize I had other options.”
“Okay, so it sounds like you’re not willing to do X right now. That’s totally cool. Just
out of curiosity, would X done in a different way / place / time work for you? Would
doing X with a friend work for you? Could you ever see yourself doing X, maybe six
months from now? What about 10% of X? I’m just wondering. Feel free to say no.”
Don’t push against your client’s resistance. You’ll only meet more resistance.
Pushing includes things like:
• “You should…”
• “What you need to do is…”
• “Look, I don’t see what’s so hard about this, you just have to…”
• “Research says that if you don’t ___, you’ll end up in big trouble.”
Don’t try to “argue”, “persuade”, or “convince.” (Yes, even if you’re 100% correct
and it’s excruciating to keep your mouth shut. It doesn’t matter.)
If you’re working harder than the client to “make” them change, you’re coach-
ing wrong.

294 | Unit 10
Expect “failure.” Reframe

Mistakes, “failures”, screw-ups, challenges, setbacks, We all have stories and scripts in our heads about “how
roadblocks — whatever you call them, they’re inevitable. things work” or “what is going on here.”
Expect them and welcome them. Get curious and com- Our perceptions and ideas about our lives make up a
passionate about them. “frame” that limits what we think we can do. Or what we
choose to see.
These are opportunities to learn, iterate, and clarify the
coaching tasks. Your client may object to something because they are
focused on what they can’t do, rather than what they
Setbacks will tell you where the gaps in your client’s can. Although there are real solutions to nearly every
knowledge and abilities are. nutrition and exercise objection imaginable, once a cli-
ent has made up their mind that their case is impossible,
For example:
their brains will shut down and accept failure.
• Did your client need to know more about the task?
They simply won’t be able to solve their own problem,
• Did your client not understand what to do? regardless of how easy or obvious the solution may seem
• Did you skip an important step in the process? to you. For the client, the solution lies “outside the frame.”
They can’t see it.
When you ask about where the setbacks happened, be
aware of vocal tone and word choice. So don’t get frustrated with them. Rather, understand
that the ideas and perceptions that make up their cur-
Don’t abruptly ask: “Why aren’t you doing what we rent frame prevent them from seeing the solutions to
talked about?” (Unless you want an anxious, defensive their problems.
client.)
Help them “re-frame” their situation.
Instead, you might ask: “You mentioned that you weren’t
able to carry out the vegetable behavior we discussed. Reframing involves three parts.
Can you tell me more about this?”
1. Acknowledge the client’s concerns rather
From that, you might learn: than dismissing them outright. These obstacles
• The task might have been too difficult. feel real to a client. If you brush the concerns off, the
client will probably feel embarrassed and / or more
• Or they forgot.
resistant. But if you respect and recognize the con-
• Or they didn’t know how to buy / prepare cerns as valid, you’ll show empathy and create trust.
vegetables.
2. Tell a different story about “how things
• Or vegetables taste boring to them.
work” or “what is going on here.” Move from
This insight will guide your next actions. focusing on the obstacles that hinder their progress
to the advantages that each client may already have,
Again, we recommend you check out MI. But even such as existing fitness knowledge, enjoyment of
if you don’t right now, just remember: Coaching is a cooking, or a flexible work schedule.
conversation.
3. Work with the client to solve perceived prob-
• Ask rather than tell.
lems and develop strategies to get around
• Open a dialogue rather than giving a monologue. the obstacles. This also helps the client feel like an
• Treat your client as a collaborator who is courageous- active participant in the process.
ly facing the challenge of change, rather than an
You can reframe with openers like:
unmotivated idiot who needs your coaching genius.

Table 10.5 Reframing

Client says / does... You respond... Client then responds...
“I want to eat more vegetables.” “Tell me more about why you’ve al- “Huh. Well. I guess I have started improving
ready started to improve your diet?” already. I was reading the labels on yogurt the
other day...”
“I really tried to eat to 80% full today, “Wow, what made you decide to “Hm, I guess I woke up and I thought ‘Today,
but fell off the wagon around dinner.” listen to your hunger cues today?” I’m going to try to make it happen, just give it a
real effort, you know?”
“I used to eat better.” “What was happening in the past, “I was really good about shopping for myself,
when you were eating better?” not getting a lot of takeout… which I guess I
could do more of now.”
“I don’t have time.” “Sounds like you have a lot on the “I have to schedule everything! I use my calen-
go. How do you get everything dar all the time.”
done?”
(Coach can then respond: “What about booking
time for grocery shopping?”)
Nothing, but they take the time to “Thanks for getting in touch! What “Well, I’d really like to get started… I know I
email or call you. made you want to take the time to haven’t done it yet… but I want to…”
call me back?”
“That’s one way to look at it. Another way to look at it We all want to be in charge of our own decisions. And
is…” when you, the coach, can ask a client the right questions,
you can get them to talk themselves into changing.
“From my perspective, here’s how that looks…”
Consider the following examples. Notice how the coach
“Is there another story you could tell about that?” draws the client’s attention to how they’re already on the
path to change, or demonstrating some ability to be a
A classic example is the client who comes to us having
little bit better.
“failed” at dieting.
By answering the coach’s question, the client is com-
Client: I suck. I can’t stick to a diet. I’ve tried so many and
pelled to comment on their own change or motivation.
have failed them all.
When they do that, they’re forced to realize that some-
Coach: How many diets have you tried? how, they are moving towards change, even just a little
bit. Or things aren’t as unworkable as they assume. See
Client: Oh, I don’t know. I’ve just tried and tried for the Table 10.5 for more on reframing.
last 20 years.
Coach: Well, from my perspective, that’s actually very How to communicate

impressive. You kept trying things that were difficult,
intimidating, and potentially upsetting for 20 years. You
effectively
persisted over and over and over again in the face of You may have guessed by now that effective and clear
setbacks. That tells me you really want to change and you communication is an essential part of coaching.
have quite a lot of resilience.
As a coach, you may be the first person a new client sees
Client: I never thought of it like that. when they decide to change their habits. Or, you may be
the latest fitness professional in a long (possibly disap-
Client in charge pointing and frustrating) line.
A powerful reframe is the “client in charge” or “better Either way, your role is very important. You may need
than expected” frame. to give new clients a great introduction to the joy of
eating healthy and living actively. Or you may need to

296 | Unit 10
un-do the damage of your clients’ previous experiences 9. Test that the client has understood you. Ask
with other fitness, health, and / or nutrition profession- them to show you or demonstrate if needed. You
als and “experts.” may have to say things several ways to make it clear.
To do this, you must communicate effectively, simply, 10. Get and keep your client’s attention. Use their
and encouragingly, particularly in these early stages of name, make appropriate eye contact and body lan-
assessment, triage, understanding, and action planning. guage, and / or explain why it is important for them
Here’s how. to understand.
1. Make your messages clear, simple, and direct. 11. Communicate for the listener, not for the
Use plain language. Avoid technical jargon or nutri- speaker. Create connection and understanding.
tion industry buzzwords. Don’t just speak to convince or impress someone.

Imagine yourself in their position. What might they
2. Make your messages clear and consistent. need to hear?
Make your words match your actions and other
non-verbal cues.
Putting it into practice:
3. If you have expectations, state them clearly. If What’s ahead
you have underlying assumptions, test them first.
In Unit 9 and 10, we’ve given you a broad overview of the
4. Separate fact from opinion. (For example, “I ISSA Coaching approach and system.
notice that you have been 15 minutes late to the last
In the next several units, we’ll take you step by step
two sessions” is a fact. “You are inconsiderate” is an
through coaching different types of clients, at different
opinion.)
nutritional levels.
5. Focus on one thing at a time. • Unit 11 introduces you to the concept of nutritional
level.
6. If you have feedback or relevant guidance,
give it immediately. • Unit 12 covers Level 1 clients.
• Unit 13 covers Level 2 clients.

7. Be supportive and accepting. You don’t have to
like what the client is giving you, but it’s what you • Unit 14 covers Level 3 clients.
have to work with right now. • Unit 15 covers some special populations and top-
ics, to help you further refine and deepen your
8. Speak to the client on their own terms. Listen
knowledge.
for and use their language. Mirror their non-verbal
cues and speech patterns a bit (though not enough Then, we’ll also show you how to develop your own
to be creepy or do that childhood game where your practice.
little brother repeated everything you said). Figure • Unit 16 shows you how to start building a sustainable
out how they learn best, and cater to that. coaching business and career.
• Unit 17 shows you how to keep learning for life.

Case study
Real people need patient, careful, empathetic coaching. • Doesn’t it taste disgusting? What do they do, put
This means: a tuna in a blender? Gross!
• Listening to the client’s needs and what they • This bottle has X mg of EPA / DHA. Is that right?
want to accomplish. What about Y mg of EPA / DHA?
• Learning how they live. • What about flax oil? Isn’t that good?
• Discovering what’s really important to them. • My doctor / pharmacist says the dose is too high.
• And then working together to create the right nu- • I’m pregnant / nursing / taking other medications
tritional approach for them: personal and unique, / etc. Is fish oil safe?
based on their goals and lifestyle.
So they “resisted.”
It also means changing your approach and / or plan
They got confused, anxious, rebellious. They asked
when the data tell you to do so — as we had to do when
about what we thought were irrelevant details, de-
we changed a foundational habit in our Coaching pro-
manded to see the supporting research, or got stuck on
gram.
“finding the perfect brand.” Some outright refused to
Clients used to start their Coaching journey with a sup- take the supplements.
plement habit right off the bat. Our standard instruc-
We wondered why our clients were being so “difficult.”
tions were:
Why didn’t they listen to us, the geniuses at ISSA?
1. Take omega-3 fatty acids (usually liquid fish oil)
We’d forgotten what it was like to be a client.
plus a multivitamin or probiotic.
We’d forgotten that our clients had to learn, know, and
2. Start now.
do dozens of things in order to understand, support,
3. Do it every day. and execute the fish oil habit consistently.
As a research-based company, we’d done our home- It was way too much, too soon, at the beginning of a
work. So we knew that supplementing would, in most program that’s already full of new things — new soft-
clients, kick-start better health and fat loss. ware, new workouts, new community of people, new
coach, new way of eating, etc.
As health-conscious, fitness-oriented researchers who
make a living learning about this stuff, to us coaches, Our clients were already nervous. Unsure of themselves.
taking fish oil and other supplements was obvious and Laden with the baggage of past diet disasters. And con-
easy: fronted with change.
• We knew what fish oil was and why it was im- Asking them to do a task that was actually pretty com-
portant. plicated… well, it was doomed to fail.
• We’d read the research and seen it help us and And that failure was our fault.
our clients.
We created resistance by asking too much, too soon.
• We knew where to get it and how to take it.
Moral: There’s no one-size-fits-all habit.
• Most of us were taking it already anyway.
Giving a few thousand people the same supplement as
We’d all been taking fish oil for so long that the habit the first in a long, overwhelming chain of new habits —
had become a no-brainer. even if in general that supplement is safe and well-prov-
Yet to most of our clients, this stuff wasn’t obvious or en — was not a good approach.
easy in any way: Eventually, we realized: People hate being told what to
• Wait… you can get oil from fish? do. As soon as a “maybe” becomes a “must”, people
instinctively panic or rebel.
• What does it do? Do I actually need that?
Clients need time to process and consider things — to
• Where do you buy that? My small town doesn’t learn, understand, and decide for themselves whether a
have that. I need to drive 20 miles to the nearest given habit is right for them.
health food store.

298 | Unit 10
So we went back to the drawing board. We realized With each tiny piece, clients get to decide for them-
that, in order to guarantee our clients’ success, we need selves:
to help them feel:
• Is this right for me right now?
• safe and secure;
• If so, how can I do this consistently and well?
• autonomous;
• If not, how can I adjust it to match my needs?
• like what they’re doing has purpose and mean- Good news! Our clients liked this new direction. They’re
ing; happier, more relaxed, and excited about being in
• supported and guided; charge of their own progress.
• like they can go at their own pace; and Fish oil is still a good supplement for most people.
• free to choose their own path, with expert help We still recommend it, along with a few other supple-
available when they need it. ments.
Now, instead of telling clients what to do at the outset But it’s no longer a required habit for everyone. It’s an
and pushing them to do it, we ask them: option.
• What do you want? Instead, we focus on:
• Where are you trying to go? How can we help • building skills, crucial behaviors, and consistent
you get there? practices that can help people learn and do any
habit; and
• Out of these available options, which one would
you choose? Why? • helping people understand how to consciously
choose healthier behaviors that meet their needs,
• What are you willing to do and not do right now?
wants, and lifestyles.
• What would make a given habit work for you No matter how great a supplement, task, or exercise
right now? program is — and we think fish oil is great — it’s no good
We recognize that things that seem simple to us (such if clients can’t or won’t do it, or if it doesn’t match their
as having a healthy kitchen or working out regularly) needs.
are actually very complex behaviors for clients. Just like
We pouted and snorted when our clients didn’t imme-
the skills that are second nature to them (like software
diately jump through our hoops. Didn’t they know we
design or knitting or building ice sculptures) would
were the experts?
take us coaches a long time to develop.
Then we got over ourselves and realized we’re here to
Each skill has to be learned, step by step, and divided
serve and guide… not be all-knowing dictators.
into several tiny pieces.
In other words: We shifted from being coach-centric
Now, we break tasks down and build skills cumulatively.
(i.e., proving ourselves “right,” or establishing our au-
Each one is an experiment, not a “rule.”
thority) to being client-centric (i.e., helping our clients
find the right path for them).

Summary
Fundamentally, nutrition coaching is about two things: As part of the coaching process, you will need to help
clients:
1. Helping people change.
• identify and clarify their values, priorities, and goals;
2. Helping them take meaningful action in their own • define what “progress” is, and how to measure it;
lives.
• set realistic expectations and decide on trade-offs.
You have six general coaching tasks:
Choosing a direction for coaching and building an early
• Step 1: Assess and gather data. action plan starts with:
• Step 2: Understand the client and “build the story.” • identifying small wins and “bright spots”; and
• Step 3: Create an action plan and possible “next • identifying limiting factors
steps.”
Make sure the client is ready, willing, and able to do any
• Step 4: Choose one next action step and test it.
action suggested.
• Step 5: Observe and monitor what happens.
Ambivalence and “mistakes” are both normal and natu-
• Step 6: Use outcome-based decision making. ral parts of the process of change.
Assessment and triage, which includes gathering infor- Coaches communicate clearly and effectively.
mation as well as sorting clients into nutritional levels, is
an essential first step.

UNIT 11
Nutritional Levels
Nutritional Levels | 301
Unit Outline
1. Working with nutritional levels 3. Summary
2. Case study
Objectives
In this unit, you’ll learn about the concept of nutritional of each group, and some important caveats about
level (Levels 1, 2, and 3) and why it is so important to sort progression.
clients appropriately. You’ll learn the various characteristics
Working with nutritional levels

In the previous unit, you learned about assessment and Why nutritional level is so important
triage. We suggested that you sort clients into the right
nutritional level at this early phase. In this unit, we’ll You must know what level your clients are at, and
take a closer look at the idea of nutritional level and structure their programs accordingly.
how it works.
Different nutritional goals, and different starting points,
You’ll learn about the specific levels in upcoming units. require different tasks, effort, skill, diligence, and
consistency.
• Unit 12: Level 1 clients
• Unit 13: Level 2 clients You’ll see what we mean in a minute.
• Unit 14: Level 3 clients

What you need to know about
The nutritional level concept nutritional levels
A nutritional level is like a stage of development. We
divide clients into three nutritional levels (aptly named Nutritional level is progressive.
Levels 1, 2, and 3), based on:
Each level builds on the previous one, step by step.
• Goals: What clients want to do
As clients master basic skills and learn to do them con-
• Knowledge: What clients know
sistently, they build a base.
• Competence and skill: What clients can do
• Consistency: What clients can do, repeatedly and Nutritional level is about the quality of the
well process.
This distinction is crucial. In 1980, Rosie Ruiz won the women’s division of the
Boston Marathon with a time of 2:31:56. This was the
Many clients will have the first three categories nailed fastest women’s time in Boston Marathon history as well
down, but don’t follow through consistently enough to as the third-fastest women’s time ever recorded in any
get the results they desire. Most often, consistency is the marathon. Even more remarkably, this was a 25-minute
factor that tells you which level your clients are in. improvement over her New York City marathon perfor-
mance six months prior.

302 | Unit 11
Wow, great results. Most clients never need to progress any

further than Level 1.
Just one problem: Ruiz never ran the Boston marathon,
or the New York marathon. Turns out, she’d just hopped We strongly encourage you to focus on the
on the NYC subway and then sneaked back into the race. fundamentals.
Trying to get great results without having fundamental Mastering the basics and doing them consistently is
skills and a consistent, repeatable process is like trying almost always enough for optimal fitness, health, body
to win a marathon by having someone drive you to the composition, performance, and life balance.
finish line. It looks good for a few minutes, until you’re
busted. For instance, consider this large survey done in North
America. Guess how many people meet the following
Quality process leads to quality outcomes. four criteria?:
Every link in the behavior and mindset chain should be • Don’t smoke tobacco
solid. • Eat five servings of fruits / vegetables daily
A client who tries to “white-knuckle” or cheat their • Exercise five times a week for 30 minutes
way into a lean body or a top athletic performance will
• Maintain a healthy body-weight
eventually crash.
Only 3% of North Americans were doing this simple
At best, they gain some weight back, get a minor injury
four-part combination of basic healthy lifestyle tasks.
or illness, or spend a few weeks of quality time with the
That’s just four basic things. Never mind all the oth-
cookie jar.
er stuff like sleeping, eating enough protein, having a
At worst, they wreck their physical and mental health healthy mindset, and so forth.
and spend months or years recovering.
Most people don’t need complexity.
(Rosie Ruiz never really got in shape, and she never tried
They need help with the absolute basics of a healthy,
to run another marathon.)
sustainable lifestyle.
You must always start at the beginning.

Even clients who can progress to Level 2 or 3
This is a step-by-step progression that always begins may only be there briefly.
with the easiest and simplest steps, and at the lowest
level. For most people, living permanently at Level 2 or 3 is
impossible… and even if it’s possible, it’s usually a bad
Do not give a Level 1 client a Level 2 program. They idea. Trying to live at Level 2 or 3 — which, again, most
will fail. people can’t even do — creates serious disordered eating,
mental health issues (such as anxiety and obsession), and
Level 1 clients will not be ready, willing, nor able to do often physical harm. It disrupts work, relationships, and
more complex tasks. (Even if they think — perhaps even other life pursuits.
insist — that they are.)
Past a certain point, “healthy eating” is not healthy.
Your clients should be winning at every stage, and doing
every task you give them. Their process should eventual- Clients must demonstrate skill, competence,
ly be bulletproof and their results should show it.
and consistency at each level before being
Success should breed success. allowed to progress.
“Failure” is not only demotivating for clients, it sets up You don’t get to enroll in calculus if you haven’t mas-
a dangerous cycle of compensation and control. Clients tered basic arithmetic.
may “fall off the wagon” immediately if the program is
You don’t get to pass your driver’s test if you can’t park
too complicated, rigid and restrictive. Or hang on for a
the car or change lanes.
few weeks, then have a spectacular blowout.

Likewise, don’t let a client move to Level 2 if they can’t • Competence and skill: What clients can do
eat vegetables consistently, or are sleeping six hours a • Consistency: What clients can do, repeatedly and
night.
well
The word “demonstrate” is important here. It’s not
To figure out a client’s level, use a mix of objective and
enough for a client to say they’re doing something. “I eat
subjective assessment.
pretty well” is worthless.
Some factors can be measured (e.g., body composition,
We like two magic words: “Show me.”
athletic performance). Other factors will be based more
“You’re eating your protein at every meal, on a feeling after you get to know them (e.g., their histo-
consistently? Great! Show me your photo food ry with food, their lifestyle, their mindset).
journal.”
It’s not clearly defined; there are gray areas. Use your
“You’re following your workout plan? Great! coaching intuition, wisdom, and gut instinct.
Show me your workout notebook.”
Most importantly:
“You ate slowly to 80% full at every meal for • Always start with Level 1 tasks, no matter who
the last month? Great! Let’s grab the measuring your client is. Fundamentals first, always. You can’t
tape and skinfold calipers and check it out.” do Level 2 tasks unless and until you have mastered
Talk is cheap. Perceptions are often wrong. Level 1 essentials.
• When in doubt, go backwards. And always re-

The only thing that counts is data.
gress a client to a lower nutritional level, rather than
Show me. assuming they can handle more complexity.
• Clients must be able to demonstrate that they

How to assess nutritional level can do assigned tasks consistently. Saying they
can do it, or knowing information about the tasks, is
Once again, your criteria should be: not enough.
• Goals: What clients want to do
Table 11.1 provides an overview. We go into more depth
• Knowledge: What clients know later.
Can you judge nutritional level from body composition alone?
Humans are remarkably diverse. Clients come in all Description Women Men
shapes, sizes, ages and backgrounds.
Essential fat 10–13% 2–5%
Body composition is one tool that we can use to assess a
client’s nutritional level. Athletes 14–20% 6–13%
Fitness 21–24% 14–17%
On the one hand, it’s a useful tool.
Average 25–31% 18–24%
You can measure body composition objectively, using
tools such as body girths, skinfold calipers, BIA, DEXA Obese 32%+ 25%+
scans (which can also tell you about bone density), func-
tional MRI, and so forth. A recent study found that the average American man
had about 28% body fat, while the average American
The American Council on Exercise distinguishes body fat woman had about 40%.
percentages by levels of athleticism.
Body composition can indeed give you clues about

304 | Unit 11
Table 11.1 Overview of nutritional levels

level 1 level 2 level 3
Goals Improve general athletic perfor- High-level recreational / amateur Elite / professional athletic per-
mance and recovery athletic performance and / or formance and career
physique competition
Elite / professional physique
/ fitness competition and / or
modeling career
Level of athletic Daily-life function; regular Dedicated recreational / amateur Elite / professional; nationally or
performance or body activity athlete internationally competitive
composition required
Body composition Normal, sustainable, metabol- Lean-athletic Extreme leanness and / or
desired or required1 ically healthy to lean-healthy muscularity
body composition Men: 8-12% body fat
Men: below 8% body fat
Men: 13-20% body fat Women: 17-22% body fat
Women: below 17% body fat
Women: 23-30% body fat
Training load <6 hours a week 6-12 hours a week 12-20 hours a week or more
Knowledge None to moderate Moderate to high2 Expert3
Competence and skill None to moderate Moderate High
Can do simple tasks when given Can do complex tasks when Follows a complex plan to the
clear instructions and the coach given clear instructions and the letter
monitors completion coach monitors completion
Can do simple tasks easily

and intuitively, often without
supervision
Consistency None to moderate Moderate High
Can do simple tasks up to 75% of Can do simple tasks 90% of the Can do any task, no matter how
the time time or more complex, 90% of the time or
more
May struggle to sustain habits or Can do more complex tasks up
“stay on track” to 75% of the time Has a base of sustainable habits
and a consistent foundation of
Has a base of sustainable habits essential behaviors
and a consistent foundation of
essential behaviors
Mindset / psychology “I have a lot of questions and / or “I feel relatively confident.” “Don’t ask; just do.”
worries.”
“I can stay on track pretty well.” “Everything is secondary to this.”
“Many things are distracting me
from full focus on this.” “This is a priority for me.” “This is my life / job.”
“This is just one part of who I “I want to be better than “I want to be one of the best in
am. I have a lot of other things average.” the world.”
going on.”
“I just want to be healthier, fitter,

stronger, leaner, and / or better
at the stuff I do regularly.”
Limiting factors Many Some; most major roadblocks Everything in the client’s envi-
have been cleared ronment (routines, people, phys-
ical environment, etc.) supports
execution of tasks; client is 100%
dedicated to getting things done
and everything around them
facilitates that
1 Note: Clients will vary widely in their body compositions depending on their age, sex, genetic makeup, etc. What is “unreasonably lean” for one person may
be another person’s “normal.” Look for natural tendencies and try to get a baseline of what is appropriate for each client. “Normal” is the body composition
that a client can easily and sanely maintain doing basic Level 1 habits consistently.
2 Most clients at Level 2 will have coaches. So the clients themselves need not be experts, but they should be guided by someone who is.
Nutrition:
3 Most clientsThe Complete
at Level GuideSo the clients themselves need not be experts, but they should be guided by someone who is.
3 will have coaches.
clients’ habits. A client who is 40% body fat probably Conversely, a heavyweight strength athlete may have
doesn’t exercise every day. superb conditioning and metabolic health.
But we shouldn’t rely on body composition alone. What does this mean for you?
A lean body isn’t always a fit or healthy body, or be- Testing body composition is part of that client’s story.
long to a person with good habits. A body with more But it isn’t the entire story.
fat isn’t always an unfit or unhealthy body.
Even if your client is leaner, start with Level 1 approach-
For instance, a teenage male may stay lean easily, es. Why?
despite an exercise routine of video games and a diet of
You want to make sure they’re doing all the basics con-
Pizza Pockets.
sistently.
Conversely, a fit and active woman in her 70s may have
You may be able to get them into fantastic shape with
lower bone density and more body fat, but still be in
only a few fundamental behaviors. Why make it any
great shape with excellent lifestyle habits.
more complicated than it needs to be?
A light body doesn’t mean a fit or healthy body. A big
or heavy body isn’t always an unfit or unhealthy body.
Clients can have a low Body Mass Index (BMI) yet Body Mass Index (BMI): A weight-to-height ratio used
still be unfit and unhealthy. For instance, a client who as an indicator of healthy body size. It’s calculated by
has lost weight during chemotherapy is hardly a model dividing one’s weight in kilograms by one’s height in
meters squared
of athletic performance and wellness.
Level 1: Essential skills and building a foundation
What you need to know about Level 1 Most clients — even athletes — can and should
stay at Level 1 forever.
Most clients are Level 1s.
You can get (and more importantly, sustain) great results
Even if clients say they’re “more advanced”, they proba- from Level 1 basics, done consistently.
bly aren’t. (Check their consistency, lifestyle, and mental
health. You’ll find Level 1 stuff to work on. Trust us.) Clients never need to “graduate” to the next level.
Level 1 is about basics. Fundamentals. Most clients don’t need complexity and can’t
do it anyway.
Level 1 tasks build the essential skills that all clients need
in order to sustain good health, a lean and strong body, Make things as simple as possible, not as complicated
and athletic performance for life. as possible.
Level 1 coaching is about Level 1 skills and tasks aren’t the sexy, headline-grab-
• making nutritional change do-able; bing stuff of “instant” body transformation. In fact, they
might seem a little boring sometimes.
• creating a solid, repeatable, high-quality process;
But remember, nutrition coaching isn’t about using cool
• ensuring ongoing success (because clients can almost
and / or fancy nutrition strategies just because you can.
always do the assigned tasks);
And it’s not about demonstrating your depth of knowl-
• building foundational skills that clients can do sus- edge by having clients try complex dietary approaches,
tainably for life; and unless this is what the client needs and can actually do,
consistently.
• helping clients be consistent enough to do what they
want to do. This should be — and feel — easy for clients.

306 | Unit 11
Level 1 coaching tasks

Most Level 1 clients will have one or more of the limiting tasks you could assign to your Level 1 clients, as well
factors and needs detailed in Table 11.2. (In fact, you as what skills they need to master in order to move to
might have several of them yourself.) Level 2. See Figure 12.2: Hand sized portions for a better
understanding of the size references we use.
The center and right-hand columns show the types of
Table 11.2 Level 1 coaching tasks

Level 1 clients struggle with... So help them with... Sample coaching tasks could be...
Food choices
Eating too many processed foods Replacing processed foods with whole, Find two whole-food substitutes for pro-
minimally processed foods (such as fruits cessed foods you commonly eat right now
Not eating enough nutritious, and vegetables) (e.g., an orange instead of orange juice)
whole, minimally processed foods
Not meeting basic nutrient Building a roster of high-quality, nutri- Eat 1-2 palms of lean protein at each meal
needs (macronutrients and ent-rich foods that the client enjoys and
micronutrients) will reliably eat Add two servings of colorful fruits and /
or vegetables to your daily menu
Supplementing to fix basic deficiencies
Take a multivitamin / multimineral sup-
Creating meal templates that “cover the plement every day
bases” (e.g., protein, healthy fats, colorful
plants)
Addressing any major “nutrient leaks”

(e.g., nutrient depletion from activity or
medications, GI malabsorption)
Getting dehydrated1 Drinking more water Drink a glass of water when you get up,
and one at each meal
Drinking too many sugar-sweet- Exploring better-quality drink options
ened drinks Progress from regular to diet soda, then
Cutting back on alcohol3; adjusting social to soda water
Drinking too much alcohol; drinking behaviors
“drunkorexia”2
Not feeling satisfied by their meals Creating satisfying, nutrient-rich meals Add 1-2 thumbs of healthy fat to each
and eating them properly — slowly, mind- meal
fully, with enjoyment
Include a cupped handful of slow-digest-
ing, high-fiber carbs at each meal
Eat slowly and chew thoroughly

Eating behaviors
Eating too quickly and while Slowing down and focusing Add 5 minutes to each meal
distracted
Eliminate meal-time distractions (e.g., TV)
Recognizing their physical hunger Appetite awareness Keep a hunger / fullness journal for a
and fullness cues week
Irregular eating habits (missing Creating a regular, balanced eating Eat every 3-4 hours
meals or not eating enough at schedule
some times and / or eating too
much at other times)
Disordered eating (restricting, Creating “normal”, healthy, balanced Sit with uncomfortable feelings for 10
purging, orthorexia, controlling, eating habits and mindset minutes
bingeing, etc.)
Work directly with an eating disorder
counselor (along with nutrition coaching)


Over-eating Awareness of physical fullness and satiety Pause for 10 minutes after each meal to
notice fullness
Appropriate portion sizing
Use hand size portions of nutrient-dense
foods template4
Use food to manage feelings Separating food from feelings; learning Keep a “food and feelings” journal for a
to regulate and express their emotions in week
healthier ways
Choose and practice 1 other option for
noticing, expressing, and regulating
emotions (e.g., writing, drawing, talking
to friend)
Exercise and activity
Getting enough regular physical Adding activity to their daily lives and Commit to X minutes of activity each day
activity building consistent exercise habits as a minimum
Over-training and not managing Balancing intensity and recovery; address- Work under the supervision of a coach /
training loads ing chronic injuries trainer to properly plan training program
Do rehab exercises 5-10 minutes daily

Recovery
Not getting enough sleep Building a sleep ritual and good sleep Schedule and do a pre-bed sleep ritual
behaviors each day
Sleeping 7-9 hours a night consistently Get outside at morning and mid-day for
10 minutes each of bright light exposure
Not getting enough recovery Boosting nutritional quality Add daily omega-3 supplement
Adding regular recovery-type activities Add 10 minutes of relaxation and mobility

(e.g., massage, yoga) work daily
Life skills
Basic food preparation skills Learning to cook and prepare food Learn to cook, then practice, 2 “go-to”
meals
Basic shopping and food aware- Learning to shop efficiently and effective- Shop with a shopping list
ness skills (e.g., reading labels) ly; being an informed food consumer
Try a farmers’ market
Read labels at the grocery store

Not being able to ask for what Learning to communicate effectively and Work with coach to practice crucial con-
they want and need; not being clearly, learning to define boundaries and versations with family, friends, coworkers,
able to define clear boundaries expectations with others etc. who are sabotaging
with others (e.g., people pushing
food; other household members
sabotaging or criticizing)
Making impulsive choices, feeling Planning and preparation; time manage- Schedule key activities in calendar
“too busy” or “too rushed”, not ment; thinking proactively
having good options available and Weekly and / or daily ritual of food (and
convenient life) prep and planning
Mindset / psychology
All-or-nothing thinking (e.g., yo- Making choices on a continuum; trying For each decision, ask, “What would be a
yo dieting, restrict-binge cycles, to be “just a little bit better”; looking for bit better?” and “What would be a little
big “diet challenges”, weekend / incremental improvement bit worse?”
night-time over-eating, “Either I’m
perfect or I’ve failed” mentality) Having self-compassion Notice and name self-critical thoughts
5 minutes of self-compassion practice

308 | Unit 11

Fixed mindset (I’m broken; I don’t Adopting a growth mindset (anything is Refer to habits as “experiments”, “games”,
have what it takes; I’m a failure, possible; just keep practicing and trying) and / or “practices”
etc.)
Not being consistent Achieving consistency Track consistency for assigned task daily;
reward consistent execution rather than
“being perfect”
Busy-ness and stress; overwhelm- Slowing down, prioritizing, being more Taking a 5 minute “time out” to practice
ing life demands; feeling rushed mindful and choice-ful relaxation and refocusing
and pressured
Daily review of goals and motivators
Having “on the road” or “last-minute”

strategies for travel and unexpected
obstacles
Environment
An environment that requires Creating environments and surroundings Kitchen cleanout (with coach present if
too much active “willpower” and that support their goals possible)
mental strength to stay on track
Making better choices simple, easy and Stocking up on convenient healthy op-
convenient tions (e.g., pre-washed baby veggies)
Unsupportive social networks Finding “fit friends” and “team members” Joining a group exercise class or activity
(family, friends, coworkers, etc.) meet-up (e.g., a hiking group)
1 This is especially important for clients who eat a lot of processed foods, which usually have a lot of sodium.
2 Drunkorexia means eating less in order to be able to drink more without gaining weight. It’s especially common among younger women.
3 Note: This can be a tricky area to address. Many clients fall into the category of “problem drinker” and are often reluctant to change their alcohol
habits, even just a little bit. You may find that it works better to refer out to an addictions counselor if this is a serious problem for your client.
4 You can find Hand-Sized Portion Guide in your forms package.
Level 2: Getting leaner, boosting performance

Once your client can do all the Level 1 behaviors well Level 2 approaches are mostly about looks and
and consistently, they can progress to Level 2. / or performance.
What you need to know about Level 2 Level 2 clients want to get leaner or improve athletic
performance beyond what they can do with the Level 1
Most clients do not need to go further than approach.
Level 1.
Level 2 strategies don’t make clients any healthier or give
Yes, we harp on this, but it’s important. them a better quality of life.
More than likely, 90-95% of your clients will thrive at Indeed, depending on how far someone takes them...
Level 1, and get all the results they need and want. They
can stay at Level 1 forever, happily, sanely, and healthily.

Level 2 (and Level 3) behaviors can become Level 2. (You’ll see what we mean when you review the
actively unhealthy. list of Level 2 behaviors in Table 11.3.)
If a client engages in Level 2 (or 3) behaviors too strin- As a coach, it’s your role to inform your clients
gently and aggressively: about all the trade-offs.
• Body fat can start to drop too low. Hormones and
recovery can be disrupted.
Help clients know what to expect and look for as they
progress into Level 2 habits. Keep it real.
• Behaviors, thoughts, and feelings about food,
eating, and training can become disordered. Your Monitor clients carefully.
client may start to have mental or emotional health
problems such as anxiety, depression, and / or OCD. At Level 2, most clients should be keeping some type of
record of what they are doing.
• Social relationships and other interests — which we
need for overall wellness and quality of life — may Track your client’s physical, psychological, and social
suffer. indicators closely. (More on that in Unit 13.) Make out-
come-based decisions using data.
Level 2 behaviors are usually short-term
Have an “escape plan” at all times to help guide your
strategies. client back to balance if needed.
Generally, clients do Level 2 tasks for a specific, short-
term goal, such as a competition, or to support higher
levels of athletic training at certain times in their com- At this stage, you’ll have to adjust some Level 2 tasks for
petitive season. fat loss, athletic performance, and / or mass gain. We’ve
given you some notes in the table.
Few clients can live consistently, sanely, and happily at

Level 2 clients can consistently... So the “next level” involves... Sample coaching tasks could be...
Food choices
Make mostly nutritious food choices Refining food and nutrient quality Choose mostly organic
Choose grass-fed / pastured / wild-
caught meats, poultry, fish, seafood,
eggs, dairy
Eat mostly whole, minimally processed Eating almost entirely whole, minimally Eliminate almost all processed foods
foods processed foods (except for sports supplements, e.g.,
protein powder)
Cook most of the week’s menu from
scratch
Meet basic nutrient needs (macronutri- Adding phytonutrients, zoonutrients, Expand the colorful fruit and vegetable
ents and micronutrients) myconutrients repertoire
Testing for nutrient status and supple- Choose grass-fed / pastured / wild-
menting specifically caught meats, poultry, fish, seafood,
eggs, dairy
Review lab test results of nutritional
status; create a targeted supplement
plan
Stay hydrated Decreasing caffeine intake Switch to green tea from coffee
Drink mostly non-caloric beverages Minimizing and / or completely elimi- Cut out or drastically minimize alcohol
nating caloric beverages intake

310 | Unit 11

Feel satisfied by their meals For fat loss: Feeling slightly less than For fat loss: Leave the table feeling a
satisfied by their meals little hungry; accept the presence of
low-level hunger much of the time
For mass gain: Feeling a bit too full For mass gain: Leave the table feeling a
little overstuffed; accept the presence
of fullness much of the time
Eating behaviors
Eat at a moderate pace, without too For fat loss: Slowing down even more Add 5-10 more minutes to usual meal
many distractions time
Eat entirely without distractions
For mass gain: Speeding it up Shorten meal times; focus completely
on getting the food down before sati-
ety signals kick in
Recognize physical hunger and fullness For fat loss: Going into the “hunger For fat loss: Practice tolerating the dis-
cues zone” comfort of mild to moderate hunger
For mass gain: Ignoring fullness cues; For mass gain: Ignore fullness cues;
eating even if not hungry stick to an eating schedule even if not
hungry
Maintain regular eating habits For fat loss: Experimenting with occa- Once a week, skip breakfast or dinner
sional intermittent fasting
For mass gain and / or athletic per- Athletic performance and mass gain:
formance: Sticking to a regular eating Eat every 3-4 hours, especially around
schedule training
Have a relatively sane, healthy mindset Closely monitoring eating psychology Keep a daily record of eating behaviors,
about eating for performance or body and mindset thoughts, and feelings
composition changes Staying alert for any compensatory Keep a daily record of all training and
Separate food from feelings behaviors (e.g., bingeing, purging, activity
over-exercising)
Be active regularly for at least 60 min- For fat loss: adding more activity Add a 30-minute walk daily
utes a day
Manage training loads Having all training under the supervi- Schedule 10-15 minutes more of active
sion of coach / trainer recovery daily
Follow specified training and recovery
program
Recovery
Sleep 7-9 hours Adding 15-30 minutes of sleep or im- Daily nap
proving sleep quality Supplement to enhance sleep (e.g.,
ZMA, L-theanine)
Refine sleep ritual
Get enough basic recovery Adding recovery protocols1 Add peri-workout nutrition (BCAAs for
fat loss, carb + protein drink for muscle
gain and / or athletic performance)
Foam rolling for 10 minutes daily
Record daily recovery indicators (e.g.,
sleep quality, HRV)
Manage stress productively and Adding stress management protocols Add 10 minutes of relaxation / mind-
effectively fulness
Practice time management and
prioritization


Life skills
Prepare basic meals and menus Improving meal preparation and plan- Add 5 meals to “go-to” roster
ning skills Try a new cooking challenge (e.g., new
food, new prep method)
Shop efficiently and be aware of food Improving shopping options Shift more food purchases towards
quality Improving food quality local / organic / seasonal, farmers’
markets, etc.
Choose grass-fed / pastured / wild-
caught meats, poultry, fish, seafood,
eggs, dairy
Ask for what they want and need Establishing Level 2 tasks as priorities Have a crucial conversation with family
Define clear boundaries and priorities and negotiating with others and friends about Level 2 priorities
and tasks; set clear expectations about
what this will involve (e.g., removing
“junk food” from the house)
Make thoughtful, informed choices Establishing purpose; setting clear Daily goal review
Ensure that good options are available priorities and abiding by them Make as many decisions in advance as
and convenient Making the decision process as easy possible; leave fewer things to chance
and streamlined as possible by elimi- (e.g., plan meals beforehand)
nating unwanted options Hire a meal delivery service
Cut down on restaurant meals
Think on a continuum from “better” to Continually moving along the continu- Identify choices that are “just a little bit
“worse” um towards “better” better” and make them consistently
Have a growth mindset Seeking continual refinement and im- Weekly review and retrospective with
provement of process and self-aware- coach; outcome-based decision making
ness Try to improve one small part of the
Using outcome-based decision making process each week, based on data
collected from the week before
Repeat a quality process Tightening up the process: Weigh and measure food portions
a) Looking for inefficiencies and re- Create and use a checklist for import-
move them ant processes (e.g., taking supple-
b) Adding more process metrics and ments)
tracking them Record ongoing food and other logs;
coach to review these weekly (or as
appropriate)
Organize most of their life around exe- Planning, prioritizing, and scheduling Schedule not only workouts but also
cuting Level 2 tasks Cutting back on lower-priority activi- food prep times, recovery times, sleep
ties and other demands ritual, etc.
Keep a 1-week time diary
Remove 1 low-priority “time sucker”
based on results of time diary
Environment
Maintain an environment that enables Further refining environment along Kitchen cleanout and organization
Level 2 choices with schedules and systems (e.g., supplements packed into pill
holders)
Add home exercise options
Access supportive social networks Getting more coaching More frequent coaching check-ins
(family, friends, coworkers, etc.) Finding more teammates Add a coach for other aspects of goals
(e.g., sport-specific skills coach)
Work with a team, group, and / or
support network (e.g., running group,
competition team)
1 At this point, much of what you’re adding for Level 2 clients are additional stressors. They’re training and potentially competing more (which may
also involve things like travel). If they’re trying to change body composition dramatically, they’re either eating much less or much more than is com-
fortable for their body. All of this can cause other stresses such as financial stress, relationship stress, and time management stress. So this recovery
angle is critical.
312 | Unit 11
Level 3: Elite performance

Once clients can do all the Level 2 behaviors well and consistently, and if they
absolutely need to do these protocols in order to compete and perform at the elite /
professional level, they can progress to Level 3.
What you need to know about Level 3
Level 3 approaches are mostly about looks and / or performance.

Level 3 clients want to get leaner or improve athletic performance beyond what
they can do with the Level 2 approach. Level 3 strategies definitely don’t make cli-
ents any healthier or give them a better quality of life. Indeed, depending on how
far someone takes them...
Level 3 behaviors can become actively unhealthy.

If a client engages in Level 3 behaviors too stringently and aggressively:
• Body fat can start to drop too low. Hormones and recovery can be disrupted.
• Behaviors, thoughts, and feelings about food, eating, and training can become
disordered. Your client may start to have mental and emotional health prob-
lems such as anxiety, depression, and / or OCD.
• Social relationships and other interests — which we need for overall wellness
and quality of life — may suffer.
Level 3 behaviors are usually short-term strategies.

Generally, clients do Level 3 tasks for a specific, short-term goal, such as a com-
petition, or to support higher levels of athletic training at certain times in their
competitive season.
Few clients can live consistently, sanely, and happily at Level 3. In fact, no one is
meant to live at this level. (You’ll see what we mean when you review the list of
Level 3 behaviors in Table 11.4.)
As a coach, it’s your role to inform your clients about all trade-offs.
Help clients know what to expect and look for as they progress into Level 3 habits.
Keep it real.
Monitor clients carefully.

At Level 3, all clients should be working under supervision and keeping detailed
records of what they are doing.
water manipulation:
Track your client’s physical, psychological, and social indicators closely. (More
Intentionally consuming more on that in Unit 14.) Make outcome-based decisions using data.
or less fluids, along with certain
nutrients, in order to lose or gain You’ll notice that many of these coaching tasks (such as water manipulation or
weight caloric restriction) put your client at risk.

Working with your Level 3 client to decide on acceptable Level 3 coaching tasks
risk in advance and have an “escape plan” at all times to
help guide your client back to balance if needed. At this stage, you’ll have to adjust some Level 3 tasks
for fat loss, athletic performance, and / or mass gain.
We’ve given you some notes in the table.

Food choices
Follow a basic meal template using IS- Following a very detailed, very spe- Follow this meal plan exactly
SA-style portion sizes and food options cific meal plan with all choices tightly
controlled Weigh and measure all food.
Cycle calories
Cycle macronutrients (usually carbs /

fat)
Meet basic nutrient needs (macronutri- Testing for nutrient status and supple- Follow this specific, targeted supple-
ents and micronutrients) menting specifically ment plan exactly
Choose only approved supplement

brands
Stay hydrated Following specific hydration Cut out caffeine except as a training aid
recommendations
Drink mostly non-caloric beverages Cut out alcohol
Manipulating water levels to cut weight
or change the look of a physique Rehydrate with this exact recipe for a
hydration solution
Follow this specific, detailed water

weight cutting protocol exactly
For fat loss: Tolerate being almost con- Consistently eating a lot less than the For fat loss: Leave the table feeling a
stantly hungry body needs / wants little hungry (or even quite hungry);
accept the discomfort of hunger much
of the time
Intermittent fasting
For mass gain: Tolerate being too full Consistently eating a lot more than the For mass gain: Leave the table feeling a
body needs / wants little overstuffed; accept the discomfort
of fullness much of the time
Manage training loads Having all training under the supervi- Follow specified training program
sion of coach / trainer exactly
Recovery
Sleep 7-9 hours Adding 15-30 minutes of sleep or im- Daily nap
proving sleep quality
Supplement to enhance sleep (e.g.,
Allowing the risk of not sleeping ZMA, L-theanine)
Refine sleep ritual

314 | Unit 11

Get enough basic recovery Following specific recovery protocols Add peri-workout nutrition (BCAAs for
fat loss, carb + protein drink for muscle
Allowing the risk of not recovering; gain and / or athletic performance)
pushing into the “danger zone”
Record daily recovery indicators (e.g.,

sleep quality, HRV)
Decide the cutoff in advance for what

is tolerable (e.g., minor injuries okay;
major injuries mean stopping Level 3
protocols)
Life skills / environment
Plan and prepare meals Preparing and planning all meals Cut out restaurant meals
Plan and prepare all meals for the week

in advance (or hire a meal prep service)
Establish clear priorities and Focusing exclusively on Level 3 goals Set clear expectations with family and
boundaries and priorities friends about eating, training and com-
petition schedule, etc.
Create and maintain a supportive Making sure everything in environment
environment supports goals Create a highly systematized, struc-
tured daily routine
Cutting out all things that don’t sup-
port these Eliminate all distractions / triggers from
immediate surroundings
Make thoughtful, informed choices Establishing purpose; setting clear Daily goal review
priorities and abiding by them
Ensure that good options are available Make as many decisions in advance
and convenient Making the decision process as easy as possible; leave almost nothing to
and streamlined as possible by elimi- chance
nating unwanted options
Limit choices1
Have a growth mindset Seeking continual refinement Weekly review and retrospective with
and improvement of process and coach; outcome-based decision making
self-awareness
Refine one small part of the process
Using outcome-based decision making each week, based on data collected
from the week before
a) Looking for inefficiencies and re- Create and use a checklist for important
move them processes (e.g., taking supplements)
b) Adding more process metrics and Record ongoing food and other logs;
track them coach to review these weekly (or as
appropriate)
1 You’ll notice that while Level 2 tasks sometimes involve expanding choices (e.g., add a new food), Level 3 tasks usually involve limiting choices.

Case study
Several years ago, Brian (co-author Brian St. Pierre) was to play with spreading out his carbs more evenly, even
visiting his girlfriend (who is now his wife). She made increasing the amount of carbs he ate (and decreasing
him a delicious dinner from scratch. They’d recently the fat to keep total calories in check).
begun dating, and this was the first time she’d made
He began having clients experiment with the same
dinner for him.
thing.
She worked for hours making a wonderful beef stew,
And the results were overwhelmingly positive.
with potatoes, carrots, onions and other delectable items.
It contained a little bit of everything: lean protein, lots of Clients began to find more satisfaction in their meals.
vegetables, quality carbs, and healthy fats. And it tasted They were less hungry between meals. They could enjoy
amazing. What wasn’t to love? social situations more.
Well, at the time Brian was a big proponent of an older They could have more “normal meals”, eating wraps,
approach: dividing meals into Post-workout (PW) and sandwiches and other meals with moderate carb intake.
Anytime (AT). The basic idea was to have the majority
of carbs after workouts (PW meals), and keep other They weren’t obsessing about when they could have
meals low in carbs (AT meals). carbs and when they couldn’t. And they weren’t feeling
guilty for having carbs when they “shouldn’t.”
These days we view that as a Level 2 strategy. But at the
time, this was standard practice. And in this case, it bit Or reasoning that since only having carbs post-workout
him in the ass. would help them lean out, that skipping the carbs then
would only help them get leaner.
As they began eating, Brian started intentionally remov-
ing potatoes from his bowl. Because, you see, he hadn’t They were developing sane and sustainable approaches
recently worked out. He thought he hadn’t “earned” his to food.
carbs. And it wasn’t hurting their health, body composition, or
(Mind you, this was probably half a potato’s worth. At performance either. Most of them were actually getting
most, one whole potato. We’re not talking about a large better.
amount of carbs or calories here.) As Brian dug deeper into the research, and as more
Midway through his potato removal surgery, it dawned long-term data on nutrient timing came out, he became
on him that his girlfriend had gone strangely silent. He less and less inclined to use it as a front-line strategy.
looked up from dissecting the stew. When Brian came to, we began to experiment with the
His girlfriend was looking at him unhappily. “What are same changes in our Coaching program. And you know
you doing?” what? We discovered the same thing happening on a
much larger scale.
“Uh. Removing the potatoes. I didn’t work out recently,
so I don’t want a lot of carbs.” Thousands of clients reported back on how much they
enjoyed the new approach. How it simplified their food
“Brian, it took me four hours to make this stew. It’s prob- choices. And allowed them to just modify beloved rec-
ably not even an entire potato.” ipes by just incorporating fewer processed ingredients,
or adjusting portion sizes, rather than reinventing the
“But, the carbs…”
wheel.
[Continued look of disapproval]
He will point out that this doesn’t necessarily discredit
Brian ate the potatoes. the PW / AT approach. It’s simply not a strategy to start
with.
And you know what? He didn’t magically get fat. In fact,
it made the meal more enjoyable. And kept him satisfied Carb timing and cycling are Level 2 strategies. These
for hours (which wasn’t normal for him at the time). types of strategies can and should be utilized with
clients who have advanced goals, and who have demon-
More importantly, this made Brian a much more gra-
strated mastery of the fundamentals.
cious guest and boyfriend. It helped him see the bigger
picture: how eating a meal with someone is more than Hopefully this story simply showcases how using Level 1
just fueling a body. It’s a part of the social fabric of life. strategies, even for fitness pros like Brian, can provide a
sustainable way to have the body we want, while living
In this moment, he realized that maybe he didn’t need
a life we really enjoy.
to worry so much about timing his carbs. Brian began

316 | Unit 11
Summary
Nutritional level is like a developmental stage; it’s a step- Always match your coaching to your client’s nutritional
by-step progression of difficulty and complexity. level.
We divide clients into three nutritional levels. We Always start at the beginning; most clients never need to
suggest that you do the same during the early stages of progress any further than Level 1. Even clients who can
assessment. progress to Level 2 or 3 may only be there briefly.
Each nutritional level has unique features, limiting fac- Clients must demonstrate skill, competence, and consis-
tors, and needs. tency at each level before progressing.

UNIT 12
Working with Level 1 Clients

318 | Unit 12
Unit Outline
1. Level 1: Where it all begins 4. Troubleshooting Level 1
2. Level 1 clients and your coaching process 5. Case study
3. Level 1 limiting factors and coaching strategies 6. Summary
Objectives
In this unit, you’ll learn more about Level 1 clients. We’ll to these clients to identify, understand, and work with their
show you how to apply the ISSA Nutrition Coaching process specific goals, motivations, needs, and limiting factors.
Level 1: Where it all begins What does a Level 1 client look like?
Here’s a quick review of the criteria for defining nutri- Almost everybody.
tional level:
In the previous unit, we gave you a brief overview of
• Goals: What clients want to do. Level 1s. Now let’s look more closely at the features that
• Knowledge: What clients know. Level 1 clients might have.
• Competence and skill: What clients can do. Not all Level 1 clients will have all of these characteristics,
• Consistency: What clients can do, repeatedly and but this gives you the general idea.
well.
Level 1 client features
To figure out a client’s level, use a mix of objective and Note that goals, knowledge, body composition, athletic
subjective assessment. performance, and training load alone do not define Level
We’ll look at that more in this unit. 1. For instance:
Most importantly: You may have a high-level recreational athlete who is

quite lean and muscular... but who binge-eats regular-
• Always start with Level 1 tasks, no matter who ly, doesn’t get enough sleep, and / or doesn’t eat their
your client is. Fundamentals first, always. You can’t vegetables.
do Level 2 tasks unless and until you have mastered
Level 1 essentials. You may have a client who has an “expert” level of
knowledge, perhaps even graduate degrees in nutri-
• When in doubt, go backwards. And always re- tion… but who can’t actually do fundamental behaviors
gress a client to a lower nutritional level, rather than consistently.
assuming they can handle more complexity.
Most fundamentally, nutritional level is about compe-
• Clients must be able to demonstrate that they
tence and consistency:
can do assigned tasks consistently. Saying they
can do it, or knowing information about the tasks, is What can you do repeatedly and sustainably in your
not enough. daily life?

Working with Level 1 Clients | 319
Table 12.1 What does a Level 1 client look like?

Typical goals Improve general athletic performance and recovery
Feel better
Look better
Lose weight
“Get in shape”; “tone up”
Get stronger; add muscle
Have more energy and vitality
Get into regular, sustainable “healthy living” habits
Improve health markers (e.g., blood cholesterol, blood pressure, glucose control)
Work through food intolerances and/or digestive issues
Have a better relationship with food; manage unwanted eating patterns such as emotional eating
Sleep and recover better
Level of physi- Daily-life function

cal performance
expected Regular activity; keeping up with workouts
“Healthy normal”
Body composi- Normal, sustainable, metabolically healthy to lean-healthy body composition

tion desired or
required1 Men: 13-20% body fat
Training load <6 hours a week
Knowledge None to moderate

Competence and None to moderate
skill
Can do simple tasks when given clear instructions and the coach monitors completion
Consistency None to moderate
Can do (or only want to do) simple tasks up to 75% of the time
May struggle to sustain habits or “stay on track”
Mindset / “I have a lot of questions and / or worries.”

psychology
“Many things are distracting me from full focus on this.”
“This is just one part of who I am. I have a lot of other things going on.”
“I just want to be healthier, fitter, stronger, leaner, and / or better at the stuff I do regularly.”
Limiting factors Many (see next page)
1 Note: Clients will vary widely in their body compositions depending on their age, sex, genetic makeup, etc. What is “unreasonably lean” for one
person may be another person’s “normal.” Look for natural tendencies and try to get a baseline of what is appropriate for each client. “Normal” is
the body composition that a client can easily and sanely maintain doing basic Level 1 habits consistently.

320 | Unit 12
Speaking Level 1 language maybe gently explain the real deal over time, as you
build a relationship.)
As a coach, you might think and talk in technical terms,
• Ask them to clarify if possible. What does “get
jargon, or “nutritionspeak.”
For instance, you might be familiar with language like: in shape” or “look better” mean to them, exactly?
Could they give specific examples of what they’re
• macronutrient split
describing?
• oligosaccharides
• Check for understanding. Are you on the same
• glycemic index page? Do you both comprehend what the other is
• contralateral saying?
• body composition Do the same when you discuss limiting factors with
them.
• hydrostatic weighing
• dialed in Clear communication is important for all clients, but

especially so for Level 1 clients, who may feel confused,
• bioavailable anxious, or overwhelmed by complex or technical
Remember that unless you are coaching other fitness language.
and nutrition pros, most people don’t think or talk like
that. Level 1 limiting factors
A client will usually have goals like: In the previous unit, we also looked at common limiting
• “tone up” factors for Level 1 clients.
• “get in shape” These can include (but are not limited to):
• “get rid of my gut”
Food choices
• “look better on the beach”
• Eating too many processed foods
• “get my pre-baby body back”
• Not eating enough nutritious, whole, minimally
• “look good for occasion X” processed foods
And, as we’re fond of reminding you, most people don’t • Not meeting basic nutrient needs (macronutrients
eat “macronutrients”, “polyphenols”, or “antioxidants.” and micronutrients)
They eat food and meals. • Getting dehydrated
Don’t lecture them on correct terminology or drown • Drinking too many sugar-sweetened drinks
them in jargon. Instead:
• Drinking too much alcohol; “drunkorexia”
• Keep it simple. Clients don’t need to know techni-
• Not feeling satisfied by their meals
cal terms or all the scientific rationale for things.
• Listen carefully and assess. What are your clients’ Eating behaviors
goals and how do they describe them? What level • Eating too quickly and while distracted
of terminology and scientific explanation are they
• Trouble recognizing their physical hunger and full-
comfortable with?
ness cues
• Match your language to theirs. If they say “tone
• Irregular eating habits (missing meals or not eating
up”, swallow your ego and say “tone up.” Don’t
enough at some times and / or eating too much at
spend 10 minutes explaining why “toning” is a
other times)
myth. Instead, tell them that your plan, if they stick
to it consistently, will get them toned as heck. (And • Disordered eating (restricting, purging, orthorexia,
controlling, bingeing, etc.)

• Over-eating Environment
• Under-eating / strictly controlling food • An environment that requires too much active “will-
• Using food to manage feelings power” and mental strength to stay on track
• Unsupportive social networks (family, friends, co-

workers, etc.)
• Not getting enough regular physical activity
• Too much stimulation and / or stress, especially
• Over-training and not managing training loads during periods that should be “down times” (e.g.,
before bed)
Recovery
• Not getting enough sleep
This is a long list. Reading this, it’s easy to get discour-
aged or overwhelmed. Or feel like you have to tackle
• Not getting enough recovery everything at once.
• Too much sympathetic nervous system “fight /
Stay calm, coach. One thing at a time.
flight” activation (i.e., spending too much time in the
“amped up” and overstimulated zone) Here’s how to begin working with your Level 1 clients.
• Not enough parasympathetic “rest and digest”
activation Level 1 clients and your
Food and cooking skills coaching process
• Not having basic food preparation skills (or confi- Review the six-step coaching system.
dence in the kitchen) Step 1: Assess and gather data; identify client goals.
• Not having basic shopping and food awareness skills Step 2: Understand the client and “build the story.”
(e.g., reading labels)
Step 3: Create an action plan and possible “next steps.”
Life skills Step 4: Choose one next action step and test it.
• Not being able to ask for what they want and need; Step 5: Observe and monitor what happens.
not being able to define clear boundaries with others
(e.g., people pushing food; other household mem-
bers sabotaging or criticizing) We covered assessment in previous units.
• Making impulsive choices
In this unit, we’ll focus mostly on Steps 3 through 5. But
• Feeling “too busy” or “too rushed” here’s a quick review of
• Not having good options available and convenient
Steps 1 and 2.
Mindset / psychology Steps 1 and 2: Assessment and

• All-or-nothing thinking (e.g., yo-yo dieting, re- understanding
strict-binge cycles, big “diet challenges”, weekend
/ night-time over-eating, “Either I’m perfect or I’ve As we’ve mentioned, you’ll probably find a lot of things
failed” mentality) to work on with Level 1 clients. You may feel like:
• Fixed mindset (I’m broken; I don’t have what it takes; • You have to do everything at once.
I’m a failure) • Everything is so broken it can’t possibly be fixed.
• Not being consistent • You have to give the client a complicated plan.
• Busy-ness and stress; overwhelming life demands; • You don’t know where to start.
feeling rushed and pressured
None of these things are true. Instead:

322 | Unit 12
• Get VERY clear on what, exactly, your client (Nor should you try.) But everything you do and assign
wants to do. All things should connect to your cli- to your client should somehow “advance the game.”
ent’s goals. Make sure you know precisely what those
goals are.
Every task should move your client towards their goals.
Choose wisely. Choose strategically.
• Do one SMALL thing at a time. Break down crit-
ical skills, such as food choices, into smaller, discrete Every task should have a clear “why.” You should be
habits (e.g., protein, carbs, veggies, fats). able to explain, simply and clearly, what the purpose of
each task is. Every habit you assign your client should
• Play the long game. Think six months, a year, or “earn its rent.”
even five years ahead. Imagine how much further
along your client will be with incremental changes, Figure 12.1 is a refresher of the exercise we use to work
done consistently. backwards from a desired goal. With this exercise, you
can see how the outcome your client wants must come
• Keep it simple. As simple as possible. Ridiculously from what they do every day.
simple.
We suggest you map out at least a few weeks of a lon-
• Start at the beginning — with whatever you and
ger-term plan for your client — or even better, a few
your client agree is the best thing to address first. (As
months.
we suggested in Unit 10, try either a piece of the Big
Kahuna, or the Low-hanging Fruit / Easy Win.) Table 12.2 provides one type of template you can use.
Assess first; understand first In Table 12.3, you can see that you have already created a
simple, understandable 8-week action plan that your cli-
Before you give any direction, make sure you under- ent can immediately start doing. (It can even be longer,
stand your client as well as possible. if your client has trouble with any of the behaviors and
needs some extra time.)
Gather relevant data. (You can collect more over time.)
Clearly identify your client’s goals. What do they want

to do? Where do they want to go? Why are these goals
significant and meaningful?
Understand what is most important to your client, and

what they want to prioritize. OUTCOME:
End goal
Review, analyze, and put the pieces together after con-
sultation with your client.
Schedule at least one session to do all of this before giv-

ing any action steps. Today This month
I will: I will:
Step 3: Creating an action plan

Now we get to the heart of coaching: Planning and
taking action.
This week
Long term; short term I will:
As a coach, think about your overall long-term plan as

well as your immediate, short-term plan.
Remember, you don’t have to do everything at once. Figure 12.1 The 4-circle exercise

Table 12.2 Behavior map template

What do I want to do: ___________________________________________________________________
What does it involve? Why does this matter? How will I know if I’ve What will tell me it’s
done it? time to move on?
Behavior 1
Behavior 2
Behavior 3
Behavior 4
Behavior 5
Behavior 6
Table 12.3 Behavior map sample

What do I want to do: Build muscle
What does it Why does this How will I know if I’ve done it? What will tell me it’s
involve? matter? time to move on?
Behavior 1 Train 3 days Regular I’ll have completed my I will have done 3
per week, workouts workout journal for the workouts per week
Work out
following stimulate day. consistently for two
regularly
specific muscle growth weeks.
workout plan and improve
strength. I will be planning
and preparing for
my workouts using a
calendar and trusted
systems.
Behavior 2 Make and This gives me I will have made and I will have made
drink 1 Super lean protein, drunk a Super Shake every and drunk a Super
Add 1 nutrient-
Shake per day fruits and day. I’ll tick this off on Shake every day for
rich, high-
vegetables, and my consistency sheet. two weeks. I will
quality meal
healthy fats, have planned this
conveniently. into my routine and
have trusted systems
to get it done.
Behavior 3 Have 2 palms Lean protein I will stock my fridge I will have had lean
of lean is essential with lean protein options. protein at almost
Add lean
protein at for building every meal for two
protein I’ll schedule time for
each meal. muscle. weeks, as shown
grocery shopping and go by my consistency
to the store with a list. sheet.
I will plan menus to
ensure that each meal has
protein.
I’ll tick off each meal on

my consistency sheet.
Behavior 4 Plan, develop, Creating an I’ll plan my bedtime in I’ll be adhering
and use a anabolic advance. 30-60 minutes consistently to my
Create and use
sleep ritual environment beforehand, I’ll be sleep ritual most
a sleep ritual
before bed requires preparing for restful sleep. nights.
to ensure I recovery. As much as possible I will
get (or try to aim for at least 7 hours of If possible, I’ll be
get) at least 7 sleep every night. getting at least
hours of sleep 7 hours of sleep
every night. consistently.
I’ll have done this

for two weeks.
324 | Unit 12
With this type of structure: do a little more of what you want to do? What was
happening at that time? How did you make that
• The client knows what they need to do right now.
possible?”
They can focus on what is immediately in front of
them: doing their single assigned task, today. • “So, given all this, what do you think you’ll do next?”
• The client knows why they are doing each behavior, • “You say now might be a time to consider cutting
but they’re not overwhelmed by information. back on food X. How would you go about it if you
were ready?”
• Both you and your client know clearly what is to be
done, what counts as “done”, and how to track prog- • “What steps do you need to take to get started on
ress and consistency. preparing more of food X?”
• As the coach, you know what is coming up. • “You mentioned that you want to start eating more
of food X. Where do you think you could start build-
• All behaviors support the goal.
ing more food X in right now?”
Use a collaborative approach • “Let’s break this down and draw out all the steps here
on the whiteboard. Let’s say doing less of behavior X
Remember that you and your client are working together
and doing more of behavior Y is your goal. Let’s map
as a team to address these behaviors.
this out, piece by piece. Step 1 might be…?”
Thus, each time you tackle a new limiting factor, treat it
• “Let’s imagine you’ve achieved goal X. What has to
as a chance to build teamwork and create a collaborative
be true in order for that to occur?”
problem-solving process.
• “Let’s brainstorm a bunch of ideas here before we
Practice this line: choose any. Off the top of your head, what are all the
possible things you could try here? I’ll write them
“I have some ideas here, but I’d like to hear
yours first.” down as you suggest them. Then, we’ll go through
and see which ones we like.”
Here are some questions that you can ask your client to
start exploring limiting factors and generating solutions Not all clients will be able to come up with solutions.
to them. That’s fine too. Then you can offer suggestions if they are
open to it. See Table 12.4.
• “Has there ever been a time when you were able to
Table 12.4 A collaborative problem-solving process

Do Don’t
Ask your client which limiting factor they would like to ad- “Should” your client.
dress first. Suggest a few options if needed.
Ask them for their input and ideas on how to start working Tell them what to do outright. (Unless you are absolutely
through that limiting factor. sure your client will like and benefit from this approach.)
Ask questions that get them generating their own solutions. Assume you know the best solution to their problem. (You
might, but hang back and let them start figuring it out.)
Help clients explore their own resistance, curiously and Lecture, preach, or “information dump.”
without judgment.
Provide suggestions and guidance. Be the boss or unquestioned “expert.”
Help with problem-solving, planning, and strategizing. Try to “convince” or argue.
Make them feel like they are in control of their own change Make it about you.
process.
Give them “principles” to work from, e.g., “Eat the rainbow” Give “rules” or strict plans. (Save that for your Level 3
or “Use your hand for portion sizing.” clients.)
Treat each client as a unique individual. (Even if their story is Compare clients or ask them to compete with each other
familiar.) (unless you’re absolutely certain they’ll find this inspiring
and motivating).

Step 4: Choosing and testing the • Make sure the client understands what “done” looks
like. If possible, show examples (for example, a pic-
next action step ture of a meal, or what a daily menu might look like).
In Unit 10: • Agree on a target for consistency (e.g., every day,
• We explained how to test “ready, willing, and able” three times a week).
with your clients. • Agree on what defines “progress.” Show how com-
• We emphasized that you should choose only ONE pleting the task moves the client closer to their goals.
next action at a time. • Agree on how often the coach will review and evalu-
• We suggested that you ensure that your client is at ate progress indicators.
least 9/10 confident they can do the assigned task. If • Agree on what would show the coach that the client
they are less confident, make the task easier and / or has “graduated” to the next level of difficulty, or is
smaller. ready for a new task.
These pieces are particularly important for Level 1 Tracking progress

clients, who usually have limited skill, motivation, time,
knowledge, and / or other resources. Here are some key principles of tracking progress.
• Use as many other progress indicators as you can.
A very small task, done consistently, helps Level 1 clients
feel increasingly successful, confident, and empowered. • Look for progress everywhere. Call it out, no matter
As they build small achievement on small achievement, now small.
and solve little problem after little problem, Level 1 cli-
• As much as possible, focus on tracking behaviors
ents learn crucial skills. They are repeatedly confronted
with evidence that they can make different, and better, instead of outcomes (such as body measurements).
choices in their daily lives. • Choose relevant, useful, and meaningful progress
indicators. Don’t measure what is not important or
Thus:
salient to the client. Make sure the indicators you
• Make sure the client understands exactly what to do. choose relate to your client’s goals.
Ask them to tell you what is to be done in their own
words. Let’s explore some ideas for both outcome-based and be-
havior-based indicators. Of course, not all clients will need
• Make sure the client understands how the assigned or want all measures. And you can certainly come up with
task relates to their goals. more than these.
• Make sure the client has all the tools and information
We’ll look more closely at what to do when progress
they need to do the task.
stalls later on in the unit.
• Set clients up for success.
Sample progress indicators: Outcomes
We give you some ideas for next actions, and how to scale
them up or down, later in the unit. Body measurements
• Bodyweight and girths
Step 5: Monitoring progress
• Body fat skinfolds (or other reliable methods of analy-
You’ll notice that in the Behavior map template, we sis, such as BodPod or DEXA)
clearly define what “progress” or “done” involves. The • Subjective measures, such as belt loops, or tightness
client must know what counts as executing the task. of clothes
Thus, as you develop the action plan: Objective physiological indicators / lab tests
• Clearly define what doing the task involves.
• Blood work, such as:

326 | Unit 12
• blood lipids
• fasting glucose, glucose control
• red and white blood cell counts
• Blood pressure (including orthostatic hypotension2)
• Nutrient status (i.e., vitamin and mineral levels)
small intestinal bacterial • Tests of GI health, (e.g., SIBO, gastric motility, GERD)
overgrowth (SIBO):a condition
in which abnormally large • Hormone levels and hormone health
numbers of bacteria are present in
the small intestine • Heart rate variability, resting heart rate
• Morning temperature
• Medication use
Subjective physiological indicators

• Pain
• Inflammation
• Sense of physical wellbeing, vitality, overall wellness
• Gastrointestinal symptoms; digestion
• Energy and fatigue
• Sleep quality
• Joint mobility / stiffness
• Immunity
Subjective psychological indicators

• Mood and emotional stability
• Overall outlook and resilience
• Calm and relaxation
• Clarity of thought; ease of learning and remembering
Subjective social and daily-life indicators

• Participation in daily-life activities
• Social engagement and confidence
• Quality of relationships and social network
Sample progress indicators: Behaviors

• Consistency (this is the big one)
• Quality of task completion (i.e., how well does the client do the task?)
• Confidence of task completion (i.e., how confident is the client when doing the
task?)
• Complexity of task (i.e., how much skill and knowledge does the task require?)
• Sense of being “aligned” with the task (i.e., the assigned task feels purposeful,
meaningful, relevant, and important to the client)

Level 1 limiting factors and 50% (in some cases over 75%) of the average Ameri-
can’s intake. Most people eat most of their food highly
coaching strategies processed.
Let’s look more closely now at some of the most common People who eat a lot of processed foods typically:
Level 1 limiting factors, and how you can start working
• have trouble regulating their appetite and hunger
through them.
cues;
Limiting factor: Food choices • are poorly nourished; and / or
• are less metabolically healthy, with undesirable body

Too many processed foods composition.
Why might clients struggle with this? Possible strategies

We live in a time of abundance. And we no longer have Dietary displacement
to raise, harvest, process, and make all our foods from
scratch. Convenient, tasty, shelf-stable processed and When we fill up on “good stuff”, there’s less room for
refined foods are cheap and easily available year-round. junk.
On the one hand, this makes life much easier. Help Level 1 clients transition gradually to adding nutri-
tious foods, without explicitly asking them to eat less of
For instance: the processed ones. In fact, you can actually tell clients
• We can buy bread instead of having to grow, gather, that they don’t have to give up the “bad stuff.” (This, para-
grind, leaven, and bake the grains. doxically, will often make them more likely to change.)
• We can open a bag of peas that have been harvested, For instance:
shelled, blanched, and frozen for us. • Keep eating those Subway sandwiches if those are
• We can keep a can of tomatoes on the shelf for the most convenient option for you right now, but
months instead of worrying about fresh tomatoes add more vegetables to them.
going bad. • Have a salad or some cut-up veggies to start your din-
Some minimally processed foods, such as frozen vegeta- ner, before you get into the main course.
bles, canned tomatoes, cold-pressed olive oil, or yogurt • Before you have that 3 PM brownie, have a piece of
can be convenient and nutritious parts of your clients’ fruit. Then go ahead and eat that brownie if you still
diets. want it.
Why is this a problem? Healthy substitutions
On the other hand, most processed foods don’t add value Ask clients to come up with a list of potential substitutes
to our health or body. for some of their most common processed foods. Then
ask them to try one or two of these.
Most processed foods are high in calories but low in nutri-
ents. They usually have a lot of sugar, salt, and / or industri- For instance:
ally produced fats (not to mention other things like colors • An orange instead of orange juice
and preservatives).
• Steel-cut or rolled oats instead of sugary breakfast
Processed foods make it hard for us to know when we cereal (with some fruit to sweeten it)
are physically hungry or full. It’s easy to over-eat them,
and we still want more (that’s how they are designed). Moving along the continuum
Processed foods are readily available and heavily pro- Ask them what might be “just a little bit better” (i.e., a
moted. Indeed, highly processed foods make up over little less processed). Then ask them to try one or two of
them.

328 | Unit 12
For instance:
• Higher-fiber noodles rather than plain white pasta Behavior Awareness Worksheet
• Natural peanut butter instead of regular peanut
butter NAME DATE
• Regular coffee instead of a flavored coffee drink (or to Research shows that while our behaviors may seem “spur-of-the-moment”, when it comes to over-eating the
groundwork is laid several hours in advance by our daily rituals, habits, mindset, and automatic thinking. Over-eating
is simply the last link in a long chain. If you can break the first link, you have a much better chance of never getting to
the last link.
decrease the amount of additives used, such as sugar The goal of this exercise is to build awareness of what your eating episodes have in common. Maybe it’s a time of day, or a situation, or
a type of food, or another person (or being alone), or a feeling – or all of these.
and / or cream)
Describe in as much detail as possible what you are experiencing, or remember experiencing, at each stage. Then go back and review.
Look for common features. Look at the steps you took.
This helps you build understanding of the process, which you can then use to disrupt these patterns. For instance, if you habitually
over-eat in your kitchen at 6 pm when stressed, then figure out strategies to deal with a stressy dinner hour before it happens – as far in
advance as possible. If you habitually think certain thoughts beforehand (e.g., “I’m a failure”, “This will make me feel better”, etc.) then
Noticing behavior patterns

come up with ways to respond to those thoughts before they hit you.
Complete this worksheet every time you have an episode of over-eating. Be honest and thorough. You are collecting data so that you
can analyze your own patterns and eventually develop strategies to deal with them.
Some clients will be more likely to eat processed foods 1. In the 1-2 hours beforehand:
at certain times, or in certain situations. Have them What are you doing?
keep a “processed food journal”, in which they simply What are you thinking?
identify when and where they tend to eat more (or fewer) What are you feeling, emotionally?
processed foods. What are you feeling, physically?
For instance, they may choose processed foods: Where are you?
What time is it?
• when they are busy and stressed;

Who’s with you?
• when they are traveling; or
• when they want to relax or “comfort eat.”
You can use the Behavior Awareness Worksheet to help

them notice these patterns, and then work backwards to

“break the chain.” Find the Behavior Awareness Worksheet in your forms package
Red-yellow-green light foods
Ask clients to take notes on their “red, yellow and green

light” foods. Each person will have a slightly different list of red, yel-
low, and green lights.
• “Red light” foods are foods that are just bad news for
the client. Maybe they make the client feel sick, or One client might leave ice cream in the freezer un-
they trigger the client to eat too much, or the client touched for months, whereas another client might need a
just knows they’re an unhealthy choice, etc. Red restraining order from Ben & Jerry’s.
means “no go.”
Once the client has come up with their red, yellow, and
• “Yellow light” foods are foods that are sometimes green light list, ask them which foods they would like to
okay, sometimes not. Maybe the client can eat a eat more of and less of, and why. Let them choose which
little bit without feeling ill, or can eat them sanely at foods to add and subtract, and discuss their rationale. Be
a restaurant with others but not at home alone, or willing to give suggestions when asked, but don’t force
they can have these foods as an occasional treat, etc. your personal preferences on them.
Yellow means “approach with caution.”
Also be sure to discuss how to do this rather than just
• “Green light” foods are foods that make the client saying “Okay, give up food X.”
feel good mentally and physically, and that the client
can eat normally, slowly, to a relatively easy 80% full.
These are usually things like fruits and vegetables,
lean protein, and legumes. Green means “go for it!”

