Metabolic time bombs – can you defuse them?

Seemingly healthy clients may be anything but. Clinical exercise physiologist Dr Bill Sukala has some pertinent advice to save you from ever having to call 000 for one of your clients.

Picture this: a prospective new training client approaches you and tells you he wants to book a package of personal training sessions with you. He is 42 years old, 170cm tall, and weighs 110 kilograms, with most of his fat located around his abdomen. He works a high-pressure corporate job that has him working very long hours (in addition to a long, crowded commute).

Filling in your risk factor questionnaire, he writes that he ‘does plenty of walking around the office’, and has ‘no problems with his blood pressure, blood sugar levels, or cholesterol’. He also claims he doesn’t smoke cigarettes, although you notice a faint whiff of smoke emanating from his clothes.

He’s excited to embark on his new health kick and wants you to start him on his fitness regime today. You’ve got a couple of timeslots free in your afternoon schedule, so what do you do?

  • Agree to his wishes and take him to the gym floor for a warm up
  • Tell him you need to do more testing before you can train him.

The reality is that many people who join fitness facilities have medical problems, both known and unknown. Assuming that your clients are healthy unless they disclose otherwise is a potentially dangerous approach. These are serious questions that must be properly addressed, as your client’s safety and your (and your club’s) liability could be on the line.

To help protect everyone involved, you need to prepare yourself for ‘apparently healthy’ clients who may actually be ticking time bombs. You can minimise risk (but never eliminate it) by putting a series of checks into place.

Risk factor questionnaires

When prospective clients fill out risk factor questionnaires you are relying on their honesty or best judgement without any corroborating information.

For example, they might declare that their blood pressure is normal, but how can you be certain unless you check it? And if you do check it, how sharp are your manual blood pressure skills? And when you get a number, what does it actually mean? Your textbooks tell you that a blood pressure of 140/90 is the threshold for high blood pressure – but if you get a reading of 138/88, does that mean the client is free to exercise?

See no evil, feel no evil …doesn’t mean evil isn’t there

The problem with heart and metabolic problems is that neither you or your clients can see or feel them. For example, there are plenty of people walking among us with undiagnosed type 2 diabetes and high blood pressure. In combination, these conditions magnify damage to critical arteries and greatly increase the risk of a heart attack and stroke.

Exercise increases both heart rate and blood pressure. In a setting of underlying metabolic disease, these increases can potentially create instability in coronary artery plaques, causing them to rupture, leading to a heart attack – something you don’t want happening to one of your clients.

The perfect metabolic storm

Clients with big bellies have a higher likelihood of their internal biomarkers, i.e. glucose, insulin and lipids, being out of balance. It may appear to be ‘profiling’ – making assumptions about people from their physical appearance – but there is much scientific evidence linking wide waistlines to health problems.

Deep belly fat, also known as visceral fat, embeds itself around the organs and secretes harmful substances known as adipocytokines into the bloodstream. Adipocytokines have a number of adverse effects on metabolic health, including:

  • blood vessel constriction, leading to high blood pressure
  • insulin resistance, leading to diabetes
  • altered fat metabolism, leading to high cholesterol and triglycerides
  • inflammation, contributing to plaques in coronary arteries and insulin resistance.

Where to from here?

Consider the following in handling would-be metabolic time bombs:

Be prepared

Before you let a single member through the door, can you answer the following three questions?

  • Does the facility at which you train clients have an automated external defibrillator (AED) in place?
  • Are you certified in first aid and CPR, including operation of the AED?
  • Do you have your own protocols in place for when a member becomes unconscious?

Know your limits

On a scale of 1 to 10, how comfortable do you feel working with people with multiple risk factors or documented medical conditions?

If the thought of working with a potential time bomb makes you squirm, you should refer your client to an advanced trainer or experienced clinical exercise physiologist. They can work with the client first to establish safe exercise boundaries and then refer the client back to you with these guidelines.

It is also advisable to pursue continuing professional development opportunities that expand your knowledge of the various medical conditions you might encounter in your role as a fitness professional.

Spot early signs and symptoms
An ounce of prevention is worth a pound of cure. Advanced heart problems and diabetes often reveal themselves through outward signs and symptoms.

Heart conditions

With regards to the heart, look out for changes in complexion, clammy skin, chest pain, pressure, or tightness, particularly localised to the left jaw, arm, shoulder or back. All these could be indicative of an underlying cardiac condition which would merit further evaluation by a medical practitioner.

In many cases, people will exhibit signs and symptoms before a full-blown heart attack. If your client is experiencing chest or associated pain, stop the training immediately and, if the pain does not subside on its own, call an ambulance. If it does, advise your client that they must see their doctor before they exercise again.

Diabetes

In the case of diabetes, low blood sugar is more likely to be experienced during or after exercise. Exercise is a very potent medicine which, depending on the person’s individual response, can cause blood sugar levels to drop to dangerously low levels (called hypoglycaemia).

Blood glucose is the central nervous system’s high-octane fuel source. This explains why common symptoms of low blood sugar are dizziness or light-headedness, fatigue, slurred speech, impaired coordination and confusion.

High blood pressure
High blood pressure is unlikely to reveal itself but, in some cases, a significant drop in blood pressure (hypotension) can result in dizziness, confusion, and loss of coordination. Because these are similar to hypoglycaemia, it is advisable to check both blood pressure and blood glucose levels (you can purchase a glucose meter at any chemist).

Denial is not a river in Africa

People – most often men – with health problems are often in denial, even when they know something is wrong. If you identify someone who is high-risk, you should tell them to make an appointment with their GP for further referral and tests. Tell them they will need a signed release from their doctor before you train them again.

Some people will ignore this recommendation and seek out another trainer. Before this becomes a problem, let them know that doing so would put them in harm’s way and would also be misleading to the other trainer if they didn’t reveal their health issues. If the other trainer is made aware of the health concerns, then proceeding with training sessions would be negligent.

Take home message

People with multiple cardiometabolic risk factors and documented medical conditions frequently train at fitness facilities and with personal trainers. With established screening, assessment, safety, and referral protocols in place, risk to both clients and trainers can be minimised. When training clients in facilities, management should be prepared for any medical event by ensuring staff members are trained in emergency protocols. Trainers should seek out additional educational opportunities to learn about cardiac and metabolic conditions, safe exercise prescription and monitoring, and handling potentially dangerous signs and symptoms.


Bill Sukala, PhD is a Sydney-based clinical exercise physiologist specialising in clients with cardiac and metabolic concerns. He holds a PhD in Exercise and Science with a research focus in diabetes and obesity, a Masters degree in Exercise Physiology with specialisation in cardiology, and a Bachelors degree in Nutrition. An international speaker who has delivered keynotes, seminars, and workshops across five continents, Bill is frequently quoted on health topics by major media outlets around the world. drbillsukala.com.au