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Resistance Training for the Client with Metabolic Syndrome

By Brad Schoenfeld, MSc, CSCS, CSPS, NSCA-CPT

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September 2012

Resistance Training for the Client with Metabolic Syndrome

By Brad Schoenfeld, MSc, CSCS, CSPS, NSCA-CPT

What is Metabolic Syndrome

Lifestyle disease directly linked to obesity. Primary clinical outcome is cardiovascular disease. Predisposes to other conditions including polycystic ovary syndrome, fatty liver, cholesterol gallstones, asthma, sleep disturbances, and some forms of cancer.

Metabolic Syndrome Stats

Approximately 25% of adults in the U.S. have metabolic syndrome Approximately 43% of those over 60 years of age have metabolic syndrome
% Afflicted


% Total Population

% Over 60

Then vs. Now

In early-hunter gatherer populations, men hunted 1-4 nonconsecutive days per week and women gathered food every 2-3 days (Eaton et al. 2002)
Estimated steps per day: 20,000

Present Westernized society has decreased caloric expenditure by approximately 1200 calories compared with early 20th century hunter-gatherer societies (Cordain et al. 1998)

Effects of Lifestyle on Health

The prevalence of Type 2 diabetes in present hunter-gatherer, rudimentary horticultural, simple agricultural, and pastoral societies is 1.1% (Diamond, 2003). An estimated 32.8% to 38.5% of female and male Americans, respectively, born in 2000 who will contract diabetes during their lifetime (Narayan et al. 2003)

Clinical identification of metabolic syndrome. Diagnosis is made when at least 3 of the 5 characteristics are present (some say that insulin resistance must be present for diagnosis). Risk Factor
Abdominal Obesity (by waist circumference Men Women
Triglycerides HDL Cholesterol Men Women Blood Pressure Fasting Glucose

Defining Level
>102 cm (>40 in) >88 cm (>35 in) 150 mg/dL <40 mg/dL <50 mg/dL 130/85 mm Hg 110 mg/dL

Predisposing Factors
Age Hispanic or South Asian descent. Family history of type II diabetes.

Metabolic Syndrome Flowchart

Genetics Inactivity Obesity Diet

Reduced Calorie Diet

Regular Exercise

High Blood Pressure


Insulin Resistance

Pro Inflammatory State

Pro Thrombotic State

Metabolic Syndrome and CVD Risk

The Kuopio Ischaemic Heart Disease Risk Factor Study of 1209 Finnish men (aged 42 to 60 years) found that metabolic syndrome increased the risk of cardiovascular mortality by ~3-4 times after adjustment of other risk factors (Lakka et al. 2002) The Framingham Heart Study showed that metabolic syndrome alone predicted 25% of all new-onset cases of CVD (Grundy et al. 2004)

Metabolic Syndrome and Life Expectancy

Metabolic syndrome is associated with a ~twofold increase in all-cause mortality (Lakka et al. 2002)
Can reduce average life expectancy by ~5 years
79 78.2 78 77 76 75 74 73 72 71 70 Normal Life Expectancy Life Expectancy Metabolic Syndrome


Even greater effect on quality of life!

The Importance of Exercise

Physical activity serves as a key physiological regulator of thrifty genes to inhibit unhealthy adiposity (Sinha et al. 2002)

Metabolic Syndrome and Strength

Muscular strength is inversely associated with prevalence of the metabolic syndrome
Effects are independent of aerobic fitness as well as age and smoking

Fitness-Based Intervention
Weight loss should be the primary target for intervention in those with metabolic syndrome Proper diet and caloric restriction is essential to achieving weight loss A combination of cardiovascular exercise and resistance training can enhance weight loss, facilitate weight management, as well as directly improving measures of cardiovascular risk


Key Point!
Combined resistance training and aerobic training is more effective in combating metabolic syndrome than either alone

Exercise Training and Obesity

Exercise increases energy expenditure both during and after training Exercise is associated in a preferential reduction in belly fat (Hunter et al. 2010)

Exercise Training and Insulin Sensitivity

Significant improvements in insulin sensitivity and glucose uptake
Increased muscle mass increases uptake capacity Enhanced GLUT4 response

GLUT4 Translocation Illustrated

Plasma Membrane Glucose

Time Course of Exercise-Induced Effects

The effects of exercise on insulin resistance are fairly short-lived.
Insulin sensitivity in rodents reverted back to baseline approximately 2953 hours after exercise (Kump et al. 2005). Insulin sensitivity declines after 2 weeks of reduced physical activity in untrained humans (2010).


Key Point!
Exercise consistency is paramount to maintaining insulin sensitivity!