Shape the path / Kitchen cleanout Help your Level 1 client review their immediate environ-
ment, especially their house and kitchen, to see where
Berardi’s First Law states: they can make changes. (Of course, ensure that the client
collaborates and agrees to any changes. Changes may
If a food is in your house or possession, either
need to be small and incremental. The client will often
you, someone you love, or someone you mar-
need to work with other household members as a team.)
ginally tolerate, will eventually eat it.
We like a “kitchen makeover” that:
The corollary of Berardi’s First Law is:
• removes “red light foods” and anything else the
If a healthy food is in your house or possession, client thinks is a problem; and
either you, someone you love, or someone you
marginally tolerate, will eventually eat it. • stocks up on “green light foods” and convenient,
healthy options.
In other words:
This means the client doesn’t have to over-think things,
• Keep healthy stuff nearby and convenient. Help the
make too many decisions, or use “willpower.”
client create routines and environments (home, work,
etc.) that support their goals. “Red lights” are gone; “green lights” are there.
• Keep unhealthy stuff far away and inconvenient. Easy.
Make it hard for unhealthy stuff to get to the client.
(Just making them less visible can help.)
Those stay versus those go
Level 1 clients need strategies that are realistic, simple, because they don’t know about, or don’t know how to
and fit with their everyday lives as “imperfect” human make, alternatives. (“Really? You can make your own
beings. So don’t create a bunch of strict rules or say salad dressing?”)
things like “Processed foods will kill you.”
Those “don’t need to have” foods can go.
Level 1 isn’t about eliminating 100% of processed foods
At the same time, help clients identify the processed
and being a purist.
food opportunities they really value. Pizza night with
If you try that approach, your Level 1 clients will resist the fellas? Sunday pancakes with the family? Wine,
you, and / or get anxious, and / or “fall off the wagon” cheese, and crackers with friends?
big time, and / or develop disordered eating patterns.
Those can — and should — stay. (For now. Unless and
It’s about finding the processed foods that clients can until your client wants to change them later.)
do without.
As a coach, help your client decide which foods and
Such as the pointless, excessive eating that doesn’t re- food habits really matter to them, and why.
ally mean much to them. Maybe it’s a handful of candy
Help them keep “treat foods” in balance… as treats.
between meals. Free samples at the store. A cookie just
because. Focus on quality and quantity of daily overall intake,
along with appetite awareness.
Or maybe the processed foods that your clients eat

330 | Unit 12
Not enough nutritious, whole, This type of diet may also mean:
minimally processed foods • Clients don’t feel confident cooking or preparing
food.
Along with eating too many highly processed and re-
fined foods, many clients don’t eat enough nutrient-rich, • Clients will have trouble applying principles like “eat
whole, minimally processed foods, such as: more lean protein.”
• fresh fruits and vegetables • Clients feel their choices are restricted because they
• whole grains don’t know there are lots of options out there.
• beans and legumes • Clients have learned to prefer the taste, texture, and
hyper-palatability of processed foods.
• whole, fresh cuts of meat or poultry
• fresh fish and seafood Possible strategies

• nuts and seeds
Try 1 new ____ every ____
They also tend to eat a fairly limited range of all of the
Encourage clients to experiment with trying new:
above. For instance:
• foods
• only chicken breasts instead of chicken legs, whole
chickens, chicken livers / hearts, etc. • types of foods (e.g., different types of apples)
• only chicken instead of turkey, goose, duck, quail, etc. • flavors
• only iceberg lettuce instead of radicchio, arugula, • recipes

Boston lettuce, endive, red leaf lettuce, escarole, etc. • cuisine styles
• cooking and food preparation techniques

Why might clients struggle with this?
This could be every day, every week, every two weeks,
Many people in industrialized countries have lost the
every month, etc.
skills of cooking from scratch and preparing whole
foods. Field trip
We’re further from our agricultural roots, and few of us Suggest a field trip to the farmers’ market (or fish store,
recognize or know what to do with unprocessed foods. butcher, “pick your own” farm, etc.) — anywhere that a
(How do you cook an artichoke? What do you do with client could learn more about whole foods, see a variety
pork necks? Wait… pigs have necks?) In addition, we of them, and learn more about how they’re produced.
may see only a small range of food varieties in the super-
market, such as one type of tomato or pepper. Cooking / food prep techniques
It’s often easier to just “grab and go” with processed Identify easy yet essential cooking or food preparation
convenience foods. techniques that would benefit your client, then assign
one technique as a weekly task to practice. For instance:
Why is this a problem? • Use a slow cooker
Humans evolved to thrive on diverse diets with a wide • Chop and store vegetables in bulk
range of naturally occurring nutrients. When our diet is • Roast or grill meat or vegetables
limited and highly processed, we don’t get this.
• Steam vegetables

• Make a Super Shake super shake: A recipe base for a

nutrition shake
• Make a basic salad
More on food preparation techniques shortly.
Make it easy
Clients may feel that eating more whole, minimally processed foods is too difficult. Show
them how it can be easy with choices like:
• pre-washed vegetables or salad greens
• ready-to-eat vegetables (baby carrots, gourmet cucumbers, celery stalks)
• fresh, easy-prep fruit (such as apples or fresh berries) or pre-cut fruit (such as
pineapple or melon)
• canned beans or lentils
• a whole rotisserie chicken (a better option than most fast food)
• boiling up a pot of eggs or potatoes to have on hand
• whole grains done over night in the slow cooker (which avoids soaking and
waiting for grains to cook)
• grating a fresh tomato on a cheese grater to make a quick pasta sauce
Remember to help your client make these choices on a continuum and look for
“just a little bit better.” A rotisserie chicken from the supermarket may not be a
pastured, lovingly hand-raised, heritage Chantecler roasted in a high-end con-
vection oven… but it sure beats chicken nuggets. Progress, not perfection.
Not meeting basic nutrient needs (macronutrients and

micronutrients)
Research shows that most people — including athletes — don’t meet basic nutri-
ent needs, whether that’s macronutrients (e.g., higher-fiber carbs, healthy fats) or
micronutrients
(e.g., vitamins, minerals, phytonutrients).
If so many people are deficient in key nutrients, can’t we just load them up on
supplements? Well, we can. But we’re not sure if it’s the same. And based on
what we know so far, it likely isn’t.
The human body has a long standing relationship with whole foods. And nutri-
ents come as a package deal in those whole foods, not isolated and delivered out
of context.
Thus, in situations where it’s possible to get nutrients from whole foods, choosing
a supplement can be a step in the wrong direction, and overdoing unnecessary
supplements may actually cause harm.
But we do live in the real world. And getting enough nutritious foods each day
will take some organization and forethought, especially for Level 1 clients who
are new to this, and / or may have to learn lots of life skills in order to plan, pre-
pare and do the tasks of healthy eating.

332 | Unit 12
Your palm determines Your fist determines Your cupped hand Your thumb
your protein portions your veggie portions determines your carb determines your fat
portions portions
Figure 12.2 Hand size portions
Thus, if a supplement will prevent a deficiency, then it This works well for many reasons.
can be a helpful tool for Level 1 clients as you help them
move towards more nutrient-rich foods. While we don’t First, hands are portable. They come with you to work
generally recommend supplements for Level 1s, there are lunches, restaurants, social gatherings, grandma’s
a few that can help. house, etc.
Be sure that any supplements you recommend do not in- Second, hands are scaled to the individual. Bigger people
terfere with other health conditions or medications your need more food, and tend to have bigger hands, therefore
clients may be taking. Check with your clients’ doctors getting larger portions. Smaller people need less food,
and / or pharmacists if you are not sure. and tend to have smaller hands, therefore getting smaller
portions.
Possible strategies Third, it provides reasonable amounts of nutrient-dense
foods and their specific macronutrients (thus preventing
Hand size portions of nutrient-dense foods
deficiencies). It helps most clients to meet their protein,
Educate clients about what nutrient density means, and vegetable, carb, fat, and calorie needs without them hav-
how to get it. Work on building meals around nutri- ing to count a gram or weigh a food.
ent-dense foods using hand size portions (as shown in
Assuming clients are active and eat about four meals per
Figure 12.2).
day, this is what we find to be a great starting point for
• The palm determines your protein portions (~ 20-30 most clients:
g protein).
For each meal, men might begin by eating:
• The fist determines your veggie portions.
• 2 palms of protein-dense foods
• The cupped hand determines your carb portions (~
20-30 g carbs). • 2 fists of vegetables
• The thumb determines your fat portions (~ 7-12 g fat). • 2 cupped handfuls of carb-dense foods
• 2 thumbs of fat-dense foods

And for each meal, women might begin by eating:

• 1 palm of protein-dense foods Hand-Sized Portion Guide
• 1 fist of vegetables
• 1 cupped handful of carb-dense foods NAME DATE
• 1 thumb of fat-dense foods
It’s important to note a few things here.
To start, men don’t need twice as much food as women.

And women don’t need half as much food as men. These
per-meal numbers simply make it very easy to appro- Your palm determines
your protein portions
Your fist determines
your veggie portions
Your cupped hand
determines your carb
Your thumb determines
your fat portions
portions
priately portion out a meal. But they don’t necessarily
provide perfect total daily intakes for everyone. This works well for many reasons.
First, hands are portable. They come with you to work lunches, restaurants, social gatherings, etc.
Second, hands are scaled to the individual. Bigger people need more food, and tend to have bigger hands, therefore getting larger
portions. Smaller people need less food, and tend to have smaller hands, therefore getting smaller portions.
When you do out the math, our hand size portion guide- Third, it provides reasonable amounts of nutrient dense foods and their specific macronutrients (thus preventing deficiencies). It will help
you meet your protein, vegetable, carb, fat, and calorie needs without having to count a gram or weigh a food.
lines come out to 8 daily servings of each food group Assuming you’re active and eat about 4 meals per day, this is what we find to be a great starting point:
For each meal, men might begin by eating:
for men (2 servings of each per meal x 4 meals). Which • 2 palms of protein dense foods;
• 2 fists of vegetables;
• 1 cupped handful of carb dense foods; and
• 1 thumb of fat dense foods.
yields roughly 3000 kcal. And 4 daily servings of each • 2 cupped handfuls of carb dense foods; and
• 2 thumbs of fat dense foods.
It’s important to note a few things here.
To start, men don’t need twice as much food as women. And
food group for women (1 serving of each per meal x 4

women don’t need half as much food as men. These per-meal
And for each meal, women might begin by eating:
numbers simply make it very easy to appropriately portion out a
• 1 palm of protein dense foods; meal. But they don’t necessarily provide perfect total daily intakes
meals). Which yields roughly 1500 kcal.

• 1 fist of vegetables; for everyone.
Some men need fewer calories than the 8 daily servings

of each food group provided by the per-meal template, © 2018 ISSA issaonline.edu
and some women need more calories than the 4 daily

servings of each food group provided by the per-meal
Find the Hand-Sized Portion Guide in your forms package
template.
In reality, most active men likely need a total daily

intake of: average-size men and women eating a mixed diet. And
for most clients, these numbers are more than close
• 6-8 palms of protein-dense foods enough.
• 6-8 fists of vegetables
Be aware that clients will need to adjust the number of
• 6-8 cupped handfuls of carb-dense foods portions they consume to best meet their needs. The
• 6-8 thumbs of fat-dense foods portion sizes themselves are static, but the number of
portions each client needs will vary.
And most active women likely need a total daily intake
of: Also keep in mind that even these per-day recommen-
dations are just starting points. They are to help people
• 4-6 palms of protein-dense foods more easily meet their protein, vegetable, carb, fat, and
• 4-6 fists of vegetables calorie needs without having to do kitchen math. But
they aren’t unchanging “rules.”
• 4-6 cupped handfuls of carb-dense foods
• 4-6 thumbs of fat-dense foods

Adjust actual number of portions up or down, de-
pending on each person’s unique needs and goals. For
For men, these intakes range from approximately example:
2300-3000 kcal. And for women, these intakes range • Men who want to gain lean mass or who are very ac-
from approximately 1500-2100 kcal. Obviously, these
tive might need to add 1-2 cupped handfuls of carbs
exact numbers depend on the size of the individual, as
and / or 1-2 thumbs of fats to a few meals.
well as the foods eaten. But they represent the intake of
• Women who want to gain lean mass or who are very

334 | Unit 12
active might need to add a 1/2-1 cupped handfuls of Fitness Nutrition plate is just a starting point – A tool
carbs and / or a 1/2-1 thumbs of fats to a few meals. to help someone learn how to build a balanced meal. It’s
not magic. And it might not resonate with some clients
• Men who want to lose body fat or who are inactive
(especially clients who eat a lot of “mixed” meals, like
might need to remove 1-2 cupped handfuls of carbs casseroles).
and / or 1-2 thumbs of fats from a few meals.
Make adjustments based on hunger, fullness, preferenc-
• Women who want to lose body fat or who are inac-
es, goals, overall activity level, and most importantly,
tive might need to remove a 1/2-1 cupped handfuls
results. Start with the basic template and then adjust
of carbs and / or a 1/2-1 thumbs of fats from a few
portions at any time using outcome-based decision mak-
meals. ing. See Figure 12.3.
Adjust portions based on hunger, fullness, preferences, Protein powder
goals, overall activity level, and most importantly, re-
sults. Start with the basic template and then adjust por- For clients who struggle to get enough protein, or find
tions at any time using outcome-based decision making. “real food” protein difficult to prepare, a high-quality
protein supplement can help.
See the Hand Size Portions Guide form for more.
Whey protein in particular has been shown to con-
The Fitness Nutrition plate tain valuable components that help boost immunity,
increase protein synthesis, and improve satiety. Other
The Fitness Nutrition plate is another option to help
protein powders, such as casein, egg, pea, rice, hemp,
clients visualize how to build a plate when they sit down
and pumpkin seed, each offer unique features and can
to a meal.
also be helpful.
Just like the hand size portions, keep in mind that the
Water
or tea
Fruit
for dessert or
after exercise
Protein • Eat slowly and stop eating

including red meat, when you’re 80% full.
chicken, fish, eggs, or
plant source • Eat more vegetables than fruit.
• Choose mostly whole foods

Veggies with minimal processing.
including a wide variety
Starches of non-starchy vegetables
• Choose local or organic foods
when possible.
including sweet potatoes,
potatoes, whole grains, bread • Use smaller or larger plates
based on your own body size.
Fats
including healthy oils,
nuts and seeds

One to two servings per day is fine for helping clients Work with your Level 1 client’s health care providers
meet protein needs, but try to avoid having more than on any targeted supplementation plans when treating a
this on a regular basis. deficiency.
Essential fatty acid supplement Dehydration; poor beverage choices

For clients who aren’t ready, willing, nor able to eat more Many clients will:
whole-food sources of omega-3, we recommend an ome-
• be chronically dehydrated;
ga-3 supplement, such as:
• consume too much caffeine;
• fish oil: 3-9 g of total fish oil per day (or 1-3 g of com-
bined DHA+EPA). • choose high-calorie drinks instead of water; and / or
• krill oil: 2-6 g of total krill oil per day (or 500-2000 mg • consume too much alcohol.
of combined DHA+EPA).
• algae oil (plant-based): 500-1000 mg of combined

DHA+EPA. Like processed and nutrient-poor food choices, pro-
cessed and nutrient-poor drink choices are everywhere
Multivitamin / multimineral supplement
and heavily promoted.
Add a good quality multivitamin / multimineral supple-
Clients may be looking for a pick-me-up from caffeinat-
ment as a daily habit to help prevent deficiencies.
ed drinks; believe that orange juice is “a great source of
Do some research to find reputable brands available in vitamin C”; and / or use alcohol to manage their social
your area that offer no more than around 100% of DV situations or emotions.
(whole-food based multi supplements often contain this
amount), and have a list ready to share with clients. The Why is this a problem?
goal for a multi is deficiency prevention, not treatment of
an actual deficiency. That should be done under medical As you saw earlier in this textbook, we need proper fluid
supervision. balance for our body to function well. Many processed
foods are high in sugar and sodium, which means we
Powdered greens supplement need even more water to compensate. Even mild de-
hydration can cause problems such as dizziness, fuzzy
A greens powder (which is a mix of dehydrated fruits thinking, headaches, and muscle cramping.
and vegetables) can help Level 1 clients who don’t (yet)
get enough fruit and veggies, and / or who may be travel- Clients may depend on caffeine and / or alcohol as un-
ing and find fresh produce hard to get. healthy coping mechanisms.
Nutrient testing Sugar-sweetened / higher-calorie beverages may replace

water and add unnecessary energy intake.
This isn’t a typical Level 1 strategy, but it’s worth noting.
If you suspect a serious nutrient deficiency, suggest that Clients may mistake thirst for hunger.
your client get tested so that you know for sure.
Possible strategies
Most often, you will find:
• vitamin B12 deficiency in plant-based eaters; Keep a “drink journal”
• vitamin B deficiencies in clients with mental health Clients can start with simply tracking their beverage
issues; intake, whether that’s alcohol, sugar- sweetened drinks,
caffeinated drinks, or water intake.
• vitamin D deficiency; and
• iron deficiency in women and plant-based eaters. Get a baseline and then discuss potentially changing
that baseline with your client by:
Get a clear diagnosis before supplementing randomly.

336 | Unit 12
• scaling back (e.g., 2 drinks per evening instead of 4; Have a crucial conversation; use referral networks
choosing a small coffee instead of a large); and / or
A lot of clients struggle with alcohol — in fact, many of
• substituting (e.g., diet soda instead of soda; soda our clients have mentioned that this is something they’d
water instead of diet soda). like to change.
Have a “water trigger” Aside from getting your client to agree to scale back or
substitute, changing alcohol habits (along with man-
One simple way to both remind your clients to drink
aging other addictions) is mostly out of your scope of
enough and to advertise your services is to get a large
practice. However, you can certainly use a drink journal
refillable water bottle with your name or coaching prac-
to start a dialogue about whether your client might
tice logo on it. As one of their regular habits, ask them to
be ready, willing, and / or able to change their alcohol
fill up the bottle once or twice during the day, then keep
habits.
it near them. They’ll drink more, and remember you as
well. (Go for a glass or stainless steel bottle if possible.) If so, and if they would benefit from some help with this,
refer out to a qualified health care professional such as
Or you can just start by asking your beginner clients to
an addictions counsellor.
drink a glass or two of water with each meal.
Coaching note: how before what and how much
It’s very common for clients to focus on two things: If your client is eating meals in under 90 seconds stand-
ing over the sink or one-hand eating while driving to
1. WHAT they are eating: carbs, gluten, calories,
work, it doesn’t matter if they are eating organic kale
protein, vitamins, and superfoods, etc.
and imported goji berries. HOW they are eating will
2. HOW MUCH they are eating: how many grams, likely hold them back.
how many calories,
So, before you worry about WHAT or HOW MUCH
what % of fat, etc.
someone is eating, consider HOW they are eating. (And
Obviously, those are important topics. later on, look at WHY too.)
But HOW clients eat is just as critical (maybe more so). The good news is that if you start with HOW and WHY…
WHAT and HOW MUCH often takes care of itself.
Limiting factor: Eating behaviors

Eating too quickly and / or mindlessly North Americans in particular aren’t very good at con-
sciously making time to eat slowly and mindfully. Many
Why might clients struggle with this? of us pride ourselves on our fast-paced, hard-working
culture while we gobble food at our desk or in our car.
Almost all of us in industrialized countries eat too fast,
with too many distractions around us. It’s hard not to. Why is this a problem?
Time is money, and we’re busy.
When we eat too quickly and without full attention, we
Plus there are lots of things demanding our attention: miss important hunger and fullness cues, along with
electronics, TV, kids, coworkers… We may be rushing other body cues (such as how certain foods make us feel
between activities or work obligations, commuting, and physically).
/ or trying to “get on top of things” by multitasking.
If we get used to eating while doing other things (such

as watching TV or working at the computer), we’ll start the slowest-eating person and match their speed. Little
to feel like we should be eating when we do those things. kids are often a great “pace setter” for slow eating.
(Have you ever noticed at the movies that people devour
almost an entire meal’s worth of buttered popcorn and Notice what affects your eating speed
other cinema goodies before the film even starts?)
Ask clients to simply notice and name what affects their
Research also shows that eating while driving makes our eating speed or focus, such as:
driving significantly worse. We’re distracted and more • who they eat with;
likely to get into an accident — driver inattention, in-
cluding eating, causes about one-quarter of all accidents. • when they eat;
• what they eat; and

Possible strategies • where they eat.
Meal timer Once your client has gathered some data, discuss their
Clients can time how long it takes them to eat a meal, findings and decide together what to do next to improve
and record a baseline for a few meals. You can then use on what is already working well, or change what isn’t
this data to discuss potential improvements. working well.
Clients can use the timer for subsequent meals to pace Use an app
themselves or set goals (e.g., “I will aim for X minutes for This is one case where a mobile device can actually be
this meal”). helpful. There are many apps that track and enable slow
Doing something between bites eating. Encourage your client to try one or more, and see
which one works for them.
Clients can do something else between taking bites of
food, including: Trouble recognizing hunger and
fullness cues
• setting down their utensils;
• taking a breath (or three); Why might clients struggle with this?
• taking a sip of water; and / or
Do you remember that class you had in school, the one
• focusing on table conversation. that helped you learn all about your personal physiologi-
cal hunger and fullness cues?
”Wine taste” your food
We don’t either.
Ask clients to practice chewing slowly, sniffing, and
savoring their food, as if it were a fine wine. Have them None of us had that class. In fact, most of us learned
record what they observe about their meals when they exactly the opposite:
do this. • Eating has no relationship to our physiological needs.
Distraction-free eating Eat whatever you like, whenever you want, wherever
you are!
Ask clients to eat without distractions such as TV, mo-
• Stop when the plate is empty, not when you’re physi-
bile devices, books or newspapers.
cally satisfied. Don’t waste food.
This is often a surprisingly difficult task, so it’s best to
ease clients into this one with an experimental feel, such As adults, most of us now eat based on social norms,
as, “Try eating just one meal today without distractions, advertising, what’s around us, and our family / friends /
and see what that’s like.” peers. We eat when:
• it’s a certain time;
Pace yourself to the slowest eater
• it’s a certain event (or no event in particular);
Ask your client to eat with a group of people, then find
• it’s a certain emotional situation (or we’re bored); or
• we’re reminded of food (which is nearly always).

338 | Unit 12
Most adults have no idea what physical hunger and / or We need to pay attention to both physiological hunger
fullness actually feel like. We have no appetite awareness. and fullness cues in order to properly regulate our intake
and energy balance.
Some clients might be able to identify extreme varia-
tions (e.g., I’ve been on a diet for a week and I’m ready And when we can learn to recognize these cues, eat-
to binge; I just ate so much I’m uncomfortable), but not ing becomes much simpler and more intuitive. Level
healthy ranges. 1 clients don’t need “food rules”, cognitive control, or
tight restrictions; they have their own bodies to tell them
Just as some folks will consistently eat when they aren’t when to start and stop.
really hungry, some folks will avoid eating when they are
hungry. They might be wrapped up in a work project,
Possible strategies
family commitment, or volunteering. Or maybe they’re
consciously trying to suppress hunger with loads of cof- Practicing noticing cues
fee, chewing gum, and diet sodas. They might be skip-
ping meals and / or stringently restricting their intake. Not all clients will be able to recognize hunger and
fullness cues right away, particularly if they have a his-
In other words: Few people start eating when they’re tory of dieting, restricting, and / or binge eating. Some
truly physically hungry and stop when they’re physical- may also be dissociated from their bodies and physical
ly satisfied. feelings in general.
Why is this a problem? Nevertheless, you can ask clients to simply observe and
notice what hunger or fullness feels like. What physical
Basic appetite awareness is one of the most useful and sensations do they feel? (You can suggest things to look
accurate ways someone can recognize how much food for, such as growling stomach or lightheadedness; a
their body needs. sense of abdominal emptiness or heaviness)
If people eat when they aren’t hungry (and don’t stop

when they’re physically satisfied), they’ll probably end up
with less-than-ideal body composition and overall health.
The Hunger Game
They may feel out of control of their eating and not sure
how to manage it. There are no clear “start” or “stop”
signals. NAME DATE
The “how you should feel timeline”

If people don’t eat when they’re physically hungry — for Today, notice how you feel before, during, and after eating. Rank your physical hunger on a scale from 1 (no hunger) to 10 (worst
hunger ever). When you’re truly physically hungry, eat. Eat slowly, and stop at 80% full. Adjust your meal size and frequency depending
on your body cues.
instance, if they purposely skip meals or stringently

restrict their physical intake — they’ll often end up with Just before
eating
Are you physically hungry? Pause and check in. Look for signals like a rumbling stomach,
lightheadedness, irritability, etc. You want to be around a 7 out of 10 on the hunger scale.
nutrient deficiencies and the consequences of ongoing

energy deprivation. Immediately
after eating
To be 80% full, shoot for about a 2 or 3 out of 10 on the hunger scale. Pause for 15-20
minutes before you eat more. This will give your brain time to catch up. You want to feel
satisfied, not stuffed.
People may also feel caught in the “scarcity” mindset, One hour You should still feel physically satisfied with no desire to eat another meal.
especially if this restriction is part of “dieting.” In this after finishing
case, they alternate between eating what they don’t need Two hours You may start to feel a little hungry, like you could eat something, but the feeling isn’t
(“Another potential dietary restriction lurks around

overwhelming.
after finishing
every corner… better eat now while I can!”) or not eating

Three to four Check in. You may be getting a bit hungry, perhaps a 4 to 6 out of 10. If you’re around a 7,
what they do need (“Fat makes you fat! I don’t eat that!”) hours after
eat. Not really hungry yet? That’s OK. Follow your body cues.
finishing
Hunger is a normal and healthy biological response, just Four or more

hours after
You’re probably quite hungry, like nothing is getting between you and the kitchen. If you’re
around a 7 or higher, eat. Not really hungry yet? That’s OK. Keep checking in with your body.
You may find you need to act fast once your body decides to be hungry — so be prepared
like going to sleep, going to the bathroom, or getting

with a healthy and quick option, just in case.
finishing
thirsty. It exists to keep us alive.
Fullness and satiation tell us when we’ve had enough. © 2018 ISSA issaonline.edu
Find The Hunger Game worksheet in your forms package

Ask clients to drink a big glass of ice water and notice • create sustainable healthy habits; and / or
the sensation as it goes down. They can also put one • normalize many health indicators.
hand on their stomach as they do so, just below their
sternum. This can help them “locate” and physically Of course, there can be some variation (especially if
sense into where their esophagus and stomach are. clients are learning to follow their own natural appetite
cues), but in general, some type of structure and regular
Appetite awareness tracker schedule works best for most Level 1 clients.
Use the The Hunger Game with clients. Ask them to
track both: Possible strategies
• how hungry they were when they started a meal; and Scheduled meal times
• how full / satisfied they were when finished.
For Level 1 clients who want to improve athletic perfor-
Ask them to also notice how much food it took for them mance and / or gain muscle, scheduled meal times work
to feel “satisfied” or “no longer hungry” versus “full / well. This needn’t be a rigid routine. Simply suggest that
stuffed.” clients eat approximately every 3-4 hours, and help them
plan and prepare for this.
Irregular eating habits
Scheduled appetite check-ins
Many clients miss meals, or don’t eat enough on some
Most of the time, Level 1 clients looking to lose weight /
occasions, while eating too much at other times.
fat need to learn to follow their hunger cues rather than
eat on a schedule. Instead of scheduled meal times, try
Why might clients struggle with this? scheduled appetite / hunger check-ins.
Life is busy. People are rushed and distracted. They may Ask clients to simply “check in” with their appetite every
not plan properly. 3-4 hours, and note how hungry they feel. If their hunger
They may unwittingly miss meals because of other com- is greater than, say, a 6 or 7 out of 10 (where 10 is absolute-
mitments, or they may purposely skip meals if they’re ly, life-threateningly starving), then it’s time to eat. If not,
trying to lose weight. check back in after another half hour or so.
They may over-eat when they’ve let themselves get too Meal planning / stocking up on healthy options
hungry or stressed, or when they’ve skipped a meal Meal planning in advance can help clients who either
earlier. They may keep things in check during the day (or “forget” to pack a healthy meal, who might be confront-
during the week), but “lose control” in the evening, or ed with a variety of poor options at certain times, and /
on the weekend. They may alternate between restriction or let things go too long (then lose control).
/ control and over-eating / bingeing / “anything goes.”
Clients can also stash things like nuts or fruit to have
Why is this a problem? on hand in case the munchies strike and they need a
healthy choice.
Most of the time, most people do best with some kind
of routine. Our body tends to prefer some predictability Using food to manage feelings /
and homeostasis, including relatively regular meal times. emotional eating
Regularly spaced, relatively predictable meals that are Many Level 1 clients eat for comfort, and to manage
roughly the same size usually work best for almost all their emotions or unwanted physical feelings (such as
Level 1 clients looking to: stress or anxiety).
• lose weight / fat;
• improve athletic performance;
• gain muscle; Food is a great way to self-medicate. It tastes good, it

340 | Unit 12
makes us feel better (at least for a few minutes), it’s easily HALT
available and legal.
HALT stands for:
Food comforts and soothes us. It stimulates pleasure
• Hungry
pathways in the brain.
• Angry (or anxious)
Food has emotional associations. It has meaning and
• Lonely
memory, reminding us of home, childhood, or that time
we went to Italy or Vietnam; visited our grandmother; • Tired
had our favorite holiday meal; etc.
When a client notices an urge to eat emotionally, ask
Food connects us to others, to our family, heritage, and them to pause for a minute and ask themselves if they
culture. It’s often a way we express love, care, concern, are hungry; angry or anxious; lonely; and / or tired.
and / or celebration to others. Or preserve our history
and who we are. Many Level 1 clients do not recognize what they are
thinking, feeling, and / or experiencing. Getting in the
Why is this a problem? habit of “checking in” helps clients notice and name
what is actually going on, even if they don’t change the
Using food as comfort, to feel good, and to stop feeling behavior (at first).
bad isn’t a problem on its own. Almost all of us do it
sometimes. It’s normal and it makes sense. Discomfort deal
The problem happens when: If a client is ready, willing, and able to start changing
• we do it to excess;
• we feel out of control, or compelled to do it;
• we can’t or don’t stop when we’re satisfied; and

FOOD JOURNAL
• we don’t have any other way of creating connection Emotional Eating Journal
or comfort, or managing our feelings.
NAME DATE
Possible strategies Instructions: Capture any urges or behaviors that you notice, especially around eating time.
MEAL TIME WHAT DID YOU EAT? WHAT ARE YOU FEELING, DOING OR THINKING?
Food and feelings journal 7 AM Black coffee

Remember to stay on track with diet today! Doing
intermittent fasting - no breakfast. Stay strong!
Did 45 minutes fasted cardio.
Use a simple food journal or the Emotional Eating Large coffee with cream & sugar Hoping to wait until lunch time.
Journal. Along with asking for food type and amount, 10 AM
Muffin Gave in and ate the muffin at the meeting.
Feeling guilty and ashamed.
ask clients to jot down any thoughts and feelings they 12” Subway sandwich Feeling rushed and anxious. Urge to over-eat is
have at meal time (or times when they are deliberately 12 PM
Diet soda
strong. Got extra-large sub and ate it quickly.
Planning longer workout tonight to make up for it.
skipping meals, purging, and / or compensating with
exercise).
For clients who don’t even want to record their food

intake, simply ask them to record thoughts and feelings
around meal times, without noting what exactly they ate
(or avoided eating).
After gathering data for a few days or a week, look at the

journal together with clients and ask them to identify
any patterns. © 2018 ISSA issaonline.edu
In particular, notice links between specific thoughts /

feelings / situations and behaviors. Find the Emotional Eating Journal in your forms package

their emotional eating behaviors, ask them to start with • using food and eating (or not eating) to manage or
a simple “discomfort deal”: avoid unwanted feelings.
“When you feel the urge to eat emotionally, just Importantly, a single incident of these behaviors (such
take five minutes and sit with that urge. Set a as forgetting a meal once when busy, or having extra
timer if you like. During this time, simply no- helpings at a holiday meal) doesn’t mean that a client has
tice what you are thinking or feeling, whatever disordered eating.
comes up. And notice that you feel uncomfort-
able, but it’s okay. After that five minutes, you Disordered eating is a chronic, systematic pattern of be-
can make any choice that feels right.” havior, thinking, and feeling. (Notice that in many cases,
it dovetails with emotional eating, described above.)
Over time, this will help clients learn to tolerate the
discomfort of not eating to soothe themselves. It will A full discussion of disordered eating is beyond the
also increase their faith in themselves and their ability to scope of this textbook, but be aware of it. Also see Unit
self-regulate. 15 for a more in-depth discussion.
Coming up with alternatives Why might clients struggle with this?

Once you and the client have identified what the client is Fundamentally, disordered eating is usually about con-
actually seeking with the emotional eating (e.g., to calm trol, or the lack of control. Clients have many reasons for
down, to have fun, to connect with others), work with engaging in disordered eating, such as:
the client to come up with a list of alternatives, such as:
• trying to manage or avoid unwanted feelings and
• basic relaxation techniques; sensations (e.g., anxiety, sadness, anger, grief, stress);
• taking a yoga class; • trying to “self-medicate” or cope;
• going for a walk; • trying to distract themselves from other things;
• having a hot shower or bath; • trying to “numb out”, “check out”, and / or dissoci-
• getting a massage; ate; and / or
• journaling; or • trying to either maintain control or enjoy the release

of losing control.
• calling a friend.
Disordered eating is, essentially, a misguided attempt to
Ask clients to choose one or two options and try these
solve a problem.
alternatives when they notice impulses to eat emotional-
ly. If possible, ask them to jot down a few notes on how it
went, or what they noticed about the experience. Why is this a problem?
Disordered eating Disordered eating has a wide range of negative effects on

body, mind, spirit, and relationships.
By definition, most of our nutrition clients are experi- • Physiological consequences can include:
encing disordered eating. Disordered eating includes a
wide range of behaviors, thoughts, and feelings, such as: • GI upset, damage, and slowed motility
• over-eating / binge eating; • oral health problems
• under-eating / restricting food; • electrolyte imbalance; nutrient deficiencies
• a preoccupation with controlling food type and in- • hormonal disruption

take (including an obsession with “healthiness”); • loss of bone density
• compulsions and intense urges; • insomnia and other sleep disorders
• compensation for eating (such as purging or over-ex- • lowered immunity and increased inflammation
ercising); and / or

342 | Unit 12
• Psychological consequences can include: Limiting factor: Exercise and activity

• anxiety, perfectionism, obsessive and compulsive
urges and impulses Not getting enough regular physical
activity
• depression, detachment, dissociation
• alexithymia (being unable to identify and express Why might clients struggle with this?
emotions)
Daily-life movement is declining in industrialized West-
• disordered thoughts, beliefs, and assumptions
ern countries. Thanks to mechanization, labor-saving
• shame, guilt, regret devices, and shifts in where goods are manufactured,
fewer people now move their bodies for a living.
• Social consequences can include:
• isolation from others We’ve moved out of the forests, farms, and factories to
become “professional sitters” parked at desks. We’ve
• withdrawing from normal activities swapped long walks or horseback riding for sitting in
moving vehicles. Most of us no longer run, throw, haul,
Possible strategies carry, climb or dig as part of our daily routine.
Refer out
Why is this a problem?
Important note: As a nutrition coach, you can use some
As humans, we need to move. We evolved to move — as
simple tools and techniques to help your client become
often as possible, in as many ways as possible. When
more aware of disordered eating patterns. However, your
we stop moving, we stop living, repairing, healing,
scope of practice is limited here.
and functioning well. Recent research in neuroscience
Refer out to a qualified health care practitioner, addic- shows that we think and feel through movement, and
tions counsellor, and / or specialist in disordered eating vice versa.
whenever necessary.
Activity changes the way our body processes nutrients.
2 Crazy Questions Movement prepares our body to handle incoming food
properly — for instance, directing nutrients to be stored
We like the 2 Crazy Questions approach to opening a as lean mass instead of fat.
discussion about disordered eating behaviors.
Less movement means:
• What is GOOD about these behaviors, thoughts, and
feelings for you? • poor metabolic health;
• What might be BAD about changing them? • faster aging and physical decline;
• loss of physical function and mobility;

For more on this style of dialogue, see Unit 10.
• poorer brain function (including learning, prob-
Remember that this is a conversation, not a lecture lem-solving, and memory);
from you. Your goal is to understand why your client is
struggling with disordered eating thoughts, feelings, and • poor emotional / psychological health; and
behaviors, rather than to tell them what they “should” be • slower transport of materials around the body.
doing or not doing.
When we don’t move regularly, our energy requirements
Break the chain become so low that the body can get crossed signals, and
it’s tough to get enough nutrients.
If clients are ready, willing, and / or able to start chang-
ing their disordered eating habits, try the Behavior
Awareness Worksheet with them. You can find this in
the forms package.

Possible strategies Help your clients discover the fun of activity, doing
things like:
Daily-life movement
• playing with their kids;
Physical activity doesn’t just mean Olympic athlete-style • taking active holidays (e.g., learning to surf, going
workouts. Household chores, walking, biking, food
hiking, or trying walking tours of new cities); and / or
preparation, taking stairs, carrying items, or volun-
teering outdoors can be a healthy and safe mix of daily • choosing recreational sports as part of their activity
movement. (e.g., Ultimate Frisbee, community softball, indoor
climbing).
Collaborate with your Level 1 client on how they could
add a little more basic movement into their day. See the Over-training and not managing
Ideas for Movement form. training loads
Scheduling and preparing for exercise While some clients don’t move enough, other clients
move too much. These are your recreational or amateur
If you’re a regular exerciser, it’s easy to forget that having
athletes who are devoted to particular sports or activi-
an exercise routine requires skills such as preparation,
ties, or the gym rats who live at the temple of iron.
planning, and scheduling, as well as a commitment to
engage in these activities and make them a priority.
So help your Level 1 clients build an exercise habit by
teaching and practicing the skills they’ll need to do it Exercise feels good, as does mastery of a sport. Many
consistently. Help them learn to prioritize exercise, and people are naturally competitive and driven to succeed.
help other people (such as family members, and spouses) Some folks love the “high” of a tough workout.
know that this is important.
Amateur athletes may also feel pressure from teachers,
Build an “activity team” parents, coaches, and other team members to train hard-
er; improve performance; get leaner, stronger, and / or
While many people thrive on solo activity, most people more muscular; and win at all costs. Many competitive
find it more motivating to have some kind of “activity seasons are long, demanding, and / or intense, often with
relationships” that give them accountability and social short recovery periods or off-seasons.
support. For instance:
Many sports also encourage athletes to ignore pain,
• walking the dog; fatigue, and discomfort. People become dissociated
• walking or running with a friend or neighbor; from their bodies, and simply don’t notice basic signs
of over-training or poor recovery.
• joining a running, hiking, or other activity group;
• doing physical activities as a family; Why is this a problem?

• joining a group fitness class; and
Not balancing training with proper recovery leads to
• joining a community gym. injury and illness. Long-term over-training can have se-
rious physiological and psychological effects that include
Work with your Level 1 client to identify people (and chronic or permanent injuries, hormonal disruptions, and
animals) that can help them add more activity and build persistent mental and physical health problems.
social support at the same time.
Make it fun Possible strategies
Many Level 1 clients think of movement as a chore. It’s Training journal

just one more un-done obligation, staring at them from
Ask your client to keep records of their training (many
their long to-do list.
hardcore exercisers and athletes will already do this).

344 | Unit 12
After a week or two of data collection, review and dis- Limiting factor: Recovery
cuss with your client.
“Recovery” is a broad concept. In general, it refers to
Collaborate with your clients’ coaches, parents, teachers, being able to:
etc. if needed.
• bounce back from stressful and traumatic events
Schedule regular, nutrient-dense meals (whether large or small);
Schedule regular meals that include: • effectively and repeatedly meet physiological and
psychological demands; and
• lean protein
• repair and rebuild after damage to be more robust
• colorful fruits and vegetables
and resilient than before.
• slow-digesting, high-fiber carbohydrates
As a coach, no doubt you want clients to rebound
• healthy fats
physically, mentally, and emotionally from whatever life
Athletes and frequent recreational exercisers should aim throws at them… and get even stronger afterwards.
to eat about every 3-4 hours. Poor recovery generally involves some combination of:
Improve nutrient intake; targeted supplementation • not getting enough sleep;
See the “Limiting factor: Food choices” section, begin- • poor sleep quality;
ning on page 380. • too much sympathetic nervous system “fight /
flight” activation (i.e., spending too much time in the
Incorporate recovery techniques
“amped up” and overstimulated zone);
See the “Limiting factor: Recovery” section. • not enough parasympathetic “rest and digest”
Explore athlete / exerciser mindset activation;
• inadequate nutrient intake to support activity or

Review the techniques from Unit 10 and 11 on under-
manage stress.
standing and communicating with clients.
Recovery and its components, like good sleep, are out-
Explore your athlete / exerciser client’s mindset, beliefs,
comes. You can’t control outcomes. But you can control
and feelings about their training. Look for limiting fac-
behaviors.
tors that you can adjust, change, and / or remove.
For instance: Why might clients struggle with this?

• Why is training important to them? What does it Our industrialized Western culture does not support
mean to them? recovery well.
• What forces are driving them to train hard? • Cycles of light and dark, which support normal sleep,
• What might impede or block them from taking are out of sync with our natural rhythms. Many peo-
enough recovery? (e.g., busy schedule, not knowing ple work shift work.
about recovery, not thinking recovery is important, • We are surrounded by constant stimulation, stressors,
lack of planning) distractions, and demands.
Remember that this is a conversation, not a lecture from • We don’t value sleep, quiet time, silent reflection, or
you. Your goal is to understand why your client is train- simple boredom.
ing hard, rather than to tell them what they “should” be
• We are often socially isolated, struggling to connect
doing or not doing.
meaningfully with others in supportive, affirming
relationships (which humans, as mammals, need for
overall wellbeing).

• Culturally, we promote fast-paced living, doing more, • We’re less able to cope with physiological and psy-
acquiring more, “having it all”, being “busy”, and chological stress.
“chasing the dream” of success. We are always “on
• We don’t perform well athletically, or in daily life.
the treadmill”, running faster and faster.
• We can’t learn, remember, think, or make decisions
• We often judge “weakness” harshly in ourselves and
well. Going 24 hours without sleep is similar to per-
others. Needing rest, care, and recovery is sometimes
forming with a blood alcohol level of 0.10%. (Good
seen as a personal failure or a waste of time.
luck navigating the grocery store and / or gym while
• Work is increasingly precarious and stressful; many “intoxicated” from minimal sleep.)
people work long hours and travel long distances for
• We end up with more chronic illnesses like heart dis-
it. And we must balance paid work with unpaid work
ease, Type 2 diabetes, cancer, and neurodegenerative
such as domestic chores; caregiving for children,
diseases.
people with disabilities, or aging parents.
• We are less able to notice or obey hunger and fullness
• Our food is processed and nutrient-poor. We get plenty
cues. Being tired is also a common trigger for emo-
of calories but are often malnourished.
tional eating.
• Level 1 clients in particular may also not understand
how training stress and life stress interact, and that Possible strategies
they must be balanced with recovery.
Sleep ritual
In addition, many Level 1 clients may be struggling with
physiological factors that actively hinder their rest and Most of us can’t go from 0 to 100 immediately in the
recovery, such as: morning. We need time to wake up and “get the motor
running.”
• sleep apnea or other breathing difficulties (which
increase as body fat and weight increase); The same is true in reverse: Most of us can’t go from 100
to 0 before bed.
• hormonal imbalances;
• perimenopause, menopause, and andropause (male Help Level 1 clients create and gradually incorporate a
menopause); “transition plan”: a sleep ritual.
• pain or discomfort from chronic illness and / or 30-60 minutes before bed, they should find ways to wind
injuries; down, activate the parasympathetic nervous system, and
tell the body it’s time to relax.
• medication use;
• insomnia related to anxiety or other mental health You may also have to help your Level 1 clients lower
issues; and / or
their caffeine and stimulant intake gradually, especially
within 8-9 hours of bedtime.
• poor immune function and / or inflammation.
Sleep or recovery journal
Have clients track a baseline of recovery behaviors and
We need proper recovery to survive and thrive. which ones seem most helpful.
If demands outweigh our ability to compensate, we Or, have them track their sleep (if they want, using an
begin to break down. app) to gather data and track progress.
Sleep is a master regulator of metabolism and brain For more ideas, see the Sleep and Recovery Form.
function. If we don’t get it, our body and mind suffers.
• We age faster, become sicker, and feel crappy.

346 | Unit 12
FOOD JOURNAL
Sleep and Recovery Ideas C
How Food Feels Journal
NAME DATE NAME DATE
Instructions: Capture any physical sensations that you notice throughout the day, especially after eating.
How to explain this to your clients

MEAL TIME WHAT DID YOU EAT? ANY PHYSICAL SENSATIONS? IF SO, WHAT?
Here’s a sample script you can use when discussing this with your clients:
“Based on the assessments we did, it appears that you are having some trouble with sleep.
Most of us can’t go from 0 to 100 immediately in the morning. We need time to wake up and “get the motor running”. Whole wheat bagel and cream cheese Noticed stuffy nose and headache about half
8 AM hour later. Stomach a bit rumbly.
The same is true in reverse: Most of us can’t go from 100 to 0 before bed. Glass of milk
Developing a “transition plan” or “sleep ritual” can really help.
30-60 minutes before bed, you can find ways to wind down, activate the parasympathetic nervous system, and tell the body it’s
time to relax.
If you are interested, I have some ideas that I can share with you now.”
Bowl of vegetable soup Ate until just satisfied. Feeling good, not over-
12 PM stuffed.
Medium-sized bowl of bean salad with tuna
Sleep hygiene best practices
1. Keep a regular schedule — our bodies like regularity. Try to go to bed and wake up at the same times. With
Large coffee Low energy; hoping coffee would pick me up. Now
a regular schedule, your body will know when to release calming hormones before bed, and stimulating
3 PM I have a headache.
hormones to wake up. Muffin
2. Keep alcohol and caffeine moderate — both will interfere with sleep. Try to avoid caffeine within 8-9 hours of
your bedtime.
3. Eat and drink appropriately — a regular to smallish-sized meal about 2-3 hours before bed, one that is balanced
in nutrients, can help facilitate sleep. Try not to drink too much liquid in the hours before bed, which will help
you avoid waking up for bathroom breaks.
4. Do a brain dump — take a few minutes to write out a list of whatever is bugging you. Whatever is in your brain,
get it out and on to paper.
5. Turn off electronics — digital devices stimulate our brain. We recommend unplugging from all screens at least
30 minutes before bed. This includes television, computers, and smartphones. The screens release a blue light
that prevents our brain from preparing for sleep.
6. Stretch / read / de-stress before bed — maybe some yoga poses, reading, or meditation.
7. Go to bed before midnight — this is better aligned with natural light cycles.
8. Sleep at least seven hours — work backwards here. If you need to wake up at 6 AM, 11 PM will be the latest you
want to hit the pillow.
9. Exercise regularly — physical movement (especially outdoors) can promote restful sleep at night.
10. Take a bath or shower — a warm bath with epsom salts or even a cool shower (depending on personal
preference) can promote restful sleep.
Find Sleep and Recovery and How Food Feels worksheets in your forms package
Nutrient-dense eating; supplementation Limiting factor: Food and cooking

Improving Level 1 clients’ food quality and nutrient skills
intake will help boost overall recovery. See the strategies
from the “Limiting factor: Food choices” section. Many Level 1 clients:
• don’t have basic food preparation skills (or confidence
Food intolerance journal
in the kitchen); and / or
More advanced Level 1 clients can track symptoms of • don’t have basic shopping and food awareness skills
food intolerance and inflammation that may be connect- (e.g., reading labels).
ed to what they eat. Try the How Food Feels Journal.
You can find this in the forms package.
Over time, relationships between foods and symptoms
In previous generations, food preparation skills were
of poor recovery may become clear; you may be able to
essential parts of home, school, religious, and military
improve clients’ overall recovery by simply removing a
education. Knowing how to correctly prepare, store, and
few offending foods.
use food could literally be a life or death issue — getting

sick from spoiled food, or running out of food before Clients with limited incomes may worry that “healthy
fresh food was available, was an ever-present concern. food” is expensive. If they don’t know how to stretch a
food budget, or know that whole foods can be affordable,
Modern transportation, refrigeration and food processing nutritious and delicious, they’ll choose cheaper pro-
means that we don’t ever have to learn to cook. Cooking cessed foods.
has been eliminated from many school curriculums.
Grocery stores are designed to entice us to buy conve- Possible strategies

nience foods. Food labels can be confusing and unhelp-
Grocery store visit
ful, and vary from region to region. Clients often aren’t
sure how to make informed decisions. Go to a grocery store with your client. Walk them
through some basic label reading and food choices. Show
Why is this a problem? them how to create a menu and shop from a list.
It’s tough to eat nutritious foods when there are no nutri- Cheap, nutritious tasty food
tious foods around. Or when they are unprepared and
packed into the back of the fridge / freezer / pantry. As part of the grocery store visit or shopping list cre-
ation, educate your client about cheaper healthy options,
Practicing basic food preparation is essential to nu- such as:
trition success. And we aren’t talking high-level chef
• cheaper cuts of meat / poultry that are ideal for stew-
skills, rather, just having a working knowledge of how to
ing or braising in a slow cooker
assemble some meals.
• buying vegetables and fruits in season
Food and cooking skills improve choices, opportunities,
and confidence. • buying and cooking in bulk (e.g., whole grains, dried
beans / lentils, whole chickens rather than chicken
When clients can’t cook or prepare food, they’ll rely breasts)
on convenient and processed foods. They’ll often feel
anxious and inept in the kitchen, and avoid trying new Help them come up with and then choose options for a
recipes. food budget.
When clients can’t shop or read labels effectively, they’ll Go-to meals
be misled by food manufacturers and make poor choic-
es. Their grocery shopping will be unorganized and Working with your client, come up with a list of 3-5 sim-
impulsive. ple meals that your client can either make, or is willing
to try making. Good beginner options include:
Most importantly, clients without skills will not be able • salads with pre-prepped protein (such as canned
to do their assigned tasks. In order to eat more protein, or tuna and / or canned beans)
plan meals in advance, or try new colorful vegetables, they
have to know: • stir-fries
• what those things are; • simple stews, such as chili
• where to find them; • boiled or scrambled eggs
• how to choose them; • beans / lentils with seasoning
• how to prepare them; and • fruit and cottage cheese
• how to make them taste good. • Super Shakes
Clients who are looking to gain weight / muscle, or fuel Ask your client to practice making their 3-5 “go-to
athletic performance, have to eat more. If they can’t meals” until they feel confident enough to try a new
choose and prepare food well, this will be tough. meal that builds on the theme (e.g., adding new vegeta-
bles to the stir-fry)

348 | Unit 12
Start with a “core” of meals and build outwards from Problem is, following external rules almost inevitably
there. leads to over-eating. Because once a client deviates from
diet rules (as everyone eventually does), they’ll have
Cooking education nothing left to guide them. They end up seeing food as
something to get while they can, before the next diet
Have some handy resources on food prep, cooking, and
starts. It’s all or none.
shopping handy, either as handouts or as videos.

Limiting factor: Mindset, psychology,
All-or-nothing thinking is part of the root of diet cycles.
and life skills
“Dieting” clients swing between rigid control or diligent
Most often, we are not limited by our actual circum-
restriction and uncontrolled release. They are either “on
stances. Rather, we are limited by our assumptions;
the wagon” or “off the wagon.”
beliefs; thoughts; and the stories we tell ourselves. We
may also be limited by not having important life skills, In between is the “f*** it moment”, known formally as
such as communication. “disinhibition.”
While addressing clients’ mindset, psychology, and life Consistency is perhaps the most important factor in suc-
skills is outside your scope of practice, you can still work cess. All-or-nothing clients typically can’t be consistent.
with these areas a bit, using a general approach. Instead they are either “on” or “off.” (Usually “off.”)
Mindset and psychology issues When they “fall off the wagon”, this confirms the “I’m a
failure” mindset. Clients become frustrated, demotivat-
Issues here can include (but aren’t limited to): ed, and even more convinced that they cannot succeed.
• all-or-nothing thinking (e.g., yo-yo dieting, re- Or that they are somehow different and broken.
Consistency doesn’t mean perfection. Help clients deter-
/ night-time over-eating, “Either I’m perfect or I’ve
mine a level of consistency they feel they can comfort-
failed” mentality)
ably achieve. Progress, regress, or maintain as needed.
• fixed mindset (I’m broken; I don’t have what it takes;
I’m a failure, etc.) Possible strategies
• not being consistent
Sensing in to body cues
• busy-ness and stress; overwhelming life demands;
feeling rushed and pressured
Level 1 clients may feel they need rigid “rules” because
they can’t trust their own bodies. See the “Limiting
factor: Eating behaviors” section for ideas on teaching
Why might clients struggle with this? appetite awareness.
There are many reasons a client may have an unproduc- The continuum / “Just a little bit better”
tive mindset, most of which are beyond the focus of this
unit. Work with clients to identify how choices are on a con-
tinuum from better to worse.
However, many of these factors are simply part of life
(i.e., busy-ness, feeling rushed) while others often come Ask clients:
from chronic dieting.
“In situation X, what might be a slightly better
When someone doesn’t trust themselves, they will look choice? Why?
for rules and regulations to follow. This is the basis of
diets. Most people don’t have a basic idea of what reason- What might be a slightly worse choice? Why?
able eating looks like. So, they find some doctrine to live What choice do you feel able to make right
by. now? Why?”

• Are they looking to socialize and have fun? How can

they still have fun without going overboard? How
All-or-None Worksheet C
can they connect with other people in more healthy
ways?
• Are they feeling a void without the distraction of

NAME DATE
work or weekday obligations? What other meaningful

How to explain this form to your clients
Here’s a sample script you can use when discussing this with your clients.
“Sometimes it can be tough to consider the big picture when it comes to nutrition. We have so many things we are trying to
juggle. It can often feel like we do the ‘healthy thing’ or do ‘nothing’.
We start to feel like healthy nutrition is taking away from something else we value, like social time or hobbies. We think to
activities can they do? (e.g., hobbies, volunteering)
ourselves, ‘I can eat a healthy meal OR go out with friends to dinner.’
Instead, we can find ways to integrate the two. We can avoid ALL or NONE, and embrace the middle ground.”
Life skills
Consider the following continuum and how it relates to your current situation/decision.
ABSOLUTE WORST CHOICE ABSOLUTE BEST CHOICE Like “recovery”, the category of “life skills” covers a wide
1 2 3 4 5 6 7 8 9 10
range of things. Here are some common skills that many
First, what would you say is:
The absolute WORST choice?
Level 1 clients lack:
The absolute BEST choice? • being able to ask for what they want and need;
Now, think about the choice you’ve made. Think about where it fits on the continuum and write it in.
• being able to define clear boundaries with others
(e.g., people pushing food; other household mem-
bers sabotaging or criticizing);
Finally, what would be a slightly better choice? Where would it rank on the continuum?
• making informed, thoughtful, evidence-based

What would be a slightly worse choice? Where would it rank on the continuum?
choices;
• strategic, long-term thinking;

• time management and scheduling;
• planning and prioritization; and /or

Find All-or-None in your forms package
• self-care

Like hunger and fullness cues, we don’t learn a lot of
Help clients identify what “slightly better” may be for them
these life skills anywhere.
in each situation. Encourage them to focus on moving one
small “notch” along the continuum, rather than trying to Plus, the world is full of people and things that are happy
do it all perfectly. to distract us, grab our attention, pressure us, and push
us to follow their agenda.
Check out the All-or-None Form for how to approach
this with clients. People who have been socialized to be “pleasers”, “help-
ers”, and / or “caregivers” may find it hard to take time
Weekend and night-time over-eating journal
for themselves, or identify and advocate for their own
Explore with clients what happens when they over-eat at needs — especially if they become parents or other types
night or on weekends. of caregivers.
Use the Behavior Awareness Worksheet (in forms pack- Why is this a problem?
age) to surface underlying patterns and the possible root
of the behaviors. For instance: Clients without life skills often:
• Are they bored? What other options for stimulation • act impulsively;
and creativity do they have?
• make poor decisions;
• Are they frustrated or stressed? What options do they
• can’t advocate for themselves and / or communicate
have for stress management?
their needs effectively;

350 | Unit 12
• don’t prioritize health, good nutrition, and / or regu- • If your client is used to strict dietary rules, ask them to
lar activity; try a day of mindful eating and “going with the flow.”
• sacrifice their wants and needs for others, to their • If your client is used to self-criticism, ask them to take
own detriment; a day (or an hour) for self-care and self-compassion.
• have poor boundaries (other people run their lives Destination postcard
and / or criticize them); and then feel resentful of
others as a result; This is both a fun exercise and a valuable way to re-route
negative thinking.
• feel out of control and / or like they “can’t get it
together”; Many of our clients know what they don’t want. Fewer
• are reactive rather than proactive, constantly “fight-
know what they do want.
ing fires”; and / or “Don’t-want” is not an action plan. So help
• can’t stick to a program consistently. your clients clearly imagine, identify, and work
towards what they do want. Start a discussion
Practice planning, prioritization, and preparation by asking this question:
Help your client practice basic planning, prioritization, “Let’s imagine the future. Maybe it’s X months
and preparation techniques, such as: / years from now. And let’s imagine that you’ve
• using a calendar and automated reminders to book
met all your goals and gotten everything you
want. Let’s not worry about being ‘realistic’
workouts, schedule grocery shopping, etc.
right now.
• looking ahead to their upcoming week and anticipat-
ing obstacles and setbacks “What, specifically does that future look like?
If you could send a ‘postcard from your future
• deciding in advance what their daily or weekly pri- self’ back in time to yourself now, what might
orities will be, and making sure good nutrition and that postcard say?”
healthy behaviors are on that list
Once your client has come up with a response, use that
Opposite day vision of the future to start building an action plan. For
instance, if the client wants to take a tropical beach va-
Often, clients with poor life skills are entrenched in cation, start framing your exercise program as “building
routines and habitual response patterns that actively fitness for surfing, sailing and swimming.” Also encour-
work against them. Rather than trying to fix all of these, age them to collect images or other meaningful objects
encourage your clients to simply play a game: Try an that remind them of the future they want (e.g., a picture
Opposite Day. of a turquoise ocean, a little fish).
For instance: As much as possible, remind clients of how specifically
• If your client is used to making snap judgments, work they are working towards the future they want.
with them to make one informed, evidence-based
decision. Limiting factor: Environment
• If your client is used to jumping from program to
Our environment can include:
program, ask them to commit to your program for a
certain number of weeks. Follow up with them often • the physical space around us, such as our home and
to ensure accountability. workplace, as well as outdoor environments;
• our relationships and the people we interact with

regularly; and
• our culture and society.

Why might clients struggle with this? at our lousy boss, we’ll often come home ready to quit
being a grownup. If we have to exert more willpower at
Environments can be limiting factors when: home because our kitchen is full of poor food choices,
• we need too much active “willpower” and mental and people around us are getting takeout pizza again...
strength to stay on track;
we’ll often just give up.
• our physical environment is stressful and over-stimu- We can either beat ourselves up each day for being a
lating, and / or discourages regular physical activity; willpower weakling... or just create an environment that
doesn’t require so much willpower.
• people in our social networks (family, friends, co-
workers, etc.) are unsupportive (or worse, actively
Possible strategies
sabotaging); and / or
• our cultural group and broader society around us Habit triggers / Habit pairing
doesn’t support healthy choices (for instance, if our
Automatic behaviors are usually triggered. For instance,
workplace culture enforces long hours; if our ethnic starting your favorite TV show may be a trigger to put
group views a lean and muscular body as unat- some popcorn in the microwave.
tractive or exercise as a waste of time; if our social
norms involve food cues everywhere, all the time, The good news is that we can use triggers to jump-start
etc.). healthy habits too.
Clients can either:

• decide on a cue they’ll use as a reminder to do their
We make thousands of decisions every day, most of them new healthy habit (e.g., when my phone alarm goes
relatively unconscious and automatic. These decisions are off, I’ll stand up and stretch); or
powerfully influenced by what’s around us, whether we
• put two habits together — an old habit and a new
realize it or not.
one (e.g., I’ll stretch while I brush my teeth; I’ll keep
If our physical and social environment supports our my workout shoes right next to where my car keys
choices, we’ll find it easier to make those choices. usually go, so I’ll be reminded to take them with me).
If our physical and social environment doesn’t support Other ways to “shape the path”
our choices, we’ll struggle and find ourselves frustrated,
demoralized, and unsure why we can’t “stay on track.” See other suggestions from the “Limiting factor: Food
choices” section on “Shaping the path.”
Even the most “motivated”, determined, and driven per-
son can’t white-knuckle all their choices forever if their Also see “Build an ‘activity team’”, earlier in the unit.
environment acts against them. Encourage clients to make new social connections and
“fit friends.”
While clients can practice strengthening their “willpower
muscle”, it can still eventually fatigue. Ask clients what small environmental changes they
could make to make things easier for themselves to
If we make hundreds of decisions all day at work and our remember and do habits consistently.
willpower tank drains because we’re trying not to yell

352 | Unit 12
Coaching: A game the whole family can play
Unless your client is an anti-social orphan and only child who lives alone on an is-
land, chances are good they’ll have to negotiate some choices with other people.
Help clients have that discussion with a simple checklist for communication.
*******
Set up the discussion so other people are on your team. It’s not you
versus family and friends; it’s you along with loved ones together against The
Problem.
“I’d really like your support. Can you help me ______?”
“You’re really good at coming up with solutions for things. Can you help me
figure out how to ______?”
Explain what you’re trying to do, and why.
“I’m trying to take better care of my health. I was really scared when I got that
warning from my doctor, and I’ve realized that I need to change some habits.”
State clearly what you would like help with, and how.
“What would help me most is ______.”
Negotiate a compromise if needed.
“I don’t want you to have to give up / change ______, because I know you
enjoy it. Is there a way you can still have / do it, but I can still stay on track with
my own choices?”
*******
If necessary, help your client practice going through this checklist, and role
playing sample dialogues.
This may be the first time your Level 1 clients have asked other people for assis-
tance and support. Help your clients prepare for this big event.
And recognize that for some people, it takes a lot of courage to do this. They
might be going up against years of avoidance, the expectations of others, or
entrenched behavior patterns.
Call out and reward their bravery as an important marker of progress.

Troubleshooting Level 1
Setbacks, obstacles, lapses, and sticking points are inevi- measure “progress” still matters to them. For example,
table with Level 1 clients. Anticipate these as best you can, do they still want to:
but treat them all as part of the natural process of change.
• get stronger, as measured by lift X?
Be compassionate and generous with them and yourself. • run faster, as measured by run time X?
It doesn’t mean you’ve failed as a coach or they’ve failed
as a client. • lose weight, as measured by the scale?
• lose body fat, as measured by skinfolds?

Sure, they’re not very good at the new skill you just
gave them. At least not yet. You were probably a lousy • have fewer over-eating episodes, as measured by
walker when you were nine months old. They’re learn- their food journal?
ing, growing, and developing.
If so: Identify where the expected outcome is different
What do you do when a baby falls down while learning than the measured outcome. Identify whether the mea-
to walk? You pick them back up, comfort them if they’re sured outcome is different than the baseline.
upset, and help them get re-started. Same with clients.
If not: Discuss changing the progress metrics and any
Sometimes it’s just a matter of taking things in a new direc- new goals that may have emerged.
tion or giving things a new perspective.
Are you focusing mostly on behaviors?
Here’s how to troubleshoot with Level 1 clients.
While outcomes are important, they’re mostly out of
your and your clients’ control. Most of your attention
Look for what is already working should focus on tracking behaviors and consistency.
In all this discussion of limiting factors, it’s tempting to When troubleshooting, include a review of key behav-
make coaching about looking for and “fixing” problems. iors, such as:
Instead, we encourage you to look for “bright spots” — • eating the right types of foods in the right amounts;
to seek out:
• prioritizing rest and recovery; or
• what is already working;
• eating slowly and mindfully (for clients looking to
• where “the problem” (e.g., over-eating, lack of exer- lose weight).
cise) does not happen;
If consistency with assigned coaching tasks is less than
• what your client can already do confidently and well; 80%, discuss how to make the task easier and / or more
and do-able.
• what interests, excites, and engages your client.
Also ensure that the client is focusing on important,
essential behaviors that really matter, rather than
Review progress indicators and “majoring in the minor.” Meeting protein needs is more
important than eating local or nutrient timing. First
outcomes things first.
Are progress metrics still meaningful?
Are expectations reasonable?
Check with your client that the way they want to
Sometimes, there’s nothing wrong with the process at
all. The problem lies with what clients expect.

354 | Unit 12
Look for what is

Did that fix Great, you’re
already working. Could Y Do it. Y
the problem? done for now.
you do more of that?
N
Not sure N
Are progress Identify where the expected outcome is

Review progress
3 metrics still Y different than the measured outcome.
indicators and
meaningful? Identify whether the measured outcome is
outcomes
Assess and find out different than the baseline.
Look for:
• What is already working; 2 1 N
• Where ‘the problem’ Discuss changing the progress metrics and
(e.g., over-eating, any new goals that may have emerged.
lack of exercise) does
not happen; Are expectations
• What your client can reasonable?
already do confidently If consistency is less than 80%,
and well; what engages Are you focusing discuss how to make the task easier
Y N
them. mostly on Y and/or more do-able.
behaviors? Ensure that the client is focusing
on important, essential behaviours that
really matter.
N
Awesome. That’s
rare and special. Why not?
Celebrate! Review inputs
and outputs
N
Make expectations reasonable if Does task Do outcomes

possible. Help clients understand N difficulty match match behaviors?
what is involved for a given outcome. expected result?
Y Y
Could something be refined

or improved? Review the quality of the process.
Improve what needs Could routines be streamlined

Y or made more effective?
to be improved.
Could the client be doing
a task more skillfully?
Could the client be doing
Are you absolutely, a task more consistently?
N
positively, 100% sure? Could you calibrate the client’s
performance objectively, rather
Yes! I have investigated
than relying on self-reporting?
every possible avenue!
Okay, fine. Reframe plateau

as a period of consolidation.
Well...
Wait a week or two and see
what happens.
Figure 12.4 Level 1 client troubleshooting

Level 1 clients often have inappropriate and unreason- Does task difficulty match the expected
able expectations. They expect things to move faster, result?
changes to be more significant, and transformations to
be more dramatic. For instance: Clients who are starting with very simple changes (such
as switching to diet soda, or walking 20 minutes a day)
• Clients who lose a lot of body fat are often shocked to
may wonder why body fat is not falling off them.
discover that they are left with some excess loose skin
(especially if they’ve been quite over-fat for a long Clients who are training 2-3 times a week may wonder
time). why they don’t look like Arnold Schwarzenegger yet.
• Women who’ve been pregnant find out the same Help clients understand the relationship between task
thing, as well as the fact that their abs may now difficulty and results.
“pooch” outwards.
Small changes can add up to big results… but it takes
• Older clients realize they can’t eat like they did in
time, and tasks need to progress.
college, and their formerly hourglass or V-tapered body
is looking more like a beer keg as visceral fat collects Do outcomes match stated behaviors?
around their midsection.
Even if you think your clients are eating well enough, if
Most Level 1 clients don’t become the immaculately bul- they don’t have the results to show for it, then their food
letproof cover models they imagined. And certainly not intake isn’t what it needs to be. Even if your clients swear
in the few weeks or months they had hoped for. that their food amounts, selections, and reasons for
eating are perfect, if their body isn’t getting better, they
Level 1 clients often don’t realize that in the course of need some nutritional adjustments.
nutrition coaching, they don’t become radically dif-
ferent people. They stay themselves… and hopefully Only results tell you whether a client is truly doing what
become a healthier, fitter, and more energetic version of they say they’re doing.
themselves.
They also don’t realize how much work it takes to get Working with plateaus
extremely fit.
Plateaus, like setbacks, are inevitable. Bodies like ho-
So, as the coach, you may have to remind clients what meostasis and will always look to “settle” somewhere.
outcomes are reasonable. Eventually, all clients will get to a point when what
they’re doing is not enough to further change things.
This includes:
Luckily, with Level 1 clients, there are so many limiting
• the type of changes they can likely expect;
factors that you can almost always make some simple
• how quickly or slowly these changes might happen; improvements and adjustments.
• how much time, energy, and focus they must invest Review the list of limiting factors and pick the most
to get the results they seek; obvious to work on.
• how consistently they must adhere to the assigned
(Hint: It’s often food amount and quality.)
coaching tasks to see progress;
• whether the results they seek are even possible given

the “raw material” your clients are working with
(such as their age, sex, ethnicity, health history and
status, or natural body fat distribution).

356 | Unit 12
UNHEALTHY
Athletes at this level of body fat Do more

Almost none. Eat processed foods.
Eat big portions.
Benefits
Eat quickly.
Easy fallback for some folks.
Does not require much thought or work. Do less
Exercise of any kind.
Tradeoffs
Eat fewer whole foods.
Poor health.
Sleep less.
Low energy levels.
Poorer life expectancy.
Risks of metabolic syndrome.
>20% >30%
May need medications to manage various conditions.
HEALTHY Very EASY Transition

College-aged athletes. Eat slowly until satisfied at 60% of meals.
Off-season elite bodybuilders. Include 1-2 palms of protein-dense foods in 1-2
meals per day.
Olympic shot putters.
Include 1-2 fists of vegetables in 1-2 meals per
Benefits day.
Improved health and energy. Exercise 3-5 times per week, any activity you
Improved sleep. enjoy, any intensity level.
Exercise is easy and enjoyable.

Do less
Tradeoffs Eat fewer desserts and processed foods.
Requires some thought and planning. Drink fewer caloric beverages.
15-20% 25-30%
You’ll look good but not super lean.
HEALTHY EASY Transition

Olympic canoe and kayak athletes. Eat slowly until satisfied at 75% of meals.
Professional baseball players. Include 1-2 palms of protein-dense foods in 2-3
meals per day.
Professional softball players.
Include 1-2 fists of vegetables in 2-3 meals per
Benefits day.
Fairly easy to maintain. Exercise 30-45 minutes daily, with 1-2 sessions
Energy levels will continue to improve. breaking a sweat
Will probably be able to reduce or eliminate many medications. Sleep at least 7 hours per night.
Trade-offs Do less
Requires some planning and may require minor social sacrifices, Eat desserts / processed foods 3-5 times per week,
13-15% 23-25%
e.g., exercising instead of hanging out with friends at a bar. within reason.
May require effort and attention to maintain this much sleep. Drink up to 3-5 caloric beverages per week.
May require some increased food prep skills and effort.
HEALTHY MEDIUM Transition
Athletes
Figure 12.5 What’s required at this
for different levelofof
levels body fat
leanness Do more
Olympic swimmers. Eat slowly until satisfied at 90% of meals.
Professional hockey players. Include 1-2 palms of protein-dense foods in each meal.
Olympic volleyball players. Include 1-2 fists of vegetables in each meal.
Include 1-2 thumbs of healthy fats and 1-2 cupped
Benefits
handfuls of quality carbs at most meals.
Fit appearance and good overall health.
Exercise 45-60 minutes daily, with 3-4 sessions
Fewer food cravings due to balanced diet and exercise regime. breaking a sweat.
Trade-offs Do less
Requires some planning and may require minor social sacrifices, Eat desserts / processed foods 3-5 times per week,
13-15% 23-25%
e.g., exercising instead of hanging out with friends at a bar. within reason.
May require effort and attention to maintain this much sleep. Drink up to 3-5 caloric beverages
Working withperLevel
week. 1 Clients | 357
May require some increased food prep skills and effort.
HEALTHY MEDIUM Transition

Olympic swimmers. Eat slowly until satisfied at 90% of meals.
Professional hockey players. Include 1-2 palms of protein-dense foods in each meal.
Olympic volleyball players. Include 1-2 fists of vegetables in each meal.
Include 1-2 thumbs of healthy fats and 1-2 cupped
Benefits
handfuls of quality carbs at most meals.
Fit appearance and good overall health.
Exercise 45-60 minutes daily, with 3-4 sessions
Fewer food cravings due to balanced diet and exercise regime. breaking a sweat.
Relatively easy to maintain once practices become habitual. Sleep at least 7-8 hours per night.
Trade-offs Do less
Requires more planning and greater overall attention to diet. Eat desserts / processed foods 1-2 times per week,
10-12% 20-22%
Requires a greater time commitment for the more consistent within reason.
exercise regime. Drink up to 1-2 caloric beverages per week.
May need assistance or coaching to achieve this amount of
consistency.
HEALTHY HARD Transition

Olympic-level boxers and wrestlers. Eat slowly until satisfied at 95% of meals.
Olympic sprinters (100-400 meters). Include 1-2 palms of protein-dense foods in each meal.
Olympic-level gymnasts. Include 1-2 fists of fibrous vegetables in each meal.
Include 1-2 thumbs of essential fats in each meal.
Benefits
Exercise 60-75 minutes daily, with 4-5 sessions breaking
Will probably look extremely lean; will have that six-pack.
a sweat.
Overall health will probably be good due to carefully balanced
Sleep at least 8 hours per night.
and minimally processed diet.
Will likely have high work capacity and good stamina.
Do less
Trade-offs Limit carbs to post-workout or designated higher-carb
days.
6-9% 16-19% May struggle in social situations, especially those involving
food. Eat desserts / processed foods once every 1-2 weeks,
within reason.
May not have time for social opportunities outside of exercise.
Drink a caloric beverage once every 1-2 weeks.
May have to give up other hobbies and interests outside fitness.
UNHEALTHY Very HARD Transition

Elite bodybuilders on contest day. Eat slowly until satisfied or even a little bit hungry
Fitness models on the day of the photoshoot. at 99.9% of meals.
Incorporate calorie / carb cycling.
Benefits
Follow meal plan with predetermined foods and
May feel pride at achieving an athletic goal. amounts, and measure food specifically.
Include exact amount of lean proteins, fibrous veggies,
Trade-offs
and healthy fats in each meal.
Will have difficulty socializing in most typical situations
Exercise 45-75 minutes, twice daily, with 6-7 sessions
where food is involved.
breaking a sweat.
May miss out on fun events with family and friends.
Sleep at least 8-9 hours per night.
Big time commitment to measure, weigh, and track all
<6% <16% foods. Do less
Hyper focus on diet and exercise may contribute to Limit carbs to post-workout or designated higher-carb
disordered eating. days.
Time required for exercise may crowd out all other pursuits Eat desserts / processed foods once every 10-12 weeks.
and interests.
Avoid caloric beverages.

358 | Unit 12
Focus on the quality of the process eventually physical improvements have to level off. And
eventually, they’ll level off for good.
Plateaus are a good time to revisit consistency and be-
havior quality. Help clients reframe the concept of a plateau away from
“failure” or “being stuck” to:
• Could something be refined or improved?
• an opportunity to refine their practice;
• Could routines be streamlined or made more
effective? • an opportunity to get better at existing skills;
• Could the client be doing a task more skillfully? • an opportunity to try new tasks and learn new skills;
• Could the client be doing a task more consistently? • an opportunity to take the pressure off for a little
while;
• Could you calibrate the client’s performance objec-
tively, rather than relying on self-reporting? (In other • an opportunity to be grateful for results when they
words, what does the client’s “80% full” or “working do start happening; and / or
out really hard” actually look like?) • an opportunity to experiment with a “new normal.”
Reframe plateaus Wow. Plenty of opportunities there!

While change is inevitable in human experience, You can even ask the client, “What does this time give
you the chance to do, that maybe you wouldn’t have oth-
erwise had?” See how they choose to reframe things.
Case study
Let’s look at how this entire six-step coaching process ing TV, mainly because he is bored and / or anxious
might look in action. about the next day, and it is an ingrained habit.
Someone emails you expressing interest in nutrition After this, he often notices he is very “full” before bed.
coaching. You invite them in to meet and go over the (This may explain why he’s rarely hungry in the morn-
Initial Assessment & Triage Questionnaire. ing.) He doesn’t sleep very well, partly because he’s
noticed some issues with breathing, and also because
You find out his name is Roy. He’s 35 years old, 220 lb,
his stomach is uncomfortably stuffed.
and 5´9˝.
He’s not much of a cook. Traditionally, the women in his
His family is originally from Mexico and Guatemala; his
family were the caregivers and food preparers.
ethnicity is partially Hispanic and partially indigenous
Mayan. (He’s just gotten back from a trip to the Yucatán Since his divorce, eating’s been a bit of an afterthought.
to see his abuela (grandmother). He shows you the (Abuela was shocked at this state of affairs, and immedi-
photos on his iPhone.) ately stuffed him with a four-course traditional Guate-
malan feast.)
He wants to feel better, have more energy during the
day, sleep better at night, and look better. Plus, with the stress of the divorce, his already crummy
sleep has gotten worse.
Here’s his daily menu right now.
So he’s been living mostly on convenience foods: white
• Breakfast: He skips it. He says he’s not hungry in
bread, deli meat, processed cheese, breakfast cereal,
the morning. He drinks a sweetened coffee drink
and snack foods like chips and sweets.
on the way to work.
He can only identify extreme variations in appetite (i.e.,
• Lunch: Eaten at his computer. Usually takeout.
being either very full or very hungry).
• Dinner: Eaten while watching TV. Usually a frozen
With his sedentary job as an IT technician, he rarely gets
meal, likely a “diet dinner.”
any physical activity.
He snacks in the afternoon while at work (candy in the
He often resolves to start a diet every January, but this
break room). And he snacks after dinner while watch-
ends after a couple of weeks.

As you can see, he fits most of the criteria for a Level 1 • has an environment that requires too much
client: willpower (including an unsupportive social
network)
• lacks sleep and recovery
• isn’t consistent
• doesn’t engage in regular physical activity
You are able to learn all of this about Roy during the as-
• eats too fast and while multitasking sessment, along with the fact that the Yucatán is lovely
• doesn’t have appetite awareness and you should probably drop in on Abuela yourself
for a great stick-to-your-ribs Guatemalan meal.
• misses meals (and then eat meals that are too
large) and / or doesn’t eat satisfying meals Roy is able to identify many of the areas that are “bad
nutrition.” And he has a basic grasp on what foods
• over-eats highly processed foods might be better for him to eat.
• under-eats nutritious whole foods With all of these potential areas to modify, how would
• doesn’t have basic food preparation skills you approach your next steps with Roy?
• drinks sugar-sweetened beverages (and doesn’t Some areas to consider:

drink enough water) • What would you start with first? Why?
• uses food to manage feelings • Would you use any forms of body composition
• has all-or-none thinking (this includes yo-yo measures?
dieting, weekend over-eating, and night-time • After you come up with a plan, how would you
over-eating) determine if it’s the right plan?
Summary
Remember the six basic steps to coaching: • Life skills
Step 1: Assess and gather data; identify client goals. • Mindset / psychology
Step 2: Understand the client and “build the story.” • Environment
Step 3: Create an action plan and possible “next steps.” Most clients are Level 1 clients. All they will need are
Step 4: Choose one next action step and test it. small, relatively simple changes.
Step 5: Observe and monitor what happens. Addressing the Level 1 limiting factors will ensure that
the client builds a strong nutritional foundation.
Level 1 clients tend to have similar limiting factors. The Until a Level 1 client is consistently addressing all of
clients themselves can often identify these when going the most common limiting factors, don’t use any more
through the Initial Assessment & Triage Questionnaire. advanced Level 2 approaches.
Limiting factors fall into several categories: When implementing Level 1 solutions, keep things sim-
ple. Focus on one small, do-able, and helpful behavior
• Food choices change at a time. Check that the client is ready, willing,
• Eating behaviors and able to do each one.
• Exercise and activity Use outcome based decision making.

• Recovery Set realistic expectations and help Level 1 clients under-
• Food and cooking skills stand the trade-offs involved.

UNIT 13

Unit Outline
1. Level 2: An introduction 4. Case study
2. Level 2 strategies 5. Summary
3. Troubleshooting Level 2
Objectives
Level 2 clients are those who have mastered Level 1 strat- nutrition, moderate carb and calorie cycling, meal frequen-
egies, have progressed as far as they can, need a bit more cy adjustments, simple forms of intermittent fasting, food
individualization, and are emotionally mature enough to log troubleshooting, workout nutrition adjustments, and
try more advanced strategies. competition day nutrition.
In this unit, you’ll learn about how to work with these You’ll also learn about some more advanced methods of
clients and use these strategies, which include body type supplementation.
Level 2: An introduction
Here’s a quick review of the criteria for defining nutri- Even clients who can progress to Level 2 or 3
tional level: may only be there briefly.
• Goals: What clients want to do.
For most people, living permanently at Level 2 or 3 is im-
• Knowledge: What clients know. possible… and even if it’s possible, it’s often a bad idea.
• Competence and skill: What clients can do. Trying to live at Level 2 or 3 — which, again, most peo-
• Consistency: What clients can do, repeatedly and ple can’t even do — can create serious disordered eating,
well. mental health issues (such as anxiety and obsession), and
physical harm. It can also disrupt work, relationships,
Most importantly: and other life pursuits.
• Always start with Level 1 tasks, no matter who Past a certain point, “healthy eating” is not healthy.
your client is. Fundamentals first, always. You can’t
do Level 2 tasks unless and until you have mastered
Level 1 essentials.
Before individualization, consistency
• When in doubt, go backwards. And always re- Stop.
gress a client to a lower nutritional level, rather than
Before you progress to Level 2 with someone, double
assuming they can handle more complexity.
check that your client is doing most or all of the follow-
• Clients must be able to demonstrate that they ing consistently and well:
can do assigned tasks consistently. Saying they
can do it, or knowing information about the tasks, is
Food choices
not enough. • Eating few processed foods

362 | Unit 13
• Eating plenty of nutritious, whole, minimally pro- Mindset / psychology

cessed foods
• Able to think on a continuum from “worse” to “bet-
• Meeting basic nutrient needs (macronutrients and ter” (and imagine “a little bit better”)
micronutrients)
• Growth mindset (“Things are possible with effort and
• Staying hydrated practice”)
• Rarely drinking sugar-sweetened drinks • Consistent
• Drinking alcohol rarely or moderately
Environment
• Feeling satisfied by their meals
• Environment supports goals
Eating behaviors • Reasonably managing stress and life demands
• Eating slowly and mindfully
STOP here until your client can do the above at least 75%
• Recognizing their physical hunger and fullness cues of the time. (For best results, we prefer to get closer to
90%.)
• Establishing regular eating habits and behaviors
• Eating the appropriate amount for physiological Wait a little while.

needs and / or goals
Make sure they can keep executing these crucial behav-
• Separating food from feelings iors, and creating an environment that supports them.
Exercise and activity This is critical.

• Getting enough regular physical activity Most people struggle to do the Level 1 strategies consis-
• Managing training loads appropriately tently and reliably. It takes time, practice, and effort —
much more time, practice, and effort than people expect.
Recovery
So, before measuring anything else, measure consistency.
• Getting enough sleep We’ve provided a Meal Consistency Chart that many of
• Getting enough recovery our clients have used.
• Enough parasympathetic “rest and digest” activation
Food and cooking skills

• Has basic food preparation skills
• Has basic shopping and food aware- Meal Consistency Worksheet C

ness skills (e.g., reading labels)
Life skills
NAME DATE
How to use this worksheet

• Each time you eat a meal that’s consistent with the habits you’re working on, put an X in the box.
• Able to ask for what they want and

• Each time you eat a meal that’s NOT consistent, put an O in the box. (Leave a cell blank if you didn’t have that many meals.)
• At the end of the week, total up all your Xs and divide by the number of meals to get a consistency percentage.
need; can define clear boundaries Coaching tips

• Emphasize “consistency” rather than “compliance”.
with others
• Use this as both a progress tracker and as a way to surface limiting factors.
• As a progress tracker: Client has made progress when consistency (as a percentage of all meals) improves.
• Treat improvements in consistency as progress in and of themselves (in other words, simply being more consistent is worth celebrating).
• Look for the reasons why consistency improved, and build on those “bright spots” as well.
• As a way to show limiting factors: Use non-adherence / non-consistency to open up a discussion about why the client didn’t do the task.
• Making mostly thoughtful and in- • Do NOT treat non-consistency as “failure” or “mistakes”. Treat it as useful data.
• Explore “ready, willing, able”.
• Look for patterns over the course of a day, and over the course of a week.
formed choices • For example, the client does well in AM, struggles in PM; client does well Monday-Thursday but struggles Friday-Sunday.
• NOTE: not all clients need to achieve the same amount of consistency to reach their goals.
• Level 1 clients, or clients with more moderate goals, will do incredibly well shooting for 75-80% consistency.
• Level 2 clients, or clients with more advanced goals, will need to aim for 90% consistency or higher.
• Able to organize one’s time and

schedule reasonably well
• Has good options available and

convenient
Find the Meal Consistency Worksheet in your forms package

Table 13.1 Level 2 client features
Typical goals Improve athletic performance and recovery
Further optimize health
Further tailor nutrition to specific needs
Get and sustain a “lean-athletic” body composition1
Work towards competing in physique or modeling
Experiment and tinker with tailoring and optimizing nutrition for individual goals and
needs
Level of physical Dedicated recreational or amateur athletic performance

performance expected
Competitive at moderate levels of athletics (e.g., regionally competitive)
Body composition desired Lean-healthy to lean-athletic

or required
Men: 8-12% body fat
Training load 6-10 hours a week
Knowledge Moderate to high2
Competence and skill Moderate
Can do complex tasks when given clear instructions and the coach monitors completion
Can do simple tasks easily and intuitively, often without supervision
Consistency Moderate
Can do simple tasks 90% of the time or more
Can do more complex tasks up to 75% of the time
Has a base of sustainable habits and a consistent foundation of essential behaviors
Mindset / psychology “I feel relatively confident.”
“I can stay on track pretty well.”
“This is a priority for me.”
“I want to be better than average.”
Limiting factors Some; most major roadblocks have been cleared
1 Note: Clients will vary widely in their body compositions depending on their age, sex, genetic makeup, etc. What is “unreasonably lean” for one
person may be another person’s “normal.” Look for natural tendencies and try to get a baseline of what is appropriate for each client. “Lean-athlet-
ic” is the body composition that is lower than average, yet that a client can easily and sanely maintain doing basic Level 2 habits consistently.
2 Most clients at Level 2 will have coaches. So the clients themselves need not be experts, but they should be guided by someone who is.

364 | Unit 13
And only then, if they really need it, should they consider performance beyond what they can do with the Level 1
the Level 2 strategies we cover in this unit. approach.
Level 2 strategies don’t make clients any healthier or give

What does a Level 2 client look like? them a better quality of life.
In Unit 11, we gave you a brief overview of Level 1s, 2s, Indeed, depending on how far someone takes them...
and 3s. Now let’s look more closely at the features that
Level 2 clients might have. Level 2 (and Level 3) behaviors can become
Level 2 clients are those who: actively unhealthy.
• have mastered Level 1 strategies; If a client engages in Level 2 (or 3) behaviors too strin-
gently and aggressively:
• have progressed as far as they can with Level 1 but
need / want to go further; • body fat can start to drop too low. Hormones and
recovery can be disrupted.
• need a bit more individualization; and
• behaviors, thoughts, and feelings about food, eating,
• are psychologically stable and emotionally mature
and training can become disordered. Your client may
enough to try more advanced strategies.
start to have mental and emotional health problems
Level 2 clients generally want to get leaner or improve perfor- such as anxiety, depression, and / or OCD.
mance more than is likely possible with the Level 1 approach
• social relationships and other interests — which we
(generally, body fat goal ranges of <12% for men, and <22%
need for overall wellness and quality of life — may
for women).
suffer.
Not all Level 2 clients will have all of these characteristics,
but this gives you the general idea. Level 2 behaviors are usually short-term
strategies.
Level 2 client features
Note that goals, knowledge, body composition, athletic term goal, such as a competition, or to support higher
performance, and training load alone do not define Level levels of athletic training at certain times in their com-
2. For instance: petitive season.
• You may have a high-level recreational athlete who
is quite lean and muscular... but who binge-eats
Level 2. (You’ll see what we mean when you review the
regularly, doesn’t get enough sleep, and / or doesn’t
list of Level 2 behaviors in Table 13.3.)
eat their vegetables.
• You may have a client who has an “expert” level As a coach, it’s your role to inform your clients
of knowledge, perhaps even graduate degrees in about all the trade-offs.
nutrition… but who can’t actually do fundamental
behaviors consistently. Help clients know what to expect and to look for as they
Most fundamentally, nutritional level is about compe-
tence and consistency: Monitor clients carefully.
What can you do repeatedly and sustainably in your At Level 2, most clients should be keeping some type of
daily life? record of what they are doing.
Level 2 approaches are mostly about looks and Track your client’s physical, psychological, and social
/ or performance. indicators closely. Make outcome-based decisions using
data.
Level 2 clients want to get leaner or improve athletic

Table 13.2 Assessing Level 2 client readiness
Level 2 client Not a Level 2 client (yet)

Can use objective indicators (such as measurements) in the Does not use objective indicators appropriately or mature-
appropriate ways. ly. Either gets anxious / obsessive about measurement, or
doesn’t bother to measure at all.
Understands that indicators, metrics, and outcomes are a Sees indicators, metrics, and outcomes as a judge of their
means to make informed decisions. personal “goodness” and “badness.”
Actively seeks coaching and other feedback (e.g., perfor- Avoids feedback, or does the opposite — constantly seeks
mance indicators) at appropriate intervals. validation in a needy and anxious way.
Receives feedback productively and looks to apply it. Becomes defensive, resentful, frustrated, and/or demoral-
ized when feedback is given.
Able to step back and see the big picture. Becomes lost in details, paralyzed, and/or over-anxious.
Able to detach self-concept from food and eating. In other Can’t detach their own self-concept from food and eating.
words, they don’t define themselves by their diet. Food and eating choices define who they are.
Able to detach emotions from food and eating. Uses food / eating to manage emotions; food / eating
decisions driven by emotions or other un-met psychological
needs.
Can stop Level 2 strategies any time. Deeply attached to Level 2 strategies and outcomes.
Reluctant to give them up; may be anxious about “losing
control.”
Understands and is willing to accept trade-offs. Balances Does not fully understand trade-offs.
short- and long-term needs effectively and intelligently.
May be willing to sacrifice long-term value or health for
short-term gains. (Or the perception of short-term gains.)
Driven in part by intrinsic factors: this project is somehow Driven entirely by external factors (e.g., get a trophy, get
meaningful and valuable to them at a deeper level. approval from others).
Growth mindset: Willing to practice and expend effort con- Fixed mindset: Wants results without effort; gives up easily;
sistently and over time. Seeks understanding and personal views setbacks as personal deficiencies.
development.
Avoids growth opportunities.
Takes responsibility for their choices and the outcomes. Does not take responsibility for themselves. Victim or blam-
ing mentality.
Have an “escape plan” at all times to help guide your Speaking Level 2 language
client back to balance if needed.
You’ll remember that in the previous unit, we advised
Assess mindset and maturity. you to keep things simple for Level 1 clients. The same
is true for Level 2s, but you can often use slightly more
You’ll notice that nutritional level isn’t just about physi- technical or complex language or concepts.
ology. It’s about psychology too.
A Level 2 client will usually have goals like:
To “graduate” to Level 2, clients must have a healthy, • “improve my performance in sport X” (often with
growth-oriented mindset along with emotional maturity specific metrics)
and resilience.
• “get down to X% body fat”
Here are some criteria you can use to assess your poten-
• “improve recovery in activity X, especially under Y
tial Level 2 clients’ readiness.
conditions”
• “do an elimination diet to pinpoint some food

intolerances”

366 | Unit 13
At Level 2, things get more technical, more measurable, • Concern about the health value of food (to the point
and more specific. of anxiety or obsession)
A few communication principles: • Overly rigid food rules or excessive worry about “eat-
ing the wrong thing” once they know what “right
• Keep it simple. You can always make things more
and wrong” are
complicated. Start with the basics.
• Limiting food choices without correctly assessing
• Listen carefully and assess. What are your client’s
whether this is appropriate (for instance, cutting out
goals and how do they describe them? What level
all grains without a measurable grain intolerance)
of terminology and scientific explanation are they
comfortable with? Eating behaviors
• Match your language to theirs. Some Level 2s • Eating too quickly and while distracted
may have advanced knowledge. Others will not.
• Can recognize their physical hunger and fullness
Speak in a way they will understand.
cues, but may ignore them (especially if rushing or
• Ask them to clarify if possible. What does “better busy)
performance” or “more recovery” mean to them,
• Potentially overly structured eating habits
exactly? Could they give specific examples of what
they’re describing? Level 2 clients will often have • Disordered eating (restricting, purging, orthorexia,
specific metrics already (e.g., “Get into the X weight controlling, bingeing, etc.)
class” or “Cut X minutes off my Y mile run”). • Doesn’t use food to manage feelings as much, but
• Check for understanding. Are you on the same may feel some distress or anxiety if food isn’t “exactly
page? Do you both comprehend what the other is right” or optimally “healthy”
saying?
Do the same when you discuss limiting factors with • Over-training and not managing training loads
them.
Recovery
Clear communication is important for all clients. Don’t
overestimate your Level 2 client’s ability to assimilate • Not getting enough sleep
and use what you’re saying right away. • Not getting enough recovery
• Too much sympathetic nervous system “fight /

Level 2 limiting factors flight” activation (i.e., spending too much time in the
“amped up” and overstimulated zone, doing high-in-
Some limiting factors will cut across all nutritional
tensity training almost exclusively)
levels. For instance, almost everyone struggles with time
management. • Not enough parasympathetic “rest and digest”
activation
But here are some limiting factors that you may find
with Level 2 clients. • Over-training / over-use injuries
Food choices Food and cooking skills

• Eating too many processed foods (in the case of Level • Stuck in a “food routine” with familiar favorites
2s, often relying too much on energy bars, gels or • May assume that certain types of foods are always
powders, “healthy junk food”, etc.) “good” (e.g., if it’s organic, if it’s bought at a “health
• Assuming (incorrectly) that more activity will com- food store”)
pensate for poor food choices, or eating too much • May assume that they always have to buy the most
• Drinking too many sugar-sweetened drinks to fuel expensive or premium types of foods
workouts

Life skills • Rules orientation: May want to “follow the rules”

over outcome-based decision making
• Feeling “too busy” or “too rushed”
• Not having good options available and convenient Environment

• Time management (especially with more time devot- • Unsupportive social networks (family, friends, co-
ed to exercise / training / competition) workers, etc.)
• Too much stimulation and / or stress, especially

during periods that should be “down times” (e.g.,
• All-or-nothing thinking (e.g., yo-yo dieting, re- before bed)
• Consciously limiting environment and social network;
/ night-time over-eating, “Either I’m perfect or I’ve
narrowing of interests and focus to support athletic
failed” mentality)
or body composition goals
• Busy-ness and stress; overwhelming life demands;
feeling rushed and pressured Possible Level 2 coaching tasks
• Overly driven to succeed; not satisfied with incremen- At this stage, you’ll have to adjust some Level 2 tasks for
tal progress fat loss, athletic performance, and / or mass gain. We’ve
• Extrinsic motivation: May measure “success” solely by
given you some notes in Table 13.3.
external factors (e.g., winning) A few more tips:
• Extrinsic cues: May rely too much on external cues
Few clients will permanently use the strategies we
(e.g., time to eat, pre-measured food amounts, specif-
mention here.
ic macronutrient splits) and not use internal cues
Set expectations appropriately.

Level 2 clients can
So the “next level” involves... Sample coaching tasks could be...
consistently...
Food choices
Make mostly nutritious food Refining food and nutrient quality Shift more food purchases towards local / organic /
choices seasonal, farmers’ markets, etc.
Choose grass-fed / pastured / wild-caught meats,

poultry, fish, seafood, eggs, dairy
Eat mostly whole, minimally Eating almost entirely whole, minimally Eliminate almost all processed foods (except for
processed foods processed foods sports supplements, e.g., protein powder)
Cook most of the week’s menu from scratch

Meet basic nutrient needs Adding phytonutrients, zoonutrients, Expand the colorful fruit and vegetable repertoire
(macronutrients and myconutrients
micronutrients) Choose grass-fed / pastured / wild-caught meats,
Testing for nutrient status and supplement- poultry, fish, seafood, eggs, dairy
ing specifically
Review lab test results of nutritional status; create a
targeted supplement plan
Stay hydrated Consuming adequate fluids Tracking fluid intake and urine color output; ensure
proper hydration status

368 | Unit 13

Level 2 clients can
consistently...
Drink mostly non-caloric Minimizing and/or completely eliminating Cut out or drastically minimize alcohol intake
beverages caloric beverages
Drink coffee and/or tea without sweeteners
Feel satisfied by their meals For fat loss: Feeling slightly less than satisfied For fat loss: Leave the table feeling a little hungry;
by their meals accept the presence of low-level hunger much of the
time
For mass gain: Feeling a bit too full For mass gain: Leave the table feeling a little over-
stuffed; accept the presence of fullness much of the
time
Eating behaviors
Eat at a moderate pace, with- For fat loss: Slowing down even more Add 5-10 more minutes to usual meal time
out too many distractions
Eat entirely without distractions
For mass gain: Speeding it up Shorten meal times; focus completely on getting the
food down before satiation signals kick in
Recognize physical hunger For fat loss: Going into the “hunger zone” For fat loss: Practice tolerating the discomfort of mild
and fullness cues to moderate hunger
For mass gain: Ignoring fullness cues; eating For mass gain: Ignore fullness cues; stick to an eating
even if not hungry schedule even if not hungry
Have regular eating habits For fat loss: Experimenting with occasional Once a week, skip breakfast or dinner
intermittent fasting
For mass gain and/or athletic performance: Athletic performance and mass gain: Eat every 3-4
Sticking to a regular eating schedule hours, especially around training
Have a relatively sane, Closely monitoring eating psychology and Keep a daily record of eating behaviors, thoughts,
healthy mindset about eat- mindset and feelings
ing for performance or body
composition changes Staying alert for any compensatory behaviors Keep a daily record of all training and activity
(e.g., bingeing, purging, over-exercising)
Separate food from feelings
Be active regularly for at For fat loss: adding more activity Add a 30-minute walk daily
least 60 minutes a day
Manage training loads Having all training under the supervision of Schedule 10-15 minutes more of active recovery daily
coach / trainer
Follow specified training and recovery program
Recovery
Sleep 7-9 hours Adding 15-30 minutes of sleep or improving Take a nap every day
sleep quality
Supplement to enhance sleep (e.g., ZMA, L-theanine)
Refine sleep ritual

Get enough basic recovery Adding recovery protocols3 Add peri-workout nutrition (BCAAs for fat loss,
carb + protein drink for muscle gain and/or athletic
performance)
Record daily recovery indicators (e.g., sleep quality,

HRV)
Manage stress productively Adding stress management protocols Add 10 minutes of relaxation / mindfulness
and effectively
Practice time management and prioritization


Level 2 clients can
consistently...
Life skills
Prepare basic meals and Improving meal preparation and planning Add 5 meals to “go-to” roster
menus skills
Try a new cooking challenge (e.g., new food, new
prep method)
Shop efficiently and be Improving shopping options Shift more food purchases towards local / organic /
aware of food quality seasonal, farmers’ markets, etc.
Improving food quality
Choose grass-fed / pastured / wild-caught meats,
poultry, fish, seafood, eggs, dairy
Ask for what they want and Establishing Level 2 tasks as priorities and Have a crucial conversation with family and friends
need negotiating with others about Level 2 priorities and tasks; set clear expec-
tations about what this will involve (e.g., removing
Define clear boundaries and “junk food” from the house)
priorities
Make thoughtful, informed Establishing purpose; setting clear priorities Daily goal review
choices and abiding by them
Make as many decisions in advance as possible; leave
Ensure that good options are Making the decision process as easy and fewer things to chance (e.g., plan meals beforehand)
available and convenient streamlined as possible by eliminating un-
wanted options Hire a meal delivery service
Cut down on restaurant meals

Think on a continuum from Continually moving along the continuum Identify choices that are “just a little bit better” and
“better” to “worse” towards “better” make them consistently
Have a growth mindset Seeking continual refinement and improve- Weekly review and retrospective with coach; out-
ment of process and self-awareness come-based decision making
Using outcome-based decision making Try to improve one small part of the process each
week, based on data collected from the week before
a) Looking for inefficiencies and removing Create and use a checklist for important processes
them (e.g., taking supplements)
b) Adding more process metrics and tracking Record ongoing food and other logs; coach to review
them these weekly (or as appropriate)
Organize most of their life Planning, prioritizing, and scheduling Schedule not only workouts but also food prep
around executing Level 2 times, recovery times, sleep ritual, etc.
tasks Cutting back on lower-priority activities and
other demands Keep a 1-week time diary
Remove 1 low-priority “time sucker” based on results

of time diary
Environment
Have environment that en- Further refining environment along with Kitchen cleanout and organization (e.g., supple-
ables Level 2 choices schedules and systems ments packed into pill holders)
Add home exercise options

Have supportive social Getting more coaching More frequent coaching check-ins
networks (family, friends,
coworkers, etc.) Finding more teammates Add a coach for other aspects of goals (e.g.,
sport-specific skills coach)
Work with a team, group, and/or support network

(e.g., running group, competition team)
3 At this point, much of what you’re adding for Level 2 clients are additional stressors. They’re training and potentially competing more (which may also involve
things like travel). If they’re trying to change body composition dramatically, they’re either eating much less or much more than is comfortable for their body.
All of this can cause other stresses such as financial stress, relationship stress, and time management stress. So this recovery angle is critical.
370 | Unit 13
Most people can’t walk around with lean-athletic body Understand the ideas behind the recommendations, then
fat all the time, or train heavily every week of the year. come up with your own possible Level 2-style strategies.
There’s a reason there are seasons for competition.
Test stuff and see what works. If it works, use it.
Look for the best results for the least amount of com-
plexity or effort.
Strategy: More precise observation
Level 2 strategies will require more trade-offs from and analysis
clients. But if you can help someone achieve their goals
by focusing on foundational Level 1 strategies that don’t At Level 2, the food log is your friend. Now you can ask
require as many trade-offs… it’s probably worth doing! for more detailed records, and more careful measure-
ment of food quantity.
Don’t add complexity for the sake of complexity.
This helps you get a baseline, identify limiting factors
A difficult program is not necessarily better, especially if (and bright spots), and track progress.
you could get the same results with a simple program.
Food logs give you great insight into the daily nutritional
habits of your clients, and often help to make them more
Level 2 strategies aware of their own intake (and often spot some of their
Here are types of strategies we recommend for Level 2 own limiting factors that might have gone unnoticed).
clients: Food log options
• Continuing with all of the Level 1 recommendations
• 3-Day Dietary Record: Your standard food log
• More precise observation and analysis (e.g., of food
• Athletic Nutrition Journal
logs)
• Improving food quality and variety
• Improving food selection, preparation and cooking

skills FOOD JOURNAL
3-Day Diet Record

• Workout nutrition to fuel performance and enhance
recovery
NAME DATE
• Improving recovery protocols Please record everything you eat and drink for 3 days. Be as thorough and detailed as possible.
Please be as honest as you can be. I am gathering data, not judging. Don’t change your normal routine. Just record what you are doing.
If your eating habits change over the week, pick 3 days that are representative (e.g., 2 weekdays plus 1 weekend day).
• Eating according to body type (e.g., ectomorph, To measure, simply use hand-sized portions (e.g., 1 palm, 1 fist, 1 cupped handful, 1 thumb) or something else standardized (e.g.,
baseball, deck of cards). You can use measuring cups or a food scale if you want, but you don’t have to.
Record any other notes about other things we’ve agreed you’ll record, such as why you are eating, physical sensations from eating, how
mesomorph, endomorph) you felt after you ate.
• Moderate carb and calorie cycling (e.g., emphasizing Example
carb-dense foods only after workouts allows for a MEAL TIME WHAT YOU ATE / DRANK AND HOW MUCH
2 pieces whole-grain toast

NOTES
natural carb cycling rhythm) 7 AM 2 thumbs peanut butter Rushing out the door; busy day
1 mug of coffee with milk + 2 sugars
• Basic supplementation if appropriate Bran muffin (about 1 fist sized)
10:15 AM 1 medium-sized orange In a meeting
• Competition day nutrition Medium coffee from Dunkin Donuts
12” Subway turkey sandwich
These aren’t the only Level 2-style tools and techniques 12:30 PM
1 can Diet Coke
No cheese
that you can use. 1 strawberry Greek yogurt

3:30 PM Ate at desk
2 handfuls Triscuits
You may find as you work with your Level 2 clients that 3 slices meat-lovers pizza
you come up with your own Level 2-style strategies and 6:30 PM 2 light beers Got home late, no energy to cook
habits. Great! 1 bowl moose tracks ice cream
Innovate. Create. Apply the key principles in new ways. © 2018 ISSA issaonline.edu
This is the essence of experimentation and out-

come-based decision making. Find the 3-Day Dietary Record in your forms package

Revisit and clarify expectations. What exactly is the

client hoping to achieve? And is it realistic? They might
Athletic Nutrition Needs Questionnaire
actually be doing great. Yet they want to look like they
did 15 years ago, or like a magazine cover model. At this
NAME DATE
point, a chat about realistic expectations, and potential
What activities do you do?
trade-offs, might be in order. (More on setting expecta-
Please list all the types of physical activity / exercise / athletic training you do, and how much / often.
tions later.)
ACTIVITY TYPE HOW OFTEN AND HOW MUCH?
e.g., Recreational hockey On-ice training 2x weekl y , 2 hours per session; 1 game per week What to look for in the food record
Walking Dail y , with the dog, 30 minutes
Once they have submitted the food log, it’s time to put
on your coach hat and troubleshoot with them.
Look for anything that could be limiting progress. Look

for anything that doesn’t quite add up.
Consider it a mystery that you are investigating.
Are you a professional, amateur, and / or devoted recreational athlete? Here are some things to look for.
 Professional athlete  Amateur, compete at local level
 Amateur, compete at national or international level  I don’t compete, but I train like I do
Not being consistent with Level 1 behaviors

 Amateur, compete at regional (state / provincial) level
If you compete, what phase are you in?
 Pre-season preparation  Off-season  Currently in competitive season
 Rehab / injury recovery

This seems like an obvious problem… but it’s not always
obvious, especially with a client who wants to be at Level
2 and may insist they “already eat really well” or “are
doing everything right.”
Find the Athletic Nutrition Needs Questionnaire in Start by reviewing the basics in the food log:
your forms package
• Appropriate portion sizes and energy intake for the
client’s goals.
• Photo food journal: Ask the client to snap an image of • A relatively regular eating schedule.
their food each time they eat. For people with smart-
• Food quality and variety.
phones this is often a much simpler alternative.
• Evidence of planning and preparation, and an environ-
Set expectations clearly and ment that supports your client’s goals.
appropriately
Also ensure that other basic factors like sleep and recov-
Close analysis of food and other records can be tricky. ery are covered.
Clients may feel judged or anxious.
Never assume a client is truly consistent with the essen-
Before moving to the more detailed food log: tial basics unless you have clear evidence. (Again, clients
aren’t bad people. They’re just human.)
Remind clients that you are on their team. You are not
a judge of their goodness or badness. You are collab- Then look for some sneaky additions:
orating with your client, working together to collect
evidence, analyze that evidence, and draw informed Too much dietary fat
conclusions about what to do next, based on their goals.
Fat is not bad. It’s just calorie-dense.
View data collection and analysis as a win-win. Whatev-
er you find will be helpful. The client will have something Clients who want to get significantly leaner will have to
to work on. You’ll be able to troubleshoot with them. watch their overall intake, and fat is a sneaky source of
Everyone is happy. excess energy. (Plus, it’s delicious and easy to over-eat.)

372 | Unit 13
For instance: On that note…
Excess oil: Clients may be doing a fantastic job of getting

Super Shakes
their vegetables in salads, or roasted. But sometimes
those veggies are a vehicle for too much oil. 1 table- Super Shakes are awesome.
spoon of oil is over 100 calories of ready-to-absorb
triglycerides. At the same time, clients may simply be consuming too
much of a good thing, throwing a few extra bananas
Too many nuts / too much nut butter: 1 thumb of nuts or spoonfuls of nut butter in there, or treating a Super
(the recommended serving size for an average woman Shake as a calorie-free drink instead of a liquid meal.
at each meal) is really, really small. Like 8-12 almonds.
Sit down and count out 8 almonds. It’s a sad little pile, Review the ingredients and make sure the portions are
isn’t it? Same deal with 1 thumb of nut butter. It’s really appropriate.
easy to lose a lot of nut butter into a Super Shake, or get a
little generous with the spoonfuls straight from the jar.
Strategy: Improving food quality and
Too much of fat-based condiments. Things like gua- variety
camole and pesto are delicious and nutritious. But their
calories add up fast, and it’s easy to eat too much. Level 2 is an ideal time to experiment and expand hori-
zons; to seek mastery and depth.
Cheese and other high-fat dairy. Two cubic inches of
Brie cheese has 120 calories. That’s about the size of a At this stage, you can challenge your Level 2 clients to
pair of dice. Goat cheese is a common salad topper. 1 try things like:
thumb of it has about 100 calories. We don’t know about
• expanding their food repertoire (for instance, trying
your wine and cheese parties, but we definitely like to eat
new types of protein-dense foods or fruits and
more than 2 dice worth of Brie at ours. Unfortunately for
vegetables);
Level 2 clients, these calories can accumulate quickly.
• upgrading their food expectations and spending
Too many protein-dense foods a little more to get better-quality items (Note: This
doesn’t mean pointlessly spending on luxuries or pre-
Many people give protein-dense foods a “free pass.” mium items; it means making food quality a spending
They’ll eat lots of meats, eggs, cottage cheese, protein priority.);
powder, fish, jerky, and so forth.
• buying more of their food from:
But if you’re trying to get lean, too much food is still too
• organic sources
much food.
• local sources
Pseudo-health-foods / concoctions • small farms / wild-caught sources
Bars and shakes are most common. But into this cat- • environmentally friendly, sustainable sources
egory also fall things like “Paleo cupcakes”, “healthy
• Fair Trade / fair labor sources; and
cookies”, baking with protein powder, etc.
• exploring other cuisines.
You might have a client who doesn’t eat “sweets”, but
they’ll polish off a protein bar or two every day. And The Phytonutrient Checklist
they won’t touch ice cream, but they don’t think twice
about an 800-calorie protein pudding recipe with ber- This is a strategy for your longevity clients — the ones
ries, nuts, coconut milk, and protein powder. This is fine who want to attain optimal health outcomes, prevent
when those calories are needed, but they can add up very chronic diseases, and live to be 100.
quickly and become excessive.
Phytonutrients are the countless chemicals starting to
Look also for “juicing”, smoothies and the like. Review be identified in plant foods that appear to have various
all ingredients.

health benefits. It appears that the greater variety we consume, the greater the fair trade: Trade in which fair
health benefits. prices are paid to producers in
developing countries
Since some clients are very predictable and routine with food selections, they
might only eat the same 2-4 veggies and / or fruits over and over.
In order to help them break this rut, challenge them with the Phytonutrient
Cheat Sheet (www.precisionnutrition.com/color-chart)
Another way to encourage more variety with veggies and fruits is to simply en-
courage a client to eat seasonally and / or join a Community Supported Agri- Community Supported
culture (CSA) program. Agriculture (CSA) : A system
in which a farm operation is
supported by shareholders within
In some regions, this will be easy. Indeed, in some areas of the world, seasonal
the community who share both
and local eating is one of the major (or even only) options. the benefits and risks of food
production
In the United States, clients can check out http://www.localharvest.org/.
In Canada, clients can check out http://www.usc-canada.org/
Outside of North America try an Internet search or go here: http://urgenci.net/
Strategy: Improving food selection, preparation and

cooking skills
As above, Level 2 is an ideal time to experiment and expand horizons; to seek
mastery and depth.
At this stage, you can challenge your Level 2 clients to try things like:
• expanding their cooking repertoire with new dishes, menus, and flavors;
• improving their ability to shop efficiently and effectively;
• learning how to choose the best quality food (e.g., buying in season, testing
ripeness or quality);
• improving their foundational cooking skills and trying new methods of cooking
and preparation;
• getting involved in the food production process, e.g., picking their own
produce or learning how to butcher (Some clients may already be raising
their own animals or hunting / fishing for food. This is a particularly important
strategy for clients in remote and rural areas, and clients from indigenous back-
grounds, such as Inuit, First Nations, Native American or Hawaiian, Australian
Aboriginal).
Strategy: Workout nutrition to fuel performance and

enhance recovery
At Level 2, most clients should be regularly active. Many will be athletes; most
will be training intensely at least occasionally. Thus, at this stage, you can consid-
er adding some specific and targeted workout nutrition.

374 | Unit 13
Workout nutrition has two key goals: • the client’s individual tolerance for food / liquids
around training times
Priority #1: Improve recovery.
Begin with a general template. Observe and assess. Then
Priority #2: Improve performance. make adjustments accordingly.
Most athletes do this the wrong way around — they fo-
cus on eating to perform, which often means short-term The value of carbohydrates
strategies like grabbing a candy bar before a training
Of course, all nutrients are important. But for most ath-
session. But ultimately, if you don’t recover, you don’t
letes, carbohydrates can be a “make or break” factor.
perform.
When training or competing, even in strength and
Recovery can include:
power sports, blood sugar levels can dictate how well an
• providing adequate hydration; athlete feels during the session.
• ensuring a steady supply of fuel and nutrients to • If blood sugar drops too low, they might fatigue
working bodies (so that those bodies don’t have to faster (both mentally and physically), and / or feel like
break down valuable lean tissue); they have less “gas in the tank.”
• reducing muscle soreness; • If blood sugar stays constant, they’ll feel like they
have adequate energy. They’ll also feel mentally
• managing inflammation;
“sharp” and emotionally “tough.”
• improving immune function;
Therefore, one of the goals of every workout, whether
• increasing protein synthesis while inhibiting protein
it’s in the gym, on the field, or on the road, is to prevent
breakdown; and
blood sugar from dropping.
• optimizing body composition (i.e., building strong,
dense muscle, bone, and connective tissues while Activity itself creates a demand for glucose; stress and
keeping body fat down).
adrenaline can eventually deplete sugar stores too.
(While adrenaline, or epinephrine, gives a fast blast of
Fundamentally, good workout nutrition helps exercisers glucose, this runs out and may leave athletes feeling
replenish and rebuild. shaky or weak. The effect will be amplified if athletes
are using pre-workout stimulants such as caffeine or
Individualizing workout nutrition: ephedrine.)
General guidelines
As you learned in previous units, activity eventually
We can divide workout nutrition into three categories: depletes muscle and liver glycogen. These stores must
be filled.
1. Pre-workout nutrition (i.e., before the workout)
2. Intra-workout nutrition (i.e., during the workout) Our body can do this without more fuel coming in, but
that requires breaking down stored fuel and valuable
3. Post-workout nutrition (i.e., after the workout) lean tissue. Eventually, if we consistently ask our body to
dig into its “savings account”, we run a deficit: We start
Exactly what this looks like for each athlete or exerciser
losing muscle, getting injured, knocking our hormones
will depend on a few things:
out of balance, and compromising overall recovery.
• how long the physical activity lasts
Thus, for optimal recovery, we replenish our glycogen
• how intense the activity is
fuel tanks with carbohydrates during and / or after
• how often the activity happens within a given period training.
(e.g., single versus multiple daily training sessions)
This means that most athletes do best with a steady
• the client’s goals supply of carbohydrates before, during, and / or after
• the client’s body type / composition exercise.

Athletic activity = Managed body damage
Training session 1
Training session 2
BASELINE
DAMAGE RECOVERY SUPERCOMPENSATION DAMAGE
Not enough recovery / session too hard
Training session 1
Training session 2
DAMAGE RECOVERY SUPERCOMPENSATION DAMAGE
Figure 13.1 Importance of recovery in athletic nutrition

376 | Unit 13
What type of carbohydrates are best for workout nutrition?
For regular day-to-day meals, we generally want high- However, there are other options available, many of
er-fiber, slow-digesting carbohydrates, such as: which are modified sugars or starches, such as:
• starchy tubers (like potatoes and sweet potatoes) • hydrothermally modified corn starch / waxy
maize (sometimes called “Superstarch” or “Gly-
• fruit
cosadeTM”)
• beans and legumes
• unprocessed corn starch
• whole grains
• maltodextrin
• higher-fiber versions of bread, pasta, etc. (e.g.,
• dextrose
sprouted bread, bean pasta)
• trehalose
And of course, we want to eat normally most of the
time, including before and after training. • isomaltulose (PalatinoseTM)
For intra-workout nutrition, we want faster-digesting • VitargoTM, made from barley starch
carbohydrates. This is especially true if we’re drinking
The different molecular configurations of each type
them in a shake or solution.
of carbohydrate can alter its effects (which you may
For this purpose, you can still use whole foods, or sup- remember from our unit on nutrients).
plements.
For instance:
Again, remember that not all clients or athletes will
• GlycosadeTM is a high-amylopectin starch, origi-
require intra-workout carbs. See Table 13.4 for more.
nally developed to treat glycogen storage diseas-
es, while other types of modified corn starch may
Whole-food options be high-amylose.
If your client has a blender and wants to use whole • Some studies have looked at galactose as a work-
foods for intra-workout nutrition, try blending (along out carbohydrate. Although it’s a monosaccha-
with protein): ride and thus technically a simple sugar, it does
not have the same effects as glucose.
• banana or cooked plantain
Vitargo’s manufacturers claim that it has a low osmolal-
• other fruits ity, which means that unlike many starches, it doesn’t
• cooked white or sweet potatoes pull a lot of water into the GI tract. This means an
athlete can theoretically consume quite a lot without an
• soaked rolled oats upset stomach — replenishing a lot of glycogen relative-
One study found that raisins were just as effective as ly quickly and efficiently.
“Sport Jelly Beans” (which are essentially sugar + vita- Be aware that many claims about supplements are
mins). based on small studies that may not be well replicated.
(For instance, one of the most-mentioned waxy maize
Supplement options studies involved nine people, and maltodextrin actually
As you can imagine, there are many supplement options increased blood glucose more.)
for workout carbohydrate. Though some researchers
A larger study of 51 endurance athletes (cyclists and
feel that high-glycemic options (in other words, sim-
triathletes) found that the best results came from a solu-
ple sugars that convert quickly to glucose) are best for
tion of 1:1:1 glucose-fructose-maltodextrin, ingested at a
intra-workout carbs, this is not yet conclusively proven.
rate of 78 g per hour.
The most basic supplement option is a sugar-sweetened
This matches up well with other research that has
protein powder or BCAA supplement.
found a 2:1 glucose to fructose carb makeup is ideal
during exercise (since maltodextrin is essentially the
same as glucose).

As always: mixture for every hour of training is usually

appropriate.
• Focus on consistency first. The exact type of “per-
fect” carbohydrate is less important than simply • Observe your clients closely. Look for things like
ensuring athletes are consistently consuming GI upset, blood sugar swings, or unwanted fat
some type of carbohydrate during and / or after gain and adjust accordingly. Test performance in-
exercise. dicators when you change the nutrition variables.
• Be a skeptical consumer. • Use the evidence of your clients’ performance
and wellbeing to test all dietary choices.
• During workouts, for clients who need carbs,
a mix of 15 g of protein with 30-45 g of carb
Table 13.4 Next steps for workout nutrition

Client type What to do
Clients with better carbohydrate tolerance Drink a protein + carbohy-
drate drink during training
Clients who need more carbohydrates (e.g., endurance athletes) session
Clients who want to gain weight
Clients with lower carbohydrate tolerance Drink BCAAs during training

session
Clients who don’t need as many carbohydrates (e.g., low-intensity movement such as yoga)
Clients who want to lose fat
General workout nutrition

For most athletes, most of the time, it’s enough to simply: Indeed, given many athletes’ busy schedules, simply
planning and preparing regular, high-quality Level
• Follow a normal, regular eating schedule of
1 meals will be an important skill to master and do
high-quality Level 1 meals with a good balance
consistently.
of lean protein, healthy fats, and slow-digesting
carbohydrates (such as fruits, vegetables, and whole Once the client is doing the basics above consistently,
grains). you can add the following, depending on goals and
needs:
• Make sure to get carbohydrates in most meals —
enough to support the athlete’s general level of Like most things, carbohydrate requirements will fall on
activity. a bell curve.
• Eat these meals every 3-4 hours, as needed or appro-
priate (depending on goals). Does exact timing matter?
For many athletes and recreational exercisers, these basic Early research suggested that there was a short, rapid
guidelines are enough to support their training. “anabolic window” for nutrient replenishment, and that

378 | Unit 13
athletes should rush to replenish lost nutrients immedi- muscle adaptation, and / or training with high volume
ately after training (within 30-60 minutes). and intensity (potentially multiple times every day).
More current research suggests that as long as athletes However, someone exercising for general health and
eventually refill the “fuel tank” with protein and carbohy- fitness — or simply to look and feel better — should only
drate within 1-2 hours after training (or, within 4-5 hours consider this question once they’ve nailed all the other
of their pre-workout meal), they’ll recover sufficiently. strategies consistently. Even a top-performing Level 2
client may never need to “graduate” to Level 3.
Thus, we recommend that athletes stick to a regular
eating schedule and simply make sure they get adequate Individualizing workout nutrition:
protein and carbohydrates within the first 1-2 hours Targeted template
both before and after an intense training session.
Here’s a starter workout nutrition template that takes activ-
The exact timing and type of post-workout nutrition ity intensity and duration into account.
doesn’t really matter for anyone but an elite athlete or
Level 3 eater who is training specifically for maximal Remember, these aren’t “rules”, just principles. A
Same as others
SD = Standard Deviation
Probably more Probably less

Definitely more Definitely less

-2 -1 Mean +1 +2
SD SD Score SD SD
2% 14% 34% 34% 14% 2%

Percentage of clients who will do best with a given amount of carbohydrate
Figure 13.2 How much carbohydrate do people likely need?

framework with which to begin. Observe, assess, and For more on competition day nutrition, in the “Competi-
adjust as necessary based on the data. tion Day Nutrition” section on page 455.
For moderate-intensity activity under 2 hours Strategy: Improving recovery

and / or high-intensity activity under 1 hour
protocols
Step 1: Eat normally 1-2 hours before training.
At Level 2, your clients should be sleeping 7-9 hours
Step 2: Drink 0.5-1 liter (2-4 cups) of water during activity. a night, and doing some form of active recovery (i.e.,
Step 3: Drink 0.5-1 liter (2-4 cups) of water after activity. non-exercise movement that helps clear out waste prod-
ucts, mobilize the joints, and is — ideally — fun).
Step 4: Eat normally within 1-2 hours after training.
Where appropriate, you can add other targeted recovery
Step 5: Drink 0.25-0.5 liters (1-2 cups) of water at each
protocols, such as:
meal.
• specific breathing, relaxation, stress reduction, and
Add-ons PNS activation exercises (such as gentle yoga or mas-
sage therapy);
• For athletes who want a little extra recovery
boost, more advanced clients looking to lose • more sleep (including daytime naps);
fat and maintain muscle, or for strength sport • anti-inflammatory supplementation;
support (e.g., powerlifting): Add BCAAs during
• workout nutrition;
workouts. Aim for 10-15 g of BCAAs every hour
during workouts. • more, and more diverse, phytonutrients (i.e., colorful
fruits and vegetables along with other bio-active
• For advanced clients who want to gain weight,
substances such as those found in herbs, green tea,
have a high need for carbs / calories, or for
onions and garlic);
specific sport performance (e.g., endurance or
intermittent sport): Add protein + carbohydrates • increasing protein intake;
during workouts / competition. The general formula: • balancing healthy fats (looking for a 1:1:1 ratio of
30-45 g carb + 15 g protein in 500-600 mL water polyunsaturated to monounsaturated to saturated
every hour during activity. fat; decreasing omega-6 intake from industrial seed
oils if necessary);
• omega-3 (EPA / DHA) supplementation;
than 2 hours and / or high intensity activity
lasting longer than 1 hour (and for those with • further limiting processed foods, particularly trans
multiple events in one day) fats;
Step 1: Eat normally 1-2 hours before activity. • reducing and / or eliminating any foods that seem to
provoke an inflammatory response in your client;
Step 2: Drink 0.2-0.5 liters (1-2 cups) of water 30-60 min-
utes before activity. • reducing and / or eliminating alcohol; and
Step 3: Consume 30-45 g carb + 15 g protein + electro- • reducing and / or eliminating caffeine, if your client
lytes (sodium and potassium) in 600 mL water every hour doesn’t tolerate it well5.
during activity.
Step 4: Consume 30-45 g carb + 15 g protein + electro- Strategy: body type eating
lytes (sodium and potassium) in 600 mL afterwards.
If you’re anything more than a casual observer of human
Step 5: Eat normally within 1-2 hours after. beings, you might have noticed that — much like breeds
Step 6: Consume 0.25-0.5 liters (1-2 cups) of water at each
of dogs — they come in different shapes and sizes.
You’ll see everything from the giant wolfhound to the
meal.

380 | Unit 13
I types (ectomorphs) V types (mesomorphs) O types (endomorphs)
Figure 13.3 Body types
Table 13.5 General tendencies in body types

Ectomorph (I type) Mesomorph (V type) Endomorph (O type)
Skeletal structure and Light and lean Medium and balanced; natu- Heavier; more body fat
morphology rally muscular
May have longer limbs May have shorter limbs
Metabolism / response “High-revving” and “fast” Flexible “Slow”
to energy excess
Excess energy tends to... Be expended through activi- Build lean mass Get stored as fat
ty (e.g., fidgeting) and heat
Appetite regulation and Easily satiated; rarely hungry Normal appetite, hunger Often very sensitive to ap-
eating behavior and satiation petite and hunger cues; may
Some may say they aren’t feel as if they are “always
all that interested in food or May be more hungry if hungry” and “never full”
often “forget to eat” active (potentially less sensitive to
satiation and satiety cues)
Hormonal environment SNS dominant Testosterone and growth PNS dominant
hormone dominant
Thyroid dominant
(hyper-thyroid)
Carbohydrate tolerance Higher on average Normal Lower on average

Chihuahua; everything from the slim and wiry whippet — principles that can potentially help us target our
to the muscular bulldog to the rotund little Corgi. nutritional strategies.
Dog breeds also vary in their body composition, energy Body types are not “carved in stone.” They are not the
levels and metabolic rates… just like humans. Some peo- basis for “nutritional rules”, nor are they any specific sys-
ple seem to be always fidgeting, always in motion; other tem. (In other words, not all ectomorphs will be exactly
people tend naturally to be more sedentary. the same, and being an ectomorph doesn’t necessarily
cause anything to happen.)
Different body type groups — aka “somatotypes” — typ-
ically include a few general characteristics: Body types are simply a starting point.
• morphology and skeletal structure; Body types are a proxy for thinking about possible
• hormonal environment; and differences in metabolism, activity types, and nutritional
needs. As a coach, you can create some working hypoth-
• metabolism (including metabolic rate and how nutri-
eses using body types, which you can then test.
ents are processed).
Here’s a brief comparison of some of the general tenden-
If you specialize in a particular sport, especially at cies that you are likely to see with body types.
an elite level, you’ll often see that certain body types
gravitate towards certain activities, or specific positions Trained versus untrained
within sports.
It’s easy to think that being an ectomorph is somehow a
We divide body types loosely into three groups: “get out of nutritional jail free” card — these lucky folks
• I types (ectomorphs) seem to devour donuts with impunity, while the poor
downtrodden endomorphs must watch every calorie and
• V types (mesomorphs) gram of carbs.
• O types (endomorphs)
As usual, reality is more complex.
Importantly, these are just general conceptual categories
Indeed, instead of thinking of only three body types, we
Table 13.6 Trained versus untrained body types

Ectomorph (I type) Mesomorph (V type) Endomorph (O type)
Trained / Likely easily maintains a Likely above-average muscularity May have denser bones than
active “lean-normal” to “lean-athletic” and “lean-normal” to “lean-ath- average
body fat % letic” body fat
May have a fair bit of lean mass;
May struggle to put on muscle May have denser bones than potentially able to produce sig-
average nificant power
May still have relatively higher

body fat % or struggle to stay
lean
Untrained / Higher % of body fat despite May be overweight / have high Overweight to obese; high % of
inactive looking trim in clothing (i.e., body fat % along with a fair bit body fat
“skinny-fat”) of lean mass; may “carry it well”
(i.e., look proportionate even May have more bone density
May have trouble maintaining with a fair bit of excess body fat) and muscularity in areas bearing
adequate bone density (especial- weight
ly dangerous with aging) May be metabolically unhealthy
May be metabolically unhealthy
May lose muscle easily (aka
sarcopenia)
May be metabolically unhealthy

382 | Unit 13
might almost think of six: trained / active and untrained They may be tall and long-limbed (which is helpful
/ inactive versions of each. in sports that need both height / reach and low body-
weight), or they may be smaller (which is helpful in
You’ll notice that while the three body types may differ sports where low absolute bodyweight is important, such
somewhat in their trained and untrained / inactive as cheerleading or horse racing).
versions of themselves, being inactive is still a recipe for
poor metabolic and overall health and function. Ectomorphs tend to prefer endurance activities, and / or
sports where a good strength-to-mass ratio is important.
Ectomorphs’ natural appetite control and carb tolerance
may help them dodge a health bullet for a while… but Their engine speed is set to “high revving.” They tend to
unfortunately, almost nobody escapes the long-term be thyroid- and sympathetic nervous system-dominant
consequences of sedentary living. An inactive ectomorph with either a higher output or higher sensitivity to cate-
is likely to lose scarce muscle tissue (a process known as cholamines like epinephrine and norepinephrine. They
sarcopenia), and become “skinny-fat” and frail. typically have a fast metabolic rate.
Conversely, a very active endomorph may have a larger They’re high-energy. They’re often fidgeters and pacers.
body with more body fat, but still be metabolically They tend to burn off excess calories with near-constant
healthy and perform well physically. movement throughout the day.
Regular movement / activity and a well-trained body en- They tolerate carbs well. These are the rare folks who
sures that all three body types use and partition nutrients seem to eat starches with impunity. And because of the
effectively, and maintain a healthy body composition for activities they tend to gravitate to, they often need more
their somatotype. carbs.
I types / ectomorphs I types therefore generally do best with more carbohy-

drates in the diet, along with a moderate protein and
Elite endurance athletes, climbers, female gymnasts and lower fat intake. Thus, we recommend more healthy
dancers are typically light and lean; sparsely muscled carbs and less fat with a moderate amount of protein.
and light-framed, with delicate bones.
2 palms of 1 palm of
protein-dense protein-dense
foods foods
2 fists of 1 fist of vegetables

vegetables
3 cupped handfuls 2 cupped handfuls

of carb-dense of carb-dense foods
foods
0.5 thumb of
1 thumb of fat-dense foods
fat-dense foods
Figure 13.4 Type I meal portion

A nutrient distribution for this body type might be For each day, I type men might aim to eat:
around 55% carbs, 25% protein, and 20% fat. (But don’t
• 6-8 palms of protein-dense foods
drive yourself crazy with the math. Just think “higher
carbs and lower fat.”) • 6-8 fists of vegetables
• 10-12 cupped handfuls of carb-dense foods

Assuming clients eat about 4 meals per day, here’s what
that might look like using our portion control guide. • 2-4 thumbs of fat-dense foods
For each meal, I type men might begin by eating: For each day, I type women might aim to eat:
• 2 palms of protein-dense foods • 4-6 palms of protein-dense foods
• 2 fists of vegetables • 4-6 fists of vegetables
• 3 cupped handfuls of carb-dense foods • 7-9 cupped handfuls of carb-dense foods
• 1 thumb of fat-dense foods. • 1-3 thumbs of fat-dense foods
For each meal, I type women might begin by eating: V types

• 1 palm of protein-dense foods
Football running backs and safeties, soccer players,
• 1 fist of vegetables hockey players, wrestlers / MMA fighters, rugby backs
and flankers, and other sports that combine all-around
• 2 cupped handfuls of carb-dense foods
athleticism with speed, strength and power are typically
• 0.5 thumb of fat-dense foods mesomorphs: solid, strong-framed bodies that easily put
on muscle.
But remember, even these meal totals aren’t set in stone.
They are a simple way for folks to ballpark their daily If they’re taller, you might find them in sports like row-
total intake. The actual daily intake has more flexibility. ing, rugby, hockey, or basketball. If they’re shorter, you
might find them in weightlifting or gymnastics.
protein-dense foods protein-dense
foods
2 fists of vegetables
1 fist of vegetables
2 cupped handfuls of
carb-dense foods 1 cupped handfuls
of carb-dense foods
2 thumbs of
fat-dense foods 1 thumb of
fat-dense foods
Figure 13.5 Type V meal portion

384 | Unit 13
V types (mesomorphs) have a medi-

um-size bone structure and athletic
body, and if they’re active, they usually 100
have a considerable amount of lean mass.
90
Protein
Their bodies are designed to be power- 25% 30% 35%
80
ful machines. Excess calories often go
Carbohydrates
to building muscle, strong connective 70
tissues, and dense bones.
Fats 60
They tend to be testosterone and growth
50 55% 40% 25%
hormone dominant.
40
Thus, they can usually gain muscle and
stay lean easily. 30
V types therefore generally do best on 20
a mixed diet, with balanced carbohy- 20% 30% 40%

10
drates, proteins, and fats. So that’s what
we recommend. 0
Ectomorph Mesomorph Endomorph
A nutrient distribution for this body
type might be around 40% carbohydrate,
30% protein, and 30% fat. (Again, don’t Figure 13.7 Macronutrient differences based on body type
drive yourself crazy with the math. Just
envision a roughly balanced mix of all
three macronutrients.)
Assuming clients eat about 4 meals per day, here’s what For each day, V type men might aim to eat:
that might look like using our portion control guide.
For each meal, V type men might begin by eating: • 6-8 fists of vegetables
• 2 palms of protein-dense foods • 6-8 cupped handfuls of carb-dense foods
• 2 fists of vegetables • 6-8 thumbs of fat-dense foods
• 2 cupped handfuls of carb-dense foods
For each day, V type women might aim to eat:
• 2 thumbs of fat-dense foods
For each meal, V type women might begin by eating: • 4-6 fists of vegetables
• 1 palm of protein-dense foods • 4-6 cupped handfuls of carb-dense foods
• 1 fist of vegetables • 4-6 thumbs of fat dense foods
• 1 cupped handful of carb-dense foods
O types
• 1 thumb of fat-dense foods
O types (endomorphs) have a larger bone structure with
But remember, even these meal totals aren’t set in stone. higher total body mass and fat mass. Football linemen,
They are a simple way for folks to ballpark their daily heavyweight powerlifters, and throwers are typically
total intake. The actual daily intake has more flexibility. endomorphs, as are some rugby players (especially those
in the pack).

protein-dense foods protein-dense foods
2 fists of vegetables 1 fist of vegetables
1 cupped handful 0.5 cupped handful

of carb-dense foods of carb-dense foods
3 thumbs of 2 thumbs of
fat-dense foods fat-dense foods
Figure 13.6 Type O meal portion
Their engine speed is set to “idle.” They tend to be For each meal, O type men might begin by eating:
parasympathetic nervous system dominant. Unlike
• 2 palms of protein-dense foods
ectomorphs, endomorphs are built for solid comfort,
not speed. • 2 fists of vegetables
• 1 cupped handful of carb-dense foods

They’re naturally less active. Where the ectomorphs tend
to burn off excess calories with near constant movement, • 3 thumbs of fat-dense foods
excess calories in endomorphs do not seem to cause that
same increase in expenditure. This means that excess For each meal, O type women might begin by eating:
calories are more likely to be stored as fat. • 1 palm of protein-dense foods
They typically have a slower metabolic rate and generally • 1 fist of vegetables
don’t tolerate carbohydrates as well, particularly if they
• 0.5 cupped handful of carb-dense foods
are sedentary.
• 2 thumbs of fat dense foods
O types therefore generally do best on a higher fat and
protein intake with carbohydrate intake being lower. So But remember, even these meal totals aren’t set in stone.
that’s what we recommend: more fat and protein, less They are a simple way for folks to ballpark their daily
carbohydrate. total intake. The actual daily intake has more flexibility.
A nutrient distribution for this body type might be For each day, O type men might aim to eat:
around 25% carbs, 35% protein, and 40% fat. Again, no • 6-8 palms of protein dense foods
math gymnastics. Just think higher fats and protein,
lower carbs. • 6-8 fists of vegetables
• 2-4 cupped handfuls of carb dense foods

Assuming clients eat about four meals per day, here’s what
that might look like using our portion control guide. • 10-12 thumbs of fat dense foods

386 | Unit 13
For each day, O type women might aim to eat: Why carbs?
• 4-6 palms of protein dense foods
We focus on carbohydrates (and not protein or fats) be-
• 4-6 fists of vegetables cause carb needs are the most variable of the macronu-
trients, and fluctuating them can have a large impact on
• 1-3 cupped handfuls of carb dense foods
many important hormones (namely insulin, glucagon,
• 7-9 thumbs of fat dense foods thyroid and leptin).
Testing and outcome-based decision Generally, protein remains as constant as possible, al-
making though there may be rare situations where a low protein
intake is called for.
Once again: These body types and meal templates are
not “rules.” They’re possibilities, tendencies, and starting By changing carbohydrate and therefore calorie in-
points. take on particular days, we can keep fat loss going and
metabolic rate humming along, without the ill effects of
Consider all relevant factors along with body type, stringent calorie or carb restriction.
including age, activity level, goals, needs, and other met-
abolic issues (e.g., other hormonal health, any known Why cycle?
glucose tolerance).
There are a few cases that particularly benefit from carb /
Observe your clients carefully, monitor results closely, calorie cycling.
and use client data to make decisions. Stay flexible and
“steer dynamically.” For example:
Clients who want to see their six-pack must endure a

Strategy: Carb and calorie cycling lower-energy intake for long periods.
Some clients who are looking for below-average leanness Cycling calorie intake (for instance, with a simple higher
and above-average body composition may find it useful day / lower day) helps stave off metabolic downregula-
to cycle their carbohydrate and calorie intake. tion that often occurs with a chronic, ongoing energy
deficit.
Important: This, like all Level 2 strategies, is not “magic”,
or a “rule.” It’s a tool and a technique. Which may work. Plus, cycling intake can make an energy deficit feel like
Or not. less of a “grind” by blocking off “eat less” days into small,
manageable units instead of several weeks of miserable,
Despite the fancy name, carb and calorie cycling are hungry slogging.
quite simple concepts.
Clients who don’t tolerate carbs well may nevertheless
• Carb cycling refers to eating more carbohydrates use them effectively when active.
on some days; and fewer carbohydrates (and often,
as a result, fewer calories) on other days. A client may So, they can literally have their cake and eat it too
also do a “mini carb cycle” during a day, eating more — by getting the bulk of their carb intake around
carbs around activity and less at other times. their workouts. (Even better, with time and sustained
activity, they may become more metabolically healthy,
• Calorie cycling refers to (you guessed it) eating which means improved overall carb tolerance and more
more calories on some days, and fewer calories on dietary flexibility.)
other days. This can also include some rudimentary
forms of intermittent fasting. (For more on IF, see Unit Clients with underlying metabolic issues (such as poor
14, “Working with Level 3 Clients.”) glucose control or elevated inflammation) may benefit
from short bursts of fasting. Periodic, brief intermittent
You can, of course, combine carb and calorie cycling, so fasting has also been shown to improve many indicators
that, for instance, higher-carb days are also higher-calo- of metabolic health.
rie days and vice versa.
For clients who can do this protocol safely and sanely,

short periods of lowered calories (or no calories) may For some clients, this could mean having specific low-
improve these health markers. carb or high-carb days, or low-calorie / high calorie
days. These days could simply be alternated, or clients
Clients who are trying to safely manage stress (includ- might deliberately deplete their carb stores over a period
ing training stress) may find that cycling carbs and calo- of several days.
ries helps them “dance at the edges” of an energy deficit
or significant change to their body, without incurring
Method 1: High / low days
major hormonal disruption.
The carb and calorie cycling approach is pretty simple,
Periodically “topping up” energy and carbohydrate
and based on the client’s activity.
stores can tell the body that everything’s okay, and star-
vation is not imminent. This is particularly useful for: • On days with minimal physical activity: The client
eats a baseline diet of mostly protein, vegetables and
• female clients (whose central hormonal regulation
healthy fats with minimal carbs (maybe a total intake
systems may be very sensitive to nutritional deficits)
of 2-4 cupped handfuls).
• leaner clients (who usually have less circulating
• On days with physical activity and / or planned
leptin)
exercise: They add starchy carbs to the baseline diet
• anyone who has a relatively lower stress tolerance (maybe a total intake of 8-12 cupped handfuls).
Getting enough carbs and energy is key for hormonal as And that’s pretty much it. No need to measure grams or
well as psychological health. Many people find they feel count calories. Just follow a baseline diet on lower-carb
mentally sluggish, moody, anxious, and / or depressed days. And add carbs on higher-carb days.
in the face of chronic carb or energy deficits. Cycling cal-
ories and carbs can help avoid these problems as clients
Method 2: Post-workout / anytime
work towards below-average leanness or higher-level
athletic performance. Another approach is to put the bulk of a day’s carbohy-
drate intake in the meal that follows physical activity
Clients who are trying to cut weight or change the
(post-workout), while minimizing carbohydrates at
appearance of their physique for competition can also
other meals (anytime).
benefit from carb cycling in particular, because carbohy-
drate intake affects fluid balance in the body. For more This would be the Post-workout and Anytime meal
on this, see “Competition Day Nutrition” on page 455. approach.
Clients with religious observations may “naturally” An Anytime meal, as its name implies, can be eaten any
do calorie cycling on fasting days such as Ramadan, time outside of exercise. An Anytime meal:
Yom Kippur, or Lent. While they may not specifically be
doing this for Level 2 goals, you can advise them on how • has an appropriate serving of lean protein (about 1-2
best to manage their nutritional needs, especially if they palms)
are active. • has an appropriate serving of healthy fats (about 2-3
thumbs)
Scheduling cycling
• fills out the remainder with non-starchy vegetables
Usually, higher-carb / higher-calorie periods occur (ideally colorful ones)
during times with lots of activity, while lower-carb / low-
er-calorie periods occur during times with less activity. An Anytime meal can also include a small portion of
high-fiber, slow-digesting carbohydrates, such as beans,
For some clients, this could mean eating more carbs lentils, or fruit (about 0.5-1 cupped handful).
around a day’s workout or training session, with fewer
carbs at other times. The Post-workout plate is for meals that take place after
physical activity. This meal type helps us take advantage

388 | Unit 13
Water Water
or tea or tea Starches
including
potatoes, pasta,
rice or bread
Protein
including red meat,
chicken, fish, eggs or
vegetarian source Protein Veggies
Veggies including red meat, & Fruit
including a wide chicken, fish, eggs or
Fats variety of vegetables vegetarian source
including a wide
variety of vegetables
including healthy and some fruit
oils, nuts and seeds
Anytime Meal Post-workout Meal
Figure 13.8 Anytime / Post-workout meals
of the body’s metabolic response to exercise, and the im- So, here is how this might play out in a few sample days:
proved glucose tolerance that occurs during the post-ex-
ercise period (or any period following higher amounts of
Monday Tuesday Wednesday
physical activity). Workout day No workout, but No workout,
still physically and not physi-
A Post-workout meal: active cally active
• has an appropriate serving of lean protein (about 1-2 Meal 1: Meal 1: Meal 1:
palms) Anytime Anytime Anytime
• is lower in healthy fats (about 0.5-1 thumb)
Workout Ride bike to work Meal 2:
• has an appropriate serving of carbohydrates (often and work physical- Anytime
ly active job
simpler, faster-digesting carbohydrates, about 3-5
cupped handfuls) Meal 2: Meal 2: Meal 3:
Post-workout Post-workout Anytime
Note:
• A baseline level of protein is included for all meals
Meal 3 Ride bike home Meal 4:
(1-2 palms). Anytime from work Anytime
• As carbs go up, fat goes down. As carbs go down, fat
Meal 4 Meal 3:
goes up. Anytime Anytime
(possibly
• We say “appropriate serving” and give some exam-
Post-workout if
ples. Of course, the actual serving size depends on extra calories
each client’s body size, body type, needs, and goals. needed)
Begin with the hand size portions of nutrient-dense Meal 4:
foods form, and tailor accordingly. Anytime

Remember: Level 1 strategies performed consistently • What objective, peer-reviewed research demonstrates
must come first. If your client hasn’t done those yet (and that this supplement does what manufacturers say it
doesn’t have the psychological maturity to try this struc- can do — without causing harm?
tured form of eating), this strategy usually backfires.
• What interactions could this supplement have with
other medications or supplements that my client is
Strategy: Basic supplementation already taking? Other foods they’re already eating?
The topic of nutritional supplements is controversial, to • Do I trust this supplement and its manufacturer? Why
say the least. or why not?
Some argue that we need nutritional supplements for a This doesn’t have to be an all-or-nothing choice. If a
healthy, energetic life; others argue that nutritional sup- client does well with their food intake some days but not
plements have little to no value and simply make supple- so well on other days, perhaps they can be a part-time
ment companies rich. supplement user.
Both views are overly simplistic. Sure, they make For example, they might take a protein supplement
answering supplement questions easy, but they prevent on days that their protein intake from whole foods is
critical thinking. low; on higher-intake days, they can skip the protein
supplement.
As a health care practitioner, it’s your job to evaluate the
evidence and decide what’s best for your clients. If you’re going to recommend a client take a supplement,
you should know which system you hope to affect.
Begin with assessment and
understanding For example, creatine targets the ATP-PCr energy
system and can also help to increase lean body mass by
As we’re fond of saying, supplements are supplemental improving the body’s work capacity. If a client doesn’t
— to a consistently high-quality diet. need to target this system (due to low-volume or in-
frequent workouts, for example), then they might not
At Level 1, your supplementation may be geared towards need creatine. However, if a client is training hard, is
correcting deficiencies. At Level 2, your supplementation looking to add lean mass, and performs high-intensity,
may become more sophisticated. ATP-PCr-dependent exercise bouts, creatine may be a
useful supplement for them.
Your approach to supplements should be pragmatic
and evidence-based: If you recommend a nutritional Choosing nutritional supplements is tough. There’s
supplement to your clients, it should be based on a strict so much information available, and most of it is from
supplement needs analysis. parties who may be biased in one direction or another.
Therefore, it’s best to ignore marketing messages and
Ask yourself the following questions before choosing to
turn to an appropriate body of knowledge to decide
use a nutritional supplement:
whether a supplement is useful and / or safe.
• How do I know for sure that my client needs and will
benefit from this supplement? (For instance: Have This knowledge can include scientific reviews, scholarly
textbooks, and academic journals, which are monitored
you done nutritional testing? Reviewed their food
by other researchers in the field (aka peer-reviewed) for
intake? And so on.)
accuracy and scientific rigor. Do not depend on main-
• Which physiological system do I hope to target with stream magazine or newspaper articles, books published
this nutritional supplement? Does my client need in the popular press, websites, or anecdotal evidence (in
that? other words, someone else’s opinion on “what worked
for them”), as the quality of these is not controlled.

390 | Unit 13
What you might recommend Level 1 strategies. This shows that we may do the same
thing for different reasons.
Here are some possible supplements that you might
consider at Level 2, depending on each client’s individual For instance:
needs:
A multivitamin / multimineral supplement
• a multivitamin / multimineral supplement (also a
• For a Level 1 client, may correct some basic deficien-
Level 1 strategy)
cies caused by a poor diet.
• an omega-3 (EPA / DHA) supplement (also a Level 1
• For a Level 2 client, the same supplement may ad-
strategy)
dress potential deficiencies caused by higher activity
• a powdered or liquid greens supplement (also a Level levels and training stresses.
1 strategy)
An omega-3 supplement
• protein powder (also a Level 1 strategy)
• For a Level 1 client, may correct some basic deficien-
• probiotics (balance gut microbiome)
cies caused by a poor diet.
• digestive enzymes (reduce digestive issues, enhance
• For a Level 2 client, may help control inflammation
food absorption)
and enhance fat loss.
• creatine (support strength, power, and anaerobic
activity) A greens supplement
• beta-alanine (support anaerobic activity) • For a Level 1 client, may correct some basic deficien-
cies caused by a poor diet, and help clients transi-
• pre-workout caffeine (enhance fuel utilization and
tion to a “whole-foods” diet that includes fruits and
CNS drive)
vegetables.
• branched-chain amino acids (BCAAs; support perfor-
• For a Level 2 client, may be part of an “on the road”
mance and recovery)
strategy for athletes who may not always have access
• specific minerals (e.g., magnesium; prevent deficien- to fresh produce.
cy or enhance function)
Protein powder
• specific vitamins (e.g., vitamin D, B12; prevent defi-
ciency or enhance function) • For a Level 1 client, may make it easier to increase
protein intake (especially for plant-based eaters).
• electrolyte solutions (support performance and
re-hydration) • For a Level 2 client, may be an essential supplement
for convenience, portability, post-workout recovery,
• anti-inflammatory formulations (e.g., curcumin,
and / or boosting protein intake to the levels neces-
ginger)
sary for top athletic performance or optimal body
• antioxidant formulations (e.g., resveratrol, green tea composition.
catechins)
Notice that “correct basic deficiencies” or “help client
• bone and joint support (e.g., glycosamingens, egg- transition to a better diet” are two of the most common
shell membrane) reasons to supplement at Level 1, while “improve perfor-
• supplements to support sleep (e.g., L-theanine, mance”, “increase recovery”, and “eat well when train-
5-HTP, valerian, ZMA, melatonin)
ing, competing, and traveling” are the most common
reasons for Level 2 supplementation.
Have clear goals and rationale for
There are many possibilities for supplementation for
supplement use Level 2 clients, depending on their needs and goals.
You may notice that some of these supplements (such
as a multivitamin / multimineral supplement) are also

Choose supplements wisely

For all supplement recommendations:
• Review the evidence supporting their use.
• Choose only trusted brands and manufacturers that have been independently
tested for quality. Be aware that poor-quality supplements may contain toxic
materials (such as heavy metals or other contaminants) or banned ingredients
(such as stimulants or substances that can cause a positive hormone test); or
simply not enough of the ingredient you want.
• If your client is an athlete, review all supplement guidelines for their sport
federation. In sports or competition levels with stringent testing, be extremely
careful.
• Only use supplements if appropriate and if your client will genuinely benefit
from them.
We recommend:
• ConsumerLabs.com (for brand testing and reviews)
• Examine.com (for research reviews of the evidence supporting specific

supplements)
To learn more about which products we recommend, check out www.precision-

nutrition.com/supplements.
Safety first
While many consumers believe that if a product is on the market, it must be okay
to use, that isn’t always the case.
Not all jurisdictions legislate or control supplements equally.
For instance, in the United States, the Food and Drug Administration (FDA) Food and Drug
does not test the effectiveness, safety, or purity of nutritional supplements. Di- Administration (FDA): A
federal agency in the United
etary supplements do not need approval from the FDA before they are marketed. States responsible for monitoring
trading and safety standards in US
And except in the case of a new dietary ingredient, where pre-market review for food and drug industries (but not
safety data and other information is required by law, a supplement manufacturer dietary supplements)
does not have to prove a supplement is safe or effective before it goes to market.
ConsumerLab, NSF: Third-party
It’s impossible to know whether a supplement contains what the label says it labs that can verify supplement
should contain, whether a supplement actually does what it’s supposed to do, ingredients
or whether taking a supplement will lead to health benefits or health problems. Natural Health Products
However, products verified by independent third-party labs (such as Consumer- Directorate (NHPD): The
Lab, NSF) should come as advertised. regulating authority for natural
health products for sale in Canada
On the other hand, in other countries like Canada, stricter regulations are in good manufacturing
place. Before any supplement is produced / marketed, this product has to be practices (GMP): Practices
cleared by the Natural Health Products Directorate (NHPD). The NHPD en- helping to ensure that
supplements are consistently
sures that each supplement company and manufacturer has a proper license, that
produced and controlled
each manufacturer follows good manufacturing practices (GMP), that there according to quality standards

392 | Unit 13
is thorough adverse event reporting, that clinical trials • If you’re working with a sports team or organization,
support claims and safety, and that standard labeling consider partnering with a trusted manufacturer to
conventions are used. provide custom product(s) for your clients / athletes.
Rather than buying from commercial supplement
Similar regulations are in place across most of the Euro- companies, go behind the scenes to set up a deal
pean Union (EU). For instance, any herbal preparation with the manufacturing company. This way you can
must show data on the supplement’s quality, safety and get exactly what you want for your clients / athletes
and you can reduce your risks of being exposed to
efficacy before being allowed on the market.
a banned substance or impure product. (Note that
This means that supplements coming out of Canada or manufacturing companies will typically only do cus-
tom supplements for very large product orders.)
the EU are more likely to be labeled properly, safe, and
effective.
As you can see, supplementation offers some real risks
(Although when it comes to athletes, it doesn’t necessar- and challenges.
ily ensure that supplements are free of banned substanc-
es. After all, some IOC-banned substances are perfectly Before making supplement recommendations, educate
legal in non-athlete populations.) yourself.
Most other regions, such as Eastern Europe, Asia, Africa, If you’re not interested in doing all this homework, that’s
or Central and South America, are much less regulated fine. After all, many clients with high-quality diets and
in both drugs and supplements. appropriate recovery protocols, all done consistently,
don’t need more than that.
Here are some steps you can take to cover your bases:
Yet, if you believe your client is falling short and / or
• If you’re working with an athlete, be sure that the
would benefit from targeted supplementation, you may
supplement you’re recommending isn’t on a banned
want to refer to someone in your health care network.
substance list.
• Be sure that the supplements / foods you recommend

don’t have any interactions with any medications /
Competition day nutrition
drugs your client is taking. The pharmaceutical com-
Since many of your Level 2 clients will be athletes, they’ll
pany Merck has a comprehensive listing of dietary
supplement- and food-drug interactions in their
undoubtedly want to know more about what to eat just
online Merck Manual of Medical Information (Home before and during a competition.
Edition). The Natural Medicines Comprehensive Da-
tabase also has a useful online tool. We also recom-
First, remember: What and how an athlete eats every
mend talking to your client’s pharmacist if possible. day is most important. Just as athletes must drill and
practice their sport skills consistently, they must start
• Choose a larger company that’s been doing business with good consistent training nutrition. See “Workout
for quite some time, that provides certificates of Nutrition.”
analysis, and that is certified by a third party. The NSF
does the most comprehensive third-party certification On the competition day, they should only have three
/ testing of nutritional supplements for sport. Another goals:
organization, HFL Sport Science, is an independent
drug surveillance laboratory providing doping con- Goal 1: Do what they’ve practiced
trol and banned substance testing for supplements
through the Informed-Sport program. Another option Athletes should practice and rehearse their competi-
is to visit www.consumerlab.com or www.labdoor. tion-day routine.
com. These comprehensive websites are devoted to
reviewing purity and label claims for a variety of nutri- Warming up at 10 a.m. and competing at 12? Then
tional supplements on the market today. they should do a trial run well before the competition
day. Wake at the same time, eat the same foods, and
• Choose supplements that only have a few ingredi-
perform the same athletic feat.
ents. If you’re looking for creatine, buy creatine only.
If you’re looking for a protein supplement, make sure
Don’t leave things to chance. Don’t try anything new on
there’s only protein. Review the ingredient list; usual-
competition day.
ly the fewer the better.