Exercise Training and Lipids

Lowered triglyceride concentrations Reduced postprandial lipemia Decreased concentrations of small LDL particles Increased HDL-C concentrations Increased lipoprotein enzyme activity

Exercise Training and Hypertension

Reduced BP response to maximal exercise Improved HR recovery Smaller elevations in BP when performing activities that require muscular effort Helps manage co-morbidities (e.g., diabetes) Modest reductions in resting BP (~2-4%)

Resistance Training vs. Aerobics

Potteiger et al. (2012) evaluated the effects of resistance training vs. aerobic training on physically inactive overweight males (age 27 48 years).
Equated training frequency and exercise session duration combined with energy restriction Calculated a MetSyn z score from the total of risk factors (triglycerides, HDL cholesterol, fasting glucose, waist circumference, and MAP) Both resistance training and aerobic produced similar reductions in clinical risk factors for metabolic syndrome

Exercise Considerations
Medical clearance should be obtained before training the client with metabolic syndrome.
Consult with physician with respect to any medications

Monitor BP before and after exercise

Routine check of BP between sets Uncontrolled hypertension is an absolute contraindication for RT (>180/110 mm/Hg) Hypertension of >160/>100 mm/Hg is a relative contraindication for RT

Avoid holding breath / straining (Valsalva Maneuver)

Exhale during concentric, inhale during eccentric

Avoid excessive tight gripping (pressor response) Be aware for signs of hypoglycemia

Exercise Intervention Program

Modified super-circuit training employing a combination of resistance and aerobic exercise Perform 3, non-consecutive days per week (e.g. M, W, F) Additional moderate intensity cardio can be performed on alternate days

Training Protocol Template

5-minute warm-up Upper body resistance circuit 5-10 minutes aerobic exercise Lower body resistance circuit 5-10 minutes aerobic exercise Cool-down

Resistance Training Variables

Exercise selection Intensity Sets Rest interval Tempo

Exercise Selection
Focus on large muscle groups using multi-joint movements
The metabolic cost of an exercise is directly related to the amount of muscle worked (Elliot et al. 1992) Greater EPOC (Farinatti et al. 2011) Enhanced insulin sensitivity of all major muscle groups Reduced pressor response

Load should allow for 12-15 sub maximal repetitions
Rating 0 1 2 3 4 5 6 7 8 9 10 Maximal exertion Very hard Description Complete rest Very light Fairly light Moderate Somewhat hard Hard

Initial loads should equal ~40% 1-RM for upper body and ~50% 1-RM for hips/legs
RPE of 3-4 (moderate to somewhat hard)

Lower rep ranges (8-10) may be needed depending on BP response

Gradually increase intensity over time


Key Point!
Hypertension is the primary moderator of resistance exercise intensity!

Begin with a single set in untrained individuals
Acclimation Single set routines have similar effects on EPOC as multi-set routines (Heden et al. 2011)

Progress to 3 sets per exercise

Greater exercise duration heightens energy expenditure during the workout (Heden et al. 2011) Increased muscle contractions has greater effect on glucose uptake

Rest Intervals
Aim to move as quickly as possible between sets (<10 seconds)
Limiting rest intervals between sets (< 30 seconds) significantly increases caloric expenditure (Haltom et al., 1999 ). Consider acute BP response: longer rest periods (90 seconds) may be required for some to allow blood pressure to return to baseline, thus requiring a conventional RT programming

Repetition speed should be fast but controlled (i.e. 10-1)
High-velocity concentric actions increase total energy expenditure during exercise (Mazzetti et al. 2007) Faster repetitions reduces the pressor response

Aerobic Exercise Protocol

Initially, steady state exercise at 40-70% HRR is best
Higher-intensity interval exercise can be employed over time to facilitate greater weight loss and reductions in fasting insulin concentrations (Trapp et al. 2008).

Avoid exercises with high ground reaction forces (e.g. running, step aerobics, jumping rope)

Measuring Progress
Skinfold testing generally not accurate in this population Girth measurements are preferred

A special thanks to my friend and colleague, Paul Sorace, for his assistance and guidance in developing this presentation.


Thank you for coming!

I can be reached through my blog:

www.workout911.com brad@workout911.com

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Jurca, R., Lamonte, M.J., Church, T. S. et al. Associations of muscle strength and aerobic fitness with metabolic syndrome in men. Med. Sci. Sports Exerc. 36:13011307, 2004. Krough-Madsen R, Thyfault JP, Broholm C, Mortensen OH, Olsen RH, Mounier R, Plomgaard P, Van Hall G, Booth FW, and Pedersen BK. A 2-wk reduction of ambulatory activity attenuates peripheral insulin sensitivity. J Appl Physiol 108: 829838, 2010. Kump D and BoothFW. Alterations in insulin receptor signalling in the rat epitrochlearis muscle upon cessation of voluntary exercise. J Physiol 562: 829838, 2005. Lakka HM, Laaksonen DE, Lakka TA, et al. The metabolic syndrome and total and cardiovascular disease mortality in middle-aged men. JAMA. 2002; 288: 27092716 Mazzetti S, Douglass M, Yocum A, Harber M. Effect of explosive versus slow contractions and exercise intensity on energy expenditure. Med Sci Sports Exerc. 2007 Aug;39(8):1291-301. Potteiger JA, Claytor RP, Hulver MW, Hughes MR, Carper MJ, Richmond S, Thyfault JP. Resistance exercise and aerobic exercise when paired with dietary energy restriction both reduce the clinical components of metabolic syndrome in previously physically inactive males. Eur J Appl Physiol. 2012 Jun;112(6):2035-44 Trapp E, Chisholm D, Freund J, and Boutcher S. The effects of high-intensity intermittent exercise training on fat loss and fasting insulin levels of young women. Int J Obes 32: 18, 2008.