Prepare, rehearse, anticipate. Keep things as familiar as Don’t rush to over-feed or over-hydrate an athlete who’s
possible. Control as many variables as you can. cut weight, unless you want them to spend their tourna-
ment time with GI upset.
Goal 2: Supply the body with energy for
the competition No alcohol until afterwards, especially if the athlete has
traveled across time zones and / or by air.
On competition days, an athlete should ensure that the
nervous system is stimulated for performance and that A note about post-competition partying
they have a constant supply of blood glucose to prevent
them from bonking. If you’ve ever cut weight or simply been very amped-
up and nervous for a competition, you’ll know that
Therefore, the competition day strategy is simple: the combination of adrenaline and energy demand
can make you ravenous afterwards. Plus, if you’re with
• Eat small, easily digested foods frequently through-
a team, you might want to go and celebrate a win (or
out the day.
drown your sorrows after a loss).
• Ensure that these smaller meals contain proteins, fats,
Many sports teams are legendary for post-game partying
and most importantly, quality carbohydrates.
and taking down all-you-can-eat platters with beastlike
• Eat familiar foods — the foods they know and trust. abandon. This may include alcohol and recreational
drugs, plus losing valuable sleep.
Certain sports supplements (even caffeine) can help with
nervous system stimulation and others can help to pro- Partying and celebrating are fine if they don’t cut into
vide carbohydrate energy. In fact, liquid nutrition is very your athletes’ performance, optimal body composition,
useful for sipping between events if an athlete is going to and recovery. A post-championship blowout comes
have several heats or events during the same day. along only once a year, for instance.
Liquid protein plus carbohydrate (P+C) drinks help re- But if you’re finding that your athletes are spending
plenish fluids, are often better tolerated, and can provide more time in the bar or at the buffet than they are on the
rapidly and easily digested protein and carbohydrates for field, have a conversation with them about balance.
between-event recovery.
Test the level of caffeine your athletes can tolerate under Troubleshooting Level 2
these more stressful conditions. Competition day nerves
(plus things like travel) may compound the effects of any
stimulants, leaving your athletes a tweaked-out mess if
Realistic expectations
they have even their normal doses of caffeine. Most people would readily admit that expecting to lose
10 lb of fat or gain 10 lb of muscle, to correct serious
Goal 3: Avoid foods that make them
blood lipid issues or to cut their 40-yard dash time from
uncomfortable 5.5 to 4.4 seconds in two weeks is unrealistic.
As many athletes are hyper-stimulated on competition Yet subconsciously, many people want to believe that
day, they find it more difficult to tolerate large meals or these results are not only possible, but likely.
slowly digested foods.
While many books, experts, programs and products may
They should eat foods that make them feel good, that promise results like these, they are not reality. In reality,
don’t aggravate their stomachs, and, for most athletes, things are often less difficult than we think they’ll be,
that make them feel “light.” but take longer than we think they’ll take.
During the practice run we suggested, experiment with Failing to achieve an impossible goal, even with perfect
different foods until you find a routine that works well nutrition, tells someone nothing about how to achieve
for you. Even foods that aren’t part of a usual “good nu- their goal. If a client’s nutrition plan hasn’t produced the
trition” plan are acceptable here as long as blood sugar is results you expected, consider whether their expecta-
managed and the athlete feels energetic and comfortable. tions (and yours) were realistic.

394 | Unit 13
Determine three things about goals: So how do you go about getting them?
What is the upper limit of achievement? Find someone who has achieved what your clients want
to achieve.
How much can someone truly hope to achieve, assuming
they do everything right, and do it consistently for as Consult as many people as you can find and take an
long as it takes? average of their responses. Generally, other knowledge-
able coaches will help you out with this for free or for a
Do they really have the genetic makeup to run a 4.4-sec- low cost.
ond 40-yard dash?
Ask about their methods, how they track progress, and
Can they really be 225 lb at 5% body fat? what they look for in terms of goal criteria (e.g., in order
to achieve X later, a client must be able to do Y now).
Are they young enough, talented enough, and hungry
enough to succeed in elite athletics? Look for small, continual progress.
How long will it take to get to this upper Kaizen is a Japanese word for the concept of small, incre-
limit? mental, continual progress. The idea is that by making
these tiny gains consistently, you can achieve goals you
What is a realistic rate of achievement? thought were beyond your reach.
Will they improve at a consistent rate or will improve- For instance, the motivational speaker Tony Robbins
ment come faster at some times than at others? used the principle to convince people to make small
strides toward personal development goals. Strength
If consistent, how much improvement should they ex-
coach Charles Poliquin used it to support or explain the
pect every two weeks?
concept of “microloading” — using load increases of as
If variable, how little improvement should they be will- little as half a pound to ensure continual strength gains.
ing to accept during periods of slow returns, and how
We’ll use the concept to help measure our progress.
long should they expect those periods to last?
When the client can’t settle on an expected result for a
Are they willing to do what it takes? two-week measurement, choose the smallest increment
that you can measure and make sure they improve by
Do they have what they need? that increment every two weeks.
If not, are they willing to change things? Spend money? Let’s say your client is trying to put on muscle mass, but
Focus on their goals to the exclusion of everything else? all they have at their disposal to measure progress is a
bathroom scale.
If they want to run a 4.4-second 40-yard dash, do they
have all the other resources in place to do so, like a great A simple but effective tactic is to simply make sure that
running coach and a great training program? every time they step on the scale, the measured weight
increases by at least the smallest measurable increment.
If they want to be 225 lb and 5% body fat, are they Every two weeks, the goal is to see that needle move one
willing to do everything it takes to get there? Are they notch to the right. That’s it.
willing to sacrifice family dinners, social events, restau-
rant meals, perhaps even health, relationships and / or Certainly, you could do a much more detailed mea-
job opportunities? surement than that, but if that’s all they do, you’re
already ahead of the game, as they’re at least moving
These are not simple questions to answer. In some cases in the right direction. The magnitude of that change
you won’t have the expertise to answer them. (i.e., how much actual progress they make) is import-
ant, but secondary.
But if you want to have a standard by which to judge a
client’s progress, you need those answers.

So here’s the process, which is essentially a feedback loop 7 steps to individualization

of observe - orient - decide - act (OODA):
1. Choose a goal. Here’s the basic outline for individualization:
2. Broadly determine whether that goal may be realistic. Step 1: Ensure that the client has mastered Level 1 strat-
(You’ll revisit this over and over.) egies and can do them consistently, even under stressful
3. Select a metric to track progress toward that goal. conditions.
4. Start moving towards the goal using whatever means Step 2: Consider your client holistically. In particular,
you have available. consider their:
5. Observe what happens. • goals
6. Revise and refine progress metrics. If your client can’t • needs
determine a realistic rate of achievement for the goal,
• skills and abilities
try to progress by the minimum measurable increment
every two weeks. • knowledge
7. Revise and refine the process as needed (e.g., Does the • willingness to follow direction and get feedback
client need more guidance or a different system?).
• mindset
8. Keep moving towards the goal.
• lifestyle
9. Observe what happens.
• physiological makeup
10. Revisit whether the goal is realistic.
Step 3: Design the baseline individualized plan. Treat it as a
And so on. starting hypothesis and a prototype.
Guidelines vs. needs Step 4: Take the new plan for a test drive.
Step 5: Monitor your client closely and measure their

Remember that all of the recommendations in this text-
progress regularly.
book are guidelines, not rules. They’re starting points
and ideas on how to tailor your nutritional advice. Step 6: If the plan delivers the results they’re looking for,
keep it up.
These recommendations are the first step of the jour-
ney, not the final destination. Step 7: If the plan doesn’t deliver the results they’re look-
ing for, use outcome-based decision making to make
We know you want answers and you want them now.
adjustments.
There are a lot of answers here. All of this information
is based on years of experience, trial and error, and the What to do afterwards
best available research.
Most of these strategies aren’t permanent. For instance,
Still, science is always provisional. Our knowledge is most people won’t stay extra-lean, or at the peak of their
always partial, always subject to change when new and competitive athletic career forever.
better evidence comes along. (For instance, new findings
in genetics, epigenetics, and our microbiome are literally Once your Level 2 client has gotten to their goals, then
rewriting our textbooks on human physiology.) what?
Every set of recommendations we make is a best The simplest step is just scaling back to Level 1. This
guess. An informed approximation of needs. allows clients to transition to normal, sustainable eating
with reasonable trade-offs.
It’s only once clients begin to apply these recommenda-
tions that true individualization begins. This also prevents the “feast / famine” cycle that often
follows periods of higher dietary restraint.

396 | Unit 13
For example, someone might follow a more regiment- back all the way to Level 1, you can also explore this
ed eating routine, but after the goal has been reached, with them. Find out what aspects of Level 2 nutrition
it becomes a food “free for all.” Over-eating ensues. were most do-able and reasonable, and build the next
Sometimes this urge to over-eat can be so strong after a program around that. Eliminate or minimize the most
restriction that it can wipe out all progress they’ve ever troublesome or difficult aspects. Level 1.5 if you will.
made, leaving them worse off than they were originally.
An example might be carb / calorie cycling.
So, a better option for the client would be to ease back
into a Level 1 approach, preventing any extremes. Maybe the client was only eating 1 cupped handful for
carb-dense foods on lower-carb days, and this was a bit
If possible, talk about this transition with clients before it too low. Maybe increasing to 1.5 cupped handfuls would
happens. Some clients will be so focused on the imme- be a next step. Or maybe they stay at 1 cupped handful,
diate goal at hand that they haven’t given any thought to but instead of 5 lower-carb days (and 2 higher-carb days)
what happens for breakfast the morning following the each week they aim for 4 lower-carb days (and 3 high-
competition / event. er-carb days).
Now, if the client wants to test the waters of Level 2 and Adjust the variables until the client finds the sweet spot
spend time finding a sustainable strategy without going of sanity and sustainability.
Case study
You’ve been working with a 34-year old female client She wants to reach 15% body fat. So, that would mean
named Shannon for the past year. she needs to lose ~0.5% body fat every week up until
the competition.
Shannon has gotten to 90% consistency with the Level
1 strategies and has met all of her initial goals. She has A few questions to consider:
no history of disordered eating and appears to be quite Would Level 2 strategies be safe and appropriate for
rational about food choices. She is only taking one med- Shannon?
ication, a birth control pill.
If yes, what would be your first step? Why?
Shannon has decided that she wants to pursue a figure
competition — a physique competition requiring lower If not, why not?
body fat and more muscularity (but less extreme than
Would any supplements be appropriate for Shannon
bodybuilding).
during this 12-week period?
You’ve discovered that for Shannon, following the
If yes, which ones and why would you choose them?
Level 1 strategies alone won’t be enough to make her
competitive in the figure competition. After a discus- If not, why not?
sion with Shannon about this, you both agree that
Are Shannon’s goals realistic for the given time frame?
higher-level strategies will be needed in order for her to
reach her goals. If yes, how so?
She has 12 weeks to prepare for the competition. If not, what might be more realistic?
Currently, she’s: What would you do after the 12 weeks are over?
• 5´8˝ (1.72 m) tall Why?
• 150 lb (68 kg)
• 21% body fat

Summary
Before progressing with Level 2 strategies, make sure • Calorie cycling is taking in more energy (calories) on
that the client is consistent with Level 1 strategies. some days and less energy on other days. This can
Most clients will be able to reach their goals with Level include basic forms of intermittent fasting.
1 strategies.
• Carb and calorie cycling can be combined.
Level 2 clients are those who have mastered Level 1 strat-
egies, have progressed as far as they can, need a bit more Supplementation is an add-on to existing good habits
individualization, and are emotionally mature enough to and a high-quality diet. When well-chosen and carefully
try more advanced strategies. applied, it can be valuable for clients.
Most Level 2 clients will require more precise obser- Be careful and smart about your supplementation.
vation, measurement, and analysis, using tools such as Review evidence, think critically, match supplements to
food journals. Food logs give the coach great insight into your client’s goals and needs, choose reputable manufac-
the daily nutritional habits of a clients and often help to turers and brands, and use extra caution when supple-
make clients more aware of their own intake. menting athletes’ diets.
Most Level 2 clients will be active; many will be athletes. Competition day nutrition should help athletes maintain
For clients doing longer, more frequent, and / or more constant energy and alertness throughout their event.
intense bouts of physical activity, adding intra-workout Rehearse all food choices and procedures well before the
nutrition can help with recovery, performance, and opti- actual event.
mal body composition. Set realistic expectations. Not everyone can look like the
Body type eating is when food intake is adjusted based professional model on the cover of a magazine or achieve
on macronutrients to better align with the tendencies of at the highest levels of athletics.
certain body compositions and activities. All of the strategies we outline in this unit are a start-
The concept of “cycling” here refers to varying energy ing point. Adjust based on feedback and measures with
intake and macronutrients over time. the client.
• Carb cycling is simply eating more carbohydrates on

some days — usually on high-volume or high-intensi-
ty physical activity days — and eating fewer carbohy-
drates on other days — usually low-volume, low-in-
tensity, or days with minimal physical activity.

UNIT 14

Unit Outline
1. Level 3: Special situation nutrition 4. Case study
2. Level 3 strategies 5. Summary
3. Troubleshooting Level 3
Objectives
In this unit, you’ll learn about the Level 3 nutritional strate- they need, and how to monitor them. You’ll learn some es-
gies, meant to be used for short periods of time in order to sential Level 3 techniques, and how to support your client
peak for an event. in executing them as safely and sanely as possible.
You’ll learn about what qualifies as a Level 3 client, what
Level 3: Special situation nutrition

Welcome to the land of numbers and exacting precision: Unless you work exclusively with bodybuilders, phy-
Level 3. It’s a foreign land that most clients don’t visit… sique competitors, elite endurance athletes, elite weight-
and never should. classed athletes, and / or professional models, almost
none of your clients will be Level 3s.
Once again, the vast majority of your clients will be —
and stay — Level 1s. Some more advanced exercisers or Table 14.1 provides an overview of what Level 3 clients
athletes, or people with higher-level physique goals, can look like.
move to Level 2 after mastering all of Level 1.
What you need to know about Level 3
And then, there’s Level 3: The few, the proud, the highly
restrictive, the counters of grams, timers of intake, and Level 3 approaches are mostly about looks and
measurers of portions.
/ or performance.
What does a Level 3 client look like? Level 3 clients want to get leaner or improve athletic
performance beyond what they can do with the Level 2
Level 3 clients are special situation clients. approach.
Level 3 strategies are for the rare, nutritionally experi- Level 3 strategies definitely don’t make clients any healthi-
enced people with specific, aggressive goals such as: er or give them a better quality of life.
• competing in a physique contest Indeed, depending on how far someone takes them...
• preparing for elite-level competition
Level 3 behaviors can become actively
• needing to reach very specific body composition
unhealthy.
numbers for performance, competitive, or aesthetic
reasons (likely body fat goal ranges of 4-8% for men, If a client engages in Level 3 behaviors too stringently
and 12-18% for women) and aggressively:

400 | Unit 14
Table 14.1 Level 3 client features

Typical goals Elite/professional athletic performance and career
Elite/professional physique/fitness competition and/or modeling career

Level of athletic performance Elite/professional; nationally or internationally competitive
or body composition require
Body composition desired or Extreme leanness and/or muscularity
required1
Men: below 8% body fat
Women: below 17% body fat

Training load 15-20 hours a week or more
Knowledge Expert2
Competence and skill High
Follows a complex plan to the letter

Consistency High
Can do any task, no matter how complex, 90% of the time or more
Has a base of sustainable habits and a consistent foundation of essential behaviors

Mindset / psychology “Don’t ask; just do.”
“Everything is secondary to this.”
“This is my life/job.”
“I want to be one of the best in the world.”

Limiting factors Everything in the client’s environment (routines, people, physical environment, etc.)
supports execution of tasks; client is 100% dedicated to getting things done and
everything around them facilitates that
1 Note: Clients will vary widely in their body compositions depending on their age, sex, genetic makeup, etc. What is “un-
reasonably lean” for one person may be another person’s “normal." Look for natural tendencies and try to get a baseline
of what is appropriate for each client. “Normal” is the body composition that a client can easily and sanely maintain doing
basic Level 1 habits consistently.
2 Most clients at Level 3 will have coaches. So the clients themselves need not be experts, but they should be guided by
someone who is.
• Body fat can start to drop too low. Hormones and Level 3 behaviors are usually short-term
recovery can be disrupted. strategies.
• Behaviors, thoughts, and feelings about food, eating,
and training can become disordered. Clients may
term goal, such as a competition, or to support higher
start to have mental and emotional health problems levels of athletic training at certain times in their com-
such as anxiety, depression, and / or obsessive-competitive season.
pulsive tendencies.
• Social relationships and other interests — which we
Level 3. In fact, no one is meant to live at this level. (You’ll
need for overall wellness and quality of life — may see what we mean when you review the list of Level 3
suffer. behaviors below.)

As a coach, it’s your role to inform your clients that loves to get things just right, and tune them into
about all the trade-offs. glorious harmony. You must be diligent, careful, and
consistent. Essentially, you’re an engineer of the human
Help clients know what to expect and look for as they body.
You must play the long game. Never sacrifice your clients’
You’ll notice that while Level 2 tasks sometimes involve long-term health for short-term gains. And make sure you
expanding choices (e.g., add a new food), Level 3 tasks monitor them almost as closely after the big event as you
usually involve limiting choices. did beforehand.
Monitor clients carefully. If this doesn’t sound like a good fit for you as a coach,
that’s okay. Have a Level 3-friendly coach in your sup-
At Level 3, all clients should be working under supervi- port network and refer out as needed.
sion and keeping detailed records of what they are doing.
And if at any point you feel the strategies we recom-
Track your client’s physical, psychological, and social mend below are beyond your ability, outsource the
indicators closely. Make outcome-based decisions using nutrition plans of your Level 3 clients to a sports nutri-
data. tionist whose nutrition programs will account for food
type, timing, and amount for different activity levels
You’ll notice that many of these coaching tasks (such as and body types.
water manipulation or caloric restriction) put your client
at risk. While you’ll certainly be able to help clients with this
level of fine-tuning, and this unit should help clarify just
In conjunction with your clients, decide on acceptable how to do so, it’s okay if you either don’t want to get this
risk in advance and have an “escape plan” at all times to involved or you feel like this level of individualization
help guide your client back to balance if needed. should only be done by licensed professionals.
What you need to know about yourself Just decide on your comfort level and boundaries, know
where you operate best and most confidently… and out-
It might seem a bit strange to talk about you, the coach, source the rest. Go team!
when we’re supposed to be talking about Level 3 clients.
But coaching Level 3 clients is both an art and a science, Level 3 limiting factors
and it’s not for everyone.
By Level 3, people won’t have many limiting factors.
You must be sane and balanced — exceptionally so.
Otherwise you can get sucked down the rabbit hole of Their routines, environment, mindset, schedule, social
compulsive, self-scrutinizing behaviors and body image network, etc. should almost completely support their
dysfunction with your client. goals. Level 3s typically organize their entire life around
their needs and pursuits — which often means things
You must be calm, cool, and collected. Otherwise your like:
client’s inevitable anxiety and pre-event jitters will freak
dropping relationships (or restricting relationships only to
you out. Nutrient depletion and stress can do strange
things to people. Your client may have mood swings, people who are in a similar situation);
strange obsessions, crying jags, or any number of other quitting jobs (or working jobs that can be organized
psychological outbursts and dysfunctions. You’ve gotta around eating and training); and / or
stay chill and keep them on track.
• reducing or eliminating other pursuits such as hob-
You must be highly organized. You’ll need to keep track bies or education.
of a lot of little things, particularly during times of high
stress (such as before a big competition, on the road). For most people, this is unhealthy. Indeed, for Level 3s,
it can become unhealthy.
You must love numbers, details and precision. You
must be the kind of thorough, meticulous watchmaker At the same time, for Level 3s who are emotionally mature

402 | Unit 14
and relatively sane and grounded, it’s what needs to be done in order to achieve
world-class performance. Such performance doesn’t last. So most people don’t live
at Level 3 forever, or even longer than a few weeks or months at most. Even the
most dedicated Level 3s usually scale back to Level 2 or even Level 1 periodically.
Level 3s will often encounter some key limiting factors, though. Most are related
to the toll that Level 3 takes on the body, mind, and spirit.
• They may deal with chronic injury and / or illness as they push the edges of
human performance or training loads.
• They may deal with loneliness and isolation, since almost nobody around them
will be living a Level 3 lifestyle, and they have to forgo many social events.
• They may find themselves anxious and obsessive with ongoing nutrient restric-
tion and the focused, compulsive behaviors required.
• They may deal with major hormonal disruption as the body rebels against
semi-starvation and / or the chronic stress of training and competing.
• They may find themselves binge eating or developing seriously disordered

thoughts, beliefs, and behaviors around food and eating.
• They may develop a skewed body image or sense of their own performance,
always feeling distressed and dissatisfied about “never being good enough."
performance-enhancing drug Some of your Level 3 clients may also be taking a variety of performance-en-
(PED): Any substance taken by to hancing drugs (PEDs) and gray-area “supplements” such as:
improve performance
• anabolic-androgenic steroids (AAS) and prohormones
anabolic-androgenic steroids
(AAS): Compounds that are • growth hormone
derivatives of testosterone used
medically or recreationally, often • insulin
to promote tissue growth and/or
performance • thyroid hormone
prohormones: A precursor of a • stimulants such as thermogenics, “fat burners” (ranging from caffeine to stron-
hormone
ger stuff)
nootropics: Any agent
(e.g,. drug, functional food, • nootropics
nutraceutical or nutritional
supplement) which is thought to
• painkillers
improve mental function
Because of these distinctive and potentially dangerous limiting factors, we rec-
ommend that you have a strong referral network that includes:
• health care practitioners such as sports medicine doctors;
• recovery and body work specialists such as massage therapists;
• pharmacists, registered dietitians, and naturopaths (for consultation on drug

and supplement use);
• counsellors and psychotherapists.

At this stage, you’ll have to adjust some Level 3 tasks for fat loss, athletic perfor-
mance, and / or mass gain. We’ve given you some notes in Table 14.2.


Level 3 clients can
consistently...
Food choices
Follow a basic meal template Following a very detailed, very spe- Follow this meal plan exactly
using ISSA-style portion sizes cific meal plan with all choices tightly
and food options controlled Weigh and measure all food.
Cycle calories
Cycle macronutrients (usually carbs / fat)

Meet basic nutrient needs Testing for nutrient status and supple- Follow this specific, targeted supplement plan
(macronutrients and menting specifically exactly
micronutrients)
Choose only approved supplement brands
Stay hydrated Following specific hydration Cut out caffeine except as a training aid
recommendations
Drink mostly non-caloric Cut out alcohol
beverages Manipulating water levels to cut weight
or change the look of a physique Rehydrate with this exact recipe for a hydration
solution
Follow this specific, detailed water weight

cutting protocol exactly
For fat loss: Tolerate being Consistently eating a lot less than the For fat loss: Leave the table feeling a little
almost constantly hungry body needs / wants hungry (or even quite hungry); accept the
discomfort of hunger much of the time
For mass gain: Tolerate being Consistently eating a lot more than the For mass gain: Leave the table feeling a little
too full body needs / wants overstuffed (or even a lot overstuffed); accept
the discomfort of fullness much of the time
Manage training loads Having all training under the supervi- Follow specified training program exactly
sion of coach / trainer
Recovery
Sleep 7-9 hours Adding 15-30 minutes of sleep or im- Nap every day
proving sleep quality
Supplement to enhance sleep (e.g., ZMA,
Allowing the risk of not sleeping L-theanine)
Refine sleep ritual

Get enough basic recovery Following specific recovery protocols Add peri-workout nutrition (BCAAs for fat loss,
carb + protein drink for muscle gain and/or
Allowing the risk of not recovering; athletic performance)
pushing into the “danger zone” of
over-training and/or under-recovering Foam rolling for 10 minutes daily
Record daily recovery indicators (e.g., sleep

quality, HRV)
Decide the cutoff in advance for what is toler-

able (e.g., minor injuries okay; major injuries
mean stopping Level 3 protocols)

404 | Unit 14

Level 3 clients can
consistently...
Life skills
Plan and prepare specific meals Preparing and planning all meals Cut out restaurant meals
Plan and prepare all meals for the week in

advance (or hire a meal prep service)
Establish clear priorities and Focusing exclusively on Level 3 goals Set clear expectations with family and friends
boundaries and priorities about eating, training and competition sched-
ule, etc.
Create and maintain a support- Making sure everything in environment
ive environment supports goals Create a highly systematized, structured daily
routine
Cutting out all things that don’t sup-
port goals Eliminate all distractions / triggers from imme-
diate surroundings
Make thoughtful, informed Establishing purpose; setting clear Daily goal review
choices priorities and abiding by them
Make as many decisions in advance as possible;
Ensure that good options are Making the decision process as easy leave almost nothing to chance
available and convenient and streamlined as possible by elimi-
nating unwanted options Limit choices3
Have a growth mindset Seeking continual refinement Weekly review and retrospective with coach;
and improvement of process and outcome-based decision making
self-awareness
Refine one small part of the process each week,
Using outcome-based decision making based on data collected from the week before
a) Looking for inefficiencies and remov- Create and use a checklist for important pro-
ing them cesses (e.g., taking supplements)
b) Adding more process metrics and Record ongoing food and other logs; coach to
tracking them review these weekly (or as appropriate)
3 You’ll notice that while Level 2 tasks sometimes involve expanding choices (e.g., add a new food), Level 3 tasks usually
involve limiting choices.
Level 3 strategies Strategy: Precise observation and

Here are the special dietary strategies for Level 3 clients:
analysis
• Precise observation and analysis In the previous unit, we talked about how to use food
recording tools for Level 2 clients.
• Meal plans with specific calorie / macronutrient
allotments At Level 3, this type of observation, monitoring, and
• Aggressive carb and calorie cycling for fat loss or analysis enters a new dimension.
muscle gain Every morsel of food, every mouthful of drink, every
• Meal frequency adjustments and intermittent fasting supplement, every exercise session, every nap, every
mood swing – all are recorded and analyzed in detail.
• Very high carbohydrate diets
You will pinch, poke, and prod your client, measure
• Water manipulation strategies them with all manner of scales and devices, and squint
at minute details of their photographs or even videos.
• Workout nutrition strategies

You will talk about pee, poop, bloating, farts, acne, Monitor indicators closely.
periods, spit, libido, and just about every other bodily
function you can think of. Like Santa Claus, you’ll know Collect as much data as possible, as often as possible, and
when they are sleeping; you’ll know when they’re awake; monitor your clients’ indicators carefully.
you’ll know when they’ve been “bad” or “good."
Decide on the acceptable trade-offs. Almost nobody
Almost nothing happens to your client’s body that you gets through Level 3 protocols without some “down”
don’t know about. times (e.g., insomnia, minor injuries, feeling depressed
or fatigued).
Your client is now a scientific curiosity, to be scrutinized
from every possible angle. Decide in advance what your priorities and limits are,
and what you and your client are willing to trade. Then
If you’re the kind of coach who likes measurement and stick to the deal. Pull the plug if your client goes out of
details (and again, if you’re working with Level 3 clients, the acceptable range of wellbeing and health.
you should be), this is your time to shine. Roll out the
spreadsheets, skinfold calipers, and measuring tape.
Strategy: Meal plans with specific
Decide on indicators. calorie / macronutrient allotments
Before starting a Level 3 project, establish a clear set Let’s look at how to create a meal plan with particular
of metrics and monitoring techniques. Use as many as calorie and macronutrient allotments, step-by-step. No-
possible. tice that we’ll start off generally, with recommendations
that can apply to more than just Level 3 clients, and get
As a baseline, we recommend: more detailed as we go along.
• precise food journals that include weighing and
Step 1: Calorie needs
measuring food according to a pre-specified plan that
you assign; To determine a client’s calorie needs, simply match their
• performance indicators (for athletes);
activity levels and goals in the following table. This will
lead you to the right equation for your client. (Note:
• photos (for physique competitors); We’ve included sedentary and moderately active people
• body composition indicators: weight, body girths, in the table for comparison and reference, but your Level
skinfolds, and any other measuring techniques you
3 client will likely fall into the “Very active” category.)
have available (e.g., BodPod, DEXA);
Table 14.3 Calorie estimator
• recovery indicators (e.g. ,sleep quality, morning heart
rate and temperature, heart rate variability [HRV]); and Client goal
Weight Weight Weight
• records of psychological wellbeing, such as a record of loss maintenance gain
moods, perceived fatigue and willingness to train, etc.
Activity level Multiply bodyweight in lbs by:
Choose a schedule. Sedentary

10-12 12-14 16-18
(minimal exercise)
At Level 3, many clients will see their coaches daily or
several times a week. At the very least, you should be Moderately active
12-14 14-16 18-20
checking in with Level 3 clients weekly. (3-4 times/wk)
Decide on a schedule for monitoring and follow-up, and Very active

stick to it. 14-16 16-18 20-22
(5-7 times/wk)

406 | Unit 14
Once you’ve found this equation, multiply their body- percentages for different body types. (For more on body
weight in pounds by the given multiplier. This will yield type nutrition, see the previous unit on working with
their daily calorie estimate. Level 2 clients.)
Notice that the bodyweight used is in pounds. If you’re To use this table, simply choose the client’s body type
used to using metric, you’ll have to convert the formula. and general goals. Then calculate the recommended
percentage of protein, carbohydrate, and fat.
1 kilogram = 2.2 pounds
Some individuals, particularly elite athletes who usually
To demonstrate how this works in practice, let’s work self-select for given sports, can easily be classified as a
through a couple of examples. specific body type. For instance, marathon runners are
likely ectomorphs; competitive bodybuilders usually me-
Example 1: A 140 lb, moderately active woman in-
somorphs; and heavyweight powerlifters endomorphs.
terested in fat loss would begin by taking in between
1680 (140 lb x 12) and 1960 (140 lb x 14) kcal / day. Other individuals are hard to classify as they naturally
fall between categories. It’s possible for a client to be a
Example 2: A 190 lb, moderately active man interested
genetic ecto-mesomorph (athletic looking yet still on the
in muscle mass gain would begin by taking in between
thin side, especially in the limbs) or genetic endo-me-
3420 (190 lb x 18) and 3800 (190 lb x 20) kcal / day.
somorph (heavily muscled yet carrying extra body fat
Step 2: Macronutrient split around the midsection).
Once you have determined the proper calorie intake, use A client’s lifestyle can also alter their natural somatotype
Table 14.4 to determine the ideal starting macronutrient to produce a hybrid type.
Table 14.4 Body type and macronutrient estimates

Suggested average
starting percentages
(approximate)
Somatotype and physical
activity preference Characteristics Typical goals Protein Carb Fat
Ectomorphic Thyroid dominant Gain muscle strength 25% 55% 20%

and size, especially in
(Naturally thin Fast metabolic rate limbs
with skinny limbs)
High sympathetic nervous Maintain bodyweight
Endurance exercise system activity and strength during
Higher carbohydrate high-volume/endurance
tolerance exercise
Mesomorphic Testosterone and growth Continue to build muscle 0% 40% 30%

hormone dominant mass while maintaining
(Naturally muscular low body fat percentage
and athletic) Moderate to high sympathet-
ic nervous system activity Support athletic
Bodybuilding and/or rel- performance
ative strength exercise Moderate carbohydrate
tolerance
Endomorphic Insulin dominant Lose body fat, especially 35% 25% 40%
in central region (ab-
(Naturally broad and thick) Slow metabolic rate dominal, lower back)
Absolute strength Low sympathetic nervous
exercise system activity
Low carbohydrate tolerance

the right amount of calories and the right macronutrient

Table 14.5 Level 3 client goals
breakdown / amounts.
If the client
wants to... Then... The calorie estimator chart tells you how many calories a
client should be eating and the macronutrient estimates
Gain muscle Begin with the recommenda-
tions for ectomorphs (Type I). chart tells you the percentage of calories that should
Improve endurance come from each macronutrient type.
performance Monitor progress closely.
Use outcome-based decision How to convert calories to macronutrient

making to adjust as needed. percentages
Lose fat Begin with the recommenda-
tions for endomorphs (Type O). As you may recall from Section 1:
Monitor progress closely. Each gram of protein contains 4 kcal.
Use outcome-based decision Each gram of carbohydrate contains 4 kcal.

making to adjust as needed.
• Each gram of fat contains 9 kcal.
Improve strength / Begin with the recommenda-
power performance tions for mesomorphs (Type V). Thus to convert macronutrient ratios to grams:
Monitor progress closely.
1. Start with the total calories.
Use outcome-based decision
making to adjust as needed. 2. Multiply the total calories by the percentage
of macronutrients. Remember that percent-
ages are decimals.
For example, your client could be a genetic ectomorph
For instance:
or endomorph that has exercised and eaten well for
years and now resembles a mesomorph. On the other 50% is 0.5.
side of the spectrum, your client might be an ectomorph
35% is 0.35.
or a mesomorph that has gained body fat and lost their
carbohydrate tolerance due to years of inactivity and Thus:
poor food choices, and now resembles a mixture of their 50% of 2000 calories is 0.5 x 2000 = 1000 kcals.
original type and the endomorphic type.
35% of 2000 calories is 0.35 x 2000 = 700 kcals.
Don’t get too bogged down trying to figure out every
client’s exact classification. 3. Divide the calories for each macronutrient by
the number of grams in each macronutrient.
This classification is just a tool to determine a client’s
ideal starting macronutrient composition. For instance: Carbohydrates have 4 kcal per gram.
If your client gets 35% of calories from carbohy-

Like all advice in this textbook, it’s a guideline, a starting
drates in a 2000-calorie diet, that’s
point, and a principle, not a “rule."
0.35 x 2000 = 700 kcals.
If you’re having a hard time determining a client’s exact 700 kcals divided by 4 kcals = 175 g of carbohydrate.
body type, skip it and work from their goals:
4. Do this for each macronutrient, and you’ll
Use both the calorie estimator chart and the macronutri-
get total grams for each.
ent estimates chart to ensure that you’re recommending
Using our two previous examples (the 140 lb woman and
190 lb man), let’s work through two sample calculations.

408 | Unit 14
Example 1: 140 lb moderately active woman Macronutrient breakdown from chart: 25% protein, 55%
carbohydrates, 20% fat.
Step 1: Determine goals and calculate her specific dietary
Combine calorie and macronutrient ratio recom-
needs by starting with the calorie estimator chart.
mendations to find calories from each macronutri-
Goal: Lose fat. ent, then convert to grams.
Calorie needs: Between 1680 and 1960 kcal (12-14 times Setting his daily energy intake at 3700 kcal, this means
bodyweight) per day. that:
Step 2: Determine body type and identify macronutrient • about 925 kcal (3700 x 0.25) should come from
ratios from macronutrient chart. protein;
• about 2035 kcal (3700 x 0.55) should come from

Body type: Assume endomorph / Type O to start with
(unless there’s obvious evidence to the contrary). carbohydrates; and
• about 740 kcal (3700 x 0.20) should come from fat.

Macronutrient breakdown from chart: 35% protein, 25%
carbohydrates, and 40% fat. Translated into grams, he will be eating:
Combine calorie and macronutrient ratio recom- • 231 g of protein (925 divided by 4);
mendations to find calories from each macronutri-
• 508 g of carbohydrate (2035 divided by 4); and
ent, then convert to grams.
• 82 g of fat (740 divided by 9).
Setting her daily energy intake at 1750 kcal, this means
that: Step 3: Nutrient timing
• about 612 kcal (1750 x 0.35) should come from Quick review: Nutrient timing is based on the idea that
protein; nutrients are handled differently during various peri-
• about 437 kcal (1750 x 0.25) should come from car- ods of the day (which does not necessarily mean “clock
bohydrates; and time”, but usually an association with activity, such as a
training session).
• about 700 kcal (1750 x 0.40) should come from fat.
For example, carbohydrate tolerance is improved after
Translated into grams, she will be eating: exercise. (You’ll remember, for instance, that muscular
• 153 g of protein (612 kcal divided by 4) contraction causes GLUT4 receptors to migrate to the
cell membrane.)
• 109 g of carbohydrate (437 kcal divided by 4), and
Therefore, most people’s bodies use dietary carbohydrates
• 77 g of fat (700 kcal divided by 9).
more effectively during this period than at any other time
of the day. While this effect is limited and likely wouldn’t
Example 2: 190 lb moderately active man make much difference to a Level 1 or even a Level 2 eater,
for the Level 3 eater looking for every advantage they can
Step 1: Determine goals and calculate his specific dietary
get, this carbohydrate timing can help.
needs by starting with the calorie estimator chart.
Table 14.6 outlines how the principles of nutrient timing
Goal: Gain muscle.
can be used to organize carbohydrate intake for each
Calorie needs: Between 3420 (190 lb x 18) and 3800 (190 body type.
lb x 20) per day.
These nutrient timing rules help to regulate carbohy-
Step 2: Determine body type and identify macronutrient drate intake based on both body type and carbohydrate
ratios from macronutrient chart. tolerance. (Remember, body type serves as a proxy for
carb tolerance / need – always defer to known carb tol-
Body type: Assume ectomorph / Type I to start with (un- erance or goals over body type per se.) Nutrient timing
less there’s obvious evidence to the contrary). comes into play only after Steps 1 and 2.

Table 14.6 Carbohydrate timing guidelines

Carb Typical Typical
tolerance Typical goal body type activity Carbohydrate timing rules
Excellent Gain muscle or Ectomorph Endurance Should include whole or sugary carbohy-
improve endurance activity drate-dense foods during/after each exercise
performance session/game.
Carbohydrate-dense foods should be eaten liberal-

ly at every meal.
A 3:1 veggie-to-fruit ratio (e.g., for every 3 serv-

ings of veggies consumed, 1 serving of fruit is
consumed)
Moderate Gain muscle Mesomorph Intermittent Should include whole or sugary carbohy-
sport athlete drate-dense foods during/after each exercise
Lose fat or improve session/game.
sport performance
Carbohydrate-dense foods should be eaten in
moderation at every meal.

consumed)
Poor Lose fat Endomorph Strength and Should include whole or sugary carbohy-
power athlete drate-dense foods during/after each exercise
session/game.
Carbohydrate-dense foods should be eaten in

small amounts at other meals.

consumed)
Let’s continue with our example clients from earlier:

• Example 1: Your 140 lb, moderately active, endo- • Example 2: Your 190 lb, moderately active, ecto-
morphic female client interested in weight loss would morphic male client interested in weight gain would
be eating about 1750 kcal per day coming from 153 g be eating about 3700 kcal per day coming from 231 g
of protein, 109 g of carbohydrate, and 77 g of fat. of protein, 508 g of carbohydrate, and 82 g of fat.
Since she’s both endomorphic and trying to lose fat, Since he’s both ectomorphic and trying to gain mus-
you can assume she has poor carbohydrate tolerance. cle, you can assume he has excellent carbohydrate
Therefore, you’d put most of the carbohydrate-dense tolerance (and has a higher need). Therefore, his diet
foods into the post-exercise period, when carbohy- should include carbohydrate-dense foods during / af-
drate tolerance is highest. ter each exercise session, liberally at each meal, along
with a vegetable-to-fruit ratio of 3:1.
The rest of the day will include smaller amounts of
carb-dense foods, along with more proteins, healthy
fats, and a vegetable-to-fruit ratio of 5:1.

410 | Unit 14
Table 14.7 Suggested nutrient breakdown by meal, 1750 calories daily
Meal Calorie intake Protein intake Carb intake Fat intake
Breakfast ~611 kcal 50 g protein 24 g carbohydrate 35 g fat
Lunch ~611 kcal 50 g protein 24 g carbohydrate 35 g fat
Dinner (Post-exercise) ~530 kcal 50 g protein 60 g carbohydrate 10 g fat
Totals ~1750 kcal 150 g protein 108 g carbohydrate 80 g fat
Note: if eating fewer (or more) meals, simply adjust per meal calories and macronutrients accordingly.
Step 4: Menu
After going through all of the specific calorie, macro- choice, you can plan which foods will fit into each set of
nutrient, and nutrient timing charts provided, you may meal guidelines above. See Table 14.8 for what this might
need some practice to actually put all of this math into a look like.
food-based menu.
As you can see, the process is a fairly straightforward
To translate math to menu, you’ll have to: step-by-step one, although you’ll likely need to familiarize
yourself with some software-based nutrition tools or the
• Use an accurate nutrient database (we like the USDA
USDA nutrient database.
nutrient database).
• Figure out the calorie and macronutrient breakdowns The most accurate online resource we’ve found is the
of the foods you intend to build into the plan.
USDA Nutrient Database (http://ndb.nal.usda.gov/ndb/
search/list). Periodically the website address changes, so
• Balance out the meal plan based on the parameters it might be worth a Google search.
calculated earlier.
Unlike with Level 1 and 2 clients, taste and variety isn’t a Strategy: Aggressive carb and calorie
big priority for Level 3 clients. If their meals are palat- cycling
able, great. But you’ll probably find that you have to keep
things to a pretty limited roster of choices. Important note: This must be a short-
term strategy
Let’s look at the example of our 140 lb woman who’s
eating her 1750 calories per day, coming from 153 g of Aggressive carb / calorie cycling is imbalanced, and
protein, 109 g of carbohydrates, and 77 g of fat. imbalances can lead to physiological problems. If you’re
considering recommending such a strategy to a client,
With three meals per day, and only one carbohy-
set a deadline and transition to more balanced eating
drate-rich meal after exercise (which happens to be the
after this timeline has expired.
dinner meal), Table 14.7 shows how this might break
down. Elite athletes should avoid extended periods of very
low-carbohydrate intake during periods of heavy train-
From here, using the USDA nutrient database to deter-
ing and / or competition, as this is not at all suitable for
mine the calorie and macronutrient intakes of each food
high training volumes or intensities.

Table 14.8 Suggested meal plan, 1750 calories daily

Meal Calorie and Actual food intake
macronutrient goals
Breakfast ~600 kcal 3 whole eggs (cage-free) (about 1.5 palms)
50 g protein 3 egg whites (cage-free) (about 0.5 palm)
24 g carbohydrate 1/3 cup cooked black beans (about 1 cupped handful)
35 g fat 1 cup vegetables (about 1 fist)
1 oz walnuts (small handful)

Lunch ~600 kcal 3 ounces beef (grass-fed) (about 1 palm)
50 g protein 1/3 cup cooked lentils (about 1 cupped handful)
24 g carbohydrate 1.5 cups vegetables (about 1.5 fists)
35 g fat 2 ounces almonds (generous handful)

Dinner ~530 kcal 2 scoops protein powder (2 palms)
50 g protein 1 banana
60 g carbohydrate 1 date
10 g fat 2 cups unsweetened coconut milk (not the full-fat canned variety)
2 cups raw kale (about 2 fists)
Following an overly aggressive approach for too long likely will result in fat loss
plateaus. The body is simply too smart. In an effort to keep someone alive, it
slows down all processes not required for life.
So, how can certain individuals with specific body composition goals out-diet
their bodies’ ever-persistent desire for homeostasis?
The value of cycling

For starters, someone can trick their body by giving it higher calorie and carbo-
hydrate intakes frequently enough so that it won’t ever get too close to metabolic
/ hormonal shut-down, but infrequently enough so that fat loss can continue.
Dieting intensely, or trying to reach very low levels of body fat, can lead to a
reduction in metabolic rate, thyroid hormone output, leptin output, sympathetic
nervous system activity, spontaneous physical activity (e.g., NEAT), reproductive NEAT: Non-exercise activity
hormone output (testosterone and estrogen), and more. thermogenesis, or, the energy
expenditure of all physical
activities other than volitional
Therefore, the premise of cycling carbs and calories is to prevent or attenuate this
sporting-like exercise.
reduction in output during periods of very low calorie and carbohydrate intake.
There are many ways to use calorie and carbohydrate cycling to your advantage.
Here are a few of those strategies:

412 | Unit 14
Infrequent, large re-feeds 3. Once calorie, protein, carbohydrate, and fat goals
have been established, plan the meal breakdown.
This type of re-feed usually occurs every one or two
weeks during a low-calorie / carbohydrate phase and Since calorie intake is low, your client may drop
consists of a single day of eating significantly more car- down to as few as two or three whole-food meals each
bohydrates and calories than a client would during their day (with calories evenly split).
other diet days.
For this example, simply divide the numbers above
This is the right type of strategy for a client who: by 3 to get the per-meal totals. Each meal doesn’t
need to be exactly a third of the daily total. Just make
has fantastic dietary discipline;
sure that you’re splitting food intake up relatively
can maintain a consistent rate of weight loss without pla- evenly throughout the day.
teau for one or two weeks; and
Example:
• can mentally handle lower-carbohydrate or lower-cal-
orie diets without significant problems. Meal 1: 500 kcal: from 44 g protein, 19 g carbs,
28 g fat
Here are some tips for structuring this type of re-feed:
Meal 2: 500 kcal: from 44 g protein, 19 g carbs,
1. For the “low-carb / calorie days”, determine calorie 28 g fat
intake based on bodyweight.
Calorie intake = Bodyweight (in lb) x 9-11 kcal 28 g fat
2. For “low-carb / calorie days”, determine protein, 4. Pick out re-feed days for the entire diet period in
carb, and fat intake. advance.
Protein should make up 35% of calories (choose Schedule them on a calendar and be sure your client
whole-food sources for greater satiation and satiety). remains committed to their strict plan, knowing
there’s light at the end of the tunnel every 7-14 days.
Carbohydrates should make up 15% of calories
(choose fibrous / non-starchy vegetable sources). 5. Until the re-feed days come, reinforce that your cli-
ents must stay the course and follow the plan with
Fat should make up 50% of intake, with a mixture of no deviations.
saturates, polyunsaturates, and monounsaturates.
After 6-13 days in a row of dietary discipline, they
Example: will use a re-feed day.
150 pounds x 10 kcal = 1500 kcal 6. On the 7th or 14th day, your client will eat high-cal-
orie / carbohydrate foods they’d never usually eat
1500 kcal x .35 (protein) = 525 kcal / 4 kcal per
while on a low-carb / calorie diet.
gram of protein = 131 g
1500 kcal x .15 (carbs) = 225 kcal / 4 kcal per Of course, this isn’t a license to go crazy.
gram of carb = 56 g To keep things in check, here’s a simple guideline:
1500 kcal x .50 (fat) = 750 kcal / 9 kcal per gram Restrict calories to about 3 or 3.5 times their daily
of fat = 83 g low-carb / calorie guideline. Therefore, if they’re
eating 1500 kcal a day, they shouldn’t go much above
4500-5250 kcal.
This will also help to prevent GI distress that can

occur in someone not accustomed to larger portions
of richer foods.

7. For “high carb / calorie days”, determine protein, 9. Make sure your client exercises on re-feed days to
carb, and fat intake. nudge the extra energy toward muscle building and
recovery.
Protein should make up 20% of calories (choose
mostly whole-food sources, but powders are especial- Notes:
ly helpful here).
Don’t follow the plan for longer than three to four months.
Carbohydrates should make up 60% of calories Set a nutrition plan expiry date in advance.
(choose fibrous / non-starchy vegetable sources).
As always, use outcome-based decision making. If these
Fat should make up 20% of intake, with a mixture of re-feeds are working, keep going. If not, try a different re-
saturates, polyunsaturates, and monounsaturates. feed strategy such as more or fewer calories, a different
macronutrient breakdown, or a difference in frequency.
Example:
If you notice any disordered eating patterns in the client,
150 lb x 30 kcal = 4500 kcal have an honest discussion with them about how this type
4500 kcal x .20 (protein) = 900 kcal / 4 kcal per of cyclical dieting can reinforce the disordered eating
gram of protein = 225 g mindset. If that’s the case, discontinue this extreme
approach.
4500 kcal x .60 (carbs) = 2700 kcal / 4 kcal per
gram of carb = 675 g Frequent, moderate re-feeds
4500 kcal x .20 (fat) = 900 kcal / 9 kcal per gram
This type of re-feed usually occurs every three or four
of fat = 100 g
days during a lower-calorie / carbohydrate phase and
8. Once calorie, protein, carbohydrate, and fat goals consists of a single day of eating a bit more carbohy-
have been established, plan the meal breakdown. drates / calories than your client would eat during their
other diet days.
Since calorie intake is high, your client may need to
increase meal frequency to 4-6 meals each day. This is the right type of strategy for a client if they have
fairly poor mental tolerance for lower-carbohydrate
For this example, simply divide the numbers above / calorie diets, stagnate on these types of diets quite
by 5 to get the per-meal totals. quickly, and are very physically active.
Example: Here are some tips for structuring this type of re-feed:
Meal 1: 900 kcal: from 45 g protein, 135 g carbs, 1. For the “low-carb / calorie days”, determine calorie
20 g fat intake based on bodyweight.
Meal 2: 900 kcal: from 45 g protein, 135 g carbs, Calorie intake = Bodyweight (in lb) x 9-11 kcal
20 g fat
2. For “low-carb / calorie days”, determine protein,
carb, and fat intake.
20 g fat
Protein should make up 35% of calories (choose
whole-food sources for greater satiation).
20 g fat
Meal 5: 900 kcal: from 45 g protein, 135 g carbs, Carbohydrates should make up 15% of calories
20 g fat (choose fibrous / non-starchy vegetable sources).

414 | Unit 14
Fat should make up 50% of intake, with a mixture of To keep things in check, here’s a simple guideline:
saturates, polyunsaturates, and monounsaturates. Restrict calories to about 1.5 times their daily low-
carb / calorie guideline. Therefore, if they’re eating
Example: 1500 kcal a day, they shouldn’t go much above 2250
150 lb x 10 kcal = 1500 kcal kcal.
1500 kcal x .35 (protein) = 525 kcal / 4 kcal per 6. For “high-carb / calorie days”, determine protein,
gram of protein = 131 g carb, and fat intake.
1500 kcal x .15 (carbs) = 225 kcal / 4 kcal per Protein should make up 20% of calories (choose
gram of carb = 56 g mostly whole food sources, but powders are especial-
ly helpful here).
of fat = 83 g Carbohydrates should make up 60% of calories
(choose minimally processed sources as much as
3. Once calorie, protein, carbohydrate, and fat goals possible).
Fat should make up 20% of intake, with a mixture of
Since calorie intake is low, your client may drop saturates, polyunsaturates, and monounsaturates.
down to as few as two or three whole-food meals each
day (with calories evenly split). Example:
For this example, simply divide the numbers above 150 lb x 15 kcal = 2250 kcal
by 3 to get the per-meal totals. Each meal doesn’t
2250 kcal x .25 (protein) = 563 kcal / 4 kcal per
need to be exactly a third of the daily total. Just make
gram of protein = 141 g
sure that you’re splitting food intake up relatively
evenly throughout the day. 2250 kcal x .40 (carbs) = 900 kcal / 4 kcal per
gram of carb = 225 g
Example:
Meal 1: 500 kcal: from 44 g protein, 19 g carbs, of fat = 88 g
28 g fat
7. Once calorie, protein, carbohydrate, and fat goals
28 g fat
Meal 3: 500 kcal: from 44 g protein, 19 g carbs, Since calorie intake is higher, your client may need
28 g fat to increase meal frequency. Let’s say you go with 5
meals a day.
4. Schedule a re-feed every three to four days during a
client’s low carb / calorie phase. For this example, simply divide the numbers above
by 5 to get the per-meal totals.
Mark them on the calendar.
Each of the 5 meals will have about:
5. On these re-feed days, have your client eat a similar
28 g protein (112 kcal)
diet to what they’d normally eat while adding some
high-quality carbohydrate-dense foods to each 45 g carbs (180 kcal)
meal.
18 g fat (162 kcal)
Again, this isn’t a license to go crazy.
This is about 450 kcal per meal, for a total of
about 2250 kcal per day.

Table 14.9 Sample calorie and carbohydrate cycling menus for fat loss1
Menu 1 Menu 2 Menu 3 Menu 4
Baseline Higher-carbohydrate Higher-carb and calorie Higher-calorie
~1000 kcal ~1250 kcal ~1500 kcal ~1500 kcal
150 g protein 150 g protein 150 g protein 150 g protein
33 g carbs 95 g carbs 125 g carbs 33 g carbs
30 g fat 30 g fat 45 g fat 85 g fat

1 These recommendations are primarily for a 125 lb female interested in fat loss. Macronutrient changes from baseline (Menu 1) are shown in bold
and italics.
Table 14.10 Sample weekly menu distribution

Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Menu 3 Menu 1 Menu 1 Menu 4 Menu 2 Menu 1 Menu 1
8. Make sure your client exercises on these higher-cal- Strategic calorie cycling and carbohydrate
orie / carbohydrate days so that the body is encour- cycling for fat loss
aged to use that extra energy for muscle building
and recovery. These types of re-feeds involve separate calorie and
carbohydrate re-feeds. You create three or four different
Notes: menu plans and the client rotates through them.
Don’t follow the plan for longer than three to four months. The table below shows an example of what the four menu
Set a nutrition plan expiry date in advance. plans might look like for a relatively lean, highly dedicat-
ed woman weighing about 125 lb and interested in rapid
Use outcome-based decision making. If these re-feeds are
fat loss.
working, keep going. If not, try a different re-feed strategy.
You’ll notice that this woman’s calorie intake fluctuates
You can use random re-feeds or scheduled ones, based on
between 8 and 12 kcal/lb of bodyweight. Thus, it’s a
your knowledge of the client’s body. If they’re just starting
lower-calorie, lower-carbohydrate diet.
out, simply schedule them every 3 or 4 days and be done
with it. If you know their body well, wait until they really However, you’ll also notice that the calories and carbo-
need a re-feed. They’ll know, as their body will start to hydrate intakes vary throughout the week to keep the
flatten out. This means that they will feel very low in ener- body from adapting to too low an intake and slowing
gy and will begin to lose muscle fullness. down the metabolism.
If you notice any disordered eating patterns in the client, • On Monday and Tuesday, the calories and carbohy-
have an honest discussion with them about how this type of drates are very low.
cyclical dieting can reinforce the disordered eating mindset.
• Wednesday brings a much higher-calorie menu,
If that’s the case, discontinue this extreme approach.
although the carbohydrates are still low (the extra
calories come from dietary fat). This helps to keep

416 | Unit 14
the body utilizing fat for energy while preventing muscle gain, choose your client’s activity level and their
starvation mode. muscle gain goal. From there you’ll know how many
calories your client needs to eat (16-22 kcal/lb).
• Thursday sees a more moderate calorie intake, but
carbohydrates are added while fats are kept low to Next, decide which body type they are and calculate
signal certain systems of the body to keep metabolic their required macronutrient split. Finally, develop three
rate high. menus:
• Next, on Friday and Saturday we’re back to a low- • one with a lower-carbohydrate intake (80% of
er-calorie and lower-carbohydrate level. suggested),
• Sunday is a high-calorie, high-carbohydrate intake. • one with the required carbohydrate intake (100% of
suggested), and
Of course, this is the most demanding strategy, but it
works quite well for individuals who are already fairly • one with a higher-carbohydrate intake (120% of
lean and in whom the body will fight every last bit of suggested).
fat loss.
Let’s take, for example, a moderately active mesomorphic
This strategy keeps the body guessing with fluctuat- male weighing 180 lb who wants to gain muscle mass.
ing calorie and carbohydrate intakes that are fairly
unpredictable. Begin by determining his calorie intake; in this case it
would be about 18-20 kcal/lb or 3200-3600 kcal/day.
Here are some tips for structuring this type of cycling:
From here he’d use a 30% protein, 40% carbohydrate,
• Plan at least three types of menus: lower-calorie, low- 30% fat diet. Assuming he eats 3500 kcal, that’s 262 g
er-carbohydrate days; higher-calorie, lower-carbohy- protein, 350 g carbohydrate, and 116 g fat.
drate days; higher-calorie, higher-carbohydrate days;
and mid-calorie; mid-carbohydrate days. Using those numbers, here’s what his three menus
would look like. See Table 14.11. Notice how the car-
• Cycle these menus depending on how much fat loss bohydrate cycling also dictates calorie cycling. As his
is required. The more fat loss is required, the more
lower-calorie days are needed. The less fat loss re-
quired, the fewer lower-calorie days are required.
Table 14.11 Sample calorie and carbohydrate
• Be sure to cycle both the calories and the carbohy- cycling menus for muscle mass gain1
drates to prevent quick adaptation and stagnation. Menu 1 3,212 kcal
• Structure the menu so that the highest-intensity 262 g protein
training days correspond with the highest-calorie and
280 g carbohydrate
carbohydrate days.
116 g fat
• Make sure to use outcome-based decision making.
Menu 2 3500 kcal
Judge the strategy by the results.
262 g protein
Strategic carbohydrate and calorie cycling for 350 g carbohydrate
muscle gain
116 g fat
The calorie and carbohydrate cycling strategies de- Menu 3 3772 kcal
scribed above can also be used for muscle gain. The idea
262 g protein
is to try to gain more muscle than fat during over-feed-
ing / muscle-building phases. This process is quite sim- 420 g carbohydrate
ple and is based on the same calorie and macronutrient
116 g fat
charts on the previous page.
1 These recommendations are for a 180 lb, moderately active meso-
morphic male interested in building muscle mass.
To design a calorie / carbohydrate cycling strategy for

carbohydrates fluctuate, so do his calories. He’d simply Because either approach is valid, you’re free to help them
rotate through this menu with menu 1 on day 1, menu 2 find the approach that works best for them.
on day 2, menu 3 on day 3, and so on.
What about meal timing?
Strategy: Meal frequency People have long debated whether it’s better to eat more
adjustments and intermittent fasting early in the day, or later in the day.
For years, dietitians and nutritionists (us included) told Some interesting research has implied that for many
their clients to eat small meals often throughout the day. people, earlier in the day may be better. For instance,
From early research we assumed that this would “speed studies on time shifting energy intake suggest that
up” metabolism, help control insulin and cortisol, and people may gain more fat when fed during their night-
help control appetite. time period than when fed the same amount of calories
during their day-time period.
We jammed breakfast down the throats of ectomorphs
who weren’t hungry in the morning. We told endo- This might be particularly relevant for shift workers,
morphs struggling with weight loss to make sure they who are known to gain more fat, have more metabolic
got snacks. disruptions, and be at higher risk of chronic diseases
compared with workers with regular day-time schedules.
Whoops.
However, this is just an average, not a “one size fits all”
As usual, science and experience like to mess with our prescription.
dearest-held convictions.
Other research has shown that other folks maintain
Current research and our own experience in coaching more muscle mass and lose more body fat when they eat
for the last 20 years suggests that as long as clients eat most of their carbs and calories at night.
the right foods in the right amounts, and are getting the
results they desire, meal frequency is a matter of person- Research on how body clocks regulate metabolic activity
al preference. is ongoing, and we already know that there are signifi-
cant genetic differences between people’s chronotypes,
Clients can eat many small meals each day (i.e., every or “time types." (Think of the differences between your
few hours). Or they can eat a few bigger meals each day “night owl” versus “morning lark” clients.) Chronotype
(i.e., with longer time gaps between them). seemingly also affects metabolism and how the body
processes nutrients.
And, if they do it right, they can have success with either
approach. For now, keep it simple: People vary.
Now, our advice is: Teach clients to listen to their own Try stuff. See what works, or doesn’t.
body and apply the “How’s that workin’ for ya?” test.
The only “rule” is using outcome-based decision making.
For Level 1 and 2 clients, learning hunger, appetite, and
fullness signals is essential. Just remember, a typical Level 1 limiting factor is a
haphazard meal schedule. So don’t confuse “haphazard
At Level 3, clients will probably be ignoring most of meals and resultant over-eating” with “adjusting meal
these signals. They’ll be hungry but not eat; or full but frequency based on body cues and success outcomes."
have to eat more.
The difference between Level 1 and Level 3 is intent,
So at Level 3, things are much more negotiable and structure, and deliberate choice. Anything Level 3s do is
flexible. planned and purposeful.
If they’re covering all other bases and their current meal

frequency isn’t working for them, experiment. Try fewer
chronotypes: The internal circadian rhythm (aka body clock)
meals if they eat more often. And more meals if they eat of an individual that influences the cycle of sleep and activity in
less frequently. a 24-hour period

418 | Unit 14
Related to meal frequency is the concept of Intermittent the subject. It’s called My Experiments with Intermittent
Fasting (IF). IF is the name some nutrition experts give Fasting and can be found at: www.precisionutrition.com/
to the practice of occasionally going for extended periods intermittent-fasting
without eating.
And remember, clients will get excited about strategies
Of course, IF is nothing new. Humans have fasted for like IF.
most of history, whether it’s during the typical overnight
period, during more extended periods of food scarcity, or Remind them that IF won’t help in the long haul if they
for religious reasons. aren’t consistent with the Level 1 strategies first. Every-
thing in the Level 3 program must be there for a reason,
What is new is that research on IF’s benefits for health and must demonstrably earn its rent.
and longevity is beginning to catch up. Current data
show that IF, when done properly, might help extend
life, regulate blood glucose, control blood lipids, manage
Strategy: Very high-carbohydrate
bodyweight, gain (or maintain) lean mass, and more. diets
So, rather than something we’re forced to endure — a High levels of muscle and liver glycogen (carbohydrate)
result of poor food availability or cultural expectations can lead to better athletic performance in long-duration
— IF is becoming something that health and phy- endurance competitions (for example, marathons or
sique-oriented people are seeking out in order to lose fat longer).
and improve health.
Long-duration athletes who eat more carbohydrates
IF sounds very promising as a general ideology. But leading up to a competition can supercompensate their
things get messy when it comes to actually doing IF. body carbohydrate supplies — essentially, “over-filling
the tank." This extra stored carbohydrate provides a
How often should you fast? For how long? Should you eat readily available source of muscle energy and blood glu-
zero calories? cose. This means athletes can perform better, for longer,
and they’re less likely to “bonk” during their event.
Should you eat the same amount of food on non-fasting
days that you normally would, or should you eat more? Thus, ectomorphic athletes preparing for a long-dura-
tion competition can briefly use very high-carbohydrate
None of these questions has a definite answer yet. So
diets to help sustain their performance. We define “very
many IF proponents have come up with their own best
high-carbohydrate diets” here as containing 3.5-5 g of
guesses from alternate day fasting (eating only every
carbohydrate / lb or 70% or more of dietary energy. For a
other day), to once per week fasting (fasting for a full day
150 lb person, this means 525-750 g of carbohydrate.
every week), to daily 16 hour fasts (fasting for 16 hours
and eating within an 8 hour window only). However, this does not mean that very high-carbohy-
drate diets are good year round, even for the ectomor-
As the various IF communities and early adopters test
phic endurance athlete.
out their different ideas, the best ones will rise to the top.
Eventually, scientists will catch wind of these and put To get carbohydrate intakes this high, many athletes
them to the test. must consume foods high in sugar and / or processed
carbohydrates. Obviously, this isn’t ideal for long-term
Right now, we’d say the scientific community is a good
body composition or overall health.
2-4 years from knowing what exactly IF does in humans
(and why), and a good 7-9 years from knowing which IF
protocols are “best."
In the meantime, if you’re interested in learning more supercompensate: When athletes eat a higher amount of
about this fairly unique approach to eating for health, carbohydrates before an event to ensure body carbohydrate
stores are full
performance and body composition, you can check out
the free (and very comprehensive) e-book we wrote on bonk: When glycogen stores become depleted

Table 14.12 Calorie and macronutrient intakes for endurance athletes

Calorie intake Carbohydrate intake Protein intake Fat intake
During high-volume endurance training periods
Bodyweight x 20-22 55% of total calories 25% of total calories 20% of total calories
3-4 days prior to competition
Bodyweight x 20-22 70% of total calories 15% of total calories 15% of total calories
This type of higher carbohydrate intake should thus be Physique competitors

purposeful, planned and brief: assigned only for the 3 or
4 days leading up to the competition. 8 days before the contest
See Table 14.12. 1. Double your water intake. For example, if you’re
If possible, clients should choose more nutrient-rich, drinking 2 L (8 cups) per day, start drinking 4 L (16
minimally processed carbohydrates rather than sugary, cups) per day.
highly processed selections during these periods.
You may need to help your Level 3 clients with menus
and recipe planning and preparation, especially if 6 days before the contest
athletes will be traveling and competing (and thus, need
foods that are convenient, portable, and easy-prep). 1. Double your water intake again. Now you’ll drink
Create your own go-to roster and resources of high-carb four times your normal water intake. If you started
food sources and recipes, and have it handy. with 2 L (8 cups) per day, you’ll now drink 8 L (32
cups).
Remember: If your clients are not long-distance endur-
ance athletes, this strategy is not for them. In fact, if a 2. Lower your carbohydrate intake. For most people,
client’s event is shorter than 90 minutes in duration, this means eating around 50-100 g of carbohydrate
the excess muscle glycogen and accompanying water
per day.
gain (the body holds about 2-3 g of water for every 1 g of
glycogen) could harm their performance. 3. Increase sodium intake: Add lots of salt to meals
and / or even small amounts of salt to your drinking
Strategy: Water manipulation water.
You’ll remember from Unit 8 that you can change both 4. Do this for four days, until you’re two days out from
bodyweight and the appearance of leanness by adjusting the contest.
fluid levels in the body.
IMPORTANT: Tinkering with body hydration
and electrolytes is a big deal, with potentially fatal 1. Drop your water intake down fourfold. For example,
consequences. if you’re now taking in 8 L (32 cups) per day, drop
Pursue only if you and your client are both confident in back to 2 L (8 cups).
the approach, and aware of potential risks.
2. Increase your carbohydrate intake. For most people,
Know the danger signs, monitor closely, and abort the this means eating two to four times what they’ve
mission if you’re compromising health and safety. been eating for the last few days. So, if you’ve been
eating 50-100 g of carbohydrate per day, increase
Here are the abbreviated versions. your intake up to 200-400 g.

420 | Unit 14
3. Finally, lower your sodium intake as much as you 6 days before the contest
can. Cut all extra salt out of your diet and avoid
foods higher in sodium. 1. Cut your water intake back to normal. So, if you start-
ed with 2 L (8 cups) per day, go back to 2 L now.
4. Continue until one day out from the contest (i.e.,
about 24 hours). 2. Lower your carbohydrate intake. For most people,
this means eating around 50-100 g of carbohydrate
per day.
1 day before the contest
3. Decrease sodium intake. Cut all extra salt out of your
1. Drop your water intake again by 50%. For example,
diet and avoid foods higher in sodium.
if you’re now drinking 2 L (8 cups) per day, drop
down to 1 L (4 cups) per day. 4. Do this for about 24 hours, until five days out from
the competition.
2. Keep your increased carbohydrate intake the same.
3. Keep your sodium low. 5 days before the contest

4. Keep doing this for about 24 hours, until the contest 1. Cut your water intake in half again. So, if you started
day. with 2 L (8 cups) per day, you’d be down to 1 L (4
cups) now.
Contest day 2. Keep carbohydrate intake low.
1. Avoid water until the contest.
2. Keep carbohydrate intake high.
4. Do this for 2 days, until 3 days out from the
competition.
Be sure to rehydrate carefully after your event. You may 3 days before the contest
want to have an electrolyte solution close at hand.
1. Cut your water intake in half again. So, if you started
Weight-class athletes with 2 L (8 cups) per day, you’d be down to 0.5 L (2
cups) now.
8 days before the contest 2. Keep carbohydrate intake low.
Weight classed athletes, such as strength athletes, wres- 3. Keep sodium intake low.
tlers, and / or fighters, often weigh in and compete on 4. Do a short sauna session (15-20 minutes) in the
different days. evening.
Below is an example program for an athlete, such as a 5. Do this for one day.
MMA athlete, who needs to weigh-in 24 hours before
their competition. 2 days before the contest
1. Double your water intake. For example, if you’re 1. Cut your water intake in half again. So, if you started
drinking 2 L (8 cups) per day, start drinking 4 L (16 with 2 L (8 cups) per day, you’d be down to 0.25 L (1
cups) per day. cup) now.
2. Increase sodium intake: Add lots of salt to meals 2. Keep carbohydrate intake low.
and / or even small amounts of salt to your drinking
water. 3. Keep sodium intake low.
3. Do this for two days. 4. Do two short sauna sessions (15-20 minutes) in the
morning and evening.
5. Do this for one day.

Until weigh-in For clients who want to gain weight, have a high need
for calories, or who are mesomorphs / ectomorphs:
1. No water until after weigh-in. Add protein + carbohydrates during workouts. The gen-
2. Keep carbohydrate intake low. eral formula: 30-45 g carb + 15 g protein in 500-600 mL
water every hour during training.
4. Eat 1-2 very small meals until weigh-in.

5. Use a sauna as needed to make weight. (Be sure to than 2 hours and / or high intensity activity
have someone keep an eye on you during this time, lasting longer than 1 hour (and for those with
as you’re in the danger zone for fluid balance.) multiple events in one day)
After weigh-in Step 1 Eat according to meal plan 1-2 hours prior
1. Start re-hydrating immediately. Step 2 Consume 0.25-0.5 liters (1-2 cups) of water 30-
60 minutes before activity
2. Keep it as gradual as possible to avoid GI upset.
Aim for no more than 1.5 L (6 cups) of fluid rehy-
dration per hour (using carbohydrate, protein, and Step 3 Consume 30-45 g carb + 15 g protein +
electrolytes). electrolytes (sodium & potassium) in 600 mL
water every hour during activity
3. Continue until bodyweight is back up to normal.
Step 4 Consume 30-45 g carb + 15 g protein +
electrolytes (sodium & potassium) in 600 mL
Strategy: Workout nutrition afterwards
Workout nutrition will be almost the same as the Level Step 5 Consume 0.25-0.5 liters (1-2 cups) of water at
2 approach. The only difference is that meals before and each meal.
after workouts will be dictated by a meal plan.
Step 6 Eat according to meal plan 1-2 hours after
Here are the basic guidelines.
For moderate-intensity activity under 2 hours Supplements

and / or high-intensity activity under 1 hour
As always, before recommending supplements, remem-
Step 1 Eat according to meal plan 1-2 hours prior ber your priorities:
• First, ensure that the client’s exercise and eating plans
Step 2 Consume 0.5-1 liter (2-4 cups) of water during
are well designed and that they are sticking to these
activity.
consistently.
Step 3 Consume 0.5-1 liter (2-4 cups) of water after • Next, ensure that any supplement suggestions you
workouts. offer have a clear rationale, are safe and based on
solid evidence, and match your client’s specific needs
Step 4 Consume 0.25-0.5 liters (1-2 cups) of water at
and goals. Also ensure that any specific brands you
each meal.
suggest are independently tested and manufactured
Step 5 Eat according to meal plan 1-2 hours after. according to Good Manufacturing Practices (GMP).
• Finally, if your client is a competitive athlete, make

absolutely sure that any supplement you give or rec-
Add-ons
ommend will not make them fail a drug test.
For those who want a little extra recovery boost, or
Table 14.13 offers a comprehensive list of all the supple-
endomorphs: Add 10-15 g of BCAAs during workouts.
ments we’ve discussed up to this point, along with a few
additional that may be considered for Level 3 clients.

422 | Unit 14
Table 14.13 Comprehensive supplements list

Frequency &
Purpose Supplement timing Dose Notes
General health, prevent Multivitamin / Daily or weekly See label Find a formulation specific to
deficiencies multimineral your client's needs
Avoid extremely high doses

General health, prevent Omega-3 Daily Fish oil: 3-9 g of total fish oil Be cautious when using
deficiencies per day (or 1-3 g of combined with any blood thinning
DHA+EPA). medications
Krill oil: 2-6 g of total krill oil

per day (or 500-2000 mg of
combined DHA+EPA).
Algae oil (plant-based):

500-1000 mg of combined
DHA+EPA
General health, boost Greens powder As needed See label Some of these have LOTS of
vegetable intake ingredients, consider potential
interactions with medications
and/or food sensitivities
General health, boost Protein powder As needed See label Various options based on
protein intake dietary preferences
General health Probiotic Daily or weekly Between 3-5 billion would be 10 billion+ can be used for
a starting dose specific health concerns
Calming, anxiety L-theanine Daily, before 200 mg Found naturally in green tea
bed
Be cautious when using
with any blood pressure
medications
Sleep Melatonin As needed, 1-5 mg Can be helpful to calibrate
before bed body to new time zone
Sleep 5-HTP As needed, See label Check medication interactions
before bed
Sleep Valerian As needed, 400 mg Don’t use with alcohol
before bed
Sleep, recovery ZMA As needed, See label (dose often lower for High intake of magnesium
before bed women) can sometimes cause GI
disturbances
If also supplementing with

other vitamins / minerals, con-
sider potential for toxicity
Digestion, enhance food Digestive As needed See label Different formulations exist for
absorption enzymes digesting different foods
General health, prevent Specific vita- As needed See label Will be decided based on
deficiencies mins / minerals dietary intake and situation
Bone and joint support Bone support As needed See label Examples include egg-
formulations shell membrane and
glycosamingens

Table 14.13 Comprehensive supplements list

Frequency &
Purpose Supplement timing Dose Notes
Anti-inflammatory Curcumin As needed 500 mg (twice daily) Be cautious when using

with any blood thinning
medications
May inhibit iron absorption
Check any medication

interactions
Anti-inflammatory Ginger As needed See label Be cautious when using
with any blood thinning
medications
Ergogenic Creatine Daily during 2-5 g Loading doses likely aren’t
periods of necessary
higher-intensity
strength/power Some people respond more
training favorably than others
Purpose Supplement Frequency & Dose Notes

timing
General health Antioxidant As needed See label Examples include resveratrol,
formulations green tea catechins
Support performance BCAAs or During/after 10-15 g Powder can be mixed with
and recovery workouts; as water or workout beverage
P + C drink needed 15 g protein 35-40 g carbs per
hour of training
Hydration, support Electrolyte During/after See label Watch for additional ingredi-
performance solutions workouts; as ents beyond electrolytes
needed
Ergogenic (more notice- Beta alanine At least 2-4 4-6 g daily, in divided doses Level 2 or 3 only
able effects in shorter weeks with food1
anaerobic activities
lasting 1-4 min)
To improve CNS output Caffeine Within 60 min- 250-500 mg Level 2 or 3 only
prior to training utes of training
Make sure it is tolerated well
Make sure it isn’t banned
Only use when needed, other-

wise tolerance can develop
Diuretic Herbal diuretic Leading up to Varies Level 3 only
high-level phy-
sique event Be safe - can interact with
medications
1 Parasthesia, or skin tingling, has been reported with single doses larger than 800-1000 mg. Thus, to reduce this problem, take
smaller doses, several times a day, and use a sustained-release formula. This parathesia seems harmless and generally dissipates
within 60-90 minutes.

424 | Unit 14
Troubleshooting Level 3 Have follow-up plans prepared before you need them.
As a coach, you must stay open and flexible, constantly In other words, when starting “Plan A” you should antic-
observing and monitoring, looking for places to adjust ipate “Plan B” and “Plan C." This may mean pre-planning
and improve. changes in exercise or calorie recommendations, etc.
Nutritional recommendations often change depending Whether you put this back-up plan into action is irrele-
on changing conditions (e.g., competition season versus vant. You should simply be ready for the possibility that
off-season), changing client needs, your own educational a program will stop working. Rather than panic at this
style, a client’s unique interpretation of your message, point, you’ll know exactly what to do.
a lack of client results, client plateaus, or a host of other When it comes to Level 3 nutrition, if things aren’t going
potential factors — many of which you can’t anticipate well, it’s usually not due to client adherence (but it still
or control. could be). More often, it will be due to an initial pro-
None of these scenarios indicate that you’re a bad coach. gramming error that needs to be adjusted. Here are a few
After all, even if you were a highly trained sports dieti- to be aware of.
tian (which requires several years of higher education),
Problem: Poor initial progress
it’s more than likely you still wouldn’t know the exact
prescription for every client in every situation. If you notice poor initial progress, you and the client
may not be communicating properly. If this happens,
But that’s the beauty of this system: By regularly moni-
there could be something “lost in translation” and the
toring client results, you’ll have an ongoing measure of
client could be following the wrong advice.
your program’s success.
To ensure that the message you intend to pass on gets
Monitor closely and regularly.
communicated properly, use the following guidelines:
Use and examine as much data as possible for Level 3s.
Have a regular schedule for monitoring, observation, Communicate clearly and specifically
and analysis.
At Level 3, you must be clear and precise.
If the data show your program is producing results,
that’s great. Keep at it. If you are vague in your nutritional communication,
your client may misinterpret your suggestions, leading to
If it isn’t getting results, that’s okay too. You can observe a false sense of adherence.
for two weeks and then adjust. In two weeks very little
“damage” can occur, if any. For example, telling your client to “Eat more protein”
isn’t the same as printing out their meal plan with precise
Using this method of regular assessment and data analy- servings of particular foods that give that client 50 g of
sis ensures that you’ll be able to catch things that need to protein at each meal, and telling them to follow it exactly.
change before they actually do any damage.
“Eat more protein” is subject to interpretation; specific
Figure 14.1 will help you visualize the outcome-based meal plans aren’t.
coaching approach you should be using with your
clients. The more precise and concrete you are, the better your
communication will be. Be very, very clear about to what
Follow a clear plan and measure changes at each step. you want your clients to do. Show them if possible (e.g.,
“Here is what 4 oz of lean beef looks like”). Test their
If things are changing in the way you want, keep going, understanding when you assign them a task.
perhaps tweaking slightly as needed. Notice especially
what is going well. See if you can do more of that. The good news is that Level 3 clients often appreciate a
very high level of detail (while Level 1 clients often find it
overwhelming).

Positive change?
Yes
Continue
A Plan A
Measure changes
Positive change?
No
B
Make changes
Continue
Plan B
Measure changes
Positive change? Positive change?

Yes No
C
Make changes
Plan C
Figure 14.1 The decision-making chart
Prioritize properly Tailor meal plans to body type, goal, and

activity
Tell clients what to focus on, and what is important.
Clients may treat all information or activities as equiv- For more advanced clients, even if their intake is based
alent, and may not know where to place their attention. on calorie control and good food selection, if they don’t
For example: eat right for their body type, goal, or activity level, their
What leafy green vegetable is best? is not important. Eating
results may still seem suboptimal.
2 cups of leafy green vegetables at meal X is.
Remember energy balance
• Taking creatine at exactly 3 PM is not important.
Taking supplements regularly and consistently, and Food quality is important. Food choice is important. But
following the meal plan, is. ultimately, the laws of thermodynamics trump all.
This will often be a relief for Level 3 clients, who general- Thus, the simplest and most important strategy for
ly prefer to be told what to do. helping a client see body composition change is to

426 | Unit 14
manipulate energy balance. This is the key to body their energy needs and energy expenditure. The same
transformation. program won’t necessarily work forever.
Assuming there’s no underlying pathology (e.g., a hor- Here are some suggestions for adjusting their exercise and
monal imbalance), if a client wants to lose fat / weight, training program when this happens.
and isn’t, then they must either take in less energy or
expend more energy. We talk more about this below. For a client who wants to lose fat:
Problem: Good initial progress followed • Ensure a foundation of regular exercise. Work up to a
by a plateau baseline of 5-7 hours of purposeful exercise per week,
either with you or outside of their training sessions.
Once you’ve found what works with your clients, keep
• Decrease daily calorie intake by about 250 calories.
their nutritional program consistent — or add small,
positive practices — until they reach a plateau. • If fat loss stagnates again, increase total weekly
exercise volume to 7-9 hours per week. Use a mix of
As your client’s body changes, so does their physiology.
intervals, weights, and longer-duration, moderate-in-
For example, when a client loses weight, the cost of each tensity cardio.
of their daily activities goes down. They’re lighter, their • If fat loss again stagnates, decrease calorie intake by
metabolism has likely slowed down a bit (due to a reduc- another 250 calories.
tion in energy intake and bodyweight), and they simply
burn less energy with every single activity. • Keep exercise volume high (although more than 10
hours a week might be too much for extended peri-
This will be particularly true of endomorphs (Type O), ods) and keep calorie intake controlled with regular
whose bodies are typically thrifty and readily downregu- decreases (250 calories per day) until a client’s specif-
late metabolism to adjust to energy deficit. ic goals are met.
Thus: A client who starts losing weight on program X • For many clients whose bodies are “threat-averse”
might not keep losing weight on program X. and may view caloric deficits as stressors, adding
low-intensity, long-duration activity is often use-
The client may have to progressively do more exercise or
ful. This activity should be relaxing and fun, ideally
eat progressively less food to continue making progress.
(Or in some cases, physiological testing may be re- outdoors, yet offer constant movement and build an
quired if you suspect underlying pathology or metabolic aerobic base. Examples of this type of activity include
disruption.) outdoor walks / hikes or bike rides.
Likewise, clients who want to gain muscle mass will Keep in mind that you can’t lower food intake and
slowly increase their bodyweight and their total met- increase exercise volume indefinitely. In fact, after a
abolic rate (due to an increase in energy intake and certain point, the client’s health will suffer and body
bodyweight). They’ll burn more energy with every single composition will move in the wrong direction.
activity.
That’s why strategies like calorie / carbohydrate cycling
This will be particularly true of ectomorphs (Type I), are so valuable. As exercise volume goes up and calorie
who naturally resist weight gain and will tend to expend intake down, the occasional day of higher calories can
excess energy as heat and movement. stimulate recovery, prevent further metabolic decline,
boost exercise tolerance, and prevent your client from
Past a certain point, they may need more food to keep going insane from restriction.
making progress.
If even these strategies aren’t working, it’s definitely time
Thus: A client who starts gaining mass on Program X for a complete metabolic assessment with full blood
might not keep gaining mass on program X. chemistry.
In other words, clients often reach a plateau because For female clients in particular, check medications. Many
their bodies have changed. These changes have altered forms of hormonal birth control or hormone replacement

are well known to stagnate or slow fat loss. Additional- Additionally, it’s easy to “lose the thread” of extreme
ly, clients undergoing menopause may struggle to lose goals. In Week 1, getting down to 6% body fat may have
fat despite an excellent nutrition and exercise program, felt very important to a client. In Week 8, they may be
because of the effects of changing hormone levels. wondering what the heck they were thinking.
With some clients, you may need to talk about realistic Check in regularly with your clients and talk about their
expectations. goals.
It’s okay if goals change. Being 6% body fat will likely

For a client who wants to gain lean mass:
not feel like a relevant goal for one’s entire life.
Muscle mass depends on well-planned and intense
strength training. Ensure that your client is training hard Just track the goals regularly — how meaningful they
enough and has a periodized program that includes a few are for your client, how willing and able your client is to
keep pursuing them, etc.
key training modalities such as maximal strength work (1-5
repetitions), power work (explosive exercise), and more Transition to new goals gradually. After aggressively
conventional bodybuilding-type training (8-12 repetitions). pursuing a particular set of goals your client will have
Increase daily calorie intake by about 250 calories. formed habits associated with these goals. Rather than
simply thrusting a new set of habits upon clients, move
If progress stagnates, increase calories by 250 calories per slowly, one step at a time.
day. With the goal of gaining muscle mass, 250-calorie in-
creases every two weeks may be required until bodyweight There is another, more practical, reason to proceed slow-
increases. However, keep an eye on their body composition ly: giving the body time to adjust.
measurements to ensure they are not gaining excessive
If, for example, a fat-loss client has been doing about 9
body fat. hours of weekly physical activity and eating 10 calories
per pound and wants to start building muscle mass, you
Note: Sometimes with muscle gain, one needs to play the
don’t want to throw 16-18 calories per lb at them all at
long game with a slower, more patient approach. Long
once. They’ll have an upset stomach and perhaps even
stretches of hard training with small calorie surpluses do
gain more fat than muscle.
add up to significant lean gains over time.
Instead, slowly increase by 1-2 calories per lb every 1-2
In both of the previous scenarios, client body type is
weeks. Thus, for example:
an important factor that affects exercise volume and
food intake. The strategies described above will work Week 1: They might eat 11 calories per lb.
regardless.
Week 2: They might eat 12 calories per lb.
However, if you’re following a more aggressive trou-
bleshooting approach, ensure that your client is eating Week 3: They might eat 13 calories per lb.
according to their body type along with manipulating And so on. This will ensure a better transition to a high-
their exercise and food volume. er calorie intake as well as less fat gain while building
muscle.
Changing goals
Similarly, scale exercise back gradually. For instance:
If a client gets to their goals and wants to change their
body in some other way, their program must reflect this. Week 1: They might go from 9 to 8 hours of exercise per
week.
For example, a client may have wanted to lose body fat.
Now they’ve done it. What’s next? Perhaps a period of Week 2: They might go from 8 to 7 hours of exercise per
gaining muscle. week.
Conversely, a client may have wanted to gain lean mass. And so on. This will help control energy balance and re-
Now they’ve done it. What’s next? Perhaps a period of program the metabolism after the goal set has changed.
fat loss.

428 | Unit 14
The opposite is also true if a client wants to switch from planned periods of rest, and / or unplanned periods
a goal of gaining muscle to a goal of losing fat: Go grad- of injury — you may need to adjust their nutrition
ually, decreasing calories a little bit at a time. This will program.
help your client reduce body fat without leading to losses
in lean mass. For example:
• The preseason calorie needs of athletes may be high-
One important thing to keep in mind as well is that after
er than their off-season needs.
a certain period of time, clients may no longer want to
gain or lose. Indeed, the yo-yo weight fluctuations of • A high-revving athlete in the midst of a busy compe-
bulking up then cutting down that are so common in the tition season may get injured and greatly reduce their
fitness world can be unhealthy and undesirable. So make activity.
sure you have a plan for helping clients get off the mer-
ry-go round of weight cycling (hint: Level 1 strategies). Change a client’s nutritional intake as their training
changes.
Changing training
In particular, adjust for any changes in energy systems
If a client’s training program changes — perhaps due (e.g., going from long slow distance to strength-power
to their athletic schedule, a periodized exercise plan, exercises) and energy intake / expenditure.
Case study
Leading up to the 2006 Winter Games, we were work- the first athlete, yet a disappointing one for the second,
ing with two female athletes, both top junior competi- we had a meeting to discuss what went right and what
tors who had done well at the Junior World Champion- went wrong.
ships. These two athletes trained together and shared
The first athlete was on top of the world. She was ecstat-
an apartment.
ic with her training and nutrition and couldn’t wait till
They wanted to fine-tune their nutritional intake so they next season to take both to the next level.
could achieve an ideal body composition for their sport
The second athlete had quite the opposite perspec-
while achieving top race form and qualifying for the
tive. She claimed that her training was off and that our
Olympics.
nutrition advice made her worse. She believed that our
One athlete was outgoing and chatty. She contacted us nutritional suggestions left her too low in energy to
every week or two, filling us in on what she was doing perform at the World Cup level. She also believed that it
training-wise, and how her nutrition plan was going. made her more susceptible to illness and injury.
The second athlete was a bit more shy and reserved. She At this point you might be wondering how two athletes
was content to simply follow along with the advice we who lived together, trained together, and ate together
gave, although we urged her to keep us updated with had had such a different experience.
progress reports in case she needed modifications.
After further questioning, the answer was clear.
As the season progressed, the first athlete seemed to be
First, the two athletes started off with different body
pulling ahead of the second. She was doing very well
types.
on the junior circuit, so much so that she advanced to
the World Cup Circuit. Even more exciting, with about The first athlete had more of a mesomorphic body type.
two months to go before the Olympics, she qualified to
So, as we coached her through the process, we kept
compete at the Games.
her protein intake, fat intake, and carb intake fairly
Her teammate, unfortunately, was only invited to one balanced. Since she kept in touch with regular feedback
World Cup event while never actually qualifying for the and reporting, we adjusted her plan so that it fit her
Olympics that year. perfectly and she continued to excel.
After the season, which was a very successful one for The second athlete, on the other hand, had more of an

ectomorphic body type. This case study should present an important lesson in
working with clients:
Although we advised her to eat a diet higher in carbohy-
drates, moderate in protein, and lower in fat, she deviat- Not only do you need to give them a solid initial pre-
ed from this plan, following her roommate’s plan instead. scription, you also need to get regular feedback and
She figured that if her roommate was succeeding on the troubleshoot based on this feedback.
plan, she would too.
Make sure you stay on top of your clients about this.
Another problem was that the second athlete stopped Monitor closely and set clear expectations about what
eating red meat during the season without mentioning tracking involves.
it to us. When red meat was on the menu at home, in-
We certainly could have done a better job with the
stead of replacing it with a different protein source, she
client in this case study. However, at the time we used
simply skipped the protein. This resulted in a nutritional
the excuse that since these were distance-based clients,
deficiency of calories and iron, and possibly protein too.
there wasn’t much more we could do. We also believed
Her food preferences set her up for under-eating and
that since she wasn’t checking in, things must have been
what we now suspect was borderline anemia.
going well for her.
If this athlete had been providing us with feedback
In retrospect, we now realize we could have done more
during the season, we could have figured this out and
to prevent this problem.
helped her troubleshoot her low energy intake, frequent
colds, and minor injuries. However, by keeping us in the These days, if a client wants to work with us to achieve
dark and simply following what seemed to work for her big goals, we require them to give bi-weekly feedback.
roommate, her entire season was negatively affected. If they’re unwilling to do so, we recommend that they
work with a different coach.
Summary
Level 3 strategies are for nutritionally experienced peo- usually recommend, they can help Level 3 clients go
ple with specific, aggressive goals such as competing in from great nutrition to extraordinary nutrition.
a physique contest, preparing for elite-level competition,
or needing to reach very specific body composition num- While aggressive carb / calorie cycling can help to
bers for performance, competitive, or aesthetic reasons. prevent plateaus due to variations in intake, it is an
imbalanced approach, and should only be followed for a
Coaching Level 3 clients isn’t for everyone. As a coach, specific timeline.
you should consider whether you’re suited for this role,
as it demands detail orientation, precision, thorough- Play with meal timing. Beyond replenishing after intense
ness, and relentless monitoring and follow-up. It’s okay workouts, there are no “rules” about meal frequency or
if this isn’t a fit for you; simply refer out to another qual- when meals occur.
ified practitioner.
Very high-carbohydrate diets should only be used for
Coaching Level 3 clients requires you track progress short periods, immediately before very long-duration
closely and analyze data carefully. Always make out- endurance sports.
come-based decisions grounded in the evidence. Sched-
Water manipulation can be helpful for physique and /
ule regular progress checks and opportunities to revise
or weight-classed athletes. Forcing variations in body hy-
and re-assess.
dration and electrolytes can be dangerous. Stay sane and
While meal plans with specific calorie and macronu- safe, monitor closely, and be willing to stop the process if
trient allotments are more complicated than what we it compromises health.

430 | Unit 14
Workout nutrition and supplementation will be similar Always use outcome-based decision making.
to Level 2, though they can be more individually tailored.
Plateaus are expected. Usually, with some simple adjust-
With any higher-level nutrition strategies, if disordered ments, you can get clients back on track.
eating patterns become noticeable, have an honest
discussion with the client about long-term health and Change nutritional approaches when client goals and /
realistic expectations. or training routines also change.
Communicate clearly, concretely, and precisely. Test to Level 3 strategies are generally short-term techniques.
make sure your client understands exactly what they Scaling back to Level 2 or 1 is always an option.
need to do.

UNIT 15
Special Scenarios
432 | Unit 15
Unit Outline
1. Start with the basics 8. Ethnicity, heritage and genetics
2. Disordered eating 9. Life stages and aging
3. Food addiction 10. Food sensitivities
4. Alcohol 11. Plant-based eating
5. Nutrition and immunity 12. How we fit into the food system
6. Injuries / inflammation 13. Summary
7. Sex and gender
Objectives
“Special scenarios” aren’t really special. They’re just ev- situations and challenges, such as injuries, food sensitivi-
eryday, real-life examples of human diversity. In this unit, ties, aging, and disordered eating.
you’ll learn some basic principles for addressing common
Start with the basics about the glycemic index of carrots while they’re staying
up late at night snacking when they aren’t hungry.
Keep it simple
In reality, the people with the best nutrition are so solid
A quick reminder: because they’re the best at the most fundamental things.
Not because they utilize more advanced practices. Or
When in doubt, go to Level 1. Fundamentals first. they can use advanced practices better than everyone else,
Always. because their nutritional foundation is so sound.
No matter what their situation or concerns, almost all Know your scope of practice
clients will improve with a solid foundation of Level 1
habits, done consistently. Know your boundaries and limits. Work within them.
So start there. Have a broad referral network that includes people like:
• health care providers (e.g., sports med doctors)
You might think this sounds obvious. But it’s not.
• pharmacists
Both clients and coaches can get distracted by the seem-
ing “specialness” of “special scenarios.” They can fall • counsellors and psychotherapists
into the trap of “mowing the lawn while the house is on • body workers (e.g., massage therapists)
fire.”
• registered dietitians
In other words, they can get focused on the stuff that
doesn’t really matter. Collaborate with other caregivers and refer out as need-
ed. And remember, “refer out” doesn’t mean send your
Perhaps they worry about a single vitamin supplement client away, never to be seen again. It means you add
while their overall eating pattern is chaos. Or they worry another person to your client’s care team.

Special Scenarios | 433
Primary care physicians refer patients out all the time, but the patients still return
to them when they need their annual physical. The physician simply calls in other
specialists when specific situations are beyond a certain area of their skillset.
Many special scenarios you’ll see in your practice have a medical component.
This means unless you are specifically trained and licensed to offer Medical
Nutrition Therapy (MNT), you cannot give advice to specifically treat these con-
ditions. However, this unit will provide you with background information (which
can be useful when discussing conditions with those in your referral network) and
help you make general recommendations for supporting and preventing particular
medical conditions by improving overall health.
In other words, you can still work with and help people with medical conditions.
You just can’t provide MNT (advice to specifically treat their condition). You
can, however, provide general advice to help them. And you can collaborate with
other professionals who can specifically treat or manage these conditions.
For those of you reading this who are trained in MNT, we hope you find this unit
useful and can incorporate it with clients, whether for treatment or prevention.
Here are some of the most common “special scenarios” you’ll see as a nutrition
coach.
Disordered eating
By definition, most of our clients have some type of disordered eating. Disordered disordered eating (DE):
eating (DE) is a complicated, multi-faceted problem. It has many, interlocking A range of abnormal eating
behaviors
causes and social, familial, and genetic links.
We use “disordered eating” rather than “eating disorder” for several reasons.
First, people’s behaviors (and the people themselves) are complex.
There is no single cause. There is no single form of DE.
Second, we want to highlight and build what is right with clients, not what is
wrong.
“Eating disorder” makes behaviors sound like pathology and clinical dysfunc-
tion. “Eating disorders” are things you have (and by extension, things you are,
e.g., “anorexic”).
Conversely, “disordered eating” is a set of behaviors that you do, and can thus be
changed.
Finally, current clinical definitions of “eating disorders” don’t capture the full
range and complexity of people’s eating experiences.
While a few people match the clinical definition of, say, “anorexic” or “binge eater”, eating disorder not otherwise
the vast majority of people with disordered eating would be termed “EDNOS”, or specified (EDNOS): An eating
disorder that does not meet the
“eating disorder not otherwise specified.” full clinical criteria for anorexia
nervosa, binge eating disorder, or
We can do better than that. bulimia nervosa

434 | Unit 15
What is disordered eating? And it involves thoughts, beliefs, feelings, physical sensa-
tions, and personal narratives — our “stories” of who we
Instead, we understand DE as: are and how the world works.
• any type of eating that regularly doesn’t All of these have reason, function, and purpose. Disor-
match physiological needs, whether eating dered eating has a job to do.
too much or too little — (and we say “regularly”
because we’re not talking about loosening your Most importantly, disordered eating is a coping mecha-
belt for a once-yearly holiday meal, or occasionally
nism and a solution to another problem, however mal-
adaptive. As a coach, you’ll have to tackle the disordered
skipping a meal when you’re traveling);
eating first… but eventually, you’ll have to tackle the
• eating behaviors that interfere with and harm underlying issue(s) driving it.
proper physical, psychological, and inter-
personal functioning — that alienate and isolate In other words, like other addictions or ineffective coping
behaviors disordered eating isn’t the problem. The orig-
people from their bodies, their deeper selves, other
inal problem is the problem. Disordered eating is just a
people, and the world;
“distress signal.”
• a systematic and longstanding preoccupation
with food / eating / not eating — thus even Somehow, disordered eating solves another problem…
if the person isn’t actively engaged in DE, they are
imperfectly.
thinking about food / eating / not eating; and / or So as the coach, ask yourself:
• eating behaviors that both cause distress and
What problem is this client’s disordered eating trying
are trying to relieve distress — the character
to solve?
Fat Bastard from the Austin Powers series made this
famous with his quote, “I eat because I’m unhappy, Disordered eating behaviors and
and I’m unhappy because I eat.” mindset
These complex and interrelated set of behaviors, We don’t define disordered eating by clinical type (e.g.,
thoughts, beliefs and emotions have a specific purpose anorexia, bulimia). We look at what clients are actually
and function within a person’s life, such as: doing — the specific behaviors.
• self-soothing;
Each client will have a unique constellation of behav-
• distraction from unpleasant sensations and emotions; iors. Not all clients will have the same behaviors.
• signalling distress; These can include any or all of the following.
• avoiding experiences or challenges;
• helping to manage situations and feelings that the

Restriction and control
client sees as unmanageable or too painful; Clients may restrict and / or tightly control food in-
• a coping mechanism and a solution to another prob- take. They may strive to feel “in control” in general.
lem, however maladaptive;
They may monitor their eating / not-eating and exercise
• can act like a drug or addiction; stringently. For example, they may keep meticulous
workout logs that include things like “calories burned”
Sometimes the process of “recovery” or a chronic state of or excessively detailed and numerically oriented food
“self help” itself can be the “drug” (e.g., being hooked on journals that include things like “calories eaten.”
fitness / nutrition information or “getting better”).
They may simply skip meals or avoid particular eating
DE is a full-body, full-person, full-life experience that situations. If they have to eat, they might pretend to eat
has multiple dimensions.

They have eating routines that include particular en-

vironments, paths (such as a route between fridge and
In cupboard), and even movements (such as the rhythmic
hand-to-mouth that distinguishes a binge). They may
control ST also have strict exercise rules and routines.
RE
TEMPORARY
RELIEF All-or-nothing thinking is common, such as:
SS
“All carbs are bad.”
“If I have one cookie, I’ve blown it, so I might as
well keep going.”
Get back Lose
“If I am not perfect then I am a failure.”
in control control
TEMPORARY TEMPORARY Clients may have “if-then” rules, such as:
RELIEF RELIEF
“If I eat this then I am bad.”
“I can only eat carbs after I have worked out.”
ST
RESS
There is no room for error, gray areas, or flexibility in
any of these rules. Disordered eaters will respond to per-
ceived “mistakes” by tightening up the rules and trying
TheThe
Figure 15.1 Cycle
cycle ofof Percieved
perceived controlControl to adhere more strictly to them, rather than loosening
the rules.
They may have rigid, inflexible identities, such as:

more, so not to avoid suspicion (e.g., at a family meal,
they’ll push the food around on their plates). I’m a runner / CrossFitter / yoga practitioner /
failure / “big guy or gal”, etc. This is who I am.
Disordered eaters often have some kind of chronic re-
striction-oriented mindset, such as: These identities also feed into the disordered behaviors,
by, again by creating “if-then”, “should”, and “must”
“I shouldn’t eat that.” rules. They might say:
“I can’t have that.” “Because I’m a runner, I must ____.”
“I don’t eat that.” “Because I’m ____ and everyone expects it
from me, I should ____.”
This “in control” is often alternated with periods of
“food chaos” where they “lose control.” (Then they get “Because I’m a failure, I always _____.”
focused on “getting back into control.”)
At every stage, control is a key player. Bingeing

Objective binges involve eating an objectively large
Routines and rules amount of food, (e.g., 2 pizzas).
Clients with disordered eating may be routine-driven Subjective binges involve eating a normal or even small
and have rigid food rules, such as: amount of food, but with the feeling of compulsion or
• when they should eat (or not); having temporarily “lost control.”
• what they should eat (or not); or So binges are not just about the amount but the feelings
that go with them.
• what foods are “good” or “bad.”

436 | Unit 15
Low self-esteem or
poor body image, so
you go on a diet
Repeat the cycle, Feel deprived on the

eventually leading to diet, so you binge or
disordered eating overeat
Feel even more Feel bad about

deprived, so you binge overeating, so you go
or overeat even more on a stricter diet
Figure 15.2 The restriction-binge cycle
What differentiates a binge from simple garden-variety • finding another, seemingly better “plan” (e.g.,
over-eating is the sense of compulsion and dissociation. “Tomorrow, I’m going strict Paleo / vegan / juicer /
The eater feels a strong sense of urgency — the binge has low-carb”);
to happen right freaking NOW.
• “cleansing” or “detoxing.”
Compensation and bargaining Clients with disordered eating may also make bargains
with you or themselves, such as:
After an episode of over-eating, a binge, or any situation
in which clients feel they have been “bad”, they may try “If I don’t eat ____ then I get to eat ____.”
to compensate with:
“Tomorrow I start a new workout plan, so to-
• purging — vomiting, laxatives, diuretics, etc.;
night is my last night to eat all the ____.”
• over-exercising;
“I’ll work this off tomorrow in the gym.”
• fasting;
“Broken cookies don’t have any calories. Every-
• restricting food;
one knows that.”
• tightening up or vowing to adhere more strictly to
the “rules”; This form of negotiation with reality is often known as
“magical thinking.”

Anxiety and avoidance This is one reason people with disordered eating feel
socially isolated.
Disordered eaters have a lot of anxiety, and they try to
avoid feeling bad. Dissociation
Clients might feel anxious about and avoid “trouble Disordered eating is a way to dissociate from anxiety,
situations”, such as traveling when they aren’t sure they boredom, sadness, or other uncomfortable thoughts,
can eat the way they prefer. They might avoid eating with feelings, and sensations.
other people, or wait to be alone to binge.
For example, despite the apparent sensation-seeking,
Disrupting your clients’ eating routines (e.g., with new when in “binge mode”, the eater “checks out.” They
habits) may also make them very anxious or resistant. become “eating zombies.”
They may avoid any discussion of changing their eating Restrictors also tend to be emotionally numb — they
habits. Or they may divert the discussion away from the restrict and control unwanted feelings along with food.
real problem (e.g., “I think if I can just eat fewer carbs / Their body becomes a disconnected chunk of flesh that
be a better vegetarian / go stricter Paleo / use a calorie needs control and constraint — even punishment.
counting app then maybe I’ll be better”).
If you ask a client after an eating episode: “What hap-
You may notice that your clients are more prone to pened?” often they will say, “I don’t know.” Or “I just
disordered eating behaviors when they are under stress, found myself doing X.”
or feeling anxious about something else. As a coach, you
can help draw their attention to these patterns. (Gently.)
External locus of control
Judgment Disordered eaters are divorced from their own internal
environment and physiological-emotional cues.
Disordered eaters focus a lot on judgment.
They typically have an external locus of control — ex-
Self-judgment ternal “rules”, other people’s desires and wishes (real
They judge themselves harshly, magnifying every per- or imagined), and arbitrary standards and measures of
ceived “failure” or “mistake.” They compare themselves “success”, such as:
to others, particularly an imaginary “everyone else.” For • winning a competition;
example:
• hitting a certain numeric target (weight, body fat,
“Everyone else seems fine. What’s wrong with rank, etc.); or
me?” • being “ahead” (or “behind”).
“Everyone else is fitter / leaner / better / losing If you ask disordered eaters whether they are physically
weight faster than me.” hungry or full, they often don’t know. They can’t read
Disordered eaters are often perfectionists, subscribing to their internal cues any more.
the proverbial “If it’s not Scottish, it’s crap!” paradigm. They may only quit eating when they’re about to explode
If they can’t be the best in all things, then it means they (and indeed, some hardcore binge eaters will eat to gas-
suck at everything. tric or intestinal rupture).
Judgment by others They may not be able to tell physical hunger from the
Not only are disordered eaters harsh self-judgers, they’re desire to eat (over-eaters may say they want to eat “all the
usually sure that other people are judging them too. This time”, and that they “never feel full”).
often involves “mind reading”, e.g., Or they may restrict so severely that hunger is the “white
“Everyone knows that I…” noise” of their life; unlike most people, a full stomach is
distressing to them.
“Everyone thinks I’m…”

438 | Unit 15
Athletes are at particular risk of DE since they have spent much of their lives
focusing on external performance and approval, trying to be “better”, and
“measuring up”; getting ranked and graded by others such as coaches and judges.
Athletes in “leanness”, weight-controlled, and body-conscious sports (e.g., gym-
nastics, bodybuilding, swimming, boxing, MMA, figure skating, dance) are at
particular risk.
Orthorexia
This is a particularly sneaky form of disordered eating, because it usually starts
out as wanting to “eat healthy.” The prefix “ortho-” refers to “correctness” or
“rightness” (think of orthodontics, which aim to straighten and correct teeth).
Thus, orthorexia is an unhealthy preoccupation and obsession with “eating

healthy” or “eating properly.” Orthorexics often restrict food, but their focus is
largely on the “correctness” of their diet. They rigidly avoid “bad foods” (how-
ever they define those) and feel badly about “slip-ups” (where they might eat the
“wrong” food).
Be wary of using terms like “eat clean” or “bad foods”, or focusing clients too
much on specific details like macronutrients or antioxidants. (Unless they’re
Level 2 or 3 clients, and can handle it safely and sanely.)
Cognitive dietary restraint (CDR)

This fascinating situation shows the power of the mind. With CDR, a person is
constantly thinking about food and dieting, or restricting food intake.
Here’s the key piece: They might not ever act on these thoughts. But the thoughts
are enough. The body responds as if the person were actually restricting.
Simply thinking about restricting food intake all day can be quite similar to
actually doing it. Stress and reproductive hormones become unbalanced, and the
body can even go into “famine” mode, holding on and storing each calorie that is
consumed.
Body dysmorphia
body dysmorphia: A mental This isn’t strictly disordered eating, but is often related to it. Body dysmorphia
disorder in which someone is refers to a significantly disordered body image.
preoccupied with an aspect of
their appearance — minor or
It may be a client who thinks they are “too big” or “too heavy” and wants to be
imagined
“skinny..”. even if they’re a normal or even low weight.
It may be a client who thinks they “need to be leaner” or feels “fat..”. even if they
have a normal or low body fat.
It may be a client who thinks they’re scrawny and needs to get more muscular…
even if they’re already fit, perhaps even already big. (This latter group is often
known as “bigorexia.”)

The diet-disorder connection of deprivation and resentment. We may develop beliefs

and assumptions about “willpower”, or work on “food
While disordered eating can manifest in many ways, rules” that we then break. After we over-eat (which
and in response to a host of thoughts and feelings, one almost everyone inevitably does), we feel shame, regret,
critical factor is often involved: dieting. and guilt. And the cycle begins again.
Food restriction / control / concern is a physical and
physiological stressor. The health effects of disordered
Physically, the body eventually thinks it’s starving, and
eating
tries to correct the problem. Hunger goes up, satiety goes
Fundamentally, disordered eating is a disruption of
down. Appetite hormones go up. Food starts to look
body, mind, and spirit. Its damage is widespread.
really appealing, and we are more sensitive to the sight,
taste, and smell of it. A full discussion of disordered eating, its effects, and
how to work with it is beyond the scope of this textbook.
Hormones also change our thoughts and moods. We be-
However, here are some of the most common problems
come more disinhibited (otherwise known as the “Screw
you may see as a coach.
it” moment, as in “Screw it, I’m having that cake!”).
Physiological effects of restriction
Stress hormones increase. We may feel more and more
anxious and distressed until that imbalance is resolved. Nutrient and energy restriction can result in:
Because particular foods, especially those higher in fat
• anemia
and sugar, stimulate “feel-good” hormones and respons-
es in the brain that help to buffer negative emotions, they • other nutrient / mineral deficiencies (e.g., low mag-
nesium, low zinc)
can also become “drug-like” for those struggling to cope
with stress. • bone loss and fractures
• electrolyte / fluid imbalances, which can lead to
Consciously, we may become preoccupied with feelings problems like
Restrictive type Binge-purge type
Over-evaluation of eating, Over-evaluation of eating,

shape, and weight control shape, and weight control
Strict weight-control behavior: Strict weight-control behavior:

dieting, purging, exercise, etc. dieting, purging, exercise, etc.
Low body weight Binge eating Low body weight
Effects of starvation Purging Effects of

starvation
Figure 15.3 Manifestations of disordered eating

440 | Unit 15
• heart failure
• kidney problems
• edema
• higher levels of hunger hormones such as ghrelin
• higher levels of stress hormones, such as epinephrine / adrenaline
• lower levels of thyroid hormones, which leads to things like:
• feeling cold
• hair loss / dry hair
• dry skin and eyes
• lower levels of sex hormones, leading to things like:
hypogonadism: Reduction or • hypogonadism
absence of hormone secretion or
other physiological activity of the
• amenorrhea (loss of menstrual period)
testes or ovaries • “pregnenolone steal” — a hormone precursor converted to cortisol instead of
normal sex hormone production
• changes in body fat distribution (often with more visceral fat being deposited)
• slowed gastric motility, which results in constipation, bloating, nausea, etc.
• insomnia and sleep disturbances
Interestingly, restriction often leads to malnutrition, which further compounds

the effects. In other words, when clients restrict, they create nutrient deficiencies
that then have the same effects as restriction. For instance, many nutrient defi-
ciencies (such as low B vitamins or magnesium) can cause restlessness, irritabili-
ty, and anxiety… which the eater will then seek to relieve by restriction… which
will make it worse.
Physiological effects of purging / compensation

Purging and compensation can take many forms, such as:
• vomiting
• laxative use
• diuretic use
• fasting / restriction
• compensation with exercise
Along with the health effects of restriction and excessive exercise, there are many
problems with purging, such as:
• fluid and electrolyte imbalances (notably hypokalemia, or low potassium)
• damage to stomach and esophagus
• eroded dental enamel from stomach acid
• enlarged and inflamed salivary glands
• other damage to oral tissues (e.g., receding gums, dental caries)
• disrupted gastric motility
Physiological effects of binge eating

Some people who binge will then restrict, purge, or otherwise try to compensate.
Thus, you’ll see the types of health effects listed above as well.

Other people who binge may not compensate. In these What you can do
cases, you’ll mostly see effects on GI tract as well as over-
all body composition and metabolic health, such as: Know your boundaries
• increased gastric capacity, which delays emptying,
Don’t play counsellor or therapist if you aren’t qualified
blunts the release of CCK and impairs the satiation
to do so. Refer out as needed. But be sure to remain
response (in worst case scenarios, people have eaten engaged with those clients as part of their team.
to the point of stomach or intestinal rupture)
Having good boundaries also means being aware of your
• indigestion, heartburn, gas, bloating, diarrhea, etc.
own DE tendencies and behaviors. It’s very common for
• metabolic diseases such as poor glucose control / people working in nutrition to have their own “secret”
Type 2 diabetes problems with food, eating / not-eating, control, and
body image. Don’t keep those problems secret. Go and
• poor sleep if the binge occurs at night
get the help you need.
Table 15.1 Dos and don’ts for working with clients

Do Don’t
Talk about “foods that don’t help us get to our goals” or Don’t use terms like “bad foods” or “eating clean.”
“foods that are high in sugar / sodium”, etc.
Keep it objective and neutral rather than assigning good-
ness or badness to foods.
Emphasize variety and flexibility in food choice. Don’t create a restricted roster of foods unless you are work-
Place foods on a continuum of ones to eat more often, or ing with a Level 3 client who needs it, and can handle it.
ones to eat less often. Don’t teach clients that there are foods to always eat, or
foods to always avoid.
Focus mostly on sustainable, long-term habits that people Don’t reinforce the feast-famine concept. “Challenges” can
can do successfully and sanely in their daily lives. be motivating for some people, but for many folks, a “30-
day detox” or “two-week ‘eat clean challenge’” just repeats
the cycle of rigid deprivation followed by a rebound.
Focus on the client’s needs and goals. Don’t talk about how you’re “feeling fat” or “feeling scraw-
ny.”
Don’t criticize yourself, or draw excessive attention to your
own body or eating habits.
Create a welcoming coaching environment in which differ- Don’t create an environment in which “fat talk” or self-criti-
ent types of bodies are okay. cism is appropriate.
Recognize and appreciate your clients’ progress beyond Don’t over-focus on external measures and indicators such
their outward appearance and changes in weight/inches. as calorie counts, scales, girths, and body fat.
This can include things like how hard they work, improve-
ments to their physical strength and endurance, better
health, overall consistency, problem-solving and growth
mindset, and their skill at particular movements.
Treat food as simply a natural physiological need and an Don’t use food as a reward, or exercise as a punishment.
important social connector. Don’t use words like “deserve” or “earn” with food. Don’t
Treat exercise as a joyful activity and something that builds connect eating to “being good”, or “treating oneself.”
our capacity to enjoy life.
Help your clients relax and unwind, take care of themselves, Don’t over-schedule food / exercise or make it more rigidly
and / or be “irresponsible” without food. scheduled (unless your client is a Level 3).

442 | Unit 15
Watch your language… and actions To count as an addiction, there must also be withdrawal
— feelings of discomfort, distress, and intense cravings
Be very, very careful with your words and what you do. Be — when the addictive substance or behavior is taken
aware of the message that you send. away or stopped.
For some Dos and Don’ts when working with clients (no Food addiction is still a debated idea. But we can see
matter if you suspect DE or not), see Table 15.1. how the concept of “addiction” helps us understand how
some people behave around food and eating.
Have a referral network
Addiction involves a regular compulsion to eat and /
Ideally, you’ll have a few trusted health care profession- or consume particular foods, even though those foods
als, such as eating disorder therapists, that you can refer harm us — whether that’s because the foods are un-
to and collaborate with. healthy (e.g., highly processed and energy dense), or
because they make us sick, or pile on body fat.
When you refer out, try to do some of the legwork for
the clients so that “I couldn’t find anyone” is no longer a Addiction is complicated. Social, motivational, emo-
justification. Using Google Maps or a therapist directory, tional, genetic, and environmental factors all interact to
search in the client’s area for therapists specializing in: create the addiction experience. An addictive substance
• disordered eating, body image alone doesn’t create addiction. But some things are more
addictive than others.
• anxiety and depression
• trauma (disordered eating is often a coping mecha- People who struggle with addictive-type behaviors and
nism for post-trauma)
food come in all shapes and sizes. Some food addicts
eat too much; some don’t consume enough. For a food
You can also search the client’s home address, then use addict, food provides the fun, entertainment, control,
the “Search nearby” function of Google Maps to search reassurance, or love that’s missing in their life. Food
for “disordered eating therapy / counseling.” Psychology may also help to numb difficult emotions like fear and
Today also has a good searchable directory (http://thera- sadness. As we’ve already talked about, some people can
pists.psychologytoday.com/rms/). even be “addicted” to restriction.
Propose specific suggestions to the client, offer to help After having a couple of cookies (or any potentially ad-
make the call, etc. Give them as much support as pos- dictive food), a non-addict will feel indifferent about eat-
sible. Match therapist by gender if possible. And then ing more. The experience of an addict is much different.
follow up to see if they contacted them. Addicts become utterly single-minded in the pursuit of
their “hit.” Eating a couple of cookies (or any potentially
We live in a world that is ripe for the creation of DE, so addictive food) sets off an abnormal reaction — and they
be prepared. want more and more until they’re physically unable to
swallow.
Food addiction Thus, the difference between normal use and progressing
along the continuum of addiction is reason and degree.
What is addiction? A normal drinker may enjoy 2-3 social drinks with
Addiction is an overpowering craving to repeatedly do friends over an evening, once a week.
an activity that gives temporary relief, even though that However, a person who struggles with alcohol addiction
activity has negative — perhaps even dangerous — con- may drink almost every evening, and to the point of
sequences. It’s something people feel compelled to do, drunkenness.
even though it harms them (and possibly others). And
even though eventually, most people no longer enjoy it. Likewise, a normal eater, or even someone who period-
ically over-eats, may enjoy a plate of nachos along with
those friends and drinks.

However, a person who struggles with food addiction may go home after that
social evening and feel overwhelmingly compelled to eat more, then do it again
the next day.
The chemistry of food

Many foods give us a chemical “hit”, working along the same brain pathways as
many drugs to stimulate “feel-good” neurotransmitters.
As with other addictive substances, we may turn to these foods when we are
stressed, upset, anxious or otherwise feeling badly. We may also associate these
foods and addictive substances with “good times” and socializing.
When “normal” goes wrong

Addiction hijacks normal human brain functions. So addicts are not “diseased”
or “screwed up” or ”different.” Addiction has simply taken over normal brain
pathways that have other functions, such as exploring, enjoying pleasurable sen-
sations, or trying new things. Thus, in a sense, we are all potential addicts.
If you aren’t a food addict, it’s not that you are a master of self-control. It’s that
food doesn’t spin your dials.
But there’s a good chance you look for other small “hits” in your life that bring
compelling rewards and a hard-to-shake habit that you may prioritize at the
expense of other things: work, shopping, Internet, binge-watching TV, alcohol or
recreational drugs, gambling, video games, your mobile phone, training hard or
competing, etc.
The Yale Food Addiction Scale is a clinical tool for assessing food addiction. Yale Food Addiction scale: A
questionnaire used to assess food
addiction
The role of environment
An oft-cited stat about addiction is that huge numbers of soldiers during the
Vietnam War regularly used heroin. When they returned home, only a few kept
up their addiction.
Arguably heroin stayed as addictive as ever. So what changed?

• Social support: If everyone around you is doing something, and helping you
do that something, it’s much more compelling for you to do it too.
• Access and availability: In Vietnam, heroin was cheap and easy to get; in the US
it was much less so.
• Social norms: In the US, drug addiction was frowned upon.
• Stress: War is hell.
In short, it was just more difficult and lonely to be a heroin addict in the US than
in the Vietnam War. Environment matters.

444 | Unit 15
What you can do “self control” or “willpower” in an addiction fuelling

environment is a set-up for failure.
If you review the factors involved in addiction in general
and food addiction in particular, you might be able to This doesn’t mean people who struggle with addictions
see some ways that you can help as a nutrition coach. are “weak.” (In fact, given how hard most food addicts
try to change — even if unsuccessfully — arguably their
Change the availability and will is very strong.) The struggle with food addiction
environment often leads to dieting, over-exercising, purging, drugs,
bingeing, and weight gain / loss. These are efforts to con-
Berardi’s First Law states that: trol the addiction, but these efforts eventually fail (and
this failure can lead to more addictive behaviors). In fact,
If a food is in your house or near you, either restriction and obsession with “fixing the problem” itself
you, someone you love, or someone you mar- can create more rebounds.
ginally tolerate will eventually eat it.
Keep records and look for patterns
If a client feels out of control with certain foods or in
certain situations, they probably are. Our behavior de- As part of a food journal exercise, you can ask clients
pends heavily on social and environmental cues. We can to jot down what they’re thinking and / or feeling when
adjust our behavior by adjusting cues from our routine they eat, and / or what situations they’re in (e.g., home,
and environment. work, school, visiting family).
Luckily, the corollary of Berardi’s First Laws is that: This can help you look for patterns and come up with
strategies for “risky situations.”
If a healthy food is in your house or near you,
either you, someone you love, or someone you In particular, look for links between emotions / stress
marginally tolerate will eventually eat it. and behaviors.
Help clients create social and physical environments that Emotions are important, useful signals. Food can be
lower the risk of addiction and help them move towards used as a coping mechanism for emotions that feel
a normal relationship with food. intolerable. But food doesn’t actually resolve emotions
or respond to what emotions are signaling (e.g., that
This includes things like: something is wrong). It’s like putting tape over your
• changing the physical environment; dashboard oil light so it doesn’t flash.
• building a social support system (including getting Once a “food rush” wears off, we’re left with the very
away from people who enable the addiction); same emotional problems… plus the additional prob-
• making it tougher to get at the addictive substances;
lems addiction brings.
• decreasing life stress, and / or working on stress Helping clients assess and describe their emotions as
management; part of a more mindful approach to eating can help.
• learning to tolerate discomfort, and getting support Eat slowly and mindfully
in doing so; and / or
Addictions depend on impulsive decisions, automatic
• changing one’s routine and schedule to favor positive
behaviors, and snap judgment. Thus, mindfulness and
behaviors, and diminish the chances for negative slowing down can help control addictions.
behaviors (which can include things like getting more
sleep, seeking out safer situations during “trigger Help shift your client’s attention
times”, scheduling activities that conflict with the
Addiction (and disordered eating) shrink people’s
addictive behavior).
worlds. Help expand those worlds again by shifting your
Structural changes are more powerful than individual client’s attention to other experiences and activities.
ones. Reason is no match for addiction. Relying only on
Recovery from addiction needs meaning and purpose.
And it needs to be from the “inner core.”

External meanings (e.g., how the body looks, a spouse, a Normal eating mindset
friend, an athletic performance) can be fleeting. Things
can change. People can change. Or leave us. External Normal eaters don’t think of food in terms of
things are always contingent. Nobody is “the best” forever. “good” and “bad.”
If we count on external meanings for sustained change, In fact, they don’t think about food much at all. Food
there’s a good chance we’ll be dissatisfied. Meaning is for normal eaters is both fuel and pleasure — with each
one of the reasons the idea of a “higher power” in many component properly balanced. It’s not a moral act.
addiction recovery programs is appealing. A higher
power isn’t fleeting, it’s eternal. However, what’s most
important is that the meaning and purpose is internal — Normal eaters don’t overthink their food.
it comes from the inside and reflects the person’s deeper They might plan and prepare, and ensure they make
values and life priorities. healthy choices. But they devote only as much mental
Getting a handle on food addiction might mean helping real estate as necessary to execute these basic tasks (e.g.,
a client take a temporary break from measurements to “Oh, I’ll have to stop by the grocery store on the way
shift their thinking towards internal measures of prog- home tonight”). No more.
ress. You might ask:
Normal eaters don’t underthink their food.
• How do you feel?
• What truly matters to you? Are you pursuing that They eat mindfully, aware of the choices they make and
thing?
how they feel. They eat at an appropriate pace, paying
attention to the mechanics and enjoyable sensations, and
• How can you serve others and add value back into they don’t gobble or rush.
the world?
• and so on. Normal eaters understand how food choices

relate to fitness, performance, and health.
What does “normal eating” look like? If they want to improve these things, they try to im-
prove their food choices. They simply get a basic under-
“Don’t do this” is not an action plan. “Do this instead” standing of what options are appropriate, then seek out
is. those options whenever possible.
With both disordered eating and food addiction, it can They don’t fret about getting it “perfect.” In fact, the
be helpful to know and demonstrate to clients what word “perfect” isn’t in their vocabulary. Neither are
normal eating looks like, so that they can work towards “good”; “bad”, or any other moral judgments.
this as a model.
There’s no one way to be a normal eater. Normal eaters enjoy food but don’t seek
emotional solace from it.
Normal eaters come in all shapes and sizes.
Normal eaters find food pleasurable, but keep it in its
They eat in all different ways — three squares a day, oc- place.
casional meal skipping, grazing, etc. They eat all types of
different foods and diets — vegetarian, Paleo, carnivore, They know that food is not a substitute for human
kosher, halal, etc. contact or love. They don’t expect food to change their
emotional state.
The one thing they have in common is they’re somehow
closely in tune with their internal cues and physiologi-
cal needs.
They’re able to “nail it” with their behaviors most of the

time.

446 | Unit 15
Normal eating behaviors As a coach, you can use these guidelines to help your cli-
ents track how well they are moving towards this “normal
Normal eaters eat when they are physically eating” ideal with specific behaviors or thought habits.
hungry.
Normal eaters can sense into and correctly interpret
Alcohol
physical sensations. They can tell the difference between In most industrialized countries, on average, about 70%
hunger and thirst, or between hunger and an anxious of adults drink alcohol. More men than women drink,
stomach. and men tend to drink more. For instance, a study of 19-
to 30 year-olds revealed that 45% of men reported heavy
Normal eaters may or may not eat when they drinking in the past two weeks, compared with 27% of
have a craving. women.
Sometimes, normal eaters will think “Oh, I’m craving Up to about one-third of alcohol users will be “problem
food X.” Then they’ll shrug and move on to something drinkers” at some point in their lives, characterized by
else. things like:
• drinking despite harm;
If they decide (consciously) to satisfy that craving, they
do it with small amounts. A few squares of chocolate are • strong desire to drink;
enough. They don’t need to eat a jumbo-size bar.
• loss of control over drinking;
Normal eaters choose whether to indulge • withdrawal symptoms;

cravings. • salience (higher priority given to drinking than other
activities); and
The craving doesn’t choose for them.
• tolerance.
Normal eaters choose foods they believe will Among young women in particular, “drunkorexia”
satisfy them or be appropriate choices. occurs when women “trade off” food calories for alcohol
If they’re interested in health, they’ll look for healthy calories.
foods. If they’re quite hungry, they’ll look for something The alcohol we drink — ethanol — is readily absorbed
hearty. If they’re hankering for a ripe strawberry in early throughout the entire GI tract. Its rate of absorption is
summer, they’ll choose that, and enjoy it. largely affected by how much food is in our stomach.
There are also ethnic, sex, and genetic differences in
Normal eaters stay connected to their physical people’s ability to metabolize ethanol.
cues at all times.
After ethanol is absorbed through the GI tract, it heads
Before, during, and after eating, normal eaters are always to the liver, which metabolizes more than 90% of it. The
tuned in to what their body wants and needs. ethanol that isn’t metabolized can enter the bloodstream
unaltered.
Normal eaters eat with awareness.
Because the body has no way to store ethanol, the liver
They attend to both their body cues as well as the food’s will prioritize utilizing its calories before oxidizing any
characteristics — taste, texture, smell, relative delicious- other macronutrients; in other words, it’ll use alcohol
ness, etc. first. Liver alcohol dehydrogenase is a rate-limiting
enzyme (i.e., it controls how fast ethanol is converted)
that oxidizes ethanol at about 15 grams per hour (equal
Normal eaters stop eating when they are
to one regular beer). A 70 kg (155 lb) adult male will be
physically satisfied.
legally drunk after four drinks in one hour.
They don’t walk around hollow and hungry all the time
While ethanol itself isn’t toxic, its metabolic byproducts,
or end up overstuffed. They hit “just right”, and quit.

acetaldehyde and acetate, are. These byproducts create nausea after drinking.
acetaldehyde : A toxic metabolic
Indeed, one drug used to treat alcoholism, called Antabuse, actually allows the
byproduct of alcohol
concentration of acetaldehyde to accumulate, which results in serious nausea and
a strong desire to avoid alcohol in the future. acetate: A toxic metabolic
byproduct of alcohol
These byproducts can undergo further metabolism or be eliminated via urine Antabuse : A medication used in
or feces. the treatment of alcoholism
In the US, one “standard” drink provides 15 g of ethanol, which is found in 12

fl. oz. of regular beer, 5 fl. oz. of wine or 1.5 fl. oz. of 80-proof distilled spirits
(e.g., vodka, rum, whiskey). In Europe, a standard drink ranges between 8 and
12 g of alcohol.
Moderate drinking would be up to one drink per day for women and up to two
drinks per day for men. Moderate drinking doesn’t appear to have negative
health consequences for most people.
For some people, moderate drinking is a great and relatively harmless way to
relax, socialize, and enjoy life. They enjoy the taste and / or the experience, and
have no problem stopping or cutting back.
Not everyone has this relationship with alcohol. (You will find which clients are
which if you suggest cutting back alcohol and observe the various reactions to
your recommendation.)
Drinking beyond moderation can lead to a host of problems, depending on the

person. It can lead to nutrient deficiencies, excessive body fat, low bodyweight,
digestive disturbances, dehydration, headaches, nausea, stomach irritation, sex
hormone disturbances, and the potential development of chronic diseases such
as cardiovascular disease, cancer, and diabetes.
For Level 1 and 2 clients, moderate and occasional / rare drinking is generally
fine, although clients may want to abstain from drinking when flying, before
athletic competitions or events involving weight cuts (as alcohol can affect fluid
levels). Level 3 clients should consider eliminating alcohol completely.
Nutrition and immunity

We all like to be and stay healthy. And of course, part of that is a healthy im-
mune system.
Our immune system can take a lot of abuse from 21st century life. We can com-
promise it with things like:
• heavy athletic training;
• chronic nutritional, physical, mental, and / or emotional stress;
• long work hours and / or intense work demands (e.g., police or military work,
nursing);
• disruptions to our body clock such as shift work or travelling across time zones;
• changing environments (e.g., hot / humid, cold, altitude); and
• exposure to pathogens (whether organic, e.g., microbes; or industrial, e.g.,

chemical exposure on the job).

448 | Unit 15
These types of stressors can either upregulate our immune response (leading to
auto-immune conditions, in which the immune system attacks healthy tissue) or
immunocompromise: An downregulate it (leading to immunocompromise and lowered immunity).
impaired immune system
Our immune system is complex, but has two general branches:
Branch 1: Our innate immune system

innate (natural) immune Our innate (natural) immune system is our non-specific first line of defense. It
system : The body’s inborn, includes:
first-line defense against invading
organisms • physical / structural barriers (like the mucous lining in nasal passages);
• chemical barriers (like our stomach acids); and
• protective cells (like our natural killer “NK” cells, white blood cells that can
destroy harmful invaders).
This immune system develops when we’re young. Interestingly, women tend to
have a stronger overall innate immune response. (Maybe this is why they often
do better than men when it comes to colds. But they suffer more often from auto-
immune diseases.)
Branch 2: Our adaptive immune system

adaptive (acquired) immune Our adaptive (acquired) immune system is a more sophisticated system
system: The body’s non-inherited composed of highly specialized cells and processes. It kicks in when the innate
defense system, made up of
specialized cells
immune system is overcome.
The adaptive immune system helps us fight infections by preventing pathogens

from colonizing and by destroying microorganisms like viruses and bacteria with
an army of T and B cells. These specialized white blood cells mature in the thymus
and bone marrow, respectively.
And believe it or not, they actually have a kind of “memory”, which is what
makes them so effective. Once they “recognize” a specific pathogen, they mobi-
lize more effectively to fight it.
When we talk about “building immunity”, we generally mean strengthening

the adaptive system. (Note: Researchers have recently found that there are
vessels connecting the brain to the immune system, which could lead to even
more implications for building immunity over time).
The adaptive immune system explains why kids get sick with viruses more than
adults. They haven’t had as much exposure, and their adaptive immune systems
are less mature.
And of course, the acquired immune response is the basis for vaccination. Subject
your body to a tiny dose of a pathogen, and it will know what to do when confront-
ed with a bigger dose.

The effect of exercise on immunity For instance, scientists gathering data on exercise habits
and influenza found:
When it comes to how training / exercise affect immuni-
• People who never exercised got sick pretty often.
ty, key variables include:
• People who exercised between once a month and
• exercise duration
three times a week did the best.
• exercise frequency
• People who exercised more than four times a week
• exercise intensity got sick most often (this will likely be where your
• the overall capacity of the exerciser (in other words, athletes reside).
how robust they already are)
How an athlete trains — and how aggressively they pur-
There’s often a “J-shaped” curve (see Figure 15.4) to the sue recovery — will play a role in both their innate and
relationship between exercise and immunity. In other adaptive immune response. For instance:
words: • After one prolonged vigorous exercise session hu-
• No exercise (which doesn’t put any demand on the mans are more susceptible to infection. For example,
body) is not good. running a marathon may temporarily suppress the
adaptive immune system for up to 72 hours. This is
• Some exercise (within a person’s zone of recovery) is
why so many endurance athletes get sick right after
good.
races.
• A lot of exercise (that goes outside a person’s recov-
• However, one brief vigorous exercise session doesn’t
ery zone) is not good.
cause the same immune-suppressing effect. Further,
Above average
Risk of URTI
Average
Below average
Sedentary Moderate Very high
Exercise Intensity
Figure 15.4 Relationship between exercise volume and infection

450 | Unit 15
just one moderate intensity-exercise session can actu- women tend to do better with colds than men.) However,
ally boost immunity in healthy athletes. women have a much higher rate of most auto-immune
disorders than men do.
• Interestingly, chronic resistance training seems to
stimulate innate (but not adaptive) immunity. While Sleep: Poor sleep means less immunity.
chronic moderate endurance exercise seems to
strengthen the adaptive immune system. Climate: Mild temperature differences don’t seem to
matter (so you can forget that old idea about how you’ll
Notice a pattern? catch a cold if you go outside without a sweater on).
• Consistent, moderate endurance exercise and resis-
But full-fledged hypothermia may suppress immune
function, while using a sauna or hot bath may stimulate
tance training can strengthen the immune system
better immunity in those with compromised immune
over time. So, athletes should be able to train hard
function.
while healthy.
• But chronic high-intensity or long-duration exercise

Mood: There’s evidence that immune alterations affect
mood and inflammation. Clinical depression is two to
sessions can interfere with immune function. So
three times higher among patients with inflammatory
when athletes are feeling run down, they should take
diseases. (Note: moderate exercise appears to act as an an-
it easy.
ti-inflammatory in those with inflammatory conditions.)
The effect of nutrition on immunity Training age: The more experienced and fit an athlete is,
the better their body tends to handle training. In other
How we eat can also affect recovery and immunity.
words, it’s not as much of a stressor. The same is true of
Along with following all the basic Level 1 habits (such experienced athletes and competition. Being more fit —
as eating lean protein, colorful veggies, quality carbohy- whether mentally or physically — may limit the stress
drates including colorful fruits, and healthy fats), those response to exercise.
clients concerned about recovery and immunity can
Pre- and probiotics: Prebiotics and probiotics deserve
consider peri-workout nutrition.
special mention for helping to prevent illness and pro-
Having carbohydrates, especially from colorful fruits mote recovery. Both are essential to gut health. And gut
like blueberries, and amino acids / proteins during and health is essential to immunity.
/ or after exercise / training and competition can boost
Prebiotics (aka food for bacteria) help nourish our good
exercisers’ overall recovery and immuno-competence.
microbial friends. Usually this is some form of semi-di-
Other factors gestible fiber that our bacteria can chow down on, and /
or that helps move food through the GI tract.
Consistently following solid Level 1 habits, staying regu-
larly active, and working on lowering stress can improve And probiotics (the bacteria themselves) have been
immunity for most clients. (Obviously there are special shown to help people recover faster, once they get sick.
cases, such as in clients with HIV or clients who’ve just That’s why athletes should probably ensure that their
had surgery, where it is more difficult to build a robust systems are well colonized by these friendly critters.
immune system.)
Dieting / nutritional stress: Not getting enough energy
Besides stress, training, and nutrition, many other fac- or nutrients can suppress the immune system. This may
tors can affect immunity, such as: explain why many people get sick a week or so after
starting a crash diet.
Age: Our innate immune response can break down as
we get older. Protein: Inadequate protein lowers immunity.
Sex / gender: Menstrual phase and oral contraceptive Body fat: Fat cells release inflammatory substances that
use may influence how the immune system responds to can activate a “false alarm” immune response. Over
exercise. Estrogens generally enhance immunity while time, the body gets tired of this false alarm and the
androgens can suppress it. (Again, this may explain why immune system doesn’t respond as it normally would.

This is similar to what might happen if you continu- • fermented vegetables: pickles, sauerkraut, kimchi
ally triggered your home smoke alarm by burning the • fermented soy: miso, tempeh
toast — until finally you decided to take the battery out.
When you actually have a fire, you’re in trouble. • soy sauce, wine, kombucha
Sugars and processed foods: Added sugars and high Supplemental doses are typically expressed in billions of
glycemic load diets may reduce white blood cell function live organisms — colony-forming units (CFUs).
and be pro-inflammatory. Gluten might also have a sim-
Start your client with a dose of 3-5 billion CFUs; in-
ilar response in people with a certain genotype.
crease to 10 billion if hoping to alleviate a specific health
Fat: While certain fats (like omega-3s) may help regulate concern. Look for a broad spectrum probiotic with
immunity through resolvins and protectins, too many multiple strains of bacteria.
saturated, omega-6, or even omega-3 fats might some-
Choose a reputable brand, and remind your client to
times be perceived as bacterial invaders and trigger an
take it with food and water.
immune response, leading to a dysfunctional gut (and
compromised immune system).
Prebiotics
Over-eating: Consistently over-eating, or eating more
The best whole-food sources of prebiotics are those with
than the body needs, might also compromise how the
fermentable fiber.
immune system responds to invaders. Much of this
might have to do with the fats we eat and ultimate- This includes:
ly store in the body. Dietary fats become part of cell
• vegetables: asparagus, garlic, Jerusalem artichokes,
membranes in the body, and thus influence how cells
respond to invaders. Some fats seem to disrupt immune leeks, and onions
functions. • starches: barley, beans, oats, quinoa, rye, wheat,
potatoes, and yams
Out-of-balance nutrients: Inadequate or excessive
intake of protein, iron, zinc, magnesium, manganese, • fruits: apples, bananas, berries, citrus, kiwi
selenium, copper, and vitamins A, C, D, E, B6, B12, and
• fats: flax seeds and chia seeds
folic acid may all decrease the ability of the body to
enlist immune defenses. Eating 2-4 g of prebiotics per day can help to feed
healthy gut bacteria and keep things balanced. Supple-
Long-term nutrient deficiency, whether minerals,
menting pre- and probiotics at the same time might be a
vitamins, protein, or calories, can reduce the immune
good idea.
system’s ability to respond. It’s a side effect of malnutrition
and certain types of disordered eating. Actually, malnutri- Note:
tion was the leading cause of acquired immune deficiency
• It’s possible to actually feel worse before feeling bet-
before HIV. Adding deficient nutrients back into the diet
can restore immune function. ter, since bacteria release toxins.
• Clients with FODMAP intolerance may have trouble

What you can do with prebiotics. More on FODMAPs later in this unit.
Probiotics Vitamins and minerals
If your client is healthy, aim for 1-2 servings of probi- These are the unsung heroes of the performance world.
otic-rich foods each day. Your client may need more to They’re everywhere in the body, and they take part in
prevent or alleviate a medical problem. thousands of chemical reactions.
The best whole-food sources of probiotics are: Deficiencies in key nutrients such as vitamin D, magne-
sium, zinc, and calcium can compromise immunity.
• dairy: yogurt, cheese, and kefir with live and active
cultures Begin with improving the micronutrient content of your

452 | Unit 15
client’s diet. Consider adding a simple multivitamin / Proteins such as fibroblasts and collagen are laid down
multimineral supplement to prevent deficiencies. and start scaffolding new tissues.
Also consider nutritional testing for clients you suspect This is what we might refer to as “scar tissue.”
may have deficiencies, such as hard-training athletes or
people who seem to be having immune system problems. Importantly, scar tissue will lay down in alignment with
the forces being placed on the area. (That’s why rehab
and therapy are so important.)
Injuries / inflammation
This scar tissue will contract and shorten as it matures.
Injuries are a fact of life. They can range from sudden This is due to fibroblast differentiation into myoblasts,
accidents (e.g., dropping a dumbbell on your foot) to which are similar to smooth muscle cells. This reduces the
chronic concerns that develop over time (e.g., elbow size of the injury.
tendon irritation after a year of learning to golf).
After an injury, the body springs into action to restore Step 3: Remodeling
balance. Cells are called upon to repair the damage and In the remodeling phase, the scar tissue (typically made
the recovery process follows a highly organized and up of type II collagen) will be degraded and type I colla-
predictable pattern. gen (much stronger) will be laid down in its place.
Step 1: Inflammation Although this new tissue will never likely be 100%
normal, it can become about 80% as strong as uninjured
In both soft tissue and bone repair, inflammation is the tissue.
first step in the process of clearing away damaged cells.
Inflammation is stimulated by the increased movement The process is similar for bone: new tissues are laid
of inflammatory / immune chemicals into injured areas. down, and early temporary tissues are eventually
The inflammatory process is characterized by pain, replaced by more permanent structures. Minerals are
swelling, and redness / heat. deposited to make the bone hard.
• Certain chemicals involved in injury repair (substance
P, calcitonin, histamines, cytokines) may interact with What you can do
local pain receptors to cause the pain associated with
During this process of injury recovery, good nutrition
inflammation.
has three purposes:
• Swelling results from fluid seeping through damaged
• manage inflammation;
vessels into injured tissues. This can put pressure on
nerve endings, causing additional pain. • support immune function; and
• Redness / heat occurs because additional blood is • support repair and rebuilding.
shunted to the area of injury.
As always, begin with solid Level 1 nutritional strategies.
We want to manage inflammation, not eliminate it. We Keep it simple. Your injured client may not be able to do
need inflammation for the process of repair. This is one many activities, or prepare an extensive menu.
of the reasons over-using anti-inflammatory medica-
Here are some other approaches to have your injured
tions, or using them too soon, is not a good idea.
clients consider:
• Limit pain relievers to 3-5 days after injury, and con-
Step 2: Proliferation sider avoiding anti-inflammatories for the first 24-48
hours. Tylenol, Advil, and NSAIDs (anti-inflammatory
In the proliferation stage, most of the damaged tissues drugs) can reduce pain and swelling. But taking them
will have been removed from the site of injury, and new for too long can slow healing. Therefore, limit use to
vasculature (blood vessels) will have developed. the first few days after an injury, simply as a way to
manage the initial pain (assuming this doesn’t conflict
Oxygen and nutrients start getting through again. with doctor’s orders).
• Eat enough total food. Adequate nutrients are critical

during injury recovery. Indeed, metabolic rate can increase during this time.
Follow appetite cues as much as possible, but be aware that some people may
need to eat on a regular schedule if injury has compromised their appetite.
• Eat more anti-inflammatory fats. Fat can influence recovery and help moderate
inflammation. Look for naturally occurring omega-3 fatty acids in particular
(e.g., oily fish, flax, chia, hemp seeds), as well as monounsaturated fats (olive oil,
avocados, nuts, etc.).
• Minimize processed carbohydrates. Too many refined carbohydrates and
added sugars may increase inflammation. Aim for no more than one serving
per day.
• Drink 2-3 cups of green tea daily.
• Eat at least 1-2 fist size servings of vegetables at each meal, and 1-2 handfuls of
fruit at most meals, emphasizing some of the following:
• foods rich in vitamin C and flavonoids: guava, red bell pepper, broccoli,
green bell peppers, grapefruit, kohlrabi, papaya, Brussels sprouts, kiwi,
mango, oranges, pineapple, berries;
• foods rich in vitamin A and flavonoids: carrots, pumpkin, sweet potato,
spinach, collards, kale, watercress, beets, winter squash, tomatoes, dried
apricots, mango;
• foods rich in zinc and flavonoids: mushrooms, spinach, sesame seeds,
pumpkin seeds, green peas, baked beans, cashews, whole grains, wheat
germ, cocoa; and
• foods rich in copper and flavonoids: mushrooms, green leafy vegetables,
barley, soybeans, tempeh, sunflower seeds, navy beans, garbanzo beans,
cashews, molasses, dark chocolate, cocoa powder.
• Consider a Super Shake. Extra protein will help with healing, and it’s an
easy-to-consume form of good nutrition. It’s also an easy way to get in those
veggies, fruits, and healthy fats from above. Plus, many injured clients will not
want to do additional food prep.
• Anecdotal evidence from many cultures suggests that broth made from
simmering bone and cartilage contains not only valuable nutrients and min-
erals in the bone but also the collagen-type proteins that make up stuff like
gelatin, as well as conditionally essential amino acids such as glycine. Some
glycosaminoglycans in cartilage reportedly have anti-inflammatory and glycosaminoglycans: Complex
immune-system-stimulating properties; either they or some of their break- polysaccharides containing
down products may also be toxic to tumor cells. amino groups occurring mainly in
connective tissues
• Supplementation for 4-8 weeks after injury (check with your client’s pharma-
cist / doctor to make sure these don’t conflict with any medications):
• 5-10 g of fish oil (or 1 g of algae oil) daily
• A multivitamin and mineral supplement (make sure it includes vitamin D,
vitamin C, vitamin A, copper, zinc)
• Vitamin A enhances and supports early inflammation during injury, revers-
es post-injury immune suppression, and assists in collagen formation via
collagenase modulation. Studies have shown that collagen cross-linkage
is stronger with vitamin A supplementation and repair is quicker. Supple-
ment with 10,000 IU/day for 2-4 weeks post-injury.
• Vitamin C enhances neutrophil and lymphocyte activity during phase 1
of acute injury. It also plays an important role in collagen synthesis, as it
helps form bonds between strands of collagen fiber. With vitamin C defi-
ciencies, collagen fibers are formed abnormally and fibrous tissue is weak
with poor adhesion. Vitamin C is also a powerful antioxidant and immune
system modulator, and research suggests that vitamin C can help people
recovering from surgery, injury, and ulcers. Supplement with 1000-2000
mg/day for 2-4 weeks post-injury.

454 | Unit 15
• Copper helps form red blood cells and works with vitamin C to form elas-
tin and to strengthen connective tissue. Supplement with 2-4 mg/day for
2-4 weeks post-injury.
• Zinc is required for over 300 enzymes in the body and plays roles in DNA
synthesis, cell division, and protein synthesis — all necessary for tissue
regeneration and repair. Zinc deficiency has been associated with poor
wound healing. As zinc deficiency is one of the most common micronutri-
ent deficiencies, we recommend supplementing 15-30 mg per day for 2-4
weeks post-injury.
• 5 g creatine monohydrate daily.
• The specific combination of arginine (7 g, 2x/day), HMB (1.5 g, 2x/day),
and glutamine (7 g, 2x/day) might assist in collagen deposition and injury
healing.
• We need protein for tissue repair. If someone isn’t getting enough from
food, a supplement can be useful.
• Turmeric has long been used as an anti-inflammatory agent and in wound
healing. Current research shows that the active ingredient, curcumin, is
responsible for some of the benefits of turmeric. While adding turmeric
to food every day is a good strategy, using 400-600 mg of supplemen-
tal turmeric extract 3 x per day (or as described on the product label) is
probably more manageable for most people. Make sure to get a curcumin
supplment that also includes piperine (or is made up of curcumin phtyo-
some), which makes it more bio-available.
• Garlic has been shown to inhibit the activity of the inflammatory enzymes
cyclooxygenase and lipoxygenase and affect macrophage function. Raw
garlic is fine, but clients may need garlic extracts for more measurable an-
ti-inflammatory effects. Typically recommended dosing is 2-4 g of whole
garlic clove each day (each clove is
1 g) or 600-1200 mg of supplemental aged garlic extract.
• Bromelain is another anti-inflammatory plant extract from pineapple.
While best known for its digestive properties, bromelain is an excellent
anti-inflammatory and analgesic compound although its mechanism of
action is poorly understood. Typically bromelain
is given in doses of 500-1000 mg/day for the management of
inflammation.
• Boswellia also has anti-inflammatory uses and has been shown to offer
benefit through the inhibition of 5-lipoxygenase and potentially other
cytokines. Typically, supplemental Boswellia is taken in 300 mg doses 3x
per day.
Sex and gender

biological sex: The Biological sex (i.e., the configuration of structures, chromosomes, hormones,
configuration of physiological etc. that characterize males and females) and gender (i.e., the social roles, norms,
structures, chromosomes,
and expectations that characterize masculinity and femininity in different cul-
hormones, etc. that characterize
males and females tures) can affect clients’ nutrition, health, and health behaviors.
gender: The social roles, norms, Obviously, a full discussion of sex and gender differences (and similarities) is
and expectations that characterize
masculinity and femininity in
beyond the scope of this text.
different cultures
However, be attentive to when sex and gender differences and similarities may be
relevant to understanding your clients’ experiences and needs.

For instance: Here are some guidelines for weight gain during
pregnancy:
• Due to gender norms, women may take on more
caregiving and household labor. Men may feel • 30-40 lb for women starting out underweight.
pressured to work longer hours at their jobs and be • 25-35 lb for women starting out at a normal / ideal
financial providers. Both may struggle to find time to weight.
take care of themselves.
• 15-25 lb for women starting out overweight, or for
• Hormones can powerfully affect body composition women 5’2” or shorter.
and health. Men’s and women’s experiences may be
significantly different across the life course; yet both To achieve this weight gain, women will need up to an
are affected by major shifts in hormonal health, such additional 300-500 kcals per day, and closer to 500 if
as puberty and aging. exercising regularly. This means total intake could climb
to 2500 or even 3000 kcal per day during pregnancy.
Sex (a biological configuration) influences immunity
(e.g., women are more likely to have autoimmune disor- According to the American Pregnancy Association, wom-
ders). There are sex-linked genetic traits (e.g., metabolic en in the first trimester are encouraged continue to eat the
disorders, mental illness). Sex influences fat deposition, same amount of calories as they did prior to becoming
muscle mass, bone density, and motor neuron recruit- pregnant. It is in the second and third trimester that calo-
ment. And sex can even influence pain perception. rie needs increase by 300-500 kcals.
Gender norms may affect body image; expectations Of course, if the food choices are sound during this
about nutrition and fitness (e.g., women often want to increased intake, pregnant women will also benefit from
lose weight while men may want to get more muscular); an increase in vitamins, minerals, and phytonutrients.
health-seeking behaviors, and many other factors. This is also critical to mothers’ health as well as the
health of developing fetuses.
Needless to say, sex and gender both make a difference
in our own health journey, as well as the journeys of Without enough calories and micronutrients, the rapidly
our clients. developing fetus can be subject to a host of birth defects.
Inadequate nutritional status during development can
also have consequences for the child’s later life, even as an
Pregnancy adult: poor nutrition during fetal development can lead to
eventual cardiovascular disease, hypertension, and Type 2
Most people recognize that during pregnancy, the moth- diabetes years later.
er’s habits can affect the health of her offspring. Thus
it’s important that clients know what to eat and what to During pregnancy, women are strongly encouraged to
avoid when pregnant. avoid the following:
Pregnancy is a period of anabolism, or growth. Women • alcohol and caffeine (no more than 300 mg/day);
are encouraged eat more when pregnant than they typi- high intakes of alcohol and caffeine can lead to birth
cally do, and recognize that the resulting weight gain is a defects and spontaneous abortion
critical part of a healthy pregnancy.
• tobacco
Studies show that low gestational weight gain (in other • cured / deli meats, raw eggs, and raw seafood, all of
words, not gaining enough weight when pregnant) which can carry harmful bacteria
often results in infants with low birth weights, who may
experience delayed development. The mother’s weight • artificial sweeteners (or at least significantly limit)
determines fetal weight: if she does not gain enough • more than 6 oz of fish per week, because of potential
weight, the fetus may remain small simply to protect the heavy metal contamination. In particular, women
mother’s bodyweight. should avoid shark, swordfish, king mackerel, and
tilefish, which are known to be high in mercury
• more than 10% of calories from highly processed

foods

456 | Unit 15
Figure 15.5 Embryo and fetal growth
The following nutrients should be included and / or increased during pregnancy:
Vitamins B12
Vitamin B12 is an important nutrient in cell development. Since B12 is abundant

in animal foods, omnivores may get enough B12. However, if clients are limiting
their intake of animal foods, a supplement will be essential.
Folate
Folate (vitamin B9) is essential to prevent neural tube defects. Intake is most
critical within the first few weeks of pregnancy. Those of childbearing age should
include ample folate and typically, a folic acid supplement is recommended by
many doctors.
Vitamin D
A deficiency in vitamin D can lead to minimal calcium absorption and a low in-
fant birth weight. Sun exposure (20-30 minutes, 2-3 times per week) is the ideal
source for vitamin D.
Calcium
pre-eclampsia: A condition in
Calcium intake can be important for the prevention of a condition known as
pregnancy characterized by high
blood pressure, protein in the pre-eclampsia. Pre-eclampsia leads to hypertension and protein in the urine of
urine, and swelling pregnant women. Calcium needs are increased during pregnancy.

Iron It’s important, though, to avoid oil that comes from the
liver of the fish, such as cod liver oil, as it can provide
Iron is essential for many processes, especially during potentially toxic levels of vitamins A and D.
pregnancy.
Zinc Broad-spectrum supplementation
Zinc is important not only for athletes but pregnant Several macronutrients and micronutrients are critical
women. Its role in growth and development is critical in for ensuring the health of both the pregnant mother and
the developing fetus. Deficiency can lead to congenital her child. Indeed, nearly 35% of major fetal cardiac de-
malformations. fects could be prevented by maternal use of vitamin and
mineral supplements rich in folate before conception
Iodine and during the post-conceptual period.
Iodine is critical for fetal brain and nervous system Along with a solid baseline Level 1 diet, consider a
development. Iodine deficiency, which is uncommon multivitamin / multimineral supplement (especially one
in the United States, is the single most important cause designed specifically for pregnancy).
of preventable intellectual disability and brain damage
worldwide. And iodine deficiency is the most common Food cravings
nutrient deficiency worldwide.
Food cravings and aversions to certain foods are com-
Iodine deficiency is associated with increased risk of mon during pregnancy. There’s no harm in satisfying
miscarriage, preterm delivery, and stillbirth. most cravings, but be mindful. Help clients choose
high-quality foods as often as possible, and to not treat
Protein
pregnancy as a food free-for-all. Poor-quality processed
Aim to increase overall protein intake by at least 25 g foods do no favors for mother or fetus.
(about 1 palm of protein-dense foods) during the second
As always, start with a baseline of a good, consistent
and third trimesters. This can be obtained by increased
Level 1 diet (plus a healthy dose of self-compassion…
overall energy intake via whole foods or by ingesting
appetite will often be weird during this time).
protein supplements.
This protein becomes part of the fetus’ structural de- Nausea and vomiting
velopment, as approximately 2.2 lb (1 kg) of protein are
incorporated into the development of the fetus and the About 80% of women will experience nausea and vomit-
placenta. ing during the first four months of pregnancy. Hormon-
al changes in the body during pregnancy can influence
Fatty acids gastric motility, contributing to nausea. H. pylori might
also play a role. (Yes, the same H. pylori responsible for
Since most women are advised to limit intake of large gastric ulcers.) Interestingly, one potential upside to
fish (e.g., tuna) due to potential environmental pol- “morning sickness” is that women who experience it
lutants, toxins, and contaminants during pregnancy, tend to have better pregnancy outcomes.
pregnant women should get an ample amount of ome-
ga-3 fatty acids from other foods including flax, chia, Several methods might help to lessen the nausea / vomit-
walnuts, hemp, small fish (e.g., herring), green leafy ing of pregnancy:
vegetables and seaweed. • Vitamin supplementation (especially vitamin B6).
Supplementation with omega-3 fish oil rich in EPA and Keep in mind that certain prenatal vitamin / mineral
DHA has also been shown to be beneficial for both supplement formulations may actually trigger nau-
mother and child. Supplementation improves infant sea. If needed, consider encouraging clients to try a
brain development during pregnancy, helps to prevent different brand through their doctor.
preterm birth, and may reduce the incidence of postpar-
tum depression in the mother after giving birth.

458 | Unit 15
• Ginger. It is recommended that ginger be used in food / beverage form (rather

than supplemental) while pregnant.
acupressure: Therapy in which • Acupressure (not acupuncture). The ideal location is at the Neiguan point
pressure is applied to certain (located three fingerbreadths above the wrist on the volar surface).
points on the body
Neiguan point: An acupoint • Emotional support. This might be useful if the woman is in distress.
located three fingerbreadths
• Eating frequent, smaller meals.
above the wrist on the palm side
of the arm • Avoiding food texture and smell aversions.
• Including bland foods when possible.
• Including enough protein each day.
• Limiting high-fat foods, spicy foods and large meals.
• Including salty foods during the AM hours.
• Trying sour / tart liquids in place of water (e.g., lemon water).
Many women don’t need to resort to anti-nausea medications after making

lifestyle adjustments. Still, if nausea / vomiting become extreme, other causes
should be ruled out with the doctor. If there are any pregnancy complications,
refer out.
Sex hormones
Sex hormones — such as testosterone, estrogen, and progesterone — can signifi-
cantly affect your clients’ metabolism, body composition, fat deposition patterns,
and overall health.
Both males and females have the same hormones, just in different proportions.
When hormones are out of balance, or supplemented exogenously (e.g., via birth
control, hormone replacement, performance-enhancing drugs), clients may no-
tice significant changes to the way their bodies look, feel, and perform.
Here are some examples.
Low or high body fat

Adipose tissue is endocrine tissue. In other words, it secretes and responds to a
cytokines: Cell signaling wide variety of hormones and cytokines (cell signaling molecules), including:
molecules
• Leptin, which signals how much stored energy the body has, and helps regu-
leptin: A hormone produced by
fat cells believed to regulate fat
late various functions throughout the body (such as food intake)
storage, appetite, and metabolism • Sex hormones
in the body
prostaglandins: Any of a group • Angiotensin, which works through the renin-angiotensin system
of cyclic fatty acid compounds
• Prostaglandins
with varying hormone-like effects
adipokines: Hormones To date, there are around 20 known adipokines. They act both peripherally and
produced by fat cells with wide- centrally (i.e., in the immediate tissues as well as the brain), and affect metabo-
ranging effects
lism, immunity, inflammation, and many more physiological functions.
Thus, as you can guess, the amount of body fat one has, and where it is located

(e.g., visceral versus subcutaneous), can affect our health and body composition
— and vice versa.
• We often see disrupted sex hormones in people who are either very lean or
obese.
• Body fat changes when hormones change (and the reverse).
• Obesity often goes hand-in-hand with chronic diseases.
PCOS
Polycystic ovarian syndrome (PCOS) is characterized by higher levels of polycystic ovarian syndrome
androgens (so-called “male” hormones) as well as poor glucose control, insulin (PCOS): A complex metabolic
disorder in women, often
resistance and potentially hyperinsulinemia (chronically high insulin). characterized by insulin resistance
and high androgen levels in
Because of the elevated androgens, women with PCOS can be normal weight, women
and may put on muscle and bone mass easily. Yet they may also struggle with
infertility and irregular menstruation, obesity and dyslipidemia, and put on fat
around their midsection.
Supplementation
Along with a good Level 1 diet, two types of supplements may be helpful for
PCOS:
• Berberine
• Chiro-inositol (both D-chiro and M-chiro forms)
As with all medical conditions, work closely with your client’s health care pro-
viders before recommending any nutritional or supplement protocols.
HPA / HPG axis dysfunction

In both men and women, sex hormone production is governed by the hypothal-
amus, which sends signals to the pituitary and then the gonads (i.e., ovaries or
testes). The hypothalamus also interacts closely with the adrenal glands, which
produce our “stress hormones” such as cortisol and adrenaline / epinephrine.
This is a carefully controlled set of feedback loops, otherwise known as an “axis.”
The HPA axis is the interaction between hypothalamus, pituitary, and adrenal HPA axis: Hypothalamic-
glands. pituitary-adrenal axis
HPG axis: Hypothalamic-
The HPG axis is the interaction between hypothalamus, pituitary, and gonads. pituitary-gonadal axis
The role of stress

If the hypothalamus detects excess stress (e.g., in the case of chronically low
energy or malnourishment, other types of chronic stressors) it will shut down the
production of sex hormones.
This can occur with situations like:

• chronic energy deficit (i.e., long-term dieting, too much intermittent fasting);

460 | Unit 15
• chronic nutrient deficiency / malnutrition; and
• chronic stressors of other types, such as relationship or work stress, poor sleep.
Even chronic mental stress can knock the HPA / HPG axis out of whack. This in-
cludes cognitive dietary restraint, which we discussed earlier under “Disordered
eating.”
Damage to the HPA / HPG axis can also downregulate thyroid hormone produc-
tion, and thus “slow” metabolism.
This is one key reason many highly stressed people often find it hard to lose
weight, and / or why hardcore dieters may suddenly start piling on body fat (of-
ten in different areas than normal) despite training more and eating less.
Women: Amenorrhea and menstrual disruption

Women with HPA / HPG axis dysfunction will often lose their periods, or have
irregular menstrual cycles. Women under stress will often have low fertility,
which is important to know for clients who want to get pregnant.
Hormone testing will usually show normal or low follicle-stimulating hormone

(FSH) and luteinizing hormone (LH) levels with correspondingly low levels of
estrogen and progesterone. This is different than menopause, in which FSH and
LH are high while estrogen and progesterone are low.
Men: Low testosterone

Men with HPA / HPG axis dysfunction will usually have low testosterone, which
tends to manifest with loss of sex drive, lower energy or more fatigue, moodiness
and anxiety. They may also have low sperm count.
Gynecomastia
Men may convert testosterone to estrogen inappropriately (e.g., if they supple-
ment too much testosterone, or have high levels of body fat).
In this case, you may see male clients with “female-pattern” fat deposition in
chest, hips, and thighs; perhaps even the growth of breast tissue — a condition
gynecomastia: Enlargement of known as gynecomastia.
the breast tissue in males, caused
by an excess of estrogens If due to obesity, this may disappear with fat loss; hormones may re-balance with
normal or leaner body composition. If due to other hormonal factors (such as a
problem with excess conversion of testosterone to estrogen), consult with your
client’s health care providers on next steps.
Hormonal contraception / replacement /

supplementation
Many female clients will be taking either hormonal contraception or replace-
hormonal contraception
or replacement (HRT): ment (HRT). Many male clients may also be taking supplemental testosterone.
Therapeutic use of hormones to
alleviate deficiency or to block Hormonal supplementation can affect health along with body fat levels and
ovulation and prevent pregnancy distribution. In particular:

• supplemental testosterone will tend to partition nutrients towards more lean

mass and less body fat (unless it aromatizes, or converts, to estrogen).
• supplemental estrogens and progesterones can have mixed effects depending

on the type.
• all types of hormone supplementation may affect your clients’ risk of chronic
diseases, such as cardiovascular diseases. Oral preparations can also harm the
liver.
As with all medications, consult with your client’s health care provider and
pharmacist to learn more about side effects — particularly effects on body
composition.
What you can do

Help all clients learn and adhere to the essentials of Level 1 eating.
If you suspect a hormonal imbalance, consult with your client’s health care pro-
vider and explore hormone testing.
Vitamin D in particular has been shown to have a significant role in both men’s
and women’s hormonal health and fertility. Low vitamin D is correlated with
male and female infertility, PCOS, endometriosis, and other disorders of repro-
duction. Consider vitamin D testing and supplementation.
Help your clients understand that hormones are powerful, and can affect their
results with nutrition and exercise. Set expectations appropriately.
Take a holistic approach. Look at various factors, including stressors (nutritional

and otherwise).
Be cautious with nutrition plans that significantly restrict energy, macronutrients

(e.g., carbs), and / or micronutrients, especially in women (who are typically more
sensitive to the effects of restriction) but also in men with lower hormonal reserves.
Ethnicity, heritage and genetics

Like sex and gender, ethnicity, heritage, and genetics have both biological and social
components.
Genetic makeup and epigenetic expression (how particular genes are “switched
on” or not) is both a product of individual factors, such as what happened to us
as we developed in the womb, as well as our familial history and ancestry.
ancestry: One’s family or ethnic
Our ancestry may affect our nutritional programming. For instance: descent
• People from indigenous groups such as First Nations in Canada, native Quech-
ua in South America, or Aboriginal / Torres Strait Islanders in Australia, may be
less tolerant of processed foods and alcohol. Often, these types of foods were
introduced relatively late (for many isolated indigenous groups, in the late 19th
or early 20th century). Thus, rates of chronic diseases such as Type 2 diabetes
are much higher among indigenous groups.

462 | Unit 15
• Lactase persistence is the genetic ability to digest What you can do

lactose, the sugar in milk, past childhood. The genes
coding for the enzyme lactase survived in many Help all clients learn and adhere to the essentials of
agricultural populations who regularly consumed Level 1 eating.
dairy, such as Europeans. About 80% of Europeans
Explore with your client how their ethnic / genetic back-
and Americans of European heritage carry the lactase
ground, ancestry, and heritage might affect their nutri-
gene, while it’s largely absent in populations of
tional programming, eating behaviors, and food choices.
sub-Saharan African and East Asian origins.
• Many Japanese people carry a unique microbial If clients are keen and interested, or if you suspect there
is a serious underlying pathology, suggest lab testing for
environment that allows them to more effectively
key genetic variants. At-home hobbyists can try 23And-
digest seaweed, a staple Japanese food. Researchers
Me, GeneticGenie, DNAFit, AthletiGen (for exercise-re-
speculate that some genes “jumped” from seaweed
lated analysis) or UBiome (for microbial diversity).
microbes to colonize Japanese GI tracts over thou-
sands of years of seaweed consumption. Make sure your nutrition plan suits the client’s needs
and preferences.
Our ancestry and heritage may also affect our food
choices socially. For instance:
• We may gravitate towards familiar recipes and foods,
Life stages and aging
or want to preserve our heritage through food. Think about how nutritional needs and eating behaviors
• Our ethnic group may have a particular relationship
differ between a 3-year-old boy, a 17-year-old teenager,
a 35-year-old man, and a 90-year-old great-grandfather.
to food and eating, and / or particular food norms.
Quite a difference.
We may have religious traditions that govern food
choices or eating times / habits (e.g., periods of
fasting). Babies
• Our cultural group may also have particular norms of During the first year of life, there are some steps the par-
body size and shape that are considered acceptable ent can take to ensure the child has a healthful start.
and desirable.
Breastfeeding
Nutrigenomics If possible, breastfeed for at least the first six months of
Genetic analysis is an emerging field of study, and it’s the infant’s life. Many women opt for longer. Avoid cow,
becoming clear that even small genetic variations can soy, and other processed milks for the first year.
affect how we absorb, process, and use nutrients. Many women need help with breastfeeding. Have a
For instance: lactation consultant / doula / breastfeeding coach etc.
in your professional network for referrals. At the same
• Mutations in vitamin D receptor proteins such as VDR time, be aware that it’s not always feasible for all women
Tak and VDR Bsm can affect vitamin D uptake and to breastfeed.
use.
• MTR (5-methyltetrahydrofolate-homocysteine meth- Good bacteria

yltransferase) provides instructions for making the
Babies need mother-to-baby transmission of gut flora
enzyme methionine synthase. Mutations in MTR have and other bacteria to build their immune systems and
been identified as the underlying cause of methylco- own microbial environment.
balamin (a form of vitamin B12) deficiency.
This comes from vaginal birth, breastfeeding, and skin-
Given the complexity of the human genome, how our to-skin contact. It can also come from infant probiotics.
unique bodies interact with nutrients may be as unique Consider suggesting supplementation, especially if baby
as our fingerprints. was born by C-section.

Some research suggests that a “too-clean” environment mashing food up with some breast milk at first, so that
also interferes with babies’ natural microbial develop- there is some familiar taste and texture.
ment, which can affect GI and immune health later on.
Consider encouraging avoidance of antibiotic soaps, Then move to puréed / mashed fruits, vegetables, and
wipes, etc. where possible; suggest clients to not create an meats.
overly sterile environment unless the baby truly needs it.
By about 8-10 months, most babies can handle finely
chopped foods. (Again, each baby is unique, so parents
Solid foods should go by baby’s ability and development.)
The modern baby food industry has created the idea that Help clients choose whole foods as much as possible:
babies need special foods. Most of the time, they don’t — the goal is to have baby develop a preference for their
parents can simply mash, crush, and / or purée “regular tastes and textures, and whole foods are the best sources
food” (a food processor is helpful). of nutrients. Avoid foods with added sugars (e.g., juice,
sweetened cereals).
If clients do choose to buy baby food, read labels carefully.
Many baby foods are actually high in sugar, sodium, and Help parents follow baby’s hunger signals, and food
other additives and preservatives, and are not “healthier” preferences, while also gently and patiently adding food
simply because they are aimed at babies. (After all, it’s the variety and meal-time structure. Encourage them not to
same food manufacturers who brought us sugared chil- rush new foods, but be persistent and stick with it.
dren’s cereal with marshmallows. Buyer beware!)
Introducing solid foods is a lot of trial and error. One day Food allergies
baby may like mashed peas, the next day she may spit it
Parents used to be told to avoid potentially allergenic
all over you. Encourage clients to go slowly, and not to get
foods, such as eggs, milk, nuts, or peanuts. Now, research
discouraged.
suggests the opposite: There’s no clear benefit to avoiding
Have them try a variety of foods, to get baby used to dif- these foods; in fact, waiting too long to introduce them
ferent tastes. Introduce one new food at a time. Look for may actually make potential food sensitivities worse.
any signs of food sensitivity, such as diarrhea, vomiting,
However, if food allergies run in the family, have clients
or a rash. If clients add foods one at a time, they’ll know
check with their baby’s doctor before introducing particu-
which one is causing the problem.
lar foods of concern. Have infant antihistamines on hand.
It’s safe to start trying solid food when:
And if a child does have a food sensitivity or allergy, help
• baby can keep her head up and steady, and sit up- clients not to be discouraged: Many children outgrow
right well; food allergies and intolerances.
• baby can chew and swallow properly, and no longer
uses his tongue to push food out of his mouth. If
Vitamin and mineral supplementation
there’s food in his mouth, he doesn’t just drool it out; Discuss supplementation with your clients, as well as
• baby seems bored of breast milk, interested in what baby’s doctor and pharmacist, if needed. The most likely
others are eating, and hungrier than what breast milk supplements to include will be:
/ formula can provide. • an infant multivitamin / multimineral supplement
For most babies, this is somewhere around 4-6 months • an infant omega-3 supplement
old. Babies develop at different rates, so follow baby’s • an infant vitamin D supplement (if breastfeeding
developmental cues. beyond six months)
Encourage clients to start with something like baby ce-
real. Rice-based, oat-based, and barley-based cereals are Food prep tips
generally well tolerated. Many pediatricians recommend
As with adult nutrition, planning and prep helps a lot.

464 | Unit 15
Some ways to make life easier for busy and tired parents Kids’ amazing abilities to self-regulate can be messed up
include: by things like:
• shopping and prep / cooking in bulk; • inappropriate portion sizing;
• getting help with chores like shopping and cooking • highly processed foods;
— whether from a meal delivery service, friends and
• restricting foods;
family, or even some extra assistance from a friendly
nutrition coach!; • labeling some foods as “bad”; and
• meal and menu planning (you should help clients • eating while rushed, distracted, or on the go.
learn how to make homemade baby food and have Strategies that DON’T work
some baby-friendly “recipes” on hand);
Parents undoubtedly want to make sure their kids are
• quick, easy alternatives to takeout (e.g., a rotisserie
happy and healthy. So they might:
chicken from the grocery store instead of a frozen
pizza). • offer them food as a reward when they’re upset;
• have strict rules about “good” and “bad” foods;

Encourage parents to just do their best. Parenting is
hard enough, and each child is unique. Don’t try to get it • push them to finish everything on their plate, or eat
“perfect.” Use the Level 1 approach and quick food prep when they aren’t hungry;
tips to make things easier.
• try bribing them (“If you finish your spinach you’ll get
ice cream”).
Children
Unfortunately, the strategies above only make things
Children don’t shop for and prepare their own food. worse. Plus, it’s a lot of work!
They depend on parents and caregivers to buy and make
foods that promote optimal health. And that means you Try these strategies instead
and me.
To ensure kids keep eating intuitively and naturally for
Eating patterns built during childhood serve as a life, have parents try these strategies:
foundation for life. What we eat early on shapes brain • Serve them a variety of minimally processed whole
development, metabolism, and overall health. foods.
Children actually tend to do a pretty good job of • Serve appropriate portions.

self-regulation when it comes to eating. The best thing
• Give them the illusion of choice and self-determina-
parents can do is provide a variety of healthy options, get
tion (e.g., “You can pick one vegetable you’d like to
them involved in preparing food, show them where food
comes from, and otherwise, stay out of the way. eat tonight”).
• Let kids stop when they’re no longer hungry (instead

How much should kids eat? of insisting they clear their plate).
Given the right conditions, kids tend to be intuitive eat- • Avoid strict “eating rules” or references to the child’s
ers. Their body cues tell them how much they need. weight.
• Don’t keep unhealthy choices in the house. Make

Some days they’ll eat more, some days less. Their bodies
healthy choices abundantly available. Don’t make
will naturally regulate their intake over the long term.
this a big deal; just make poor choices simply and
So trying to count calories for otherwise healthy kids is
wasted effort. quietly… unavailable.
• Involve kids in shopping, menu planning, and

cooking.
• Slow down.
• Eat together as a family as often as possible; make

meal-time family time.

How do I incorporate more fruits and Give kids the illusion of choice, such as:
vegetables? • “Here are three options for vegetables tonight. Which
one would you like?”
Adding fruits and vegetables is another great and simple
way to start improving kids’ nutrition. • “We’re having carrots. How would you like them?
Cooked or raw? Would you like daddy to cut them
Fruits and veggies come in their own handy packages,
into funny shapes again?”
are easy to prepare, and full of important nutrients that
growing bodies need. • “We’re going to have food X tonight. What vegetable
would you like to go with it?”
Of course, not all children will love all fruits and veggies
right away. Here are some tips to help parents address • “You can have food X if you like, but first you have to
common problems: have a piece of fruit.”
Problem: Kids don’t like the taste of vegetables. Give kids a shopping / prep job and the illusion of hav-
ing some authority.
Solution: Prepare vegetables differently. Try roasting,
• “You’re in charge of picking out things for the salad.
making into a soup, sneaking veggies into a shake with
Which type of lettuce do you want? And what else
fruit, or serving them raw.
would you like? Cherry tomatoes? Okay, now it’s your
It might require 10 or more exposures before a child job to wash the tomatoes and rip up the lettuce.”
embraces a new food. So give it time. Keep trying new
options. Keep repeating old ones. And keep looking for Have a conversation. (As much as you can with a small
ways to incorporate veggies into meals. child.) Talk to kids about WHY they like things. Encour-
age them to describe and talk about their preferences.
Problem: Preparation seems inconvenient or difficult.
Problem: Peer pressure to eat non-nutritious foods
Solution: Keep prepared vegetables such as pre-washed
baby veggies handy. Involve children in vegetable and Solution: What happens around peers stays around
fruit prep — even young children can do things like peers. Focus on eating better at home.
snap the ends off green beans, mash avocados, or tear
Problem: Parents aren’t eating veggies.
up lettuce for salad. The more involved children are, the
more likely they are to try new foods. Solution: Parents eat veggies. (You knew that one was
coming, right?)
Problem: No access.
Veggies and fruits — along with other healthy options —
Solution: Keep vegetables at home and at school. Rear-
should be part of normal daily life and routines.
range the fridge to make prepared vegetables accessible
and less-healthy alternatives harder to reach. Note, also, that raw veggies can be risky for young kids
as they can pose a choking risk. (Then again, so do hard
Problem: Fruits and vegetables aren’t cool because they
candies, nuts, nut butters, hot dogs, and popcorn.) No
don’t have their own commercial.
big deal — cut them up into little pieces and ensure that
Solution: Don’t rely on advertising to make food choic- the child eats them slowly while sitting down.
es. Teach kids to be media-savvy. Help them understand
that advertising is designed to sell stuff — not necessari- Parents are guides and role models
ly with their well-being in mind.
Above all, have clients remember: They’re the parents.
Problem: Kids are exploring boundaries and being
their own person. (In other words, you hear “No!” a lot That means they’re in charge of setting guidelines for
these days.) food choices, meal-times, and family routines. They’re
still buying the foods and deciding what’s available in
Solution: Take kids shopping with you. Let them their house. They’re the role models, educators, and wise
explore the produce section and choose some things
they’d like to try.

466 | Unit 15
guides. They provide healthy structure and set clear, Puberty

appropriate limits.
Teenagers.
While children can and should have input (as well as
the illusion of choice), they’re still driving the bus. Nuff said.
Take a slow, gentle, “whole family” approach It’s a crazy time. Bodies and brains are changing,
hormones are swinging around wildly, identities and
As a nutrition coach, help support busy, stressed, and allegiances are changing, lives are changing.
overwhelmed parents by creating manageable, realistic
family routines and systems. Get everyone involved. On the plus side, with emerging maturity comes skill
development and autonomy. Teenagers can learn to
Remember that new parents will be less able to deal with shop, choose menus, and prep food in more complex and
complicated plans or high expectations. Go slowly, one sophisticated ways — if they’re encouraged to do so.
step at a time. Give handouts and gentle reminders.
Energy and nutrient intake
Don’t drown them in information; simply help them
clarify and address what is most important to them right As bodies grow, demand for energy and nutrients
now. Give them clear, concrete strategies and help them increases.
manage all their demands.
Energy intake for adolescents will depend on age, activi-
Keep expectations realistic: Don’t freak out exhausted ty, and body size, but generally will be higher during this
parents with rules about organic eating or scary stories time than most other phases of life.
about BPA in baby bottles. If they ask on their own,
encourage reasonable strategies or provide helpful tips to Many teens will just eat everything in sight. If they’re
navigate those more complex topics. active, this won’t usually be a problem (although they
should still learn healthy eating habits for life, even if
Don’t bombard new mothers with “inspirational” im- they get a brief freebie for a few years of blast-furnace
ages of celebrities who “bounced back” after pregnancy metabolism). But if they’re sedentary, they’ll become
and got their six-pack abs back in six weeks. overweight / obese.
Parents have enough to feel guilty and anxious about; Teenagers shouldn’t count calories, but here’s a general
don’t add to the burden. set of targets:
Just help parents do their best in difficult times. Teenagers can and should follow the basic Level 1 habits
as best as possible. This will cover most of the bases for
Help them set realistic expectations and cover the basics. energy intake and macronutrients.
Let them scale back to an earlier nutritional level for a
while, if needed. Add a multivitamin / multimineral supplement if
needed.
Table 15.2 Approximate calorie needs per day for pre-teenagers and teenagers
Boys Girls
Ages 9-13 Moderately active: 1800–2200 calories Moderately active: 1600–2000 calories
Active: 2000–2600 calories or more Active: 1800–2200 calories or more
Ages 14-18 Moderately active: 2400–2800 Moderately active: 1700–2000
Active: 2800-3200 or more Active: 2200–2400 or more

Activity
Activity is essential for growing bodies’ proper development.
Not all kids or teens will like organized sports, but all kids and teens should
somehow be active. Limit screen time and encourage movement of all kinds.
(That goes for parents too.)
Sports and activity can improve self-esteem, focus attention on the body’s func-
tion (rather than looks), and be a great pathway into healthy eating. If clients
have a young athlete at home, they now have extra motivation to eat well.
Unfortunately, sports can also sometimes fuel body image anxiety and disordered
eating. Especially keep an eye on teens involved in body-conscious / weight-con-
scious activities like wrestling, figure skating, gymnastics, dance, and the like.
Food prep skills

By adolescence, kids should be building some substantial food prep skills. They
should know how to grocery shop and make basic meals.
Childhood development experts generally agree that by age 13 or 14, most kids
should be able to prepare a full meal on their own. Even if little Jamie Oliver isn’t
whipping up four-course tasting menus for the family, they should know their
way around a grocery store and kitchen, beyond microwaving some frozen Pizza
Pockets or making toast.
The other plus of having kids who can prep healthy food? Parents can ease off
their role as short-order cook. This is especially helpful for working parents.
Many teenagers may have part-time jobs in grocery stores or restaurants, where
they can learn about food production and consumption.
Disordered eating
With increased awareness of self and others comes new anxieties and behaviors.
Disordered eating is on the rise in both boys and girls.
For instance, a recent study in the British Journal of Psychiatry that followed
6,000 children to the age of 14 found that at age 8, 5% of girls and 3% of boys
were unhappy with their bodies. By age 14, that rose to about 32% of girls and
16% of boys. And by 14, about 47% of the girls and 16% of the boys were either
restricting food or binge eating.
Know the kids you coach. You should be “tuned in” to them as much as possible.
Review the section in this unit on disordered eating and be alert for danger signs.
Menopause / andropause
menopause: Permanent end of
Physical, intellectual, and emotional changes in midlife are normal for men and menstruation in women
women. Menopause (from menos or “month”) occurs in women, while andro- andropause: An endocrine
pause (from the ancient Greek andro or “male”) occurs in men. state marked by a decline in the
production of androgens in men;
Changes take many forms. occurs with advancing age

468 | Unit 15
Hormonal changes Each person’s experience is unique. And your clients can
significantly affect their symptoms with good nutrition
Production of sex hormones (such as testosterone, estro- and regular activity.
gen, and progesterone) decline with age, as does produc-
tion of other hormones such as thyroid hormone.
Older age
This can affect a wide range of things, including:
Each birthday brings changes. And not just to achy
• weight and body fat (and where body fat is joints, but to teeth, muscle mass, and life priorities.
distributed);
We are, on average, living longer. We can manage or
• body composition and lean mass (muscle, bone, and
stave off chronic diseases with better health care and
connective tissue);
medications. However, we may not all be living better.
• healing and inflammation;
People tend to be less active as they age, which (along
• mood, mental clarity, outlook on life; with changing hormone levels) means less muscle, more
• sleep, energy, and fatigue; and fragile bones, stiffer joints and connective tissues, and
poorer circulation. Many taken-for-granted symptoms
• digestion and GI health.
of aging are simply disuse and decay from sedentary
Symptoms are complex and inter-related. For instance, living, rather than an inevitable progression. In other
changes in digestion or the hormonal environment can words: Use it or lose it.
affect fat loss. Insomnia can add to clients’ stress, worsen Appetite, oral health, taste preferences, and GI patterns
their moods, and make them want to reach for that also change with age.
caffeine.
In midlife, people often grapple with weight gain. But
If you suspect that clients’ symptoms and experiences in old age, the opposite may happen: People may eat
might reflect changing hormone levels, suggest hormone less, and eat more poorly. What they do eat, they may
testing to be sure. Also check with your clients about not chew, swallow, and / or digest well. They may also
whether they are taking any hormone replacement. become dehydrated.
If you’re a younger coach, resist the urge to lecture This is especially true for elderly who live alone and
your older clients about what they “should” be doing. A / or who are on a limited budget; as well as people
52-year-old woman dealing with midlife weight gain and who are on certain medications. Indeed, some esti-
her mother with Alzheimer’s will not want to hear about mate that about 20% of elderly people are significantly
how “easy” fat loss is from a 25-year-old coach. malnourished.
Life changes Ensure that older clients have a varied and nutrient-rich
diet that is nevertheless easy to chew, swallow, and digest.
Hormonal and physical aging also tends to correlate
• Super Shakes are a good option, as they’re easy to
with changes in life, such as divorces / second marriages,
kids leaving home, career changes, death and loss. It’s make, convenient, and easy to sip / swallow. Plus,
often hard to tell which came first: social or biological you can include some normally hard-to-chew vegeta-
changes. bles in them (such as carrots or celery).
• Older clients may find it easier to digest cooked vege-

For instance:
tables or fruits over raw ones.
• The stress of a job loss, or juggling work and caregiv-
ing for children and aging parents may contribute to Supplementation can include:
weight gain or suppress sex hormone production. • a multivitamin / multimineral supplement
• Clients who are facing an “empty nest” as children • vitamin D
leave home may be confronted with their own mor-
• vitamin B12, taken sublingually (due to changes in
tality and notice menopause / andropause symptoms
intrinsic factor, which can inhibit the digestion of B12)
more acutely.

• omega-3 supplement
Food sensitivities
• probiotic
As with most of the topics in this unit, food sensitivities
• digestive enzymes (including betaine HCl) is a broad and complex subject that could easily have its
• protein powder (for quick and convenient meals) own textbook.
• powdered greens But here’s the most important point: Get clients to tune
• glutamine, arginine, and HMB (potentially carnitine) in to their bodies and connect the dots between what
they are eating and how they are feeling.
• creatine
No matter what food a person tolerates, or doesn’t,
• fiber supplement
awareness and connection are the over-arching goals.
Check with your clients’ doctor / pharmacist for all of
A food sensitivity can be an allergy and involve the
these, as they may interfere with particular health condi-
immune system (e.g., you eat shellfish and get hives). Or
tions or medications (or vice versa).
it can be an intolerance that doesn’t involve the immune
While the idea of calorie restriction has been thrown system at all (e.g., you drink milk, you can’t digest lac-
around as a means to enhance longevity, at this point, it tose, you get bloated).
only makes for a fascinating discussion with colleagues.
A person can be sensitive to ANY food. True food
Until we know more, stick with tried and true nutrition-
allergies have been recorded with over 170 foods, but
al foundations (such as the Level 1 strategies).
there are eight that account for more than 90% of food
allergies:
What you can do • shellfish • tree nuts
Help all clients learn and adhere to the essentials of • fish • peanuts
Level 1 eating.
• wheat • eggs
Encourage all clients (and their children) to be as active as • soy dairy
possible, in as many ways as possible.
Step back and look at the whole client (or whole family)
in the context of life stage. It’s estimated that between 3-8% of the population has a
• What are their needs, wants, limitations, and advan- true food allergy, but it’s challenging to get an accurate
tages at every stage? number here, due to many factors.
• What is realistic and manageable for them? Almost half of food allergies will be “outgrown” and
dissipate over time, especially dairy, egg, wheat, and
• What things do you need to consider in developing
soy allergies. Peanut, tree nut, fish, and shellfish aller-
their action plan?
gies are generally lifelong allergies.
Think about concrete, real-world strategies rather than For clients who want a definite diagnosis on a food aller-
“rules” or “shoulds.” Help your clients get the nutritional gy, a serum IgE immunoassay may be their best bet. This
job done in the ways they can manage, right now. will have to be set up through a specialist.
Use your support and referral networks as needed. With For clients who want a definite diagnosis on a food
older clients in particular, you’ll likely be collaborating intolerance (non-allergy), they are out of luck. Some
with doctors and pharmacists to balance supplementation companies are offering testing, but it’s not yet known
and medications. how accurate they are.

470 | Unit 15
Gluten intolerance / celiac disease gluten. The true prevalence of non-celiac gluten sensi-
tivity remains unknown. Some experts estimate 3-6% of
The gluten-provoked autoimmune disorder celiac dis- the population may have some form of this. There is also
ease affects around 1% (0.3-1.2%) of the US population, evidence that other cereal grains may be similarly reac-
and some evidence suggests that the prevalence increas- tive. And other evidence suggests that non-celiac gluten
es with age. People with celiac disease have a higher sensitivity might actually be a FODMAP intolerance.
mortality risk than the general population, and most
cases remain undiagnosed. That alone is a huge chronic FODMAP intolerance
disease burden attributable to a single protein.
Wheat contains FODMAPs, a class of fermentable fibers
Although research is ongoing and the area remains that exacerbates irritable bowel syndrome (present in
controversial, some research suggests that certain people 10-20% of Americans). In some cases, an apparent gluten
without celiac disease are nevertheless sensitive to intolerance may actually be a problem with FODMAPs.
FODMAPs
FODMAP stands for: fermentable oligosaccharides, Here are some examples of where to find FODMAPs in
disaccharides, monosaccharides, and polyols. the diet:
Hence, the acronym FODMAP. • Oligosaccharides (e.g., fructans and galacto-oli-
gosaccharides): globe artichokes, Jerusalem
FODMAPs are carbohydrates found in a wide variety of artichokes, large amounts of garlic, leeks, onion,
foods. large amounts of wheat, large amounts of rye,
Some people don’t break them down or absorb them large amounts of barley, inulin, fructo-oligo-
properly in the small or large intestine. When this saccharides, baked beans, kidney beans, lentils,
happens, FODMAPs will draw water into the gut and chickpeas
get fermented by the bacteria in our colon, producing • Disaccharides (e.g., lactose): milk, ice cream, cus-
hydrogen over methane, and a bunch of undesirable GI tard, yogurt, soft unripened cheese
symptoms. Thus, eliminating FODMAPs from the diet
can help to relieve the symptoms. • Monosaccharides (eg., excess fructose): honey,
apples, mango, pear, watermelon, high fructose
For those who tolerate FODMAPs, it would be unnec- corn syrup, agave
essary to eliminate them from the diet, as some of the
foods rich in FODMAPs tend to be nutrient dense. Plus, • Polyols (e.g., sorbitol, mannitol, maltitol, xylitol,
certain oligosaccharides, mainly in legumes and whole isomalt): apples, apricots, avocado, cherries,
grains, appear to be a beneficial class of compounds for nectarines, pears, plums, prunes, mushrooms,
gut health. sugar-free candy
A low FODMAP diet is best administered by a health care
professional trained in MNT.
Processing Stress
Few of us consume wheat in its original whole-grain form. The mind-body relationship is complex. Many neu-
Most people consume wheat after it’s been highly pro- rotransmitters and hormones affect the GI tract.
cessed. Thus, certain food “intolerances” might just be as
simple as over-eating too many highly processed foods. For instance, noradrenaline / norepinephrine — gen-
erally thought of as a stress hormone — can affect gut

motility by acting on sacral parasympathetic preganglionic neurons through

alpha-1 adrenoceptors. This can cause diarrhea and abdominal pain.
In general, stress usually worsens any symptoms of inflammation and

intolerance.
What you can do

One of the best tools for identifying food sensitivities is a simple food journal.
Capture:
• why the client ate • when
• what the client ate • how they felt after, including any symptoms
noticed, even if they don’t seem related (e.g.,
• how much
headaches, menstrual cramps, skin rashes)
Then, work through the food journal with your client to look for possible rela-
tionships and start solving the puzzle. Again, remember that stress often plays a
big role.
Experiment with food variety. For instance, if a client reacts to cow’s milk, do they
also have a problem with goat or sheep milk? What about yogurt? Or hard cheese?
Or whey protein? None of these may work, but you don’t know until you try.
Try to create a roster of foods (or food prep methods) that keep your clients’ op-
tions as open as possible. Substitute where you can. Limiting / eliminating foods
is a last resort.
Help clients build new routines if they have to substitute, limit, and / or eliminate
foods. This can include building new menus, re-learning how to shop or order at
restaurants, etc.
If you suspect a true food allergy, refer out for testing.
Plant-based eating
“Eat real food. Not too much. Mostly plants.”
—Michael Pollan, In Defense of Food
People become plant-based eaters for many reasons.
For instance, they may be concerned about health and longevity. Religiously
observant. Animal lovers. Focused on environmentalism and sustainability. Or
maybe they just don’t really like the idea or taste of meat.
People also vary in what “plant-based eating” means to them.
For instance, it can look like Michael Pollan’s dietary advice (in other words,
just shifting the ratio to eat more plant foods and fewer animal foods). It can be
a loose interpretation of “vegetarianism”, where people eat plant-based some- vegetarianism: Dietary practice
times and more omnivorously at other times. People may avoid just red meat or of avoiding meat products

472 | Unit 15
chicken while still eating fish or seafood. Most Level 1 • Try to move away from your client consuming a lot of
eaters will eventually be eating more plants. processed soy products (e.g., “soyloney”, soy cheese)
and towards fermented soy products (e.g., natto,
Plant-based eating could also be a stricter regimen such tofu, tempeh) in small amounts.
as veganism or even raw veganism.
Supplement as needed.
For most people who choose some type of plant-based
eating, what that looks like exactly usually varies over • Start with a basic multivitamin / multimineral
time, and with changing preferences and priorities. supplement and algae-based omega-3 fatty acid
supplement.
Experiment. If clients want to try a 100% plant-based
diet, help them test out different approaches. You won’t • Consider adding a plant-based protein powder to
know exactly how a 100% plant-based diet will influ- help meet protein needs.
ence someone’s health and performance. Each person • Consider some nutritional testing to see whether
responds differently to various foods and patterns of there are other deficiencies (vitamins B12, A, K 2, and
eating. Don’t follow anyone else’s regime or “rules” —
D along with many minerals are common ones), and
trust the evidence of each client’s body, experience, and
then supplement accordingly. (For plant-based eaters
results.
not eating any animal products, they will definitely
need to supplement with vitamin B12).
What you can do
• Creatine: For strength athletes, 3-5 g of creatine each
Clarify what your clients are doing and eating. “Mostly day can be helpful
vegetarian” can cover a lot of bases. When appropriate, • Taurine and beta-alanine: These might be useful sup-
ask for a food journal so you can see exactly what’s going
plements for 100% plant-based athletes interested in
on.
performance.
Understand your clients’ reasons for their food choic-
Look for any symptoms of hormonal disruption or issues
es. Those reasons may be scientifically sound, logically
with energy balance. For instance:
consistent, and evidence-based… or they may not be.
“Because celebrity X is doing it” is not a great basis for a • Eating a lot of processed soy can affect thyroid and sex
nutrition plan. Educate and inform where needed. hormones. The same is true of eating a lot of cruci-
ferous vegetables (which can happen with someone
Don’t assume that all plant-based eaters are healthy.
who’s consuming a lot of juices that include things like
There’s plenty of processed and refined plant-based food
kale), which can potentially disrupt hormonal balance.
out there. (Vegan cookies anyone?)
• Eating a lot of fibrous plant material can also affect
Help plant-based eaters cover their nutritional bases. hormonal health and nutrient status, as fiber can
Start with improving the quality of their food choices bind to many fat-based substances such as steroid
(e.g., more whole foods, more variety, enough protein hormones, removing them from the body.
and healthy fats). • Some plant-based eaters who eat a lot of whole,
high-fiber foods may be inadvertently under-eat-
In particular, for exclusively plant-based eaters:
ing (because these are so filling), while others may
• Include beans and legumes for protein. Experiment be over-eating if they are consuming a lot of highly
to find out which ones are better tolerated; you may processed foods or using nuts / nut butters as primary
need to start with small amounts to allow the GI tract protein sources.
to adapt.
• Include higher-protein whole grains such as sorghum

and quinoa.

How we fit into the food system

“How we produce and consume food has a bigger Yet someone’s hands picked the beans for your coffee.
impact on Americans’ well-being than any other Same with your berries. Perhaps it was a child or teenag-
human activity. The food industry is the largest er doing that picking.
sector of our economy; food touches everything from
our health to the environment, climate change, eco- Perhaps a team of scientists worked on the tomato
nomic inequality and the federal budget.” — Mark or apple breed you’re eating, testing it for years in a
Bittman, Michael Pollan, Ricardo Salvador, Olivier greenhouse.
De Schutter (Washington Post - November 2014)
Your bananas or chocolate likely had to travel to get to
People don’t make food choices in isolation. you. Someone packed them and shipped them.
The food choices made each day influence body fat Someone on a farm dumped a bag of animal feed out,
percentage and farm laborers. Disease risk and animal and listened to mooing, or oinking, or clucking. (Or
welfare. Big biceps and the planet as a whole. nothing, because fish and shrimp aren’t very chatty.)
Food choices are based on cultures / traditions, religion, Someone drove a truck. Cleaned a fish or carved a steak.
ethics, income, the economy, food accessibility, conve- Sprayed pesticide or disinfectant or water. Unloaded
nience, habit, and dozens of other factors. boxes at 4 AM so you could buy food at 8 AM.
It’s the “meta” perspective of food and eating. In other words, there are real people making up the links
in the food chain. Real impacts on the environment —
Sure, you can design countless dietary strategies for clients both human and ecological.
that improve personal health and body composition, but
what about how each of those dietary strategies influences When appropriate, help clients gain a larger perspective
everything else? of this food chain over time.
Part of being an informed eater is — eventually — un- The trade-offs of food production
derstanding how and why we make choices… and what
consequences or effects those choices have. Before the modern industrial food system, food short-
ages and malnutrition were common and widespread.
All choices have trade-offs. We decide what to prioritize. More of us than ever before in history can now buy a
variety of food, relatively cheaply. Our food is relatively
As a nutrition coach, you can help clients to make safe and clean: unspoiled, refrigerated and preserved,
informed choices. Remember, the choices are theirs to mostly free of parasites and pathogens.
make, it is simply your job to guide and inform, not
enforce or choose for them. That’s good.
Over time, as clients become more aware of the impli- Yet industrial food systems come at a cost. Producing
cations of their choices, those priorities may shift. Or food on a large scale means we’ve got more food than
they may factor other things into their choice-making ever, but often involves significant trade-offs to nutrient
process. Such as how they fit into a larger “food system” density, worker protections, animal welfare, the environ-
of production, processing, transport, and consumption. ment, and sometimes even political stability.
For instance:
The global food chain • We produce enough food to feed everyone… yet
The food available to us is the product of global pat- some people eat too much, while others not enough.
terns in food production, transport, and trading. • Worldwide, some people struggle with obesity and
related illness; other people struggle with hunger
For most of us, food appears magically in a grocery
store. and malnourishment.

474 | Unit 15
• To feed more affluent regions, workers in poorer regions often suffer, as do the
ecosystems around them.
• To standardize food production (in other words, to create a product that is

reliable, repeatable, and can survive harvesting, transport, and storage), we’ve
often sacrificed biodiversity and prioritized durability and sameness over taste
or nutrition.
• Small pastoral farms build sustainable systems that include animals who live
confined animal feeding in a more natural environment. Confined animal feeding operations
operation (CAFO) : Large-scale (CAFOs) take animals out of this natural environment and may treat them as
industrial agricultural facility that
raises animals, usually at high- expendable units to make profit.
density, for the production of
meat, eggs, or milk All of that is not so good.
So now, many of us are asking: What can we do about this?
How can we balance the need for global food production with human health,
worker safety, biodiversity, and environmental protection?
What does “sustainable eating” mean?

Most of your clients will be looking for habits that are sustainable. In other words,
things they can do reasonably well, forever. They’ll also probably realize — if
they’ve been up and down on the diet roller coaster — that training short-term
results for long-term damage is a bad plan.
Sustainable eating and agriculture is the same idea: Things that we can do, forev-
er. Not trading short-term results for long-term damage.
This means things like:

• managing and conserving natural resources including land, water, plants, and
animals;
• making sure any developments consider human needs now and in the future;
and
• using technology wisely.
“Sustainable diets are those diets with low environmental impacts, which contrib-
ute to food and nutrition security and to healthy life for present and future gener-
ations. Sustainable diets protect and respect biodiversity and ecosystems. They are
culturally acceptable, accessible, economically fair, and affordable; nutritionally
adequate, safe, and healthy; while optimizing natural and human resources.”
— Food and Agriculture Organization of the United Nations
Of course, just like sustainable habits, there are many options for sustainable
eating and agriculture.

What you can do • Explore environmentally friendly methods of food

disposal, such as composting. Many municipalities
As your clients get more conscious of their food choices, now have “green bin” programs for large-scale food
they may wonder what they can do to “eat better” — not recycling.
just in terms of macronutrients or getting their vegeta-
• Shop strategically. Buy only what you need. Don’t get
bles, but in a larger sense.
sucked in by the “Buy in bulk and save!” mentality,
Here are some possible options to explore with interest- unless you are really going to use all that bulk.
ed clients. • Store carefully. Keep your fridge cold so things don’t
spoil; prune your pantry regularly.
Think critically about “value”
• Plan meals properly. Don’t make big feasts that get
In North America, we often define “good value” as tossed out when people don’t finish them. A “value
“getting a lot of stuff cheaply.” We don’t often define it as
meal” is not valuable if you don’t actually consume
“getting a quality product.”
the excess. Notice how much people normally eat,
But “cheap” is more like “cheapened.” Something has to and prepare the right amount.
happen to make all that stuff cheap. Costs have to be cut • Treat “best by” and “use by” dates with skepticism:
somewhere.
Use good judgment. “Sell by” dates can be ignored
Help your clients think more broadly about “value”, completely.
and explore the idea of “quality” as an alternative. • Check out local gleaning opportunities. Some organi-
zations will go around to farms and gather the unhar-
Would they be willing to pay a little more for a bet-
ter-quality product? Or a product that was more sus- vested crops, and then transport it to food banks and
tainably produced? A product with better working rescue missions.
conditions for the people who produce, process, and / or • Notice when you’re relying on plastic; choose
transport it? less-packaged products and use plastic sparingly
(e.g., if you’re buying a bunch of bananas, they
Why or why not?
probably don’t need to go into a plastic produce
Cut down food and packaging waste bag). Try glass, cardboard / paper, and / or metal
containers, which can be recycled.
In the United States, between 25% and 50% of all food
is wasted (depending on sources and estimates). And Consider supporting small farms
processed foods tend to use a lot of packaging.
Small farms offer opportunities for supporting local
Food waste is expensive to deal with. It’s an environ- agriculture and farming families. Small farms may
mental burden, and — with so many people still in need be more willing to try sustainable / organic farming
of nutritious food to eat — irresponsible. methods, offer a wider variety of crops or animals, and
exchange directly with the consumer.
Luckily, you can help clients cut down on food and pack-
aging waste by providing them with some simple steps: Sometimes this may be more expensive than buying
• Figure out the source of food waste: Do you keep too industrially farmed products. Other times it can be
much food around that goes bad? Should you simply
cheaper (or comparable) — for instance, when buying
vegetables in season, or meat in bulk.
buy less? Do you need better “leftover-fu” to make
good use of what’s in the fridge? Options for clients can include:
• Examine reuse opportunities: Can you cook the • shopping at local farmers’ markets. Even if only to
wilted fruits or veggies? Can you make a stew with a buy the occasional jar of jam or apple pie at a farm-
leftover stir fry? Can you give food scraps to animals? ers’ market, it’s a great opportunity to support small
Can you donate leftovers to places like food banks or farmers, meet people who grow food, and learn
agencies serving homeless people? more about how agriculture works.

476 | Unit 15
• participating in a CSA (community-supported agri- Most organic farming systems tend to be more soil, wa-
culture) program. ter, animal, and air friendly than other growing meth-
ods. Many organic farms grow diverse crops and create
• considering direct-to-consumer options, such as
beneficial ecosystems to manage pests and diseases
buying a side of beef.
naturally.
In many regions of the world, small farms and small-
Of course, while “organic” is generally a good thing, it’s
scale producers are the only options.
not a universal solution.
Explore food variety For example:
Instead of choosing a narrow selection of foods, help cli- • “Organic” doesn’t mean that animals are grass-fed,
ents explore a range of food types and cooking methods. humanely treated, or free to roam pastures. Those are
completely separate issues.
For instance, you can suggest:
• Nor does “organic” mean it’s a healthy, nourishing
• Try cooking a whole chicken, then using the bones
food. Organic, highly processed, high-sugar cookies
for stock, instead of prepackaged chicken breasts.
are still cookies.
• Try other types of fish and seafood, especially small
• Organic food may travel just as far, or farther, than
fish that may be more sustainable.
conventional foods.
• Try other varieties of fruits and vegetables, such as
heirloom strains that may grow easily in your local However, to find the foods that are generally healthiest,
climate. most nutritious, least chemically adulterated, and poten-
tially more sustainable — whole, minimally processed
• Try other types of meat, such as wild game, rabbit, or organic foods are usually wise options.
goat, which require fewer resources.
• Try other cuts of meat, which are often cheaper and

Consider inputs, outputs, and
more flavorful — and which otherwise might get
“footprints”
thrown away simply because consumers don’t buy Much like systems of the body, help clients think about
them. food production as a whole system: inputs, outputs and
• Try choosing more plants, especially easy-to-grow “footprints.”
ones that don’t require a lot of chemicals and fertiliz-
For instance:
ers, or a lot of transport.
• How much water and other resources (such as fuel,
Explore organic options feed, and / or fertilizers) are used to produce a given
food?
Organic farming avoids the use of synthetically pro-
duced fertilizers, biocides, growth regulators, modern • How much waste is created, especially if we consider
genetic engineering, and livestock feed additives such as the entire food chain — from farm to transport to
antibiotics and growth hormones. table to garbage dump?
• What impact does a particular food, or meth-

Organic fruits and vegetables tend to be higher in nu-
trients and lower in certain heavy metals and pesticides od of food production, have on people and the
that conventionally farmed foods. environment?
• How does this food contribute to or take away from

Organically raised animals typically get organic feed
ecological health and biodiversity?
without chemical pesticides, herbicides, fungicides, and
fertilizers. And they don’t get growth hormones, antibi- • What is the net effect of this food production, pro-
otics, or other types of drugs. cessing, and transport? Does it add value back, or
take value away?

On the one hand, many sources of food, and many It gets even more complex if we consider the big picture
methods of production, may offer more nutrients per — how food is produced, transported, processed, bought
unit of food. For instance, a pound of meat or fish has and sold… and by whom.
more protein than a pound of wheat or lentils.
For instance, that wild-caught mackerel might have
On the other hand, if we consider the entire impact of the been caught by a polluting ship with lousy working
food chain, plants typically use less water and fossil fuels conditions, while the feedlot cow might have had more
and create fewer waste products than animals, especially scientists and veterinarians attending to it than a prize
large livestock like cattle. So, on average, a more plant- racehorse.
based diet can be a more sustainable option.
Thus, eating sustainably and ethically is a balance of
However, we can’t say definitively that all plant sources many factors. There are no simple, easy, morally tidy
are “good” and all animal sources are “bad.” solutions. (Even hunting, gathering, and growing all of
our own food ourselves is pretty tough, as our ancestors
For instance, an organically grown carrot is not the can attest.)
same thing as industrially produced canola that is then
made into cooking oil. Likewise, wild-caught mackerel Each person should consider the overall impact of their
is not the same thing as feedlot cattle that is transformed choices, and decide accordingly. This is a somewhat more
into whatever the heck is in that takeout burrito. advanced concept for clients, and requires lots of educa-
tion and research.
(Indeed, many farmers are exploring the potential of
“microlivestock” ranging from smaller breeds of familiar Luckily, before trying to solve the world’s agricultural,
animals such as cows and pigs, to animals such as rep- labor, and environmental problems today, we can all
tiles and insects — which are already commonly eaten in start with some very simple steps that help us move
many parts of the world.) towards more sustainable eating.

478 | Unit 15
Summary
There can be a lot to think about when you consider the Good nutrition is important for a strong immune sys-
“big picture” of food and eating. tem. Good nutrition can also help with injury recovery
and managing inflammation.
On the one hand, start with the basics and keep things
as simple as possible. On the other hand, be aware that Many biological and social factors can affect our nutri-
many factors shape our experiences of food, eating, tional needs, our eating behaviors and food choices, and
health, body composition, and performance. what results we get from nutrition programs. These can
include:
Know your own boundaries and scope of practice. Build
referral networks and collaborate with other health care • sex and gender
providers so that you feel comfortable working with a • ethnicity / ancestry and genetic makeup
wide range of clients.
• life stage and development from conception to old
Disordered eating is a complex phenomenon with age
many types of beliefs, thoughts, feelings, and behav-
iors. By definition, most of your clients will have some There are many types of food sensitivities, ranging from
form of it, although most will not have the standard mild intolerance to full-blown allergy. You can identify
clinical presentation. and work around many of these with simple observa-
tions and interventions, such as using a food journal.
While “food addiction” is a debated concept, it can be
useful to think of some foods, or some eating behav- More advanced / interested clients might want to learn
iors, as having an addictive component. Clients may more about the “big picture” of eating. This includes sus-
also struggle with addictions or compulsions for other tainability and environmental impact, as well as the whole
things, such as alcohol. “food chain” of production, processing, and transport.
Having addictions, compulsions, and / or strong urges Just as there is no one “best diet”, there are no easy an-
does not mean clients are deficient or defective. Addic- swers for complex questions like how to eat sustainably.
tions simply “hijack” normal brain function in dysfunc- However, we can help clients make some simple every-
tional ways. Some people may be more susceptible to this day choices that may move them closer towards “ethical
than others. eating” and long-term benefit.
One way we can help clients is by giving them a template

for what “normal” eating looks like.

UNIT 16
Business 101 for Fitness and Nutrition Pros

480 | Unit 16
Unit Outline
1. What’s next for your coaching practice? 3. How to attract clients: Frequently asked questions
about sales and marketing
2. Smart business strategies for nutrition coaching
Objectives
You have some great nutrition and coaching knowledge In this unit, we’ll give you some tools — in particular, some
now. Congratulations. The next step is figuring out how to business models — to help you put your new expertise
build your business and your brand. knowledge to good (and profitable!) use.
What’s next for your coaching practice?

The fitness industry is evolving. And with it, coaching is that, you’ll already be a better, more well-rounded train-
evolving too. er than most. Plus your clients’ results may be incremen-
tally better.
We see a new type of fitness professional emerging,
which we think of as the “complete fitness professional.” The downside: this approach won’t necessarily make you
more profitable or successful. In fact, it could cost you
This kind of practitioner is able to coach people through more time with no discernible financial payoff. So while
practical improvements in their training, eating, stress, it’s okay for a little while, we don’t recommend it as a
other lifestyle choices, and overall health. And their long-term strategy.
clients achieve significant, sustainable life change.
Option 2. Use your knowledge to be a
Of course, just like there are many nutrition programs
better trainer, AND use a system to run
that “work” for clients, there are many ways that you can
make coaching “work” for you.
a better business.
If you follow a system, you’ll be able to deliver nutrition
Option 1: Use your knowledge to be a services in a focused way that aligns with your priorities.
better trainer. You’ll get more consistent client results. You’ll set bound-
Once you’re ISSA Certified, one option is to simply hang aries and save time. And you’ll make a better profit.
onto all your nutrition knowledge until the moment it But what kind of a system should you use?
becomes obviously useful.
To give you some ideas and best practices to follow, we
For example, when a client asks you a question about nu- spoke to some of the fitness industry’s leading experts.
trition. Or you see a chance to share a particular dietary
recommendation to improve a client’s results. Game In this unit, you’ll learn some different options, so you
time: You can spring into action and help them out. can pick what works best for you.
In other words, you can share the knowledge when the Remember: There’s no “right” way to do this. There’s
opportunity presents itself. And that’s good: If you do only the way that’s right for you.

Business 101 for Fitness and Nutrition Pros | 481
Smart business strategies for nutrition coaching
Individual model fewer clients?” Probably not. As current (and prospec-

tive) clients see the tremendous value this sort of holistic
As recommended by John Berardi coaching provides, they’ll be more eager than ever to
work with you.
For many trainers, working one-on-one is a good start.
This model incorporates nutrition coaching into your However, even if you did lose a few clients at first (which
fitness training services. isn’t likely), you’ll begin attracting clients who are really
ready for change, and willing to commit. Of course, that
In this model, you present yourself to your clients as a means you’ll get better results, a better shot at establish-
well-rounded lifestyle coach immediately. One of the ing a great reputation, not to mention profitability that
best ways to do this is simply build nutrition coaching reflects what you’re really worth.
into your rate and your package of services.
Ask for the level of commitment you need from a client Benefits of this model:
to get real sustainable change. That’s probably at least six Easy to get started: If you have any training clients at all,
months... maybe 12. Sign an agreement for this dura- you have potential nutrition clients too.
tion and bill per unit time (weekly, monthly, quarterly)
instead of per session. Keeps the scale small and manageable: This is a great
place to start if you don’t feel ready for large-scale
Then begin coaching your clients on practical nutrition. training, or if you’re simply happier training people
Here you have a couple of options. one-on-one.
Simple integration with existing services: You’ll still be

Option 1: Offer a dedicated, regularly leaps and bounds ahead of the run-of-the-mill trainers
scheduled nutrition session every 1-2 weeks. out there because you’ll be coaching people to better,
lasting change. You’ll have real results to show for your
Value that session equal to what you’d value a fitness efforts — and you’ll be able to charge for it.
session.
For example, if you think in terms of $100 / session for What does an hour of coaching look like?
fitness training, you’ll charge the same $100 / session of
Here’s a sample template.
nutrition coaching.
1. Start with an assessment (if warranted).
Option 2: Add 15 minutes to each client
training session. This would involve tracking the things important to
your client. It could be objective things like weight,
Do this ideally at the start of the session before your girths, skinfolds, photos and food intake. Or subjec-
client is tired. tive things like mood and perceived health.
Meet in a quiet place. Don’t do this while your client is 2. Review check-in questions.
foam rolling or warming up.
During the prior week or two, you should have
Factor this extra time into your price per session. For assigned new habits or practices for your clients to
example, if you think in terms of $100 / session, consider work on.
charging $125 / session that includes nutrition assess-
ment and consultation. Review how they’ve done with those practices, cele-
brate all successes, and talk through any challenges
At this point, you’re probably asking: “With a higher around those habits.
price point and a longer commitment, won’t that mean

482 | Unit 16
3. Look back, look ahead. There you have it: a complete nutrition coaching
session that builds in assessment, review, celebrat-
Most clients tend to focus on how far their goals are ing success, establishing next actions, and planning
ahead of them, and how much time, effort, and work for success.
still remains.
Change their focus by looking backwards and re- How to differentiate between a paid session
framing the future as a set of opportunities. Review and general nutrition advice
what they’ve accomplished and what they’re current-
What if you’re training a fitness client (who hasn’t hired
ly excited about, or looking forward to.
you for nutrition coaching) or talking with a prospect
Question #1: Looking back over the last xx days, and they ask for your opinion on a nutrition question?
what are you most proud of?
As someone who gets asked a lot of questions — some-
Question #2: Today, what are you most excited times by total strangers — I’ve learned to follow the
about? 1-minute rule:
• If it’s something I can explain within one minute, I’ll
Question #3: Looking forward, what are you
answer it.
most confident about for the next
xx days? • But if the question requires a more in-depth answer
or a longer conversation, I’ll refer them to a suitable
4. Establish the next practice to work on.
resource.
Together with your client, collaborate on what to
Consider taking this approach with your own business.
do next. As part of your decision-making process,
consider your client’s progress, their changing goals, Refer people with complicated or multiple nutrition
current sticking points, and what feels most import- questions to your nutrition program, where you can
ant and / or urgent to them. deliver your full coaching system, as outlined above.
(Remember, though, questions outside your scope of
Once you agree on next actions, ask:
practice should be referred to clinical professionals.)
How confident are you that you can follow this
This approach allows you to stay friendly and helpful,
for the next xx days?
while setting boundaries and helping to sell your service
Adjust as necessary until you come up with some- to those who really need it.
thing you think will make a difference and they
think they can actually do. Remember why you’re doing this in the first
place
(Review the client coaching practices in previous
units to see how to refine a coaching task.) The certifications next to your name… how many Face-
book followers you have... even how many new clients
5. Look ahead. you can attract: None of this matters.
To close out the session, make sure your client is set Your success fundamentally depends on the value you
up to achieve success with the following questions. deliver to your clients.
Based on what we decided to practice over the next
xx weeks... And that means keeping your promise. If clients hire you
because they want to live better, healthier lives, you need
Question #1: What advantages do you have to help them do that.
that’ll make this easy?
That’s the biggest reason nutrition coaching belongs in
Question #2: What surprises or challenges may a fitness business. It’s also why you have the potential
come up and get in the way? to be immensely successful in this industry. Because if
you deliver on that promise, you will stand out, and you
Question #3: What sort of things might you do to
will be successful.
overcome these challenges?

Small group model consistency: if they miss a habit, they get an X; if they
do the habit, they get the checkmark.
As recommended by Alwyn Cosgrove
(www.results-fitness.com) An alternative (or additional) option is to assign “ac-
countability buddies.” This allows people to partner up so
Unlike the one-on-one model, the small group model they may check in with each other about their progress.
coaches several people simultaneously in the same ses-
sion. The sessions are held at a specific, recurring time, You may choose to “front-load” the service: Encourage
and everyone works together. Usually, there’s also a finite uptake of the program by offering a free “entry level”
end point (such as an 8-week or 12-week program). nutrition starter class or kit when a client signs up with
the gym.
This is a nice way to add on to an existing fitness
business. If you have existing training clients, you can For example, at Results Fitness, every new client gets a
suggest that for an additional fee, they join your small “Phase 1” nutrition program that includes some initial
group nutrition class in addition to your fitness training habit-based coaching with some bonus tools (like a food
services and / or gym membership. journal). From there, Cosgrove estimates that 90% of
clients upgrade to the 8-week small group program.
This is also a nice way to make the most of your time.
You’re spending an hour (or whatever) regardless; ten Feel free to experiment and discover the “winning formu-
people paying $20 each will yield twice the revenue of la” that works for your own coaching style and client base.
one client paying $100 for that same hour. Clients may A few key principles:
also prefer to trade off one-on-one attention for a cheap-
er price — or simply like the idea that they’re sharing the • Keep the class size manageable. Observe the group
journey with others. dynamics and see what “clicks.” More than 25 people
tends to be too much.
Class size can be anything you like, depending on your
client base and comfort level. However, generally some- • Meet regularly at appointed times for a set number of
where between 5 and 25 is ideal. weeks (e.g., Wednesday at 6p for 8 weeks).
• Build accountability, not just lessons, into the pro-

The class structure could involve something like this:
gram to encourage consistency and good results.
• 30-minute lecture on a given topic
• 15-minute Q&A Benefits of this model

• 15-minute check-in and accountability session Return on investment: You maximize your profitability
without investing more time. Serving more people at
Accountability generally involves reviewing wheth-
once, even at a lower rate than an individual hourly mod-
er the client has met their stated goals from the last
el, will allow you to increase profits per unit of time spent.
session; and identifying what the client will commit to
work on for the next period of time. Accountability: For many people, the biggest barrier to
success isn’t knowledge, it’s consistency. And consistency
The coach can assign the same habit to everyone, or
can be helped tremendously by accountability — some-
allow each client to choose their own habit for the week,
thing that naturally flows from having other people
based on what they’re learning and their progress in the
check in on your progress week after week.
program. (Perhaps take a certain supplement each day or
practice eating slowly at dinner time.) They sign a visibly Social support: We also know clients are more likely
placed whiteboard or chalkboard each week, committing to stick with the program if they have peers, friends or
to their intention. family with similar habits. A group model can provide a
community feel and give clients a sense of support. They’ll
Similarly, you may choose to keep a “compliance grid.”
keep coming back (and re-subscribing to your program)
Throughout the program, track each individual’s
because they want to remain a part of the community.

484 | Unit 16
Is a higher hourly rate better (or worse)?
Some people chase after high hourly rates. But even if That’s it. (Told you it was easy.)
you’re working at an unusually high, “celebrity-trainer”
What this is meant to demonstrate is the value of train-
rate, the profits of group coaching are hard to beat.
ing in groups. Even the most elite, well-paid trainers will
Here’s an easy equation to gauge your profitability: have trouble getting the same profits, per unit of time,
as a group coach.
1. Take your hourly coaching rate.
For example, if you’re charging one person $500 / hour
2. Multiply it by the number of people you’re
you’re still making less than if you train 25 people at a
coaching at a given time. (If you’re doing indi-
mere $25 / hour.
vidual coaching that might be just one.)
Transformation contest model

As recommended by Pat Rigsby
(www.patrigsby.com)
In a transformation contest model, you provide coaching

within a limited time frame (about 4–6 weeks), with a or webinars throughout the program that discuss the
very clear goal. The contest offers a prize for a particular week’s topic — for example, a certain nutritional habit.
achievement, such as: You may also choose to set up an online group, such as
• body composition changes a private Facebook group, where you can send a daily
reminder or “check-in” asking people to confirm they
• visual transformation
did their daily habit. This helps to build accountability
• habit transformation into the program.
• athletic accomplishment Find some way to objectively measure results. For
instance:
You decide on the criteria and find an enticing price to
draw people in. (Note: You will likely need a sponsor for • If the goal is physical transformation, set times for
this prize, particularly if you are independent.) in-person measurements throughout the program.
You set a price you’re comfortable with. $225 is a typical • Or set times for group workouts or “fitness tests” if
starting point. the goal is athletic achievement.
Now, of course, to make a good contest, you need Make sure criteria and measurements are clear and
plenty of people. While you can have as many people as transparent. You don’t want people feeling misled or
you like, to make it sporting we recommend about 20 shortchanged.
people as a minimum.
While the program is short, it enables you to offer a lot
Throughout the pre-specified time frame of the program, of value in a short period.
you deliver a combination of email coaching and in-per-
son (or online) educational workshops. For example, you Benefits of this model
might send out a different email at the start of each week
with that week’s program (ie., workouts and nutritional Creates urgency: The short time frame with specific
habits), plus follow-up emails throughout the week. set dates encourage people to make a commitment.
In addition, you might host weekly in-person workshops Highly motivating; keeps people focused: People can
see real change within a short time frame, with a set

end-point. They can go “all in”, with an intense and logistics. Within a company environment, they become
focused effort. much more straightforward.
Immediate cash influx and long-term financial ben- Broader audience: A corporate program can give you
efit: Enhance value of existing clients (i.e., upgrade the access to a large group of people (e.g., 100+), allowing
amount they are spending with you by adding on this you to sell / upgrade more clients after the program is
program to their current activities) and bring new clients complete. (This assumes you have your clients’ permis-
in the door, who may be transferred to other programs / sion to do so.)
training with you.
Enables you to deliver nutrition coaching and fitness Online coaching model
coaching together in a structured way. This may be a
good model if you want to incorporate some nutrition As recommended by Jonathan Goodman
coaching into your work but aren’t ready to transfer it to (www.theptdc.com)
your regular programs / training models. Online coaching typically involves weekly programming
(by email or a software service), which may include writ-
Corporate model ten, photo and / or video content. It will require a degree
of one-on-one time from you to provide accountability
As recommended by Sean Greeley or answer questions, but that time should be structured
(www.netprofitexplosion.com) and limited, as described below.
Once you’re comfortable with training large groups of Here’s how to proceed.
people (for example, in the transformation contest style)
you may want to create a corporate offering. In the cor- 1. Start by choosing how many clients you want.
porate training model, you’ll provide nutrition coaching
Your goal number of clients should depend on what
to a workplace (either a whole company or a specific
you are trying to accomplish. Are you starting an
department).
online-only business? Or is this supplemental to other
For corporate clients, you’ll need to make a few amend- projects or full-time work?
ments to your existing model, but you can borrow many
If it’s supplemental, or you’re just getting started, you
of the same practices of either the small group program
may choose to begin with a small group (e.g., 10–20)
or the transformation contest program, depending on
and a small price point ($100 / month). Up to around
company size.
30 or 40 people seems to be manageable without
Corporate demand is increasing. It’s a great way to scale special software. Beyond that point, you may wish to
up your business and sell your services at a higher cor- use a special software system to help manage clients
porate rate. And it’s mutually beneficial: Employees ap- and content delivery.
preciate getting access to quality nutrition coaching and
2. Choose your speciality or “niche.”
employers love the corporate culture and team-building
benefits while improving the health of their employees. Efficient online training requires you to focus and
establish templates for client “type.” Pick no more than
Benefits of this model three types of clients you want to include in your online
personal training program.
High profits: Corporate programs usually come with
a higher price tag. Just be sure you can deliver on your For example:
promises. They will expect good service.
• 25- to 30-year-old males looking for muscle
Less investment of time and administration: Corpo-
• Women in their 30s who have recently had
rate programs don’t need the marketing or sponsorship
children.
of free-standing transformation contests. This makes
things more efficient (and potentially more profitable) • 18- to 25-year-old male college athletes
for you. Transformation contests can be a bit heavy on

486 | Unit 16
3. Assess your prospects in advance. appointments for yourself for when you will send ma-
terials to clients, when you will check email or conduct
Ask potential clients to fill out a questionnaire. You accountability check-ins, schedule follow-ups, etc.
can set up a simple survey online using a system such
as Survey Monkey.
Benefits of this model:
This will not only help you vet clients to make sure
It can save you time and money... if you do it right:
they fit your area of specialty, but also to anticipate
Remember, online training doesn’t have to be a big busi-
needs and problems in advance. (For example, if they
ness: it can be a great adjunct to your existing in-person
have a shoulder injury, you will need to adjust their
training business. For example, if you are training at a
workouts accordingly.)
gym and want to try combining nutrition coaching with
4. Create three to four phases of programming for fitness, this can be a good way to do that on the side.
each client type.
Client adherence can actually be better: Think about
Each client in the same category will receive a similar it: At a big box gym, the client buys “training.” Not the
program, tailored slightly for them, based on their trainer. The gym usually picks the trainer for them. The
questionnaire answers. client and trainer may or may not be a good fit — and
the client feels no sense of agency in the decision.
5. Set appointed times for compliance check-ins.
On the other hand, when you’re an online trainer, the
For example, at the end of the week, the client can client picks you. Not a gym. You. (Of course, this applies
send you their food journal, or their update on what if you’re an independent trainer too. In this case, online
habits they kept. You can schedule a time to review training is a way of broadening your reach.)
your email and check off your clients’ success using
your favorite method (e.g., a spreadsheet). You reach the people who need you: Online training is
a great way to reach people who need the help, such as
This system will give you the basics of serving clients people who can’t afford gym memberships or personal
online. You can, of course personalize this approach training, or who are intimidated by gyms. It’s more
as much as you like. accessible for many people.
Once you get a broader scope of clients — should you More flexibility: Online training can give you more
choose to — then you might look at buying software to freedom for how and when you train, allowing you to
help you deliver your materials. (Unfortunately not all block off time according to your own schedule and use
software services support nutrition coaching. If you’re your preferred ways of working.
going the software route, be sure to speak with a repre-
sentative about nutrition coaching in advance to make Just remember, in order to save you time, you must
sure it has the functionality you need.) work efficiently and systematically. If you’re redesign-
ing your programs for each person and answering
Schedule your time carefully. Set up regular email all day long, you’re probably not going to get the
results you hoped for.

How to safeguard your time
Whether you’re training online, or in-person, or both, you Determine which times you’ll devote each week to train-
must safeguard your time. ing. When do you want to do fitness training? When do
you want to do nutrition coaching?
Coaching online is no guarantee of more money. In fact,
if you’re not careful with your time, an online approach Make yourself available during these periods, and
could be worse. safeguard the rest for your other priorities — which may
include your own training, education, or other parts of
Don’t offer “unlimited access.” You don’t want to be
your business.
answering emails, texts or phone calls all day, every day.
Getting strict about your time might mean losing a few
Structure your communication time (whether it’s
clients — at first. But it can also mean you get better at
email, Facebook or Skype “office hours”). Be clear
your job, you increase your focus and efficiency, and
about when you will answer questions and provide
stay passionate about what you do, because you’re not
one-on-one support.
overloaded and overwhelmed.
In-person trainers can benefit from this approach too.
And that means a better business in the long run.
The partnership model

Another option presented by John Berardi 1. Start by picking your partner.
What if you decide that offering nutrition coaching This may be a local nutritionist or dietitian who you
within your business just isn’t for you? Or that, while trust and respect. Or it may be a reputable online
you’d like to offer this type of coaching eventually, your coaching company, like us. (Obviously, at ISSA, we
business priorities are elsewhere and it’s not something believe we’re the best in the world at what we do. And
you can focus on right now? we’re assuming you do too, since you’ve chosen us for
your certification.)
No problem. You can outsource it.
2. Once you’ve found a partner, decide on your part-
The truth is, sometimes people get their ISSA Certifica- nership arrangement.
tion but decide that now isn’t the right time to integrate
practice-based nutrition coaching. If you’re teaming up with a local nutrition pro, figure
out what works best for the both of you: Will you ex-
That’s a fair decision. After all, it takes time to make any change referrals? Go with affiliate-type commissions?
kind of addition or change to your business. It takes time Come up with a barter system?
to put all this nutrition stuff into practice, let alone be-
come an expert at it. And it takes time to settle into your There are lots of options, although my experience
sweet spot of expertise, wherever you find it. suggests that affiliate / referral commissions work
best. With affiliate commissions, you determine a
Meanwhile, you want the best for your clients. You don’t commission rate. Your affiliate partner pays you that
want them getting lost in diet fads or repeating harmful rate for each person you refer to them. (And vice
patterns. You want them to feel good and succeed, in and versa if they’re referring clients to you.)
out of the gym.
This type of revenue-sharing model is commonly
So let’s say you decide that, at least for the time being, used in the digital / online world but there’s no
you’d like some help delivering nutrition coaching. This reason it can’t be done offline too. Obviously, you
is where a partnership model can be useful. can both negotiate whatever you agree is fair, but a
commission of 10 to 20% on each coaching package
sold is standard.

488 | Unit 16
3. Stay in touch with the client about their nutrition

coaching.
How to attract clients:
Frequently asked questions
For example, you might schedule regular check-ins to
see how it’s going, or what habits they’re working on. about sales and marketing
Just stay informed so you have a sense of their prog- “How do I answer the question
ress and so you can make sure your programming
dovetails with what’s happening on the nutrition side. ‘What do you do’?”
Of course, a partnership model doesn’t mean you aren’t Expertise from Pat Rigsby
capable of giving nutrition advice: After all, you’ll have (www.patrigsby.com)
been through this program and gained a lot of knowl-
edge. You’ll already be a stellar coach, certainly a step (or When someone asks what you do, what do you say?
a flight of stairs!) above the norm. Many trainers describe the technical details of what they
But if you want to give your clients more support in do: They talk about boot camps, or rear elevated split
this area, and aren’t ready (or inclined) to add a whole squats.
new element to your business, partnership is an excel- What they don’t talk about is the results they get for
lent option. their clients. Or the real reason they work in the fitness
industry.
Benefits of this model:
To market yourself more effectively, answer the question
You can take care of your clients: If you aren’t ready or “What do you do?” by focusing on the people you help,
able to offer nutrition coaching right now, you’ll know and the value you bring them.
they’re getting quality support in this area. Part of being
a great coach is knowing when to call in extra resources For example, “I help new moms get their pre-baby bodies
to help your client succeed. Not everything needs to back so they can feel strong, sexy and confident as they
come from you. enter this new stage of life.”
You buy yourself some time: Keep working in the areas When you’re asked how you do that, then you can talk
in which you’re already a superstar. Meanwhile, keep about boot camp and squats.
learning and practicing in areas you want to grow. Re-
member, you don’t have to do everything all at once. Even better, use your nutrition certification as a power-
ful differentiator.
You keep it simple: Like your business the way it is now?
Not excited about adding or changing things? Outsourc- For example:
ing is an easy solution. “I’m a coach and my focus is helping men and women
You make a bit of money, and / or find some new eat, move, and live better. And I don’t just tell them what
clients: Partnership can open up new opportunities and to do, I help them through every step of the process. Plus
it can even make you some cash, with very little invest- I’m certified by ISSA, one of the most respected organi-
ment on your part. zations in my field.”
Sounds good, right? Now make it your own.

“How do I become a leader, “How do I ‘win’ at Internet

authority, or celebrity in my marketing?”
industry?” Expertise from Bedros Keuilian
Expertise from Bedros Keuilian (www.keuilian.com)
(www.keuilian.com) To succeed at Internet marketing you must find your
Many fitness trainers are generalists. They know a little tribe. You do that by sharing your expertise through
about a broad range of health and fitness topics. Some are quality content that matters to them.
specialists, focusing on a particular niche. In both of these While the tools and medium will change — at the
cases, the trainers might be able to make an okay living moment it’s Facebook and YouTube, and video is king
for themselves, but they’re probably not particularly well — you must provide valuable content to the people you
known (and their financial compensation reflects that). want to reach.
Then there are those who are authority figures — rec- To stand out from the competition, focus on bringing
ognized as leaders in their industry or community. value to your specific community. In other words, pro-
And, at an even higher level of notoriety (and usually, vide targeted information that matters to the people you
profitability) are celebrities — those who are celebrated want to attract.
and well known.
Learn how to use keywords to get more eyeballs on your
Celebrity status may seem like it’s relegated to the rare content, and make sure people see it. Drive views of
few, but truthfully you can manufacture celebrity status your videos or other content to an email list so you can
for yourself. And you can do so quickly, in as little as three communicate with your followers — and turn them into
to six months as long as you are savvy at Internet market- paying clients of your product or service.
ing. See the question after this one for more.
If this process seems daunting, just look to the people
To become an authority figure, you must choose your who’ve done it. Study those you admire: what do their
area (or areas) of specialty, and you must learn every- videos look like? What makes them work? You can ask
thing about that subject that you possibly can. Dedicate for help or even hire people to share their expertise.
yourself to becoming a better expert than anyone else.
And while you’re learning, don’t wait to get started.
Remember that becoming an authority, or even a celeb- Done is better than perfect. It’s okay if you receive some
rity, doesn’t mean you have to be on TV with millions criticism; it’s okay if you make mistakes.
of fans. It means you’re known in your community
— whether that’s your town or your area of specialty. What matters is that you keep going, continue refining
You are known and respected to the point that business your process until you get good — really good — at it.
comes to you.
You must be completely dedicated to the specialty area of “How do I get people to say ‘yes’?”
your choosing. Don’t fall into the trap of trying to become
known for something that pays well but that you don’t Expertise from John Berardi, inspired by author Dr.
particularly like. Robert Cialdini
To succeed, you must know your stuff better than In his famous 1984 book Influence: The Psychology of Per-
anyone else — and until you’ve reached that point, you suasion, Dr. Robert Cialdini forever changed how we look
must be entirely dedicated to learning, practicing and at marketing and sales. Here are three of the most import-
getting better. ant lessons to learn and integrate into your marketing and
sales strategy to help you close business.
The biggest difference between an average trainer and a
truly successful fitness authority? The average one gave
up too soon.

490 | Unit 16
Lesson one: The law of reciprocity nothing more powerful than sitting in front of a poten-
tial client and showing them the amazing results you’re
When someone gives us a gift or does us a favor, we try to able to achieve with people they can identify with.
repay them. It’s a natural human response to want to re-
ciprocate. In your business this means people need to get You can create social proof with a “success book” of
some kind of result in advance. And that result should be before-and-after photos (either print or online). You can
a piece of whatever progress they want to make. also share client success stories or case studies. Or even
share videos of clients showing off their achievements.
For example: Keep an iPad filled with photos handy, or even put up
• What if you coached someone for a full week before client success photos on the walls of your gym.
asking for payment?
The options are endless.
• Or put together a packet with your best exercise, nu-
trition, and lifestyle tips and gave that away for free, “How do I get a steady stream of
to any person who wanted one?
referrals?”
• Or gave a free grocery store tour for anyone who
wanted help with eating better? Expertise from Pat Rigsby
(www.patrigsby.com)
If you give someone a small taste of what you’re capable
of, they will reciprocate. They will eventually pay you. One of the very best ways to find new clients is to ask for
And they might just become a client for years. referrals. Referral clients are some of the most cost-effi-
cient, profitable and loyal clients you could find.
Lesson two: Consistency
The biggest mistake fitness trainers make when it comes
It’s human nature to want to be consistent. When we to asking for referrals is… not asking. You may be hop-
say we’ll do something, we want to do it. We want to ing it will happen naturally by “word of mouth.” Or you
be — or at least we want to feel — congruent with our might be afraid of being told ‘no.’
own self image.
But if you earn the referral — that is, you do good work
One great way to encourage consistency and secure for your existing client and you get them results — than
clients is to create a VIP list prior to offering a program. asking is the next natural step.
Offer clients a discount or simply the change to sign up
A good way to do this is by sharing valuable content.
early so that they have a better chance of getting a spot
That can be something you’ve written (a blog post or an
when the program begins.
article in the local paper) or an article or newsletter from
By putting their name on this list, potential clients make a another source you respect (for example, a web link to
small early commitment to you and to themselves. When an ISSA article you like).
it’s time to sign up, they’re more likely to follow through.
Share the content with your client and ask them to pass
it on, with your info, to anyone they know who might
Lesson three: Social proof benefit from the sort of support you’ve given them.
We’re surrounded by choice. The number of options for Thank them kindly no matter the response.
everything is staggering. So how do we decide things?
We look around to see what other people are doing. And if they give you a referral, be sure to reward them,
whether it’s through a free session, a small gift, or simply
Even if we’re not aware of it, our own choices are often a thank you card.
shaped by the choices of our peers. And in the fitness
industry the power of social proof is tremendous. There’s Show your appreciation properly, keep doing good work,
keep asking, and the referrals will keep coming.

“How much commitment should I So when do you do it? If you adopt one of the models
previously outlined then you’re set: You’ll establish a
ask for?” recurring meeting in a small or large group setting.
Expertise from Sean Greeley But if you prefer to add it to one-on-one client sessions,
(www.netprofitexplosion.com) you may choose to add 15 minutes to each training
session. Find a quiet space where you can engage and
If you’re selling individual training or a subscription
talk freely without distractions.
service, you might be tempted to sell a short-term pack-
age, such as three months. That might be okay when you
get started, but pretty soon you’ll probably want to raise Set clear boundaries
your game.
All this great nutrition knowledge can make you feel
The best commitment you can get from a client is not like you’ve discovered a whole new set of superpowers.
three months, or six months, it’s 12 months. Because we And that can make you feel eager to set off and change
know that’s what it takes to get results. the world!
It’s also the sign of a client who is ready and willing to What’s more, your clients are keen to access all that great
commit. stuff you’ve got to offer. Suddenly they want to know
everything you do!
When you sell a year-long program, you’re not selling
sessions or packages. You’re asking people to commit to While both of those things are kind of awesome, they
the length of time it takes to achieve their goal. can also be a deadly combination when it comes to man-
aging your time.
That is a client-centric sales process. It’s focused on their
results and what is required for real change. By selling a Keep strict, carefully defined limits on your time. The
year-long program you’re saying: this is going to take a cliché “time is money” is especially true for a trainer,
commitment and it’s going to take time. who’s typically paid by the hour.
It also makes it easier to sell, because you know you’ll Over-availability can actually have the reverse effect of
make a difference. You can sell with integrity. making you seem less available in your clients’ eyes.
That said, it also takes confidence to sell at a higher Set your boundaries and make them clear to your clients:
price point, and a higher commitment. Sometimes that here’s when we’ll meet, here’s how long each session will
requires sales training. In other words, a commitment be, and so on.
from you, the coach, to develop the skills to sell at a
higher level. All that said — feel free to break your own boundaries
once in a while. If you want to go “above and beyond”
for a client once in a while, go for it. Just be aware of it
Making it work: Avoid when you do it.
common mistakes
Pace your information delivery
Keep nutrition coaching separate There’s a reason why we recommend that coaching lasts
from fitness coaching an entire year. And why habits and lessons typically
don’t take more than 15 minutes to do.
Don’t try to squeeze in nutrition coaching while your
clients are foam rolling or stretching, or worse, lifting Sometimes less really is more.
weights. Nutrition coaching needs its own time; it needs
focus and attention from both of you. If you’re treating Less information means clients get just the most mean-
it the same way you’d treat casual chit chat, your clients ingful, pertinent information they need right now: so
won’t see it as something worth paying for, and they won’t there’s less other stuff to worry about or draw away their
get the value out of it they deserve. focus.

492 | Unit 16
It means they’re more likely to actually digest the infor- Value nutrition coaching
mation we’re giving them, and more likely to complete
the challenge we’ve put in front of them. Your job as a trainer is to change lives, right? That’s an
important job. And based on the fact that you’re still here,
Similar to failing to set boundaries, some newly certified working through this textbook, we’re guessing you’re
trainers want to share all their information with their pretty dedicated to it.
clients.
Your nutrition coaching will be just as valuable as your
Resist the temptation. fitness coaching. So why would you charge less?
Zero in on what your client needs to do next. What is the If you want clients to value your services you need to
next piece of information they need to know? The next value them yourself. That requires charging appropriate-
step they should take? ly. To put it another way: Don’t be afraid to charge what
Focus on that and leave the rest for another day. you’re worth.
Summary
Above all else, fulfill your promise. Use your nutrition for you. That’s okay too. If that’s the case, consider
knowledge to help your clients change their lives for partnership.
the better. If you’re truly good at what you do, you will
be successful. Learn the essentials of sales and marketing. Integrate
the basic principles of buying psychology: reciprocity,
Charge for it. If you want to make a living as a train- consistency and social proof. (But be honest and operate
er, you need to put a price on your nutrition coaching with integrity, of course.)
services — whether that’s an increased hourly rate or a
special program See the next point. Know why you do what you do. Be clear about the types
of people you help and how you help them. Practice
Use a system. Choose a business model that suits your talking about your business so you can express what you
goals and preferred way of working. This may be an do with clarity and passion.
individual model, a small group model, a large group
or transformation contest model, a corporate model, an Raise your game. Ask for referrals when you’ve earned
online model, or something completely different. It may them. Share your expertise and build authority in your
take some experimentation before you find what works community. Expand into new directions like online
best for you. Pick a system, try it out, learn from your services or working with corporate clients — but only if
mistakes, and adapt accordingly. you’re ready and actually want to do so.
Value your time. The adage “time is money” is particu- Keep learning and practicing. Try things even if they’re
larly true for fitness professionals. Be clear and specific not polished and perfect. Remember: “Done is better
about when you’re available to clients, and how the time than perfect.”
will be used. Templates and tools can be especially im-
Do what you’re passionate about. Build a business that
portant if you’re an online trainer.
makes you happy and helps others. Don’t be afraid to
In some cases, you will decide nutrition coaching isn’t deviate from the norm to create the kind of work — and
life — that you want.

UNIT 17
Continuing Ed for the Coach

494 | Unit 17
Unit Outline
1. Keeping up to date 3. Staying on top of research
2. Taking it further 4. Developing your coaching practice
Objectives
Completing one course or certification program is a solid In this unit we suggest how to approach your continu-
start and / or addition to your existing education, but ing education, now that you have nearly finished this
learning for the health and fitness professional is a lifelong certification.
pursuit.
Keeping up to date conference you attended. Your clients feel overwhelmed

and confused.
A tale of two extremes
You run out of money. Burn out. And wind up living in a
When it comes to continuing education, there are two surf shop in Central America.
opposite paths.
We’re being a little facetious, of course. But maybe you
Path #1: Forget about it. recognize yourself here… just a little.
Wait until the last minute and rush to complete inexpen- Find the middle ground
sive online quizzes. Don’t actually advance your career
or evolve as a professional. Spend all time outside of your We’re always trying to find some middle ground
job on unrelated hobbies, unrelated books, and unrelat- between those two extreme paths of under- and
ed events. over-achievement.
Feel stagnant. Don’t implement anything new in your Here’s what that could look like, and how you could
daily job. Your clients don’t feel challenged or engaged. work towards it:
You run out of money. Burn out. And wind up living in a Build a breadth of training and perspective.
surf shop in Central America.
Gather experience and seek wisdom. Older, more experi-
Path #2: Devote your entire life to learning. enced mentors can often help with this. They’ve usually
“been there, done that”, know what’s most important,
Fly around the country attending conferences and semi- and know what to apply, and when.
nars. Do countless internships and certifications. Always
be reading textbooks and non-fiction. The certification Your mission is to eventually become an older, more
companies give up trying to track your credits because experienced mentor yourself. But, for now, consider
you always exceed the minimal requirement. leaning on others as you develop.
You implement everything that you learn, flipping from Take your time. Relax and enjoy the journey. You don’t
one approach to another depending on the most recent have to do everything at once. If you’re new to the
field, or if you’re younger, you won’t know it all. That’s

Continuing Ed for the Coach | 495
normal. As you slowly build your own store of wisdom Start with why
and expertise, be open minded, evolved, and secure in
your coaching practice. Purposely seek out a breadth of Just as you ask your clients what their goals are, and
education and perspective. why those goals are meaningful to them, start with your
“why” — your values, priorities, and goals.
(It’s very easy to become static, close-minded, and defen-
sive if you’re not exposed to new and varied ideas.) Have an objective for learning if possible. And consider
doing the “5 Whys” exercise with it: Why is that import-
Have a comfortable balance between ant? And why does that matter? And what will that help
professional and non-professional pursuits. me do? And so on.
Maybe you alternate non-fiction continuing education This exercise — and really understanding what you’re
books with fiction books. seeking — helps to prioritize and keep the destination
in mind rather than just gobbling up “stuff” because it’s
Maybe you set aside one trip per year for a conference there. In a 21st century Internet world, you could spend
and one trip for a vacation with your family. all day, every day, just accumulating information.
Devote plenty of time, energy, and hours to your job... So, get clear on:
and have other hobbies too.
• why you’re learning; and
Continually challenge yourself with new ideas • what will be most useful to you (and why);
and concepts. • how each option could help you get where you want
to go.
Purposely explore different perspectives.
Talk to people who are experts in your field… and out- Learning how to learn
side of it.
Before focusing on what you learn (or while you’re
Talk to people who don’t believe the same things as you. learning), consider how you learn. Learning will be easier
if you understand your own learning style, and develop
Cross-fertilize.
your learning skills.
Critically review new scientific findings and This includes things like:
compare them to real-life best practices. • reading skills (e.g., being able to understand the
Be a skeptical and careful reader and reviewer. Explore meaning of what you read, and / or read critically);
scientific concepts and test them against what you are • writing skills (e.g., writing well and clearly);
noticing with your clients.
• research skills (e.g., knowing where to go to get
Also, while we do our best to update this textbook regu- questions answered);
larly, it will always be a bit behind the speed of science.
• information processing skills (e.g., being able to
filter through lots of “stuff” to extract what’s most
Taking it further important);
So what’s next? • analytical skills (e.g., being able to pick apart a

system or ideas to see what’s most useful);
Before you decide what your next steps towards continuing
• evaluation skills (e.g., judging how good or useful
education might be, think first about the big picture. This
particular data or ideas are);
will help you make specific decisions with a clear agenda
and objectives, and help you see the path through what • application skills (e.g., being able to use an idea in
can sometimes seem like a forest of options. day-to-day work with your clients).

496 | Unit 17
Being a good learner will help you absorb, process and use Other informal education options include:
anything you choose to learn about.
• Adult community education programs: These
We all have different backgrounds in our education and may be offered by education boards, community
career. But just as with athletic skills, we can all improve organizations, professional organizations, or other
with training and repetition. groups.
The best readers practice reading. • One-on-one tutoring or apprenticeships: Find

the Big Cheese in your field (or at least someone
The best writers practice writing. recognized as knowledgeable), and study with them
individually, or work in their facility under their
The best researchers practice doing research.
guidance.
You get the idea. • Self-study: Got library card, will travel! The coffee
shops of the world await your presence.
This is important not only so you have a better “learn-
ing” experience, it’s important because you are the As with formal education, be careful to differentiate
information filter for your clients. Learning how to filter “courses for fun” from “courses I need to advance my
and prioritize information is absolutely essential. career.” Although it could make you an interesting party
guest, certification in Advanced Aerial Tap Dancing
If you feel like to you need to learn some of the afore-
from the Institute for Breatharianism will probably not
mentioned skills, there are various ways to build them.
help your professional credibility.
Which leads to the next section.
Formal and informal education Staying on top of research

Once you’ve built your research and critical reading
There are many choices for both formal and informal ed-
skills, and perhaps gotten some guidance from a mentor
ucation. Both formal and informal education pathways
or formal instructor, you’re ready to embark on your
may offer an in-person or online option.
own research program.
Formal education — through universities, colleges, and
professional institutions — is a good option if you are Research journals
looking for professional accreditation and / or licensing.
It’s important to know the difference between peer-re-
For instance, to become a Registered Dietitian (RD), you viewed research and a mainstream media or blog article.
must usually have a BSc plus a dietetic internship. You’ll
also need formal education if you are looking for a more Peer-reviewed research is research that has been pro-
academic path, such as a PhD researcher. duced and then (as the name implies) reviewed critically
by one’s academic peers, such as other scientists working
Be a careful consumer: in the same field. This ensures that when the research
• Make sure that the institution you’re studying with is article is published, it’s scientifically sound and accurate.
recognized and accredited by your province / state
Generally, peer-reviewed research appears in academic
and / or country.
and professional journals (such as the American Journal
• Look closely at what your specific job or industry of Clinical Nutrition or the European Journal of Clinical
considers valid. Ensure you are pursuing the right Nutrition, the British Medical Journal, the Journal of the
credentials. American Medical Association (JAMA), Nature, Interna-
tional Journal of Obesity).
Informal education is a good option if you prefer either
open-ended, modular educational programs (e.g., short- With books, look for an academic publisher, such as
er certifications), general-interest continuing education, Oxford University Press.
and / or short courses geared towards professional train-
ing on topics of interest.

Almost all studies that appear on PubMed (http://www. Dietary supplements

ncbi.nlm.nih.gov/pubmed ) or Google Scholar (https://
scholar.google.com) will be peer-reviewed, so that’s a For the latest on dietary supplements, we like the follow-
great place to start. ing resources:
You can also subscribe to electronic tables of contents • Examine.com
(eTOCs) for different nutrition and exercise related aca- http://examine.com
demic journals. This is when you sign up to be emailed • ConsumerLab.com
when the latest table of contents is released. That way
https://www.consumerlab.com
you can review it and see if any articles might be worth
checking out. • Labdoor.com
https://labdoor.com
Many research articles and journals are open source (i.e.,
readily available for public consumption, rather than
behind a paywall). You can often access paid journals Developing your coaching
through your public library or a university / college
library if you are a student.
practice
At this point, you likely have plenty of ideas on how to
Non-peer-reviewed research includes things like: stay balanced and continue to improve yourself moving
• magazines forward. As we’ve mentioned, another option to consid-
er to really enhance your coaching practice and build
• newspapers
mastery is our Level 2 Master Class.
• blogs
The Level 2 Master Class focuses on helping coaches
Anything goes here. There’s no vetting process. Reader develop hands-on, “real-world” skills, helping them to
beware. There’s a lot of scientific ignorance, quackery, master areas such as:
fraud, and outright kooks in that mix.
• being a self-aware and self-questioning coach:
Okay, so, you’ve got your peer-reviewed academic Looking at coaching as an active practice that re-
journals and are firing up PubMed. But without a clear quires constant care, growth, and development for
process and filter, the sheer amount of research can be ongoing improvement;
overwhelming. • developing strong working relationships with
Thus, we recommend starting with research reviews. clients: learning to build empathy and the “coaching
alliance”; and how to effectively use a client-centered
approach;
Research reviews
• being able to guide clients through all stages
Research reviews do the work of investigation and criti- of the nutritional coaching and consultation
cal review so you don’t have to. Two of our favorites: process; developing a broad-based and robust
• Alan Aragon Research Review system of theory and practice for client nutritional
http://www.alanaragon.com/researchreview management, regardless of the client;
• Examine.com Research Digest • understanding what’s truly important: learning

http://examine.com/store/erd to identify, understand, and prioritize key coaching
and nutrition concepts, principles, and ideas, as well
Those publications spell things out in a very clear and as distill practical applications from broader, more
useful format, with a slant towards those in fitness abstract theories;
nutrition.
• using the right tools and techniques for the job
at hand: learning and practicing a wide range of skills
and coaching methods, and learning when to choose
the correct ones for clients;

498 | Unit 17
• treating clients as unique individuals, address- them.) Give yourself time to digest the feedback, and
ing their needs holistically: understanding what consider it a potentially true alternative perspective on the
factors shape client coaching needs, process, and world.
outcome;
Stay open minded and ask for examples where possi-
• working effectively on your own and as part of ble, e.g., “You’re saying I do X. Can you give me some
a team, regardless of whether you’re self-employed instances where that happened, and walk me through it
or part of a large organization; step by step?”
• solving complex problems thoughtfully: no lon- So much of our potential to become better people — and
ger being intimidated by “complicated clients”; better coaches — hinges on our ability to accept and
• communicating clearly and effectively, using learn from feedback.
various methods;
Two excellent books we recommend:
• acting, working, and presenting yourself as
• Crucial Conversations: Tools for Talking When Stakes
a respected professional; learning to serve as an
Are High by Kerry Patterson, et al.
“ambassador of the industry” committed to integrity,
courtesy, collegiality, and “best practices”; • Thanks for the Feedback: The Science and Art of Re-
ceiving Feedback by Douglas Stone and Sheila Heen
• developing your own self-sustaining “growth
practice”: learning how to learn, seek feedback, and Using data and indicators
develop your entire career.
Of course, as you work with clients, you talk about how
to measure progress.
The value of feedback
• What do they want to measure, and why?
Receiving feedback on your coaching (or any other • What tells them they’re moving towards their goals?
professional skill) can be a bit uncomfortable at times. It
doesn’t have to be. And, in your client practice, you set up a system of regu-
lar monitoring and check-ins.
Feedback makes us better. Feedback is constructive.
Feedback is information — information about how to The same concept applies here.
improve, about what to keep doing and what to change,
• What tells you that you’re making progress in your
and about what to do next.
coaching practice and skills? What indicators might
And importantly, giving and taking feedback is a skill. you use?
Just like learning how to cut vegetables, you can learn • How often do you track your coaching performance,
how to receive feedback productively, and share your
and what system do you have for regular monitoring?
own feedback with others.
Pay attention and take stock of how your practice is
Building this skill can be vital for allowing open com-
developing. To do this most effectively, you’ll need to
munication with colleagues, partners, friends, family,
gather some data and use key performance indicators
and clients.
(KPIs).
Accepting feedback starts with listening, and then seek-
As much as we all like to go by our gut feelings 100%
ing understanding. Make sure you truly grasp what is
of the time, sometimes gut feelings can lead us astray,
being said, and that you heard (or read) it accurately.
or just be fuzzy — especially earlier in your coaching
Be aware of your own instinctive emotional response career, when you lack context and experience.
to feedback, which will likely be to defend, explain, or
So figure out how you want to measure your growth as a
correct the other person giving the feedback. (Or punch
coach, and set a schedule to assess it regularly.

Just like when a client steps on the scale and sees a cer- No matter what metric you choose for tracking your
tain number, that number is simply a form of data that coaching progress:
can be used to guide future directions.
• Identify it clearly.
• Maybe it’s providing surveys to your clients to assess
• Understand why you’re using that metric, and what
how much you are helping them.
value it has.
• Maybe it’s a certain skill or tool you want to learn and
• Create a process of regular accountability, and stick
practice.
to it.
• Maybe it’s looking at how you manage your time and
• Consider getting additional feedback (there’s that
commitments.
feedback thing again!) from others.
• Maybe it’s time spent on a new concept.
Don’t under-estimate your own capacity for growth.
Yes, development takes time… but you have your whole
life ahead of you. Who knows where you could end up
with consistent and focused effort?
Summary
Being a good coach is a lifelong project. Figure out your own unique best strategy for regular
continuing education and development. Test and refine
Find some balance between not caring at all about im- the strategy as you discover what works best for you and
proving yourself, and dedicating every waking minute your clients.
to it.
Explore different ways to make yourself better: reading,
Before you consider learning, consider how you learn best, writing, collaborating with others, volunteering, etc.
and what your learning goals are.
Don’t under-estimate your own capacity for growth. Yes,
Be a critical consumer of educational material. For development takes time… but you have your whole life
instance, opt for peer-reviewed books and articles over ahead of you. Who knows where you could end up with
popular press books and articles; or accredited institu- consistent and focused effort?
tions over non-accredited ones.

References
References | 501
References
Introduction - Nutrition: The Big Picture
Ahlenius H. UNEP/GRID-Arendal website http://www.grida.no/graphicslib/ Lawrence RS, Nachman K. Industrial food animal production and the high-meat
detail/water-requirements-for-food-production-1960-2050_73bd. Accessed diet: health and environmental consequences. Webinar: June 28, 2011.
November 2015.
Livesey GA. Perspective on food energy standards for nutrition labeling. Br J
Andrews R. All about organic foods. Precision Nutrition website. http://www. Nutr. 2001;85:271-287.
precisionnutrition.com/all-about-organic-foods. Published
Lock K, et al. The global burden of disease attributable to low consumption of
Baranski M, et al. Higher antioxidant and lower cadmium concentrations and fruit and vegetables: implications for the global strategy on diet. Bull World
lower incidence of pesticide residues in organically grown crops: a systematic Health Organ. 2005;83:100.
literature review and meta-analyses. Br J Nutr. 2014;Jun 26:1-18.
Marlow M. Where has all the water gone? The American Prospect website
Bradbury KE, et al. Organic food consumption and the incidence of cancer http://prospect.org/cs/articles?article=where_has_all_the_water_gone. Accessed
in a large prospective study of women in the United Kingdom. Br J Cancer. November 2015.
2014;110:2321-2326.
Massey LK. Dietary animal and plant protein and human bone health: a whole
Chen GC, Lu DB, Pang Z, et al. Vitamin C intake, circulating vitamin C foods approach. J Nutr 2003;133:S862.
and risk of stroke: a meta-analysis of prospective studies. Heart Assoc. 2013
Nov;2(6):e000329. McMichael AJ, et al. Food, livestock production, energy, climate change and
health. Lancet 2007;370:1253.
Crum AJ, et al. Mind over milkshakes: Mindsets, not just nutrients, determine
ghrelin response. Health Psychol. 2011;30:424-429. Michels AJ, Frei B. Myths, artifacts, and fatal flaws: identifying limitations and
opportunities in vitamin C research. Nutrients 2013 Dec;5(12):5161-5192.
Eshel G, Martin PA. Diet, energy and global warming. Earth Interactions
2006;10:1. Miller D. Farmacology: What can good farming teach us about nurturing
ourselves? William Morrow; 2013.
Fryar CD, Ervin RB. Calorie intake from fast food among adults: United States,
2007-2010. NCHS Data Brief 2013;114:1-8. Moubarac JC, et al. Consumption of ultra-processed foods and likely impact on
human health. Evidence from Canada. Public Health Nutr. 2013;16:2240-2248.
Harmon AH, Gerald BL. Position of the American Dietetic Association. Food
and nutrition professionals can implement practices to conserve natural resourc- Nellemann C, MacDevette M, Manders T, et al. The environmental food crisis
es and support ecological sustainability. J Am Diet Assoc. 2007;107:1033. – The environment’s role in averting future food crises. A UNEP rapid response
assessment. United Nations Environment Programme, GRID-Arendal website.
Harrison FE, Bowman GL, Polidori MC. Ascorbic acid and the brain: Rationale Published February 2009. http://www.grida.no/publications/rr/food-crisis/ebook.
for the use against cognitive decline. Nutrients 2014;6:1752-1781. aspx. Accessed November 2015.
The hidden water we use. National Geographic website. http://environment. ‘Peak soil’ threatens future global food security. Reuters website. Published
nationalgeographic.com/environment/freshwater/embedded-water/. Accessed July 17, 2014. http://www.trust.org/item/20140717123900-1e5nx. Accessed
November 2015. November 2015.
International Food Policy Research Institute. Global Hunger Index. The Peng C, Wang X, Chen J, et al. Biology of ageing and role of dietary antioxidants.
challenge of hunger: Taming price spikes and excessive food price volatility. Biomed Res Int. 2014;2014:831841.
October 2011.
Reiss R, et al. Estimation of cancer risks and benefits associated with a
Johansson E, et al. Contribution of organically grown crops to human health. Int potential increased consumption of fruits and vegetables. Food Chem Toxicol.
J Environ Res Public Health. 2014;11:3870-3893. 2012;50:4421-4427.
King AC, et al. Behavioral impacts of sequentially versus simultaneously Robinson E, et al. Eating attentively: a systematic review and meta-analysis
delivered dietary plus physical activity interventions: the CALM trial. Annals of of the effect of food intake memory and awareness on eating. Am J Clin Nutr.
Behavioral Medicine 2013. 2013;97(4):728-742
Krupke CH, et al. Multiple routes of pesticide exposure for honey bees living Rogers A, Laffoley, Dd’A. International Earth system expert workshop on ocean
near agricultural fields. PLoS One. 2012;7(1):e29268. stresses and impacts. Summary report. IPSO Oxford. 2011:18

502 |
Seufert V, et al. Comparing the yields of organic and conventional agriculture. Buclin T, et al. Diet acids and alkalis influence calcium retention in bone. Oste-
Nature 2012;485:229-232. oporos Int. 2001;12:493.
Steinfeld H, et al. Livestock’s Long Shadow: Environmental Issues and Options. Cori CF. The fate of sugar in the animal body. 1. The rate of absorption of
Food and Agriculture Organization of the United Nations, Rome 2006. ftp://ftp. hexoses and pentoses from the intestinal tract. J Biol Chem. 1925;66:691.
fao.org/docrep/fao/010/a0701e/a0701e00.pdf. Accessed July 8, 2008.
Crawford MA. The role of dietary fatty acids in biology: their place in the
Stuart T. Waste: Uncovering the global food scandal. W. W. Norton & Compa- evolution of the human brain. Nutr Rev. 1992;50:3.
ny; 2009.
Denis I, Potier B, Heberden C, Vancassel S. Omega-3 polyunsaturated fatty
Tangney CC, et al. A review: which dietary plan is best for your patients seeking acids and brain aging. Curr Opin Clin Nutr Metab Care. 2015, 18:139-146
weight loss and sustained weight management? Dis Mon. 2005:51;284.
Do R, et al. The effect of chromosome 9p21 variants on cardiovascular disease
Trivedi B. The calorie delusion: Why food labels are wrong. New Scientist web- may be modified by dietary intake: evidence from a case/control and a prospec-
site. Published 2009 July 15;Issue 2717. https://www.newscientist.com/article/ tive study. PLoS Med. 2011;9(10):e1001106.
mg20327171-200-the-calorie-delusion-why-food-labels-are-wrong/. Accessed
November 2015. Dreyer HC, et al. Resistance exercise increases AMPK activity and reduces 4E-
BP1 phosphorylation and protein synthesis in human skeletal muscle. J Physiol.
Wagner SC, Markosian B, Ajili N, et al. Intravenous ascorbic acid as an adjuvant 2006;576:613.
to interleukin-2 immunotherapy. J Transl Med. 2014 May 13;12:127.
Durstine JL, Moore GE. ACSM’s Exercise Management for Persons with
Water, sanitation and hygiene. UNICEF website. http://www.unicef.org/wash/. Chronic Diseases and Disabilities. 2nd ed. American College of Sports Medi-
Accessed November 2015. cine. Champaign, IL: Human Kinetics; 2003.
Weikel KA, Garber C, Baburins A, et al. Nutritional modulation of cataract. Essen-Gustavsson B, Tesch PA. Glycogen and triglycerides utilization in
Nutr Rev. 2014 Jan;72(1):30-47. relation to muscle metabolic characteristics in men performing heavy resistance
exercise. Eur J Appl Physiol. 1990;61:5.
West PC, et al. Leverage points for improving global food security and the
environment. Science 2014;345:325-328. Escott-Stump S. Nutrition and Diagnosis-Related Care. 5th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2002.
Zastrow M. Cutting down crop waste could feed 3 billion. Nature News website.
Published July 17, 2014. http://www.nature.com/news/cutting-down-crop-waste- Flatt JP. The biochemistry of energy expenditure. In: Bray GA (ed.) Recent
could-feed-3-billion-1.15575. Accessed November 2015. Advances in Obesity Research. London: Newman; 1978:211.
Unit 1 - Cells Forbes GB. Body fat content influences the body composition response to nutri-
tion and exercise. Ann N Y Acad Sci. 2000;904:359.
Abdull Razis AF, Noor NM. Cruciferous vegetables: dietary phytochemicals for
cancer prevention. Asian Pac J Cancer Prev. 2013;14:1565-1570. Groff JL, Gropper SS. Advanced Nutrition and Human Metabolism. 3rd ed.
Delmar Publishers, Inc.;1999.
Axen K, Axen KV. Illustrated Principles of Exercise Physiology. 1st ed. NJ:
Prentice Hall; 2001. Guyton AC, Hall JE. Insulin, glucagon, and diabetes mellitus. In: Guyton AC,
Hall JE (ed.) Textbook of Medical Physiology. Philadelphia, PA: W. B. Saun-
Baechle TR, Earle RW. Essentials of Strength Training and Conditioning. 2nd ders; 2000:884-898.
ed. National Strength Training Association. Human Kinetics; 2000.
Helander HF, Fändriks L. Surface area of the digestive tract – revisited. Scand J
Barnard ND, Weissinger R, Jaster B, Kahan S. Nutrition Guide for Clinicians. Gastroenterol. 2014;49:681-689.
1st ed. Physicians Committee for Responsible Medicine; 2007.
Howley ET, Franks BD. Health Fitness Instructor’s Handbook. 4th ed. Cham-
Beers MH, Berkow R. The Merck Manual. 17th ed. Merck Research Laborato- paign, IL: Human Kinetics; 2003.
ries; 1999.
Jequier E. Leptin signaling, adiposity and energy balance. Ann NY Acad Sci.
Berthoud HR. Multiple neural systems controlling food intake and body weight. 2002;967:379.
Neurosci Biobehav Rev. 2002;26:393.
Jones PJH, Kubow S. Lipids, sterols and their metabolites. In: Shils ME, Olson
Borer KT. Exercise Endocrinology. 2nd ed. Human Kinetics; 2003. JA, Shike M, Ross AC, eds. Modern Nutrition in Health and Disease. 9th ed.
Baltimore, MD: Williams and Wilkins; 1999:67.
Brungger M, Hulter HN, Krapf R. Effect of chronic metabolic acidosis on the
growth hormone/IGF-1 endocrine axis: New cause of growth hormone insensi- Kishino Y, Moriguchi S. Nutritional factors and cellular immune responses.
tivity in humans. Kidney Int. 1997;51:216. Nutr Health. 1992:8;133.

References | 503
Laidlaw SA, et al. Plasma and urine taurine levels in vegans. Am J Clin Nutr. Axen K, Axen KV. Illustrated Principles of Exercise Physiology. 1st ed. NJ:
1988;47:660-663. Prentice Hall; 2001.
Larsen FJ, et al. Dietary inorganic nitrate improves mitochondrial efficiency in Badillo R, Francis D. Diagnosis and treatment of gastroesophageal reflux dis-
humans. Cell Metab. 2011;13:149-59. ease. World J Gastrointest Pharmacol Ther. 2014;5(3):105-112.
Ludewig AH, Klapper M, Döring F. Identifying evolutionarily conserved genes Baechle TR, Earle RW. Essentials of Strength Training and Conditioning. 2nd
in the dietary restriction response using bioinformatics and subsequent testing ed. National Strength Training Association. Human Kinetics; 2000.
in caenorhabditis elegans. Genes Nutr. 2014 Jan;9(1):363.
Barnard N, Weissinger R, Jaster B, Kahan S. Nutrition Guide for Clinicians. 1st
MacDougall JD, et al. Substrate utilization during weightlifting. Med Sci Sports ed. Physicians Committee for Responsible Medicine; 2007.
Exerc. 1988;20:S66.
Beers MH, Berkow R. The Merck Manual. 17th ed. Merck Research Laborato-
Mahan LK, Escott-Stump S. Food, Nutrition and Diet Therapy. 11th ed. Phila- ries; 1999.
delphia, PA: Saunders; 2004.
Berthoud HR. Multiple neural systems controlling food intake and body weight.
McArdle W, Katch F, Katch V. Exercise Physiology. 4th ed. Philadelphia, PA: Neurosci Biobehav Rev. 2002;26:393.
Bird AR, et al. Resistant starch, large bowel fermentation and a broader per-
Prentice A, Jebb S. Energy intake/physical activity interactions in the homeosta- spective of prebiotics and probiotics. Benef Microbes. 2010;1:423-431.
sis of body weight regulation. Nutr Rev. 2004;62:S98.
Borer KT. Exercise Endocrinology. 2nd ed. Human Kinetics; 2003.
Rampone AJ, Reynolds PJ. Obesity: Thermodynamic principles in perspective.
Life Sci. 1988;43:93. Boughton CK, Murphy KG. Can neuropeptides treat obesity? A review of neu-
ropeptides and their potential role in the treatment of obesity. Br J Pharmacol.
Siebrecht S. L-carnitine: physiological and pharmacological effects. Ann Nutr 2013;170(7):1333-1348.
Metab. 2000;44:79.
Brooks M. Top 100 most prescribed, top-selling drugs. Medscape Medical
Talanian JL, et al. Two weeks of high-intensity aerobic interval training in- News. http://www.medscape.com/viewarticle/829246. Published online August
creases the capacity for fat oxidation during exercise in women. J Appl Physiol. 1, 2014.
2007;102:1439.
Brown AM, Ransom BR. Astrocyte glycogen and brain energy metabolism.
Tappy L. Thermic effect of food and sympathetic nervous system activity in Glia 2007;55:1263-1271.
humans. Reprod Nutr Dev. 1996;36:391.
Tesch PA, Colliander EB, Kaiser P. Muscle metabolism during intense, heavy growth hormone/IGF-1 endocrine axis: new cause of growth hormone insensi-
resistance exercise. Eur J Appl Physiol. 1986;55:362. tivity in humans. Kidney Int. 1997;51:216.
Thibodeau GA, Patton KT. Anatomy and Physiology. 4th ed. Mosby, Inc.; 1999. Buclin T, et al. Diet acids and alkalis influence calcium retention in bone. Oste-
oporos Int. 2001;12:493.
Tremblay A, et al. Effect of intensity of physical activity on body fatness and fat
distribution. Am J Clin Nutr. 1990;51:153. Burke LM, Maughan RJ. The governor has a sweet tooth – Mouth sensing of
nutrients to enhance sports performance. Eur J Sport Sci. 2015;15(1):29-40.
Tremblay A, Simoneau JA, Bouchard C. Impact of exercise intensity on body
fatness and skeletal muscle metabolism. Metabolism 1994;43:814. Burnett BJ, et al. Sa2034 Accurate interpretation of breath test results depends
on measuring hydrogen sulfide in non-methane excretors. Gastroenterology
Yoshioka M, et al. Impact of high-intensity exercise on energy expenditure, lipid 2014;146(5)(1 suppl.):S360.
oxidation and body fatness. Int J Obes Relat Metab Disord. 2001;25:332.
Castaño-Rodríguez N, Kaakoush NO, Lee WS, Mitchell HM. Dual role of
Unit 2 - Through the GI Tract Helicobacter and Campylobacter species in IBD: a systematic review and
meta-analysis [published online ahead of print October 27, 2015]. Gut. http://
Abadi ATB. Helicobacter pylori: A beneficial gastric pathogen? Front Med. gut.bmj.com/content/early/2015/10/26/gutjnl-2015-310545?papetoc. Accessed
2014;26(1). October 30, 2015.
Abdull Razis AF, Noor NM. Cruciferous vegetables: dietary phytochemicals for Cori CF. The fate of sugar in the animal body. 1. The rate of absorption of
cancer prevention. Asian Pac J Cancer Prev. 2013;14:1565-1570. hexoses and pentoses from the intestinal tract. J Biol Chem. 1925;66:691.
Adamska E, et al. The role of gastrointestinal hormones in the pathogenesis of Crawford MA. The role of dietary fatty acids in biology: their place in the
obesity and type 2 diabetes. Prz Gastroenterol. 2014;9:69-76. evolution of the human brain. Nutr Rev. 1992;50:3.

504 |
Dewhirst FE, et al. The human oral microbiome. J. Bacteriol. Howley ET, Franks BD. Health Fitness Instructor’s Handbook. 4th ed. Cham-
2010;19(19)5002-5017. paign, IL: Human Kinetics; 2003.
Do R, et al. The effect of chromosome 9p21 variants on cardiovascular disease Hughes R, Rowland IR. Metabolic activities of the gut microflora in relation to
may be modified by dietary intake: evidence from a case/control and a prospec- cancer. Microb Ecol Health Dis. 2000;(2 suppl.):179-185.
tive study. PLoS Med. 2011;9(10):e1001106.
Jensen RT, et al. International Union of Pharmacology. LXVIII. Mammalian
Dreyer HC, et al. Resistance exercise increases AMPK activity and reduces 4E- bombesin receptors: Nomenclature, distribution, pharmacology, signaling and
BP1 phosphorylation and protein synthesis in human skeletal muscle. J Physiol. functions in normal and disease states. Pharmacol Rev. 2008;60(1):1-42.
2006;576:613.
Durstine JL, Moore GE. ACSM’s Exercise Management for Persons with 2002;967:379.
Chronic Diseases and Disabilities. 2nd ed. American College of Sports Medi-
cine. Champaign, IL: Human Kinetics; 2003. Jones PJH, Kubow S. Lipids, sterols and their metabolites. In: Shils ME, Olson
JA, Shike M, Ross AC (eds.) Modern Nutrition in Health and Disease. 9th ed.
Escott-Stump S. Nutrition and Diagnosis-related Care. 5th ed. Philadelphia, Baltimore, MD: Williams and Wilkins; 1999:67.
PA: Lippincott Williams and Wilkins; 2002.
Katz DL, Friedman RSC, Lucan SC. Nutrition in Clinical Practice. 3rd ed.
e Silva T, de Souza M, de Amorim JF, et al. Can carbohydrate mouth rinse Wolters Kluwer Health; 2015.
improve performance during exercise? A systematic review. Nutrients
2014;6(1):1-10. Kishino Y, Moriguchi S. Nutritional factors and cellular immune responses.
Nutr Health. 1992;8:133.
Essen-Gustavsson B, Tesch PA. Glycogen and triglycerides utilization in
relation to muscle metabolic characteristics in men performing heavy resistance Kostic AD, et al. Fusobacterium nucleatum potentiates intestinal tumorigene-
exercise. Eur J Appl Physiol. 1990;61:5. sis and modulates the tumor-immune microenvironment. Cell Host Microbe.
2013;14(2):207-215.
Evenepoel P, et al. Uremic toxins originating from colonic microbial metabo-
lism. Kidney Int. 2009;76 (114 suppl.):S12-S19. Larsen FJ, et al. Dietary inorganic nitrate improves mitochondrial efficiency in
humans. Cell Metab. 2011;13:149-59.
Ferrua MJ, Singh RP. Modeling the fluid dynamics in a human stomach to gain
insight of food digestion. J Food Sci. 2010;75:R151-R162. MacDougall JD, et al. Substrate utilization during weightlifting. Med Sci Sports
Exerc. 1988;20:S66.
Flatt JP. The biochemistry of energy expenditure. In: Bray GA (ed.) Recent
Advances in Obesity Research. London: Newman; 1978:211. Mahan LK, Escott-Stump S. Food, Nutrition and Diet Therapy. 11th ed. Phila-
Forbes GB. Body fat content influences the body composition response to nutri-
tion and exercise. Ann N Y Acad Sci. 2000;904:359. McArdle W, Katch F, Katch V. Exercise Physiology. 4th ed. Philadelphia, PA:
Ghoshal UC. How to interpret hydrogen breath tests. J Neurogastroenterol
Motil. 2011;17(3):312-317. Paz-Filho G, et al. Leptin treatment: Facts and expectations. Metabolism:
Clinical and Experimental. 2015;64(1):146-156.
Gonzalez N, Moody TW, Igarashi H, et al. Bombesin-related peptides and their
receptors: Recent advances in their role in physiology and disease states. Curr Phillips SM, Findlay S, Kavaliauskas M, Grant MC. The influence of serial
Opin Endocrinol Diabetes Obes. 2008;15(1):58-64. carbohydrate mouth rinsing on power output during a cycle sprint. J Sports Sci
Med. 2014;13(2):252-258.
Groff JL, Gropper SS. Advanced Nutrition and Human Metabolism. 3rd ed.
Delmar Publishers, Inc.; 1999. Pimentel M, Mathur R, Chang C. Gas and the microbiome. Curr Gastroenterol
Rep. 2013;15(12):356.
Guyton AC, Hall JE. Insulin, glucagon and diabetes mellitus. In: Textbook of
Medical Physiology. Philadelphia, PA: W. B. Saunders; 2000:884-898. Prentice AM, Jebb SA. Energy intake/physical activity interactions in the
homeostasis of body weight regulation. Nutr Rev. 2004;62:S98.
Gastroenterol. 2014;49:681-689. Rampone AJ, Reynolds PJ. Obesity: Thermodynamic principles in perspective.
Life Sci. 1988;43:93.
Herbella FA, Neto SP, Santoro IL, Figueiredo LC. Gastroesophageal reflux
disease and non-esophageal cancer. World J Gastroenterol. 2015;21(3):815-819. Ray K. Fusobacterium nucleatum found in colon cancer tissue – Could an infec-
tion cause colorectal cancer? Nat Rev Gastroenterol Hepatol. 2011;8(12):662.
Hong SJ, Sang WK. Helicobacter pylori infection in gastroesophageal reflux
disease in the asian countries. Gastroenterol Res Pract. 2015; 2015: 985249.

References | 505
Ricci V, Romano M, Boquet P. Molecular cross-talk between helicobacter pylori August 14, 2013. http://www.the-scientist.com/?articles.view/articleNo/37047/
and human gastric mucosa. World J Gastroenterol. 2011; 17(11):1383-1399. title/Mouth-Microbe-Turns-Carcinogenic/. Accessed November 2015.
Salama NR, Hartung ML, Müller A. Life in the human stomach: persistence Windey K, et al. Modulation of protein fermentation does not affect fecal
strategies of the bacterial pathogen helicobacter pylori. Nat Rev Microbiol. water toxicity: A randomized cross-over study in healthy subjects. PLoS One.
2013;11(6):385-399. 2012;7:e52387.
Segata N, et al. Composition of the adult digestive tract bacterial microbiome Yoshioka M, et al. Impact of high-intensity exercise on energy expenditure, lipid
based on seven mouth surfaces, tonsils, throat and stool samples. Genome Bio. oxidation and body fatness. Int J Obes Relat Metab Disord. 2001;25:332.
2012;13(6).
Unit 3 - Energy Transformation &
Shen X, et al. Microbial regulation of host hydrogen sulfide bioavailability and
Metabolism
metabolism. Free Radic Biol Med. 2013;60:195-200.
Abdull Razis AF, Noor NM. Cruciferous vegetables: Dietary phytochemicals
Sinclair J, Bottoms L, Flynn C, et al. The effect of different durations
for cancer prevention. Asian Pac J Cancer Prev. 2013;14:1565-1570.
of carbohydrate mouth rinse on cycling performance. Eur. J. Sport Sci.
2014;14(3):259-264. Axen K, Axen KV. Illustrated Principles of Exercise Physiology. 1st ed. NJ:
Prentice Hall; 2001.
Sobrino Crespo C, et al. Peptides and food intake. Front Endocrinol (Laus-
anne). 2014;5:58. Baechle TR, Earle RW. Essentials of Strength Training and Conditioning. 2nd
ed. National Strength Training Association. Human Kinetics; 2000.
Stevens CE, Hume ID. Comparative Physiology of the Vertebrate Digestive
System. Cambridge University Press; 2004. Barnard ND, Weissinger R, Jaster B, Kahan S. Nutrition Guide for Clinicians.
1st ed. Physicians Committee for Responsible Medicine; 2007.
Subramanian CR, Triadafilopoulos G. Refractory gastroesophageal reflux
disease. Gastroenterology Report. 2015;3(1):41-53. Beers MH, Berkow R. The Merck Manual. 17th ed. Merck Research Laborato-
ries; 1999.
Svane MS, et al. Updates in weight loss surgery and gastrointestinal peptides.
Curr Opin Endocrinol Diabetes Obes. 2015 Feb;22(1):21-8. Berthoud HR. Multiple neural systems controlling food intake and body weight.
Neurosci Biobehav Rev. 2002;26:393.
Talanian JL, et al. Two weeks of high-intensity aerobic interval training in-
creases the capacity for fat oxidation during exercise in women. J Appl Physiol. Borer KT. Exercise Endocrinology. 2nd ed. Human Kinetics; 2003.
2007;102:1439.
Tappy L. Thermic effect of food and sympathetic nervous system activity in growth hormone/IGF-1 endocrine axis: new cause of growth hormone insensi-
humans. Reprod Nutr Dev. 1996;36:391. tivity in humans. Kidney Int. 1997;51:216.
Tesch PA, Colliander EB, Kaiser P. Muscle metabolism during intense, heavy Buclin T, et al. Diet acids and alkalis influence calcium retention in bone. Oste-
resistance exercise. Eur J Appl Physiol. 1986;55:362. oporos Int. 2001;12:493.
Thibodeau GA, Patton KT. Anatomy and Physiology. 4th ed. Mosby, Inc.; 1999. Carlsen MH, et al. The total antioxidant content of more than 3100 foods, bever-
ages, spices, herbs and supplements used worldwide. Nutr J. 2010;9:3.
distribution. Am J Clin Nutr. 1990;51:153. Cori CF. The fate of sugar in the animal body. 1. The rate of absorption of
hexoses and pentoses from the intestinal tract. J Biol Chem. 1925;66:691.
Tremblay A, Simoneau JA, Bouchard C. Impact of exercise intensity on body
fatness and skeletal muscle metabolism. Metabolism 1994;43:814. Crawford MA. The role of dietary fatty acids in biology: Their place in the evolution
of the human brain. Nutr Rev. 1992;50:3.
Troke RC, et al. The future role of gut hormones in the treatment of obesity.
Ther Adv Chronic Dis. 2014;5:4-14. den Besten G, et al. The role of short-chain fatty acids in the interplay
between diet, gut microbiota, and host energy metabolism. J Lipid Res.
Turner C, et al. Carbohydrate in the mouth enhances activation of brain
2013;54(9):2325-2340.
circuitry involved in motor performance and sensory perception. Appetite
2014;80:212–219. Do R, et al. The effect of chromosome 9p21 variants on cardiovascular disease
may be modified by dietary intake: evidence from a case/control and a prospec-
Vandiver MS, Snyder SH. Hydrogen sulfide: A gasotransmitter of clinical
tive study. PLoS Med. 2011;9(10):e1001106.
relevance. J Mol Med (Berl). 2012;90(3):255-263.
Dreyer HC, et al. Resistance exercise increases AMPK activity and reduces
Vence T. Mouth microbe turns carcinogenic. The Scientist website. Published

506 |
4E-BP1 phosphorylation and protein synthesis in human skeletal muscle. J Mahan LK, Escott-Stump S. Food, Nutrition and Diet Therapy. 11th ed. Phila-
Physiol. 2006;576:613. delphia, PA: Saunders; 2004.
Durstine JL, Moore GE. ACSM’s Exercise Management for Persons with McArdle W, Katch F, Katch V. Exercise Physiology. 4th ed. Philadelphia, PA:
Chronic Diseases and Disabilities. 2nd ed. American College of Sports Medi- Lippincott Williams and Wilkins; 1996.
cine. Champaign, IL: Human Kinetics; 2003.
MacDougall JD, et al. Substrate utilization during weightlifting. Med Sci Sports
Escott-Stump S. Nutrition and Diagnosis-related Care. 5th ed. Philadelphia, Exerc. 1988;20:S66.
Paoli A, et al. Beyond weight loss: a review of the therapeutic uses of
Essen-Gustavsson B, Tesch PA. Glycogen and triglycerides utilization in very-low-carbohydrate (ketogenic) diets. Eur J Clin Nutr. 2014;68:641.
relation to muscle metabolic characteristics in men performing heavy resistance
exercise. Eur J Appl Physiol. 1990;61:5. Prentice A, Jebb S. Energy intake/physical activity interactions in the homeosta-
sis of body weight regulation. Nutr Rev. 2004;62:S98.
Flatt JP. The biochemistry of energy expenditure. In: Bray GA (ed.) Recent
Advances in Obesity Research. London: Newman; 1978:211. Rampone AJ, Reynolds PJ. Obesity: Thermodynamic principles in perspective.
Life Sci. 1988;43:93.
Forbes GB. Body fat content influences the body composition response to nutri-
tion and exercise. Ann N Y Acad Sci. 2000;904:359. Ruskin DN, Masino SA. The nervous system and metabolic dysregulation:
emerging evidence converges on ketogenic diet therapy. Front Neurosci.
Gibala MJ. Protein metabolism and endurance exercise. Sports Med. 2012;6:33.
2007;37:337-340.
Groff JL, Gropper SS. Advanced Nutrition and Human Metabolism. 3rd ed. creases the capacity for fat oxidation during exercise in women. J Appl Physiol.
Delmar Publishers, Inc.; 1999. 2007;102:1439.
Guyton AC, Hall JE. Insulin, glucagon and diabetes mellitus. In: Textbook of Tall AR, Yvan-Charvet L. Cholesterol, inflammation and innate immunity. Nat
Medical Physiology. Philadelphia, PA: W. B. Saunders; 2000:884-898. Rev Immunol. 2015 Feb;15(2):104-116.
Hallböök T, et al. The effects of the ketogenic diet on behavior and cognition. Tappy L. Thermic effect of food and sympathetic nervous system activity in
Epilepsy Res. 2012;100:304-309. humans. Reprod Nutr Dev. 1996;36:391.
Helander HF, Fändriks L. Surface area of the digestive tract – revisited. Scand J Tesch PA, Colliander EB, Kaiser P. Muscle metabolism during intense, heavy
Gastroenterol. 2014;49:681-689. resistance exercise. Eur J Appl Physiol. 1986;55:362.
Howley ET, Franks BD. Health Fitness Instructor’s Handbook. 4th ed. Cham- Thibodeau GA, Patton KT. Anatomy and Physiology. 4th ed. Mosby, Inc.; 1999.
paign, IL: Human Kinetics; 2003.
Janssens PL, Hursel R, Westerterp-Plantenga MS. Long-term green tea extract distribution. Am J Clin Nutr. 1990;51:153.
supplementation does not affect fat absorption, resting energy expenditure and
body composition in adults. J Nutr. 2015 May;145(5):864-70. Tremblay A, Simoneau JA, Bouchard C. Impact of exercise intensity on body
fatness and skeletal muscle metabolism. Metabolism 1994;43:814.
2002;967:379. Vinolo MAR, Rodrigues HG, Nachbar RT, Curi R. Regulation of inflammation
by short chain fatty acids. Nutrients 2011;3(10):858-876.
Jones PJH, Kubow S. Lipids, sterols and their metabolites. In: Shils ME, Olson
JA, Shike M, Ross AC (eds.) Modern Nutrition in Health and Disease. 9th ed. Yoshioka M, et al. Impact of high-intensity exercise on energy expenditure, lipid
Baltimore, MD: Williams and Wilkins; 1999:67. oxidation and body fatness. Int J Obes Relat Metab Disord. 2001;25:332.
Kishino Y, Moriguchi S. Nutritional factors and cellular immune responses. Unit 4 - Energy Balance in the Body
Nutr Health. 1992:8;133.
Abdull Razis AF, Noor NM. Cruciferous vegetables: dietary phytochemicals for
Lamarche B, Couture P. Dietary fatty acids, dietary patterns and lipoprotein metab- cancer prevention. Asian Pac J Cancer Prev. 2013;14:1565-1570.
olism. Curr Opin Lipidol. 2015, 26:42-47.
Alang N, Kelly CR. Weight Gain After Fecal Microbiota Transplantation. Open
Larsen FJ, et al. Dietary inorganic nitrate improves mitochondrial efficiency in Forum Infect Dis. Winter 2015;2(1).
Axen K, Axen KV. Illustrated Principles of Exercise Physiology. 1st ed. NJ:
Prentice Hall; 2001.

References | 507
Baechle TR, Earle RW. Essentials of Strength Training and Conditioning. 2nd equations for resting metabolic rate in healthy nonobese and obese adults: a
ed. National Strength Training Association. Human Kinetics; 2000. systematic review. J Am Diet Assoc. 2005;105:775-789.
Barnard ND, Weissinger R, Jaster B, Kahan S. Nutrition Guide for Clinicians. Gibala MJ. Protein metabolism and endurance exercise. Sports Med.
1st ed. Physicians Committee for Responsible Medicine; 2007. 2007;37:337-340.
Beers MH, Berkow R. The Merck Manual. 17th ed. Merck Research Laborato- Groff JL and Gropper SS. Advanced Nutrition and Human Metabolism. 3rd ed.
ries; 1999. Delmar Publishers, Inc.; 1999.
Berthoud HR. Multiple neural systems controlling food intake and body weight. Guyton AC, Hall JE. Insulin, Glucagon and Diabetes Mellitus. In: Textbook of
Neurosci Biobehav Rev. 2002;26:393. Medical Physiology. Philadelphia, PA: W. B. Saunders; 2000:884-898.
Borer KT. Exercise Endocrinology. 2nd ed. Human Kinetics; 2003. Helander HF, Fändriks L. Surface area of the digestive tract – revisited. Scand J
Gastroenterol. 2014;49:681-689.
growth hormone/IGF-1 endocrine axis: new cause of growth hormone insensi- Howley ET, Franks BD. Health Fitness Instructor’s Handbook. 4th ed. Cham-
tivity in humans. Kidney Int. 1997;51:216. paign, IL: Human Kinetics; 2003.
Buclin T, et al. Diet acids and alkalis influence calcium retention in bone. Oste- Jequier E. Leptin signaling, adiposity and energy balance. Ann NY Acad Sci.
oporos Int 2001;12:493. 2002;967:379.
Carlsen MH, et al. The total antioxidant content of more than 3100 foods, bever- Jones PJH, Kubow S. Lipids, sterols and their metabolites. In: Shils ME, Olson
ages, spices, herbs and supplements used worldwide. Nutr J 2010;9:3. JA, Shike M, Ross AC (eds.) Modern Nutrition in Health and Disease. 9th ed.
Baltimore, MD: Williams and Wilkins; 1999:67.
Cori CF. The fate of sugar in the animal body. 1. The rate of absorption of
hexoses and pentoses from the intestinal tract. J Biol Chem. 1925;66:691. Kishino Y, Moriguchi S. Nutritional factors and cellular immune responses.
Crawford MA. The role of dietary fatty acids in biology: Their place in the
evolution of the human brain. Nutr Rev. 1992;50:3. Larsen FJ, et al. Dietary inorganic nitrate improves mitochondrial efficiency in
Cunnane S, Stewart K. Human brain evolution: The influences of freshwater
and marine food resources. John Wiley & Sons; 2010. MacDougall JD, et al. Substrate utilization during weightlifting. Med Sci Sports
Exerc. 1988;20:S66.
may be modified by dietary intake: evidence from a case/control and a prospec- Mahan LK, Escott-Stump S. Food, Nutrition and Diet Therapy. 11th ed. Phila-
tive study. PLoS Med. 2011;9(10):e1001106. delphia, PA: Saunders; 2004.
Dreyer HC, et al. Resistance exercise increases AMPK activity and reduces 4E- McArdle W, Katch F, Katch V. Exercise Physiology. 4th ed. Philadelphia, PA:
BP1 phosphorylation and protein synthesis in human skeletal muscle. J Physiol Lippincott Williams and Wilkins; 1996.
2006;576:613.
McDonald L. Another look at metabolic damage. Body Recomposition blog.
Durstine JL, Moore GE. ACSM’s Exercise Management for Persons with http://www.bodyrecomposition.com/fat-loss/another-look-at-metabolic-damage.
Chronic Diseases and Disabilities. 2nd ed. American College of Sports Medi- html/. Accessed November 2015.
cine. Champaign, IL: Human Kinetics; 2003.
Prentice A, Jebb S. Energy intake/physical activity interactions in the homeosta-
Escott-Stump S. Nutrition and Diagnosis-related Care. 5th ed. Philadelphia, sis of body weight regulation. Nutr Rev. 2004;62:S98.
Rampone AJ, Reynolds PJ. Obesity: Thermodynamic principles in perspective.
Essen-Gustavsson B, Tesch PA. Glycogen and triglycerides utilization in Life Sci. 1988;43:93.
relation to muscle metabolic characteristics in men performing heavy resistance
exercise. Eur J Appl Physiol. 1990;61:5. Reidlinger DP, Willis JM, Whelan K. Resting metabolic rate and anthropometry
in older people: a comparison of measured and calculated values. J Hum Nutr
Flatt JP. The biochemistry of energy expenditure. In: Bray GA (ed.) Recent Diet. 2015 Feb;28(1):72-84.
Advances in Obesity Research. London: Newman; 1978:211.
Forbes GB. Body fat content influences the body composition response to nutri- creases the capacity for fat oxidation during exercise in women. J Appl Physiol.
tion and exercise. Ann N Y Acad Sci. 2000;904:359. 2007;102:1439.
Frankenfield D, Roth-Yousey L, Compher C. Comparison of predictive

508 |
Tappy L. Thermic effect of food and sympathetic nervous system activity in Cunnane S, Stewart K. Human brain evolution: The influences of freshwater
humans. Reprod Nutr Dev. 1996;36:391. and marine food resources. John Wiley & Sons; 2010.
Tesch PA, Colliander EB, Kaiser P. Muscle metabolism during intense, heavy Di Donato DM, et al. Influence of aerobic exercise intensity on myofibrillar and
resistance exercise. Eur J Appl Physiol. 1986;55:362. mitochondrial protein synthesis in young men during early and late postexercise
recovery. Am J Physiol Endocrinol Metab. 2014;306:E1025-E1032.
Thibodeau GA, Patton KT. Anatomy and Physiology. 4th ed. Mosby, Inc.; 1999.
Tremblay A, et al. Effect of intensity of physical activity on body fatness and fat may be modified by dietary intake: evidence from a case/control and a prospec-
distribution. Am J Clin Nutr. 1990;51:153. tive study. PLoS Med. 2011;9(10):e1001106.
Tremblay A, Simoneau JA, Bouchard C. Impact of exercise intensity on body Dreyer HC, et al. Resistance exercise increases AMPK activity and reduces 4E-
fatness and skeletal muscle metabolism. Metabolism 1994;43:814. BP1 phosphorylation and protein synthesis in human skeletal muscle. J Physiol.
2006;576:613.
Yoshioka M, et al. Impact of high-intensity exercise on energy expenditure, lipid
oxidation and body fatness. Int J Obes Relat Metab Disord. 2001;25:332. Duncan MJ, Weldon A, Price MJ. The effect of sodium bicarbonate ingestion
on back squat and bench press exercise to failure. J Strength Cond Res. 2014
Unit 5 - Aerobic and Anaerobic May;28(5):1358-1366.
Metabolism
Durstine JL, Moore GE. ACSM’s Exercise Management for Persons with
Abdull Razis AF, Noor NM. Cruciferous vegetables: dietary phytochemicals for Chronic Diseases and Disabilities. 2nd ed. American College of Sports Medi-
cancer prevention. Asian Pac J Cancer Prev. 2013;14:1565-1570. cine. Champaign, IL: Human Kinetics; 2003.
Afman G, Garside RM, Dinan N, et al. Effect of carbohydrate or sodium bicar- Egger F, Meyer T, Such U, Hecksteden A. Effects of sodium bicarbonate on
bonate ingestion on performance during a validated basketball simulation test. high-intensity endurance performance in cyclists: a double-blind, randomized
Int J Sport Nutr Exerc Metab. 2014 Dec;24(6):632-644. cross-over trial. Earnest CP, ed. PLoS One. 2014;9(12):e114729.
Axen K, Axen KV. Illustrated Principles of Exercise Physiology. 1st ed. NJ: Escott-Stump S. Nutrition and Diagnosis-Related Care. 5th ed. Philadelphia, PA:
Prentice Hall; 2001. Lippincott Williams and Wilkins; 2002.
Baechle TR, Earle RW. Essentials of Strength Training and Conditioning. 2nd Essen-Gustavsson B, Tesch PA. Glycogen and triglycerides utilization in
ed. National Strength Training Association. Human Kinetics; 2000. relation to muscle metabolic characteristics in men performing heavy resistance
exercise. Eur J Appl Physiol. 1990;61:5.
Barnard ND, Weissinger R, Jaster B, Kahan S. Nutrition Guide for Clinicians.
1st ed. Physicians Committee for Responsible Medicine; 2007. Flatt JP. The biochemistry of energy expenditure. In: Bray GA (ed.) Recent
advances in obesity research. London: Newman; 1978:211.
Beers MH, Berkow R. The Merck Manual. 17th ed. Merck Research Laborato-
ries; 1999. Forbes GB. Body fat content influences the body composition response to nutri-
tion and exercise. Ann N Y Acad Sci. 2000;904:359.
Berthoud HR. Multiple neural systems controlling food intake and body weight.
Neurosci Biobehav Rev. 2002;26:393. Frankenfield D, Roth-Yousey L, Compher C. Comparison of predictive
equations for resting metabolic rate in healthy nonobese and obese adults: a
Borer KT. Exercise Endocrinology. 2nd ed. Human Kinetics; 2003. systematic review. J Am Diet Assoc. 2005;105:775-789.
Brungger M, Hulter HN, Krapf R. Effect of chronic metabolic acidosis on the Gibala MJ. Protein metabolism and endurance exercise. Sports Med.
growth hormone/IGF-1 endocrine axis: new cause of growth hormone insensi- 2007;37:337-340.
tivity in humans. Kidney Int. 1997;51:216.
Groff JL, Gropper SS. Advanced Nutrition and Human Metabolism. 3rd ed.
Buclin T, et al. Diet acids and alkalis influence calcium retention in bone. Oste- Delmar Publishers, Inc.; 1999.
oporos Int. 2001;12:493.
Guyton AC, Hall JE. Insulin, glucagon and diabetes mellitus. In: Textbook of
Carlsen MH, et al. The total antioxidant content of more than 3100 foods, bever- Medical Physiology. Philadelphia, PA: W. B. Saunders; 2000:884-898.
ages, spices, herbs and supplements used worldwide. Nutr J. 2010;9:3.
Cori CF. The fate of sugar in the animal body. 1. The rate of absorption of Gastroenterol. 2014;49:681-689.
hexoses and pentoses from the intestinal tract. J Biol Chem. 1925;66:691.
Hill EE, Zack E, Battaglini C, et al. Exercise and circulating cortisol levels: the
Crawford MA. The role of dietary fatty acids in biology: their place in the evolution intensity threshold effect. J Endocrinol Invest. 2008 Jul;31(7):587-591.
of the human brain. Nutr Rev. 1992;50:3

References | 509
Hobson RM, Harris RC, Martin D, et al. Effect of sodium bicarbonate supple- Northgraves MJ, Peart DJ, Jordan CA, Vince RV. Effect of lactate supplemen-
mentation on 2000 m rowing performance. Int J Sports Physiol Perform. 2014 tation and sodium bicarbonate on 40 km cycling time trial performance. J
Jan;9(1):139-144. Strength Cond Res. 2014 Jan;28(1):273-280.
Howley ET, Franks BD. Health Fitness Instructor’s Handbook. 4th ed. Cham- Prentice A, Jebb S. Energy intake/physical activity interactions in the homeosta-
paign, IL: Human Kinetics; 2003. sis of body weight regulation. Nutr Rev. 2004;62:S98.
Jequier E. Leptin signaling, adiposity and energy balance. Ann NY Acad Sci. Rampone AJ, Reynolds PJ. Obesity: Thermodynamic principles in perspective.
2002;967:379. Life Sci. 1988;43:93.
Jones PJH, Kubow S. Lipids, sterols and their metabolites. In: Shils ME, Olson Reidlinger DP, Willis JM, Whelan K. Resting metabolic rate and anthropometry
JA, Shike M, Ross AC, eds. Modern Nutrition in Health and Disease. 9th ed. in older people: A comparison of measured and calculated values. J Hum Nutr
Baltimore, MD: Williams and Wilkins; 1999:67. Diet. 2015 Feb;28(1):72-84.
Katz DL, Friedman RSC, Lucan SC. Nutrition in Clinical Practice. 3rd ed. Saunders B, Sale C, Harris RC, et al. Sodium bicarbonate and high-intensi-
Wolters Kluwer Health; 2015. ty-cycling capacity: variability in responses. Int J Sports Physiol Perform. 2014
Jul;9(4):627-632.
Kendall K, Hyde P. Beta-alanine supplementation and exercise performance.
SCAN’s PULSE. Winter 2015:34(1). Schiavon M, et al. Postprandial glucose fluxes and insulin sensitivity during
exercise: A study in healthy individuals. Am J Physiol Endocrinol Metab.
Kishino Y, Moriguchi S. Nutritional factors and cellular immune responses. 2013;305:E557-E566.
LaForgia J, et al. Effects of exercise intensity and duration on the excess creases the capacity for fat oxidation during exercise in women. J Appl Physiol.
post-exercise oxygen consumption. J Sports Sci. 2006;24:1247-1264. 2007;102:1439.
Larsen FJ, et al. Dietary inorganic nitrate improves mitochondrial efficiency in Tappy L. Thermic effect of food and sympathetic nervous system activity in
humans. Cell Metab. 2011;13:149-159. humans. Reprod Nutr Dev. 1996;36:391.
MacDougall JD, et al. Substrate utilization during weightlifting. Med Sci Sports Tesch PA, Colliander EB, Kaiser P. Muscle metabolism during intense, heavy
Exerc. 1988;20:S66. resistance exercise. Eur J Appl Physiol. 1986;55:362.
Mahan LK, Escott-Stump S. Food, Nutrition and Diet Therapy. 11th ed. Phila- Thibodeau GA, Patton KT. Anatomy and Physiology. 4th ed. Mosby, Inc.; 1999.
Tobias G, Benatti FB, de Salles Painelli V, et al. Additive effects of beta-alanine
Mann S, Beedie C, Jimenez A. Differential effects of aerobic exercise, resis- and sodium bicarbonate on upper-body intermittent performance. Amino Acids.
tance training and combined exercise modalities on cholesterol and the lipid 2013 Aug;45(2):309-17.
profile: Review, synthesis and recommendation. Sports Med. 2014;44:211-221.
Marriott M, Krustrup P, Mohr M. Ergogenic effects of caffeine and sodium distribution. Am J Clin Nutr. 1990;51:153.
bicarbonate supplementation on intermittent exercise performance preceded by
intense arm cranking exercise. J Int Soc Sports Nutr. 2015;12:13. Tremblay A, Simoneau JA, Bouchard C. Impact of exercise intensity on body
fatness and skeletal muscle metabolism. Metabolism 1994;43:814.
McArdle W, Katch F, Katch V. Exercise Physiology. 4th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 1996. Yoshioka M, et al. Impact of high-intensity exercise on energy expenditure, lipid
oxidation and body fatness. Int J Obes Relat Metab Disord. 2001;25:332.
McMurray RG, et al. Examining variations of resting metabolic rate of adults: A
public health perspective. Med Sci Sports Exerc. 2013;46:1352-1358. Unit 6 - Macronutrients
McNaughton LR, Siegler J, Midgley A. Ergogenic effects of sodium bicarbon- American College of Sports Medicine position stand. Nutrition and Athletic
ate. Curr Sports Med Rep. 2008 Jul-Aug;7(4):230-236. Performance. Med Sci Sports Exerc. 2009;41:709-731.
Mekary RA, et al. Weight training, aerobic physical activities and long-term American Dietetic Association position stand. Health Implications of Dietary Fiber.
waist circumference change in men. Obesity 2015 Feb;23(2):461-467. J Am Diet Assoc. 2008;108:1716-1731.
Mueller SM, Gehrig SM, Frese S, et al. Multiday acute sodium bicarbonate in- Andrews R. All about “natural” sweeteners. Precision Nutrition website. http://
take improves endurance capacity and reduces acidosis in men. J Int Soc Sports www.precisionnutrition.com/all-about-natural-sweeteners.
Nutr. 2013 Mar 26;10(1):16.
Antonio J, et al. The effects of consuming a high protein diet (4.4 g/kg/d) on

510 |
body composition in resistance-trained individuals. J Int Soc Sports Nutr. Accessed online at: http://www.nal.usda.gov/fnic/DRI//DRI_Energy/589-768.
2014;11:19. pdf. Washington, DC: National Academies Press; 2005.
Arentson-Lantz E, et al. Protein: A nutrient in focus. Appl Physiol Nutr Metab. Hall KD, et al. Calorie for calorie, dietary fat restriction result in more body
2015;40:755-761. fat loss than carbohydrate restriction in people with obesity. Cell Metab.
2015;22:427-436.
Astrup A, et al. The role of reducing intakes of saturated fat in the prevention of
cardiovascular disease: Where does the evidence stand in 2010? Am J Clin Nutr. Hernandez-Alonso P, et al. High dietary protein intake is associated with
2011;93(4):684-688. an increased body weight and total death risk. Clin Nutr. 2015 Apr 7;pii:
S0261-5614(15)00091-6.
Babault N, et al. Pea proteins oral supplementation promotes muscle thickness
gains during resistance training: a double-blind, randomized, placebo-con- Helms ER, et al. A systematic review of dietary protein during caloric restric-
trolled clinical trial vs. whey protein. J Int Soc Sports Nutr. 2015;12:3. tion in resistance trained lean athletes: a case for higher intakes. Int J Sport Nutr
Exerc Metab. 2014;24:127-138.
Bier DM. Saturated fats and cardiovascular disease: Interpretations not as
simple as they once were [published online ahead of print March 16, 2015]. Crit Hoenselaar R. Saturated fat and cardiovascular disease: The discrepancy be-
Rev Food Sci Nutr. tween the scientific literature and dietary advice. Nutrition 2012;28:118-123.
Bilsborough S, Mann N. A review of issues of dietary protein intake in humans. Hooper L, et al. Reduction in saturated fat intake for cardiovascular disease.
Int J Sport Nutr Exerc Metab. 2006;16:129-152. Cochrane Database Syst Rev. 2015;6:CD011737.
Bray GA, et al. Effect of protein overfeeding on energy expenditure measured in Hoertel HA, et al. A randomized crossover, pilot study examining the effects of a
a metabolic chamber. Am J Clin Nutr. 2015;101:496-505. normal protein vs. high protein breakfast on food cravings and reward signals in
overweight/obese “breakfast skipping”, late-adolescent girls. Nutr J. 2014;13:80.
Bray GA, et al. Effect of dietary protein content on weight gain, energy expendi-
ture and body composition during overeating. JAMA 2012;307:47-55. Joy JM, Lowery RP, Wilson JM, et al. The effects of 8 weeks of whey or rice
protein supplementation on body composition and exercise performance. Nutr
Campbell B, et al. International Society of Sports Nutrition position stand: J. 2013;12:86.
protein and exercise. J Int Soc Sports Nutr. 2007;4:8.
Katz DL, Friedman RSC, Lucan SC. Nutrition in Clinical Practice. 3rd ed.
Chien KL, et al. Comparison of predictive performance of various fatty acids Wolters Kluwer Health; 2015.
for the risk of cardiovascular disease events and all-cause deaths in a communi-
ty-based cohort. Atherosclerosis 2013;230:140-147. Kresser C. The Diet-Heart Myth: Why everyone should know their LDL
particle number. Published online April 26, 2013: http://chriskresser.com/
Chilton FH, Murphy RC, Wilson BA, et al. Diet-gene Interactions and PUFA the-diet-heart-myth-why-everyone-should-know-their-ldl-particle-number/.
metabolism: A potential contributor to health disparities and human diseases.
Nutrients. 2014;6(5):1993-2022. Kuipers RS, de Graaf DJ, Luxwolda MF, et al. Saturated fat, carbohydrates and
cardiovascular disease. Neth J Med. 2011 Sep;69(9) 372-378.
Cura AJ, Carruthers A. The role of monosaccharide transport proteins in carbo-
hydrate assimilation, distribution, metabolism and homeostasis. Compr Physiol. Lamarche B, Couture P. It is time to revisit current dietary recommendations for
2012;2:863-914. saturated fat. Appl Physiol Nutr Metab. 2014:39.
DiNicolantonio JJ, Niazi AK, McCarty MF, et al. Omega-3s and cardiovascular Lawrence GD. Dietary fats and health: dietary recommendations in the context
health. Ochsner J. 2014;14(3):399-412. of scientific evidence. Adv Nutr. 2013;4:294-302.
de Oliveira Otto MC, et al. Dietary intake of saturated fat by food source and Leidy H J, et al. The role of protein in weight loss and maintenance [published
incident cardiovascular disease: The multi-ethnic study of atherosclerosis. Am J ahead of print April 29, 2015]. Am J Clin Nutr. pii: ajcn084038.
Clin Nutr. 2012;96(2): 397-404.
Levine ME, et al. Low protein intake is associated with a major reduction in
Eshel G, et al. Land, irrigation water, greenhouse gas and reactive nitrogen IGF-1, cancer and overall mortality in the 65 and younger but not older popula-
burdens of meat, eggs and dairy production in the United States. Proc Soc Exp tion. Cell Metab. 2014;19:407-417.
Biol Med. 2014;111:11996-12001.
Lin Y, et al. Dietary animal and plant protein intakes and their associations with
Food and Agriculture Organization of the United Nations. Dietary protein obesity and cardio-metabolic indicators in European adolescents: the HELENA
quality evaluation in human nutrition. Auckland, New Zealand: 2011. cross-sectional study. Nutr J. 2015;14:10.
Food and Nutrition Board, Institute of Medicine of the National Academies. Malhotra A. Saturated fat is not the major issue. The BMJ website. http://www.
Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, bmj.com/content/347/bmj.f6340. BMJ 2013;347:f6340. Accessed November
Cholesterol, Protein and Amino Acids. Unit 10 Protein and Amino Acids. 2015.

References | 511
Metges CC, Barth CA. Metabolic consequences of a high dietary-protein Wall BT, et al. Strategies to maintain skeletal muscle mass in the injured
intake in adulthood: Assessment of the available evidence. J Nutr. 2000 athlete: nutritional considerations and exercise mimetics. Eur J Sport Sci.
Apr;130(4):886-889. 2015;15:53-62.
Michaelsen KF, Greer FR. Protein needs early in life and long-term health. Am Wilson J, Wilson GJ. Contemporary issues in protein requirements and con-
J Clin Nutr. 2014;99:718S-722S. sumption for resistance trained athletes. J Int Soc Sports Nutr. 2006;3:7-27.
Mitchell WK, et al. A dose- rather than delivery profile-dependent mechanism Zhao F, Keating AF. Functional properties and genomics of glucose transporters.
regulates the “muscle-full” effect in response to oral essential amino acid intake Curr Genomics. 2007 Apr; 8(2):113–128.
in young men. J Nutr. 2015;145:207-214.
Unit 7 - Micronutrients
Myles IA. Fast food fever: reviewing the impacts of the Western diet on immu-
nity. Nutr J. 2014;13:61. Abelow BJ, Holford TR, Insogna TL. Cross-cultural association between
dietary animal protein and hip fracture: a hypothesis. Calcif Tissue Int.
Neacsu M, et al. Appetite control and biomarkers of satiety with vegetarian (soy) 1992;50:14.
and meat-based high-protein diets for weight loss in obese men: a randomized
crossover trial. Am J Clin Nutr. 2014;100:548-558. Agren MS, Franzen L. Influence of zinc deficiency on breaking strength of
3-week-old skin incisions in the rat. Acta Chir Scand. 1990;156:667.
Paddon-Jones D, et al. Protein and healthy aging. Am J Clin Nutr. 2015; doi:
10.3945/ajcn.114.084061. Ali M, Thomson M, Afzal M. Garlic and onions: their effect on eicosanoid
metabolism and its clinical relevance. Prostaglandins Leukot Essent Fatty
Pasiakos SM, et al. Higher-protein diets are associated with higher HDL Acids. 2000;62:55.
cholesterol and lower BMI and waist circumference in US adults. J Nutr.
2015;145:605-614. Alvarez OM, Gilbreath RL. Effect of dietary thiamine on intermolecular
collagen cross-linking during wound repair: a mechanical and biochemical
Pesta DH, Samuel VT. A high-protein diet for reducing body fat: mechanisms assessment. J Trauma. 1982;22:20.
and possible caveats. Nutr Metab (Lond). 2014;11:53.
American College of Sports Medicine position stand. Nutrition and athletic
Phillips SM, et al. A critical examination of dietary protein requirements, bene- performance. Med Sci Sports Exerc. 2009;41:709-731.
fits and excesses in athletes. Int J Sport Nutr Exerc Metab. 2007;17:S58-S76.
Andrews R. Fighting acne with food. Precision Nutrition website: http://www.
Reedy J, et al. Higher diet quality is associated with decreased risk of all- precisionnutrition.com/all-about-acne-nutrition.
cause, cardiovascular disease and cancer mortality among older adults. J Nutr.
2014;144:881-889. Anthony TG, et al. Feeding meals containing soy or whey protein after exercise
stimulates protein synthesis and translation initiation in the skeletal muscle of
Rowlands DS, et al. Protein-leucine fed dose effects on muscle protein synthesis male rats. J Nutr. 2007;137:357.
after endurance exercise. Med Sci Sports Exerc. 2015;47:547-555.
Aprahamian M, et al. Effects of supplemental pantothenic acid on wound heal-
Sabate J, et al. The environmental cost of protein food choices. Public Health ing: experimental study in rabbit. Am J Clin Nutr. 1985;41:578.
Nutr. 2014;Nov 6:1-7.
Arnold M, Barbul A. Nutrition and wound healing. Plast Reconstr Surg. 2006;
Siri-Tarino PW, Sun Q, Hu FB, Krauss RM. Meta-analysis of prospective cohort 117(suppl):42S.
studies evaluating the association of saturated fat with cardiovascular disease.
Am J Clin Nutr. 2010;91(3):535-546. Augustsson K, et al. A prospective study of intake of fish and marine fatty acids
and prostate cancer. Cancer Epidemiol Biomarkers Prev. 2003;12:64.
St. Pierre B. Is nutrient timing dead? Precision Nutrition website. http://www.
precisionnutrition.com/nutrient-timing. 2014. Bailey JL. Metabolic acidosis and protein catabolism: mechanisms and clinical
implications. Miner Electrolyte Metab. 1998;24:13.
St. Pierre B. The paleo problem: Examining the pros and cons of a paleo diet.
Precision Nutrition website. http://www.precisionnutrition.com/paleo-diet. Bailey JL, Mitch WE. Mechanisms of protein degradation: What do the rat
Published 2014. studies tell us? J Nephrol. 2000;13:89.
St. Pierre B. Workout nutrition explained. Precision Nutrition website. http:// Bandyopadhyay D. Farmer to pharmacist: curcumin as an anti-invasive and
www.precisionnutrition.com/workout-nutrition-explained. Published 2014. antimetastatic agent for the treatment of cancer. Front Chem. 2014;2:113.
Varbo A, et al. Elevated remnant cholesterol causes both low-grade inflam- Barlow M. Where has all the water gone? The American Prospect website.
mation and ischemic heart disease, whereas elevated low-density lipoprotein http://prospect.org/article/where-has-all-water-gone. Published May 23, 2008.
cholesterol causes ischemic heart disease without inflammation. Circulation
2013;128:1298-1309.

512 |
Beauchamp GK, et al. Ibuprofen-like activity in extra-virgin olive oil. Nature Cetin I, Koletzko B. Long-chain omega-3 fatty acid supply in pregnancy and
2005;437:45. lactation. Curr Opin Clin Nutr Metab Care. 2008;11:3.
Bemben MG, Lamont HS. Creatine supplementation and exercise performance: Champ MM. Non-nutrient bioactive substances of pulses. Br J Nutr. 2002;88(3
Recent findings. Sports Med. 2005;35:107. suppl.):S307-S319.
Bemelmans WJ, et al. Change in saturated fat intake is associated with progres- Chandler RM, et al. Dietary supplements affect the anabolic hormones after
sion of carotid and femoral intima-media thickness and with levels of soluble weight-training exercise. J Appl Physiol. 1994;76:839.
intercellular adhesion molecule-1. Atherosclerosis 2002;163:113.
Cho SY, et al. Quercetin suppresses proinflammatory cytokines production
Berkow SE, Barnard N. Vegetarian diets and weight status. Nutr Rev. through MAP kinases and NF-kappaB pathway in lipopolysaccharide-stimu-
2006;64:175. lated macrophage. Mol Cell Biochem. 2003;243:153.
Bernhardt S, Schlich E. Impact of different cooking methods on food quality: Chun OK, Kim DO, Lee CY. Superoxide radical scavenging activity of the
Retention of lipophilic vitamins in fresh and frozen vegetables. J Food Eng. major polyphenols in fresh plums. J Agric Food Chem. 2003;51:8067.
2006;77: 327-333.
Craig WJ. Health effects of vegan diets. Am J Clin Nutr.
Berning J, Steen S. Nutrition for Sport and Exercise. 2nd ed. Colorado: Aspen 2009;89(suppl.):S1627-S1633.
Publications; 1998.
Craig WJ, Mangels AR. Position of the American Dietetic Association: Vegetar-
Biolo G, et al. Increased rates of muscle protein turnover and amino acid trans- ian diets. J Am Diet Assoc. 2009;109(7):1266-1282.
port after resistance exercise in humans. Am J Physiol. 1995;268:E514.
Cross CE, et al. Oxygen radicals and human disease. Ann Intern Med.
Blankson H, et al. Conjugated linoleic acid reduces body fat mass in overweight 1987;107:526.
and obese humans. J Nutr. 2000;130:2943.
Crowe FL, et al. Diet and risk of diverticular disease in Oxford cohort of Euro-
Blom PC, et al. Effect of different post-exercise sugar diets on the rate of muscle pean Prospective Investigation into Cancer and Nutrition (EPIC): prospective
glycogen synthesis. Med Sci Sports Exerc. 1987;19:491. study of British vegetarians and non-vegetarians. BMJ. 2011;343:d4131.
Blom WA, et al. Effect of a high-protein breakfast on the postprandial ghrelin Dahlquist DT, et al. Plausible ergogenic effects of vitamin D on athletic perfor-
response. Am J Clin Nutr. 2006;83:211. mance and recovery. J Int Soc Sports Nutr. 2015;12:33.
Bodinham CL, et al. Acute ingestion of resistant starch reduces food intake in Davis B, Melina V. Becoming Vegan: The Complete Guide to Adopting a
healthy adults. Br J Nutr. 2010;103:917-922. Healthy Plant-Based Diet. Summertown, TN: Book Publishing Company;
2000.
Borsheim E, et al. Essential amino acids and muscle protein recovery from
resistance exercise. Am J Physiol Endocrinol Metab. 2002;283:E648. Davis BC, Kris-Etherton PM. Achieving optimal essential fatty acid status in
vegetarians: current knowledge and practical implications. Am J Clin Nutr.
Brown L, et al. Cholesterol-lowering effects of dietary fiber: a meta-analysis. 2003;78 (suppl.):640S.
Am J Clin Nutr. 1999;69:30.
Delarue J, et al. Effects of fish oil on metabolic responses to oral fructose and
Buchholz AC, Schoeller DA. Is a calorie a calorie? Am J Clin Nutr. glucose loads in healthy humans. Am J Physiol. 1996;270(2 Pt 1):E353.
2004;79:899S.
Demigné C, et al. Protective effects of high dietary potassium: nutritional and
Butler LM, et al. A vegetable-fruit-soy dietary pattern protects against breast metabolic aspects. J Nutr. 2004;134:2903.
cancer among postmenopausal Singapore Chinese women. Am J Clin Nutr.
2010;91:1013-1019. Drobnic F, et al. Reduction of delayed onset muscle soreness by a novel curcum-
in delivery system (Meriva®): a randomised, placebo-controlled trial. J Int Soc
Carmichael SL, et al. Reduced risks of neural tube defects and orofacial clefts Sports Nutr. 2014;11:31.
with higher diet quality. Arch Pediatr Adolesc Med. 2012;166(2):121-126.
Ehrlich HP, Tarver H, Hunt TK. Effects of vitamin A and glucocorticoids upon
Centers for Disease Control and Prevention. State-specific trends in fruit and inflammation and collagen synthesis. Ann Surg. 1973;177:222.
vegetable consumption among adults – United States, 2000-2009. MMWR:
Morbidity and Mortality Weekly Report. 2010;59(35). Ehrlich HP, Tarver H, Hunt TK. Inhibitory effects of vitamin E on collagen
synthesis and wound repair. Ann Surg. 1972;175:235.
Centers for Disease Control and Prevention. Division for Heart Disease and
Stroke Prevention. Heart Disease Fact Sheet. http://www.cdc.gov/dhdsp/data_ Evenepoel P, et al. Digestibility of cooked and raw egg protein in humans as
statistics/fact_sheets/docs/fs_heart_disease.pdf. Accessed November 2015. assessed by stable isotope techniques. J Nutr. 1998;128:1716-1722.

References | 513
Feingold D, Hame SL. Female athlete triad and stress fractures. Orthop Clin Higdon, J. An Evidence-based Approach to Vitamins and Minerals. Linus
North Am. 2006;37:575. Pauling Institute; 2003.
Food and Agriculture Organization of the United Nations. FAOSTAT online Higgins JA. Resistant starch: metabolic effects and potential health benefits. J
statistical service (FAO, Rome, 2004). http://faostat.fao.org/site/291/default. AOAC Int. 2004;87:761-768.
aspx. Accessed online January 8, 2008.
Jenkins DJ, et al. Effects of a dietary portfolio of cholesterol-lowering foods vs.
Ford ES, et al. Low-risk lifestyle behaviors and all-cause mortality: findings lovastatin on serum lipids and C-reactive protein. JAMA 2003;290:502-510.
from the National Health and Nutrition Examination Survey III Mortality
Study. Am J Public Health. 2011;101:1922-1929. Jiang R, et al. Nut and seed consumption and inflammatory markers in the
multi-ethnic study of atherosclerosis. Am J Epidemiol. 2006;163:222.
Freund-Levi Y, et al. n-3 fatty acid treatment in 174 patients with mild to mod-
erate Alzheimer disease: OmegAD study: a randomized double-blind trial. Arch Johnston KL, et al. Resistant starch improves insulin sensitivity in metabolic
Neurol. 2006;63:1402. syndrome. Diabet Med. 2010;27:391-397.
Fung TT, et al. The Mediterranean and dietary approaches to stop hypertension Kalman D, et al. Effect of protein source and resistance training on body com-
(DASH) diets and colorectal cancer. Am J Clin Nutr. 2010;92:1429-1435. position and sex hormones. J Int Soc Sports Nutr. 2007;4:4.
Furst P, Stehle P. What are the essential elements needed for the determination Kris-Etherton PM, et al. Polyunsaturated fatty acids in the food chain in the
of amino acid requirements in humans? J Nutr. 2004;134(6 suppl):1558S. United States. Am J Clin Nutr. 2000;71(1 suppl):S179.
Gaesser GA, Angadi SS. Gluten-free diet: Imprudent dietary advice for the Kris-Etherton PM, Harris WS, Appel LJ. AHA Scientific Statement: Fish con-
general population? J Acad Nutr Diet. 2012;112:1330-1333. sumption, fish oil, omega-3 fatty acids and cardiovascular disease. Circulation
2002;106:2747.
Ganong WF. Endocrine functions of the pancreas and regulation of car-
bohydrate metabolism. In: Review of Medical Physiology. New York, NY: Lemon PW, et al. Protein requirements and muscle mass/strength changes
McGraw-Hill; 2001:322-343. during intensive training in novice bodybuilders. J Appl Physiol. 1992;73:767.
Geelen A, et al. Fish consumption, n-3 fatty acids and colorectal cancer: a me- Linus Pauling Institute: Micronutrient Information Center website. Phytochem-
ta-analysis of prospective cohort studies. Am J Epidemiol. 2007;166:1116. icals. http://lpi.oregonstate.edu/infocenter/phytochemicals.html. Accessed
November 2015.
Geller SE, Studee L. Botanical and dietary supplements for menopausal symp-
toms: What works, what does not. J Womens Health. Sep 2005;14:7. Liu, RH. Health benefits of fruit and vegetables are from additive and synergis-
tic combinations of phytochemicals. Am J Clin Nutr. Sep 2003;78:3.
Grabitske HA, Slavin JL. Gastrointestinal effects of low-digestible carbohydrates.
Crit Rev Food Sci Nutr. 2009;49:327-360. Lombardo YB, Chicco AG. Effects of dietary polyunsaturated n-3 fatty acids
on dyslipidemia, and insulin resistance in rodents and humans: A review. J Nutr
Griffenberg L, et al. The effect of dietary fiber on bowel function following Biochem. 2006;17:1.
radical hysterectomy: a randomized trial. Gynecol Oncol. 1997;66:417.
MacDonald IM, et al. Effect of docosahexaenoic acid supplementation on retinal
Grotto D. The Best Things You Can Eat. Da Capo Lifelong Books; 2013. function in a patient with autosomal dominant Stargardt-like retinal dystrophy.
Br J Ophthalmol. 2004;88:305.
Haminiuk CWI, et al. Phenolic compounds in fruits – an overview. Int J Food
Sci Tech. 2012;47:2023-2044. Maes M, et al. Lowered omega 3 polyunsaturated fatty acids in serum phospho-
lipids and cholesteryl esters of depressed patients. Psychiatry Res. 1999;85:275.
Hankenson KD, et al. Omega-3 fatty acids enhance ligament fibroblast collagen
formation in association with changes in interleukin-6 production. Proc Soc Exp Maki KC, Raines TM. Dietary fibers, insulin sensitivity and risk of type 2
Biol Med. 2000;223:88. diabetes. SCAN’s PULSE. 2011;30:6-9.
Havlik RJ. Vitamin E and wound healing. Plastic Surgery Educational Founda- Marchioli R, et al. Early protection against sudden death by n-3 polyunsaturated
tion DATA Committee. Plast Reconstr Surg. 1997;100:1901. fatty acids after myocardial infarction: Time-course analysis of the results of
the Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto Miocardico
Heijnen CG, et al. Flavonoids as peroxynitrite scavengers: the role of the hy- (GISSI)-Prevenzione. Circulation 2002:105;1897.
droxyl groups. Toxicol In Vitro. 2001;15:3.
Marcos A, Nova E, Montero A. Changes in the immune system are conditioned
He K, et al. Accumulated evidence on fish consumption and coronary heart by nutrition. Eur J Clin Nutr. 2003;57(1 suppl.);S66.
disease mortality: a meta-analysis of cohort studies. Circulation 2004:109;2705.
Martin C, et al. Plants, diet and health. Annu Rev Plant Biol. 2013;64:19-46.

514 |
Millward DJ. Optimal intakes of protein in the human diet. Proc Nutr Soc. Rizzo NS, et al. Vegetarian dietary patterns are associated with a lower
1999;58:403. risk of metabolic syndrome: the Adventist health study 2. Diabetes Care.
2011;34:1225-1227.
Millward DJ. The nutritional value of plant-based diets in relation to human
amino acid and protein requirements. Proc Nutr Soc. 1999;58(2):249-260. Robinson J. Eating on the Wild Side. Little, Brown and Company; 2013.
Misner B. Food alone may not provide sufficient micronutrients for preventing Rotstein NP, et al. Protective effect of docosahexaenoic acid on oxidative
deficiency. J Int Soc Sports Nutr. 2006;3:51-55. stress-induced apoptosis of retina photoreceptors. Invest Ophthalmol Vis Sci.
2003;44:2252.
Murphy MM, et al. Resistant starch intakes in the United States. J Am Diet
Assoc. 2008;108:67-78. Schaffer M, et al. Curcuma as a functional food in the control of cancer and
inflammation. Curr Opin Clin Nutr Metab Care. 2011;14:588-597.
National Center for Complementary and Integrative Health (NCCIH) http://
nccam.nih.gov/news/newsletter/2010_may/antioxidants1.htm Shen C, et al. Fruits and dietary phytochemicals in bone protection. Nutr Res.
2012;32:897-910.
Nelson HD, et al. Nonhormonal therapies for menopausal hot flashes. JAMA
2006;295:2057-2071. Simopoulos AP. The importance of the ratio of omega-6/omega-3 essential fatty
acids. Biomed Pharmacother. 2002;56:365.
Nemets B, Stahl Z, Belmaker RH. Addition of omega-3 fatty acid to mainte-
nance medication treatment for recurrent unipolar depressive disorder. Am J Tai Le, L, Sabate J. Beyond meatless, the health effects of vegan diets: Findings
Psychiatry. 2002;159:477. from the adventist cohorts. Nutrients 2014;6:2131-2147.
New SA. Intake of fruit and vegetables: implications for bone health. Proc Nutr Van Marken Lichtenbelt WD, Mensink RP, Westerterp KR. The effect of fat
Soc. 2003;62:889. composition of the diet on energy metabolism. Z Ernahrungswiss.1997;36:303.
Nieman DC. Physical fitness and vegetarian diets: Is there a relation? Am J Clin Venderley AM, Campbell WW. Vegetarian diets: nutritional considerations for
Nutr. 1999;70(3 suppl.): S570-S575. athletes. Sports Med. 2006;36(4): 293-305.
Nimni ME, Han B, Cordoba F. Are we getting enough sulfur in our diet? Nutri- Venn BJ, Mann JI. Cereal grains, legumes and diabetes. Eur J Clin Nutr.
tion & Metabolism. 2007;4:24. 2004;58:1443.
Nugent AP. Health properties of resistant starch. British Nutrition Foundation. Yang M, Koo SI, Song WO, Chun OK. Food matrix affecting anthocyanin
Nutrition Bulletin. 2005;30:27-54. bioavailability: review. Curr Med Chem. 2011;18(2):291-300.
Nutrilite Health Institute. Global Phytonutrient Report. http://www.nutrilite. Young VR, Pellett PL. Plant proteins in relation to human protein and amino
com/en-us/Media/AmericaPhytonutrientReport.pdf. Accessed November 2015. acid nutrition. Am J Clin Nutr. 1994;59(5 suppl):1203S-1212S.
Oh RC, Brown DL. Vitamin B12 deficiency. Am Fam Physician. Zeisel SH, da Costa KA. Choline: An essential nutrient for public health. Nutr
2003;67:979-986. Rev. 2009;67(11):615-623.
Perera CO, Yen GM. Functional properties of carotenoids in human health. Int J Zhang X, et al. Soy food consumption is associated with lower risk of coronary
Food Prop. 2007;10:201-230. heart disease in Chinese women. J Nutr. 2003;133:2874.
Pitkanen H, et al. Free amino acid pool and muscle protein balance after resis- Unit 8 - Water and Fluid Balance
tance exercise. Med Sci Sports Exerc. 2003;35:784.
Cotter JD, et al. Are we being drowned in hydration advice? Thirsty for more?
Position of the American Dietetic Association: Vegetarian diets. J Am Diet Extrem Physiol Med. 2014;3:18.
Assoc. 2009;109:1266-1282.
Croftan AC. Edema as a danger signal in the starvation treatment of diabetes.
Position of the American Dietetic Association: Health implications of dietary fiber. JAMA. 1917;LXIX(23):1962-1963.
J Am Diet Assoc. 2008;108:1716-1731.
Haller E. Eating disorders: A review and update. West J Med. 1992;157:658-662.
Quinlan JD, Hill DA. Nausea and vomiting of pregnancy. Am Fam Physician.
2003;68:121-128. Hermida RC, Ayala DE, Fernández JR. Circadian rhythms in blood pressure
regulation and optimization of hypertension treatment with ACE inhibitor and
Reddy MB, Hurrell RF, Cook JD. Estimation of nonheme-iron bioavailability ARB medications. Am J Hypertens. 2011;24(4):383-391.
from meal composition. Am J Clin Nutr April. 2000;7(4):937-943.

References | 515
Hew-Butler T, et al. Statement of the Third International Exercise-Associated Units 9, 10, 11 - What it Means to be
Hyponatremia Consensus Development Conference, Carlsbad, California, 2015.
a Good Coach, The ISSA Coaching
Clin J Sport Med. 2015;25:303-320.
Methodology, Working with Nutritional
Hunger oedema. Acta Psychiatr Scand. 1953;28(s83):93-112. Levels
Javaheri S, Redline S. Sleep, slow-wave sleep, and blood pressure. Curr Hyper- Banaji MR, Greenwald AG. Blindspot: Hidden Biases of Good People. Random
tens Rep. 2012 Oct;14(5):442-448. House; 2013
Kawano Y. Diurnal blood pressure variation and related behavioral factors. Duhigg C. The Power of Habit: Why We Do What We Do in Life and Business.
Hypertens Res. 2011;34(3):281-285. Random House; 2012.
Kurnick, NB. War edema in the civilian population of Saipan. Ann Intern Med. De Jong P, Berg IK. Interviewing for Solutions. Brooks/Cole; 2002
1948;28(4):782-791.
Duncan B. What’s Right with You: Debunking Dysfunction and Changing Your
Lima R, Wofford M, Reckelhoff JF. Hypertension in postmenopausal women. Life. Health Communications; 2005.
Curr Hypertens Rep. 2012;14(3):254-260.
Duncan BL, Miller SD, Sparks JA. The Heroic Client: A Revolutionary Way to
Lumbers ER, Pringle KG. Roles of the circulating renin-angiotensin-aldoste- Improve Effectiveness Through Client-Directed, Outcome-Informed Therapy.
rone system in human pregnancy. Am J Physiol Regul Integr Comp Physiol. John Wiley & Sons; 2011.
2014;306(2):R91-101.
Gawande A. The Checklist Manifesto: How to Get Things Right. Picador; 2011.
Mayer M. Nutritional edema and “war dropsy.” JAMA. 1920;74(14):934-941.
Goldsmith M. Triggers: Creating Behavior That Lasts – Becoming the Person
Morgan TO. The importance of sleep blood pressure. Expert Rev Cardiovasc You Want to Be. Crown Business; 2015.
Ther. 2010;8(6):803-9.
Greene R. Mastery. Penguin Books; 2013.
Oelkers WK. Effects of estrogens and progestogens on the renin-aldosterone
system and blood pressure. Steroids 1996;61(4):166-71. Guise S. How to Be an Imperfectionist: The New Way to Self-Acceptance, Fear-
less Living, and Freedom from Perfectionism. Selective Entertainment; 2015.
Park FS. War edema (Kriegsoedem). JAMA. 1918;70(24):1826-1827.
Guise S. Mini Habits: Smaller Habits, Bigger Results. CreateSpace Independent
Position of American College of Sports Medicine. Exercise and fluid replace- Publishing Platform; 2013.
ment. Med Sci Sports Exerc. 2007;39:377-390.
Halvorson HG. No One Understands You and What to Do About It. Harvard
Position of American College of Sports Medicine. Nutrition and athletic perfor- Business Review Press; 2014.
mance. Med Sci Sports Exerc. 2009;41:709-731.
Heath C, Heath D. Switch: How to Change Things When Change is Hard. New
Salstrom JL, Kent M, Liang, X, Wang M. Toddlers with anasarca and severe York: Random House; 2011.
anemia: a lesson in preventive medicine. Curr Opin Pediatr. 2012;24(1)129-133.
Kahneman D. Thinking, Fast and Slow. Doubleday; 2011.
Strumia R. Dermatologic signs in patients with eating disorders. Am J Clin
Dermatol. 2005;6(3):165-173. Katz DL, Meller S. Can we say what diet is best for health? Annu Rev Public
Health 2014; 35:83-103.
Szmuilowicz ED, et al. Relationship between aldosterone and progesterone in
the human menstrual cycle. J Clin Endocrinol Metab. 2006;91(10). Legge A. How to set weight loss goals that work [part 2]. Alan Aragon’s Re-
search Review. July 1, 2014.
Tierney EP, Sage RJ, Shwayder T. Kwashiorkor from a severe dietary restriction
in an 8-month infant in suburban Detroit, Michigan: case report and review of Legge A. Why you never seem to reach your weight loss goals (and what to do
the literature. Int J Dermatol. 2010;49(5):500–506. about it). Alan Aragon’s Research Review. June 1, 2014.
Vogelaar JL, et al. Anasarca, hypoalbuminemia and anemia: What is the correla- Li C, Ford ES, Zhao G, et al. Estimates of body composition with dual-energy
tion? Clin Pediatr. 2014;53(7):710-712. X-ray absorptiometry in adults. Am J Clin Nutr. 2009 Dec;90(6):1457-1465.
Xue B, Johnson AK, Hay M. Sex differences in angiotensin II- and aldoste- Marcus BH, Forsyth L. Motivating People to Be Physically Active. 2nd ed.
rone-induced hypertension: the central protective effects of estrogen. Am J Champaign, IL: Human Kinetics; 2008.
Physiol Regul Integr Comp Physiol. 2013;305(5):R459-R463.
Markey C. Smart People Don’t Diet: How the Latest Science Can Help You
Zhao Z, Wang H, Jessup JA, et al. Role of estrogen in diastolic dysfunction. Am Lose Weight Permanently. Da Capo Lifelong Books; 2014.
J Physiol Heart Circ Physiol. 2014;306(5):H628-640.

516 |
McGonigal J. SuperBetter: A Revolutionary Approach to Getting Stronger, Unit 12 - Working with Level 1 Clients
Happier, Braver and More Resilient. Penguin Press; 2015.
Abrahão V. Nourishing the dysfunctional gut and whey protein. Curr Opin
McGonigal K. The Willpower Instinct: How Self-Control Works, Why It Mat- Clin Nutr Metab Care. 2012 Sep;15(5):480-484.
ters, and What You Can Do to Get More of It. Avery; 2013.
Arciero PJ, Baur D, Connelly S, Ormsbee MJ. Timed-daily ingestion of whey
Medina J. Brain Rules (Updated and Expanded): 12 Principles for Surviving protein and exercise training reduces visceral adipose tissue mass and improves
and Thriving at Work, Home, and School. 2nd ed. Pear Press; 2014. insulin resistance: the PRISE study. J Appl Physiol. 2014 Jul 1;117(1):1-10.
Miller WR, Rollnick S. Motivational Interviewing: Helping People Change. 3rd Fear G. Lean Habits for Lifelong Weight Loss. Page Street; 2015.
ed. Guilford Press; 2012.
Grobler L, Siegfried N, Visser ME, et al. Nutritional interventions for reducing
Mischel W. The Marshmallow Test: Mastering Self-Control. Little, Brown and morbidity and mortality in people with HIV. Cochrane Database Syst Rev. 2013
Company; 2014. Feb 28;2:CD004536.
Rath T. Eat Move Sleep: How Small Choices Lead to Big Change. Missionday; Hector AJ, et al. Whey protein supplementation preserves postprandial myo-
2013. fibrillar protein synthesis during short-term energy restriction in overweight and
obese adults. J Nutr. 2015 Feb;145(2):246-252.
Rollnick S, Miller WR, Butler CC. Motivational Interviewing in Health Care:
Helping Patients Change Behavior. Guilford Press; 2007. Jensen GS, Patel D, Benson KF. A novel extract from bovine colostrum whey
supports innate immune functions. II. Rapid changes in cellular immune func-
Rubin G. Better Than Before. Mastering the Habits of Our Everyday Lives.
tion in humans. Prev Med. 2012 May;54(1 suppl.)S124-S129.
Crown; 2015.
Markow K, Coveney J, Booth S. Enhancing food literacy through school-based
Segar M. No Sweat: How the Simple Science of Motivation Can Bring You a
cooking programs: What’s working and what’s not? Accessed online: http://
Lifetime of Fitness. AMACOM; 2015.
search.informit.com.au/documentSummary;dn=081989203951811;res=IELIND.
Journal of the Home Economics Institute of Australia. 2012;19(2): 2-11.
Society for Public Health Education (SOPHE). Fertman CI, Allensworth DD
(ed.) Health Promotion Programs: From Theory to Practice. Jossey-Bass; 2010.
Nelson AR, Jackson L, Clarke J, et al. Effect of post-exercise protein-leucine
feeding on neutrophil function, immunomodulatory plasma metabolites and
Sterner T. The Practicing Mind: Developing Focus and Discipline in Your Life
cortisol during a 6-day block of intense cycling. Eur J Appl Physiol. 2013
– Master Any Skill or Challenge by Learning to Love the Process. New World
Sep;113(9):2211-2222.
Library; 2012.
Pal S, Radavelli-Bagatini S, Hagger M, Ellis V. Comparative effects of whey

Stutz P, Michels B. The Tools: 5 Tools to Help You Find Courage, Creativity,
and casein proteins on satiety in overweight and obese individuals: a random-
and Willpower and Inspire You to Live Life in Forward Motion. Spiegel &
ized controlled trial. Eur J Clin Nutr. 2014 Sep;68(9):980-986.
Grau; 2013.
Piccolo BD, Comerford KB, Karakas SE, et al. Whey protein supplementation
Ratey JJ, Hagerman E. Spark: The Revolutionary New Science of Exercise and the
does not alter plasma branched-chained amino acid profiles but results in unique
Brain. Little, Brown and Company; 2013.
metabolomics patterns in obese women enrolled in an 8-week weight loss trial.
Roth B. The Achievement Habit: Stop Wishing, Start Doing, and Take Com- J Nutr. 2015 Apr;145(4):691-700.
mand of Your Life. HarperBusiness; 2015.
Radnitz C, et al. Investigation of lifestyle choices of individuals following a
Silverberg F. Make the Leap: A Practical Guide to Breaking the Patterns That vegan diet for health and ethical reasons. Appetite 2015;90:31-36.
Hold You Back. Marlowe & Company; 2005.
Schroer AB, Saunders MJ, Baur DA, et al. Cycling time trial performance may
Thaler RH, Sunstein CR. Nudge: Improving Decisions about Health, Wealth, and be impaired by whey protein and L-alanine intake during prolonged exercise.
Happiness. Yale University Press; 2008. Int J Sport Nutr Exerc Metab. 2014 Oct;24(5):507-515.
Trout JD. Why Empathy Matters: The Science and Psychology of Better Judg- Verreijen AM, Verlaan S, Engberink MF, et al. A high whey protein-, leucine-,
ment. Penguin; 2010. and vitamin D-enriched supplement preserves muscle mass during intentional
weight loss in obese older adults: a double-blind randomized controlled trial.
Zuckoff A, Gorscak B. Finding Your Way to Change: How the Power of Mo- Am J Clin Nutr. 2015 Feb;101(2):279-286.
tivational Interviewing Can Reveal What You Want and Help You Get There.
Guilford Press; 2015. Witard OC, et al. Myofibrillar muscle protein synthesis rates subsequent to a
meal in response to increasing doses of whey protein at rest and after resistance
exercise. Am J Clin Nutr. January 2014;99(1):86-95
Young MS, et al. Crash dieting: The effects of eating and drinking on driving
performance. Accid Anal Prev. January 2008;40(1):142-148.

References | 517
Unit 13 - Working with Level 2 Clients Macdermid PW, et al. A comparative analysis between the effects of galactose
and glucose supplementation on endurance performance. Int J Sport Nutr Exerc
Aulin KP, et al. Muscle glycogen resynthesis rate in humans after supplemen- Metab. 2012 Feb;22(1):24-30.
tation of drinks containing carbohydrates with low and high molecular masses.
Eur J Appl Physiol. 2000; 81:346-351. McClain AD, et al. Adherence to a low-fat vs. low-carbohydrate diet differs by
insulin resistance status. Diabetes Obes Metab. 2013;15:87-90.
Baker LB, et al. Acute effects of carbohydrate supplementation on intermittent
sports performance. Nutrients 2015;7(7):5733-5763. McLellan TM, Pasiakos SM, Lieberman HR. Effects of protein in combination
with carbohydrate supplements on acute or repeat endurance exercise perfor-
Bracken RM, et al. Comparison of the metabolic responses to ingestion of mance: a systematic review. Sports Med. 2014 Apr;44(4):535-550.
hydrothermally processed high-amylopectin content maize, uncooked maize
starch or dextrose in healthy individuals. Br J Nutr. 2014;111(7):1231-1238. Oosthuyse T, Carstens M, Millen AM. Ingesting isomaltulose versus fruc-
tose-maltodextrin during prolonged moderate-heavy exercise increases fat
Bracken RM, et al. Isomaltulose improves glycemia and maintains run perfor- oxidation but impairs gastrointestinal comfort and cycling performance. Int J
mance in type 1 diabetes. Med Sci Sports Exerc. 2012;44(5):800-808. Sport Nutr Exerc Metab. 2015 Oct;25(5):427-438.
Carlsohn A, et al. Does immediate carbohydrate intake following glycogen-de- Ormsbee, Michael J, et al. Pre-exercise nutrition: The role of macronutrients,
pleting exercise affect next day’s 5000 m time trial performance? Int J Sport modified starches and supplements on metabolism and endurance performance.
Nutr Exerc Metab. 2013; 23(S1-S15). Nutrients 2014;6(5):1782-1808.
Cathcart AJ, et al. Combined carbohydrate-protein supplementation improves Richardson KL, Coburn JW, Beam WC, Brown LE. Effects of isocaloric carbo-
competitive endurance exercise performance in the heat. Eur J Appl Physiol. hydrate vs. carbohydrate-protein supplements on cycling time to exhaustion. J
2011 Sep;111(9):2051-2061 Strength Cond Res. 2012 May;26(5):1361-1365.
Correia-Oliveira CR, et al. Strategies of dietary carbohydrate manipulation Rietschier HL, Henagan TM, Earnest CP, et al. Sun-dried raisins are a cost-ef-
and their effects on performance in cycling time trials. Sports Med. 2013 fective alternative to sports jelly beans in prolonged cycling. J Strength Cond
Aug;43(8):707-719. Res. 2011 Nov;25(11):3150-3156.
European Commission. Directive 2004/24/EC of the European Parliament Roberts, Michael D, et al. Ingestion of a high-molecular-weight hydrothermally
and of the Council of 31 March 2004 amending, as regards traditional herbal modified waxy maize starch alters metabolic responses to prolonged exercise in
medicinal products, Directive 2001/83/EC on the Community code relating to trained cyclists. Nutrition. 2011 Jun;27(6):659-665.
medicinal products for human use. Published 2004.
Smith JW, et al. Curvilinear dose-response relationship of carbohydrate (0-120
Ferguson-Stegall L, et al. Postexercise carbohydrate-protein supplementation g·h(-1)) and performance. Med Sci Sports Exerc. 2013 Feb;45(2):336-341.
improves subsequent exercise performance and intracellular signaling for pro-
tein synthesis. J Strength Cond Res. 2011 May;25(5):1210-1224. Stannard SR, Hawke EJ, Schnell N. The effect of galactose supplementation on
endurance cycling performance. Eur J Clin Nutr. 2009 Feb;63(2):209-214.
Goh Q, et al. Recovery from cycling exercise: effects of carbohydrate and
protein beverages. Nutrients. 2012 Jul;4(7):568-584. Temesi J, et al. Carbohydrate ingestion during endurance exercise improves
performance in adults. J Nutr. 2011 May;141(5):890-897.
Gualano AB, et al. Branched-chain amino acids supplementation enhances
exercise capacity and lipid oxidation during endurance exercise after muscle Vandenbogaerde TJ, Hopkins WG. Effects of acute carbohydrate supple-
glycogen depletion. J Sports Med Phys Fitness. 2011 Mar;51(1):82-88. mentation on endurance performance: a meta-analysis. Sports Med. 2011
Sep;41(9):773-792.
Higgins JA. Resistant starch and energy balance: impact on weight loss and
maintenance. Crit Rev Food Sci Nutr. 2014; 54(9):1158-1166. Unit 14 - Working with Level 3 Clients
International Olympic Committee. Nutrition for Athletes. 2010. Accessed Azevedo FR, Ikeoka D, Caramelli B. Effects of intermittent fasting on metabo-
online: http://www.olympic.org/documents/reports/en/en_report_833.pdf. lism in men. Rev Assoc Med Bras. 2013 Mar-Apr;59(2):167-173.
Jacobs H, Delcour JA. Hydrothermal modifications of granular starch, Barnosky AR, et al. Intermittent fasting vs daily calorie restriction for
with retention of the granular structure: A review. J Agric Food Chem. type 2 diabetes prevention: a review of human findings. Transl Res. 2014
1998;46(8):2895-2905. Oct;164(4):302-311
Kraemer WJ, et al. The addition of beta-hydroxy-beta-methylbutyrate and iso- Harvie M, et al. The effect of intermittent energy and carbohydrate restriction
maltulose to whey protein improves recovery from highly demanding resistance v. daily energy restriction on weight loss and metabolic disease risk markers in
exercise. J Am Coll Nutr. 2015;34(2):91-99. overweight women. Br J Nutr. 2013 Oct;110(8):1534-1547.

518 |
Harvie MN, et al. The effects of intermittent or continuous energy restriction Bittman M, Pollan M, Salvador R, De Schutter O. How a national food policy
on weight loss and metabolic disease risk markers: a randomized trial in young could save millions of American lives. Washington Post. Published November
overweight women. Int J Obes (Lond). 2011 May;35(5):714-727. 7, 2014. https://www.washingtonpost.com/opinions/how-a-national-food-policy-
could-save-millions-of-american-lives/2014/11/07/89c55e16-637f-11e4-836c-
Hoddy KK, et al. Safety of alternate day fasting and effect on disordered eating 83bc4f26eb67_story.html. Accessed November 2015.
behaviors. Nutr J. 2015;14:44-47.
Blumenthal DM, Gold MS. Neurobiology of food addiction. Curr Opin Clin
Mattson MP, et al. Meal frequency and timing in health and disease. PNAS 2014 Nutr Metab Care. 2010 Jul;13(4):359-365.
Nov; 111(47):16647-16653.
Blundell J, Finlayson G, Halford J, King N. The Regulation of Food Intake in
Trexler ET, et al. International society of sports nutrition position stand: Beta-Ala- Humans. Endotext website. http://www.endotext.org/obesity/obesity7.3/obesi-
nine. J Int Soc Sports Nutr. 2015;12(30). ty7-3.html. Accessed November 2015.
Unit 15 - Special Scenarios Boeing H, et al. Critical Review: Vegetables and fruit in the prevention of chronic
diseases. Eur J Nutr. 2012;51:637-663.
Agnelli G. Current issues in anticoagulation. Pathophysiol Haemost Thromb.
2005:34;(1 suppl.):2-9. Boffetta P, Garfinkel L. Alcohol drinking and mortality among men enrolled in
an American Cancer Society prospective study. Epidemiology 1990;1:342-348.
Alatalo PI, et al. Effect of moderate alcohol consumption on liver enzymes
increases with increasing body mass index. Am J Clin Nutr. 2008;88:1097-1103. Bongaerts G, Severijnen R, Timmerman H. Effect of antibiotics, prebiotics
and probiotics in treatment for hepatic encephalopathy. Med Hypotheses.
Almawi WY, et al. Luteinizing hormone/choriogonadotropin receptor and folli- 2005;64:64-68.
cle stimulating hormone receptor gene variants in polycystic ovary syndrome. J
Assist Reprod Genet. 2015;32:607-614. Brenner GM. Cardiovascular, renal and hematologic pharmacology; Pharma-
cology of the respiratory, gastrointestinal, and other organ systems; Endocrine
Al-Suhaimi EA, Shehzad A. Leptin, resistin and visfatin: the missing link pharmacology; Chemotherapy. In GM Brenner (ed.) Pharmacology. Philadel-
between endocrine metabolic disorders and immunity. Eur J Med Res. phia, PA: Saunders; 2000: 127-130; 170-171; 258; 301-302; 344-349; 404-410.
2013;18(1):12.
Cao H. Adipocytokines in obesity and metabolic disease. J Endocrinol. 2014
Alvarez MA, Cabre E, Lorenzo-Zuniga V, et al. Combining steroids with enteral Jan;220(2):T47-59.
nutrition: a better therapeutic strategy for severe alcoholic hepatitis? Results of
pilot study. Eur J Gastroenterol Hepatol. 2004;16:1375-1380 Carithers RL Jr. Alcoholic hepatitis and cirrhosis. In Kaplowitz N (ed.) Liver
and Biliary Diseases. 2nd ed. Baltimore, MD: Williams & Wilkins; 1996.
Anestis MD, Selby EA, Crosby RD, et al. A comparison of retrospective self-re-
port versus ecological momentary assessment measures of affective lability in Carithers RL Jr, Herlong HF, Diehl AM, et al. Methylprednisolone therapy in
the examination of its relationship with bulimic symptomatology. Behav Res patients with severe alcoholic hepatitis: a randomized multicenter trial. Ann
Ther. 2010 Jul;48(7):607-613 Intern Med. 1989;110:685-690.
An Y, Sun Z, Zhang Y, et al. The use of berberine for women with polycys- Carmean CM, Cohen RN, Brady MJ. Systemic regulation of adipose metabo-
tic ovary syndrome undergoing IVF treatment. Clin Endocrinol (Oxf). 2014 lism. Biochim Biophys Acta. 2014 Mar;1842(3):424-430.
Mar;80(3):425-431.
Chung KW. Effects of chronic ethanol intake on aromatization of androgens
Arroyo V. Pathophysiology, diagnosis and treatment of ascites in cirrhosis. Ann and concentration of estrogen and androgen receptors in rat liver. Toxicology
Hepatol. 2002;1:72-79. 1990;62:285-295.
Avena NM, Rada P, Hoebel BG. Evidence for sugar addiction: Behavioral and Cohen DA. Neurophysiological pathways to obesity: Below awareness and
neurochemical effects of intermittent, excessive sugar intake. Neurosci Biobe- beyond individual control. Diabetes 2008;57:1768-1773.
hav Rev. 2008;32:20-39.
Committee on Assessing Interactions Among Social, Behavioral, and Genetic
Avena NM, Rada P, Hoebel BG. Sugar and fat bingeing have notable differences Factors in Health. Lyla M. Hernandez and Dan G. Blazer (ed.) Genes, Behavior,
in addictive-like behavior. J Nutr. 2009;139:623-628. and the Social Environment: Moving beyond the nature/nurture debate. National
Academy of Sciences; 2006. http://www.nap.edu/catalog.php?record_id=11693.
Balleisen L, et al. Epidemiological study on factor VII, factor VIII and fibrin- Accessed November 2015.
ogen in an industrial population: I. Baseline data on the relation to age, gender,
body-weight, smoking, alcohol, pill-using, and menopause. Thromb Haemost. Conceição EM, Crosby R, Mitchell JE, et al. Picking or nibbling: frequency and
1985;54:475-479. associated clinical features in bulimia nervosa, anorexia nervosa, and binge
eating disorder. Int J Eat Disord. 2013 Dec;46(8):815-818.
Barnard N. Breaking the Food Seduction. St. Martin; 2003.

References | 519
Dabrowski FA, Grzechocinska B, Wielgos M. The role of vitamin D in ovary syndrome: etiology, pathogenesis and diagnosis. Nat Rev Endocrinol.
reproductive health: A trojan horse or the golden fleece? Nutrients. 2015 2011;7:219–231
May;7(6):4139-4153.
Grant BF, et al. Epidemiology of DSM-5 alcohol use disorder: Results from the
Davies MJ, Baer DJ, Judd JT, et al. Effects of moderate alcohol intake on fasting National Epidemiologic Survey on Alcohol and Related Conditions III. JAMA
insulin and glucose concentrations and insulin sensitivity in postmenopausal Psychiatry. 2015 Aug;72(8):757-766.
women. JAMA. 2002;287:2559-2562.
Grodstein F, Goldman MB, Cramer DW. Infertility in women and moderate
Dean J. Five Techniques for Avoiding Short-sighted Decision-making. PsyBlog. alcohol use. Am J Public Health. 1994;84:1429-1432.
http://www.spring.org.uk/2011/06/five-techniques-for-avoiding-short-sighted-
decision-making.php. Published June 6, 2011. Accessed November 2015. Groff JL, Gropper SS. Advanced Nutrition and Human Metabolism. 3rd ed.
Belmont, CA: Wadsworth/Thomson Learning; 2000:99-103.
Eshel G, et al. Land, irrigation water, greenhouse gas, and reactive nitrogen
burdens of meat, eggs, and dairy production in the United States. PNAS Haber PS, Warner R, Seth D, et al. Pathogenesis and management of alcoholic
2014;111:11996-12001. hepatitis. J Gastroenterol Hepatol. 2003;18:1332-1344.
Ferreira C, Pinto-Gouveia J, Duarte C. Self-compassion in the face of shame Halstead LA. Extraesophageal manifestations of GERD: diagnosis and therapy.
and body image dissatisfaction: implications for eating disorders. Eat Behav. Drugs Today (Barc). 2005;41(B suppl.)19-26.
2013 Apr;14(2):207-210.
Hasse J, Matarese L. Medical nutrition therapy for liver, biliary system, and
Ferreira MP, Weems MKS. Alcohol consumption by aging adults in the United exocrine pancreas disorders. In L.K. Mahan & S. Escott-Stump (eds.) Food,
States: Health benefits and detriments. J Am Diet Assoc. 2008;108:1668-1676. Nutrition, & Diet Therapy. 11th ed. Philadelphia, PA: Saunders; 2004:738-764.
Fitzgerald LZ, Robbins WA, Kesner JS, Xun L. Reproductive hormones Hasse J, Weseman B, Fuhrman MP. Nutrition therapy for end-stage liver disease
and interleukin-6 in serious leisure male athletes. Eur J Appl Physiol. 2012 a practical approach. Support Line. 1997;19:8-15.
Nov;112(11):3765-3773.
Hines IN, Wheeler MD. Recent advances in alcoholic liver disease III. Role of
Food and Agriculture Organization (FAO) of the UN. SAFA Guidelines: Sus- the innate immune response in alcoholic hepatitis. Am J Physiol Gastrointest
tainability Assessment of Food and Agriculture Systems. Version 3.0. Published Liver Physiol. 2004;287:G310-G314.
2013. http://www.fao.org/fileadmin/templates/nr/sustainability_pathways/docs/
Ifland JR, et al. Refined food addiction: A classic substance use disorder. Med
SAFA_Guidelines_Final_122013.pdf. Accessed online November 2015.
Hypotheses. 2009 May;72:518-526.
Galica S, et al. Adipose tissue as an endocrine organ. Mol Cell Endocrinol. 2010
Jazet IM, Pijl H, Meinders AE. Adipose tissue as an endocrine organ: impact on
Mar 25;316(2):129-139
insulin resistance. Neth J Med. 2003 Jun;61(6):194-212.
Gavaler JS, et al. Ethanol: its adverse effects upon the hypothalamic-pitu-
Johnston JL, Fanzo JC, Cogill B. Understanding sustainable diets: a descriptive
itary-gonadal axis. Subst Alcohol Actions Misuse. 1983;4:97-110.
analysis of the determinants and processes that influence diets and their impact
Gearhardt AN, et al. Can food be addictive? Public health and policy implica- on health, food security, and environmental sustainability. Adv Nutr. 2014 Jul
tions. Addiction. 2011;106:1208-1212. 14;5(4):418-29.
Geller J, Srikameswaran S, Zelichowska J. Resilience to shape and weight Katz DL. Nutrition in Clinical Practice. 3rd ed. Lippincott Williams and
concerns and disordered eating: The role of self-compassion. Adv Eat Disord. Wilkins, Wolters Kluwer Health; 2015.
2014;3(1):1-9.
Kelly AC, Vimalakantha K, Miller KE. Self-compassion moderates the rela-
Gibson PR, Shepherd SJ. Evidence-based dietary management of functional tionship between body mass index and both eating disorder pathology and body
gastrointestinal symptoms: The FODMAP approach. J Gastroenterol Hepatol. image flexibility. Body Image. 2014 Sep;11(4):446-53.
2010;25:252-258.
Kenny PJ. Reward mechanisms in obesity: New insights and future directions.
Goldschmidt AB, Crosby RD, Cao L,et al. Ecological momentary assessment of Neuron 2011;69:664-679.
eating episodes in obese adults. Psychosom Med. 2014 Nov-Dec;76(9):747-752.
Kessler DA. The End of Overeating. Rodale; 2009.
Goldschmidt AB, Crosby RD, Engel SG, et al. Affect and eating behavior in
Kiernan J. Why Food Addiction is Deadlier Than Drinking. The Fix website.
obese adults with and without elevated depression symptoms. Int J Eat Disord.
Published June 23, 2011. http://www.thefix.com/content/oa-vs-aa. Accessed
2014 Apr;47(3):281-286.
November 2015.
Goodarzi MO, Dumesic DA, Chazenbalk G, Azziz R. Polycystic
Klatsky AL, Armstrong MA, Friedman GD. Alcohol and mortality. Ann Intern
Med. 1992;117:646-654.

520 |
Kratina K. Orthorexia Nervosa. National Eating Disorders Association (NEDA) pathobiochemical and clinical chemical aspects of leptin, ghrelin, adiponectin,
website. https://www.nationaleatingdisorders.org/orthorexia-nervosa. Accessed and resistin. Clin Chem. 2004 Sep;50(9):1511-1525.
November 2015.
Mezey E, Potter JJ, Rennie-Tankersley L, et al. A randomized placebo con-
Kroenke CH, Chu NF, Rifai N, et al. A Cross-sectional study of alcohol controlled trial of vitamin E for alcoholic hepatitis. J Hepatol. 2004;40:40-46.
sumption patterns and biologic markers of glycemic control among 459 women.
Diabetes Care. 2003;26:1971-1978 Micali N, et al. Adolescent eating disorder behaviours and cognitions: gen-
der-specific effects of child, maternal and family risk factors. Br J Psychiatry.
Kuhn C, Swartzwelder S, Wilson W. Buzzed: The Straight Facts About The 2015 Oct;207(4):320-327.
Most Used And Abused Drugs. 3rd ed. W.W. Norton & Company; 2008.
Michopoulos V, Mancini F, Loucks TL, Berga SL. Neuroendocrine recovery
Latifi R, Killam RW, Dudrick SJ. Nutritional support in liver failure. Surg Clin initiated by cognitive behavioral therapy in women with functional hypothalamic
North Am. 1991;71:567-578. amenorrhea: a randomized, controlled trial. Fertil Steril. 2013 Jun;99(7):2084-2091
Lieber C. Medical and Nutritional Complications of Alcoholism: Mechanism Naitou, K. et al. Colokinetic effect of noradrenaline in the spinal defecation
and Management. New York: Plenum Medical Book Co., 1992. center: implication for motility disorders. Sci Rep. 2015;5:12623.
Living Planet Report 2010. Global Footprint Network website. http://www.foot- Nakaya AC. Alcohol. Opposing Viewpoint Series. Greenhaven Press; 2008.
printnetwork.org/en/index.php/newsletter/det/human_demand_outstripping_na-
tures_regenerative_capacity_at_an_alarming_rate. Accessed November 2015. National Eating Disorders Association (NEDA) website. https://www.nationale-
atingdisorders.org/get-facts-eating-disorders. Accessed November 2015.
Li Y, et al. Effect of berberine on insulin resistance in women with polycystic
ovary syndrome: study protocol for a randomized multicenter controlled trial. Novick J. Gluten & Peanuts: Learning from History.
Trials 2013 July;14:226.
Obesity and Food Addiction Summit webcasts: http://www.foodaddictionsummit.
Lochs H, Plauth M. Liver cirrhosis. Rationale and modalities for nutritional org/agenda.htm. Accessed November 2015.
support – the European Society of Parenteral and Enteral Nutrition consensus
O’Shea RS, McCullough AJ. Treatment of Alcoholic Hepatitis. Clin Liver Dis.
and beyond. Curr Opin Clin Nutr Metab Care. 1999;2:345-349.
2005;9:103-134.
Loucks AB. Is stress measured in joules? Military Psychology. 2009;21(1 suppl)
Ostrovsky NW, Swencionis C, Wylie-Rosett J, Isasi CR. Social anxiety and
S101-S107.
disordered overeating: An association among overweight and obese individuals.
Louveau A, et al. Structural and functional features of central nervous system Eat Behav. 2013 Apr;14(2):145-148.
lymphatic vessels. Nature website. http://www.nature.com/nature/journal/vaop/
Otero Bedoya J, Landeira G, Corino M, et al. Ascites due to hypothyroidism
ncurrent/full/nature14432.html. Published June 1, 2015. Accessed November 2015.
in a patient with alcoholic cirrhosis. Acta Gastroenterol Latinoam. 2001
Maneesh M, et al. Alcohol abuse-duration dependent decrease in plas- May;31:77-81.
ma testosterone and antioxidants in males. Indian J Physiol Pharmacol.
Parylak SL, Koob GF, Zorrilla EP. The dark side of food addiction. Physiol
2006;50:291-296.
Behav. 2011 Jul;104(1):149-156.
Matheson BE, Tanofsky-Kraff M, Shafer-Berger S. Eating patterns in
Perney P, et al. Are preoperative patterns of alcohol consumption predictive
youth with and without loss of control eating. Int J Eat Disord. 2012
of relapse after liver transplantation for alcoholic liver disease? Transpl Int.
Dec;45(8):957-961.
2005:18;1292-1297.
Milkman KL, Rogers T, Bazerman MH. Harnessing our inner angels and
demons: What we have learned about want/should conflicts and how that
Pollert GA, Engel SG, Schreiber-Gregory DN, et al. The role of eating and
emotion in binge eating disorder and loss of control eating. Int J Eat Disord.
knowledge can help us reduce short-sighted decision making. Perspect Psychol
2013 Apr;46(3):233-238.
Sci. 2008;3:324-338.
Position of the Academy of Nutrition and Dietetics: The role of nutrition

McCullough AJ, O’Connor JFB. Alcoholic liver disease: proposed recommen-
in health promotion and chronic disease prevention. J Acad Nutr Diet.
dations for the American College of Gastroenterology. Am J Gastroenterol.
2013;113:972-979.
1998;93:2022-2036
Position of the American Dietetic Association: Vegetarian diets. J Am Diet

McQuillan S. Breaking the bonds of food addiction. Psychology Today. Penguin
Assoc. 2009;109:1266-1282.
Group; 2004.
Preedy VR, Adachi J, Ueno Y, et al. Alcoholic skeletal muscle myopathy:

Meier U, Gressner AM. Endocrine regulation of energy metabolism: review of
definitions, features, contribution of neuropathy, impact, and diagnosis. Eur J
Neurol. 2001;8:677-687.

References | 521
Pronsky ZM. Food-Medication Interactions. 12th ed. Birchrunville, PA: Suter PM. Is alcohol a risk factor for weight gain and obesity? Crit Rev Clin Lab
Food-Medication Interactions; 2002. Sci. 2005;42:197-227.
Purohit V. Can alcohol promote aromatization of androgens to estrogens? A Szalavitz M. Heroin vs. Haagen-Dazs: What food addiction looks like in the
review. Alcohol 2000;22:123-127. brain. Time. Published April 4, 2011. http://healthland.time.com/2011/04/04/
heroin-vs-haagen-dazs-what-food-addiction-looks-like-in-the-brain. Accessed
Ramond MJ, Poynard T, Rueff B, et al. A randomized trial of prednisolone in November 2015.
patients with severe alcoholic hepatitis. N Engl J Med. 1992;326:507-512.
Szalavitz M. Hooked on addiction: From food to drugs to internet porn. Time.
Ramoz N, Versini A, Gorwood P. Anorexia nervosa and estrogen receptors. Published April 15, 2011. http://healthland.time.com/2011/04/15/hooked-on-ad-
Vitam Horm. 2013;92:141-163. diction-from-food-to-drugs-to-internet-porn/. Accessed November 2015.
Rehm J, et al. Alcohol-related morbidity and mortality. National Institute on Alco- Teran J. Nutrition and liver diseases. Cur Gastroenterol Rep. 1999;1:335-340.
hol Abuse and Alcoholism (NIAAA) website. Published December 2003. http://
pubs.niaaa.nih.gov/publications/arh27-1/39-51.htm. Accessed October 2008. Thase ME. Bipolar depression: issues in diagnosis and treatment. Harv Rev
Psychiatry. 2005;13:257-271.
Sacks FM, et al. DASH-Sodium Collaborative Research Group. Effects on blood
pressure of reduced dietary sodium and the dietary approaches to stop hyperten- Tilman D, Clark M. Global diets link environmental sustainability and human
sion (DASH) diet. DASH-Sodium Collaborative Research Group. N Engl J Med. health. Nature 2014;515:518-522.
2001;344:3-10.
Wehr E, et al. Vitamin D-associated polymorphisms are related to insulin
Sandor RS. Thinking simply about addiction. Penguin Books; 2009. resistance and vitamin D deficiency in polycystic ovary syndrome. Eur J Endo-
crinol. 2011 May;164:741-749.
SCAN DPG webinar. Treating the Injured Athlete: Nutrition strategies to pro-
mote healing and recovery. http://www.scandpg.org/store/products/10299/. Dana Wei W, et al. A clinical study on the short-term effect of berberine in compar-
Angelo-White; 2015. ison to metformin on the metabolic characteristics of women with polycystic
ovary syndrome. Eur J Endocrinol. 2012 Jan;166(1):99-105.
Schreiber-Gregory DN, Lavender JM, Engel SG, et al. Examining duration
of binge eating episodes in binge eating disorder. Int J Eat Disord. 2013 Wenk GL. Your brain on food. Oxford University Press; 2010.
Dec;46(8):810-814.
White AC, Thannickal VJ, Fanburg BL. Glutathione deficiency in human
Schulte EM, et al. Which foods may be addictive? The roles of processing, fat disease. J Nutr Biochem. 1994;20:139-144.
content, and glycemic load. PLoS One. 2015 Feb 18;10(2):e0117959.
United States Health and Human Services. Dietary Guidelines for Americans.
Shire US Inc. What is binge eating disorder? BingeEatingDisorder.com website. United States Department of Agriculture; 2010.
http://www.bingeeatingdisorder.com/what-is-BED.aspx. Accessed November
2015. Zhao S. et al. Family-based analysis of eight susceptibility loci in polycystic
ovary syndrome. Sci Rep. 2015 Jul 29;5:12619
Shomaker LB, Tanofsky-Kraff M, Elliott C, et al. Salience of loss of control
for pediatric binge episodes: does size really matter? Int J Eat Disord. 2010 Unit 16 - Business 101 for Fitness &
Dec;43(8):707-716. Nutrition Pros
Simmons MA. Anticoagulants, Fibrinolytics & Antianemics. In M.A. Simmons None used
(ed.), Pharmacology. Ventura, CA: Biotest Publishing Company, Inc.; 2002:
132. Unit 17 - Continuing Ed for the Coach
Sokoloff NC, Ackerman KE. Treatment and prevention of eating disorders in None used
athletes. SCAN’s PULSE. Winter 2015;34:6-9.
Stickel F, Hoehn B, Schuppan D, Seitz HK. Review article: Nutritional therapy

in alcoholic liver disease. Aliment Pharmacol Ther. 2003;18:357-373.
Strassner C, et al. How the organic food system supports sustainable diets and
translates these into practice. Front Nutr. 2015;2:19.
Strauss E, Gomes de Sá Ribeiro Mde F. Bacterial infections associated with

hepatic encephalopathy: prevalence and outcome. Ann Hepatol. 2003;2:41-45.

522
INDEX ambivalence 290 biological sex 454 cells 23

amine 108 BMI. See Body Mass Index goblet 42
SYMBOLS amino acid pool 80 body dysmorphia 438 parts of 31

cytosol 33
amino acids 9 Body Mass Index 305
5 Whys 284 endoplasmic reticulum
ammonia 108 bolus 51 37
6 steps of coaching 272
amylase 50 bomb calorimeter 114 Golgi apparatus 37
7 steps to individualization
395 amylopectin 157 bonk 418 lipids 31
ß 39 amylose 157 branched chain amino acid lysosomes 38

107, 188 mitochondria 33
α 183 anabolic-androgenic steroids
402 bright spots 274 nucleus 37
α-ketoacid 108
anaerobic 100 business strategies 481 peroxisomes 38
A anaerobic threshold 147 corporate model 485 plasma membrane 31
anasarca 240 individual model 481
AAS. See anabolic-androgen- types 42
ic steroids ancestry 461 online coaching model
change 271
485
absorption 70 andropause 467 cholecalciferol 213
partnership model 487
acetaldehyde 447 Antabuse 447 cholesterol 31, 39
small group model 483
acetate 447 antidiuretic hormone 223 transformation contest chromosomes 37
acetyl-CoA 84 apolipoproteins 173 model 484 chronic disease 7
acquired immune system. arginine vasopressin. See an- chronotypes 417
See adaptive immune system tidiuretic hormone C
chylomicron 96, 172
actin 141 atherosclerosis 102 CAFO. See confined animal
chyme 54
active listening 274 atom 28 feeding operation
circadian 34
active transport 70 ATP / PCr system 82 calciferol 213
cisterna 38
acupressure 458 avidin 209 calorie 113
coaching super powers 255
adaptive immune system 448 Calorie 113
B capillarization 149
co-enzyme 40, 199
adenosine triphosphate 33
co-factor 28
adipocyte 64, 79 bariatric surgery 57 carbohydrates 13
cognitive dietary restraint
adipokines 458 BCAA. See branched chain carbon skeleton 107
438
amino acid cardioprotective 102
adipose tissue 96 columnar epithelial cells 42
beta. See ß catalyst 39
adrenal medulla 91 communication skills 267,
bicarbonate 58 catalyze 40 295
aerobic 100
bile 39 cations 223 Community Supported Agri-
ALA. See alpha linolenic acid
bioactive 30 culture 373
alcohol 446 CDR. See cognitive dietary
bioavailability 199 restraint compounds 28
alpha linolenic acid 99
concentration gradient 70,
202
Behavior Modification
Index | 523
conditionally essential amino

acids 189
E F GERD. See gastroesophageal
reflux disease
confined animal feeding eating disorder not otherwise facilitated diffusion 70 glucagon 91
operation 474 specified 433
FAD+ 85 gluconeogenesis 93
ConsumerLab, NSF 391 edema 239
FADH2 85 glucoregulatory hormone 61
continuing education EDNOS. See eating disorder
fair trade 373 glucose 157
494–499 not otherwise specified
fast-twitch muscle fibers 127 glucose 6-phosphate 89
Cori cycle 94 eicosanoids 180
fat soluble 199 glutamine 186
creatine 82 eicosapentaenoic acid.
See EPA fatty acid 169 GLUT family 164
creatine kinase 82
electrolyte 133, 202 fatty acid synthase system 99 glycemic index (GI) 161
cross-bridges 141
electron transport chain 84 FDA. See Food and Drug glycemic load 162
CSA. See Community Sup- Administration
ported Agriculture elongation 99 glycerol 171
feces 61
cytochrome 85 emesis 71 glycogen 60
first pass metabolism 60
cytokine 188 emulsification 58 glycogenesis 88
fluid balance 233
cytokines 458 endocrine 61 glycogenolysis 89
FODMAP 470
cytoplasm 33 endocrine system glycogen phosphorylase 89
digestion and 65 food addiction 442
cytosol 27 glycogen synthase 89
endoplasmic reticulum 37 Food and Drug Administra-
tion 391 glycolysis 91
D energy balance 113 glycoproteins 37
food sensitivities 469
DE. See disordered eating energy imbalance 124 glycosaminoglycans 453
fructose 157
deamination 60, 107 energy transfer 78 GMP. See good manufactur-
dehydration 236 enterocytes 58 G ing practices
deoxyribonucleic acid. enterohepatic circulation 59 goals 283

galactose 157
See DNA enzyme 26 goblet cells 42
gallbladder 58, 61
desaturation 99 EPA 180 goitrogens 217
gastric hydrochloric acid 184
detoxify 39 epigenetics 9 Golgi apparatus 37
gastric juice 54
DHA 31, 180 epiglottis 51 good manufacturing practic-
gastroesophageal reflux dis- es 391
digestion 46 epinephrine 89 ease 52, 53
direct calorimetry 121 growth hormone (GH) 97
EPOC 145 gastrointestinal tract 47
discrepancy 293 gynecomastia 460
esophagus 52 gastrotransmitter 64
disordered eating 433 essential amino acid 104 gender 454 H
DNA 29 essential amino acids 189 gene 30
HDL particles 102
docosahexaenoic acid. evolutionarily conserved 30 genetic polymorphism 30
See DHA heme iron 218
exocrine 61 genetics 9, 29
duodenum 58 hemochromatosis 202
gene variant 9
hemoglobin 149

524
hepatic portal system 59 innate immune system 448 features 318 M

hepatocyte 60, 79 insulin index (II) 162 limiting factors 327
macrominerals 202
hiatal hernia 54 intermittent fasting 11 strategies 327
troubleshooting 353 macromolecules 28
homeostasis 26 intestinal brush border 58
Level 2 308, 361–397 macronutrients 28, 156
hormesis 227 intrinsic factor (IF) 211
body type eating 379 Malabsorption syndromes
hormonal contraception. introduction 3 204
See HRT coaching tasks 309
ionic state 202 menopause 467
hormonal replacement thera- features 364
isoforms 164 mental skills 264
py. See HRT limiting factors 366
hormone 28 J readiness 365 MET 143
steroid 37 strategies 370 metabolic testing 143
jejunum 58
hormone sensitive lipase 97 troubleshooting 393 metabolism 24
Joule 113
HPA axis 459 Level 3 312, 399–430 MI. See motivational
interviewing
HPG axis 459 K coaching tasks 313, 402
features 399 microbiome 5
HRT 460
Kashin-Beck disease 223 microminerals 202
HSL. See hormone sensitive limiting factors 401
lipase kcal 113 strategies 404 micronutrient 198
hydration strategies 245 Keshan disease 223 troubleshooting 424 micronutrients 3, 28
hydrocarbons 169 ketone body 59 life stages microorganism 38
hydrophilic 31, 173 kinetic energy 113 nutrition and 462 minerals 3
hydrophobic 32 Koilonychia 219 ligand 40 mitochondria 33
hyper-palatable 14 Krebs cycle 84 linoleic acid 99, 176 mitochondrial membrane 33
hypervitaminosis 205 linolenic acid 176 molecule 28
L
hypogonadism 440 lipase 50 monosaccharides 157
hyponatremia 238 lactic acid 84 lipid mobilization 97 monounsaturated fat 33
large intestine 62 lipids 31 monounsaturated
I laws of thermodynamics 78 lipogenesis 96 fatty acid 99
ileocecal valve 59 LCAT. See lecithin-cholester- lipolysis 97 motivational interviewing

ol acyltransferase 291
ileum 58 lipoprotein 59, 96
LDL particles 102 muscle hypertrophy 149
immunity lipoprotein lipase 96, 174
leaky gut syndrome 73 myocyte 79
nutrition and 447 liver 59
lecithin-cholesterol acyltrans- myofibrillar hypertrophy 149
immunocompromise 448 ferase 102 lock-and-key model 39
myofibrils 141
indirect calorimetry 120 leptin 458 lower esophageal sphincter
52
myoglobin 143
induced fit model 40 Level 1 305, 318–359
lysosome 38 myosin 141
inflammation 3, 452 coaching process 321
injury 452 coaching tasks 306
Index | 525
N omega-3 99 phospholipids 31 R
omega-6 99 phytochemicals 4
NAD+ 84 reactive oxygen species 86
omega-6 / omega-3 fatty acid phytonutrients 47
NADH 83 ratio 181 receptor-ligand binding
plant-based eating 471 complex 40
Natural Health Products organelle 27
Directorate 391 plasma amino acid pool 186 renin-angiotensin-aldoste-
organic compounds 199 rone system 223
natural immune system. plasma membrane 31
See innate immune system orthorexia 438 research
plasma pool of amino acids
NEAT. See non-exercise Orthorexia 240 104 continuing education and
activity thermogenesis osmolarity 237 polycystic ovarian syndrome 496
Neiguan point 458 459 respiratory quotient 120

osmoreceptor 237
nervous system polysaccharides 157 retronasal olfaction 49
ostomies 204
digestion and 67 polyunsaturated fat 33, 99 ribonucleic acid. See RNA
outcome-based decision
neurotransmitter 68 making 278 portal vein 59 ribosomes 37
neurotransmitters 68 oxaloacetate 94 potential energy 28, 113 RNA 38
NHPD. See Natural Health oxygen debt 145 prebiotic 64 ROS. See reactive oxygen
Products Directorate oxygen deficit 145 pre-eclampsia 456 species
nitrosamines 221 pregnancy 455 RQ. See respiratory quotient
non-essential amino acid 104
P probiotics 64
non-essential amino acids
S
paleo 11 proenzyme 184
189 salivary amylase 158
palmitate 99 prohormones 212, 402
non-exercise activity thermo- sarcomeres 141
pancreas 58, 61 prostaglandin 39
genesis 411
pancreatic lipase 171 prostaglandins 458 sarcoplasmic hypertrophy
non-heme iron 218 149
PCOS. See polycystic ovarian protein breakdown 105
nootropics 402 saturated fat 33
syndrome
norepinephrine 89 protein synthesis 38, 105
PCr. See phosphocreatine saturated fatty acid 99
nucleus 29 Proteoglycan 220
PED. See performance-en- saturated fatty acids 170
nutrigenomics 31 hancing drug proteolytic enzyme 58
secondary 183
nutritional levels 301 peptic ulcer 71 proton 86
second messenger 40
peptide chain 107 Purine 207
short-chain fatty acids 54
O pyloric sphincter 54
peptides 183 SIBO. See small intestinal
OBDM. See outcome-based performance-enhancing drug pyruvate 83 bacterial overgrowth
decision making 402 signal transduction 40
olfaction 49 peristalsis 52
Q
simple diffusion 70
retronasal 49 peroxisome 38 quaternary 183 small intestinal bacterial
oligosaccharide 64 pharynx 51 overgrowth 326
oligosaccharides 157 phosphocreatine 82 small intestine 57

526
solute 235 villi 58

stearic acid 180 villus atrophy 58
steroid hormones 37 vitamins 3
stomach 54 VLDL. See very low density
lipoprotein particles
supercompensate 418
super shake 331 W
supplements 422
water manipulation 312
T water soluble 199
ws of thermodynamics 78
tertiary 183
thermogenesis 117 Y
tight cellular junctions 71
Yale Food Addiction scale
tocopherols 214 443
tocotrienols 214
transamination 86 Z
transcription 37 Z-discs 141
trans fat 33, 182 zoochemicals 4
translation 37 zoonutrients 47
triage 278
triglyceride 59
triglycerides 171
U
understanding clients 262
unsaturated fatty acids 170
upregulated 30
urea cycle 108
V
vascularization 129
vasodilation 68
vegetarianism 471
very low density lipoprotein
particles 99
vesicles 38
800.892.4772 • ISSAonline.edu
The Complete Guide to Nutrition Workbook and Study Guide

The Complete Guide to Nutrition
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Krista Scott-Dixon, PhD
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1.800.892.4772 • 1.805.745.8111 (international) Helen Kollias, PhD, CSCS
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About the Authors

Through writing, coaching, speaking, teaching, and curriculum development, Krista

Ryan Andrews is a world-leading educator in the fields of exercise science and

A nationally ranked competitive bodybuilder from 1996-2001, and now a certified

International Sports Sciences Association

Brian St. Pierre is a renowned expert in performance nutrition.

As Precision Nutrition’s Director of Performance Nutrition, Brian contributes to

Camille DePutter is an author, speaker, and communications consultant with a rich

Nutrition: The Complete Guide

How to Use This Text

“Will I ever need to know this in the real world?”

“Will this be on the test?”

“Will I ever need to know this again in my life?”

So why learn all this information?

Be prepared for anything. Learn as much foundational knowledge as possible. Now

What this means

In this program, we’ll provide a lot of foundational knowledge.

We give you more details below.

International Sports Sciences Association

By the end of this course, we expect you to understand:

• how to apply that knowledge to working with clients;

• how to assess, monitor, and revise client programs;

• how to communicate your knowledge effectively; and

How the program is organized

Section 1: Nutrition science

Section 2: Nutritional practice

In Section 2, we’ll introduce you to how to coach, including:

• How to prepare for clients

• How to interact with different clients

• How to assess clients

• How to know which approaches are best for which clients

Nutrition: The Complete Guide

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Nutrition: The Big Picture

1. Objectives 5. The cycle of food

2. What is food? 6. What is nutrition coaching?

3. What is good nutrition? 7. What this program will cover

4. What’s the best diet? 8. Case Study

You’ll learn: • how to answer the often-asked question: “What’s the

Micronutrients: Vitamins and minerals

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• suppress cancer cell development; and

Food is so much more than fuel. What’s more…

Your body isn’t even completely

Nutrition: The Complete Guide

We’re incredibly complicated, self-organizing, agenda-driven, only-sorta-human