Exercise Management Obesity Chapter 25. Exercise Management OBESITY Obesity is the excessive accumulation of body fat and is associated with numerous

Exercise Exercise ManagementManagement

ObesityObesityChapter 25Chapter 25

Exercise Exercise ManagementManagementOBESITYOBESITY

Obesity is the Obesity is the excessive excessive accumulation of accumulation of body fat and is body fat and is associated with associated with numerous numerous

comorbiditiescomorbidities.. Prevalence of Childhood Obesity in the United States, 2011-2012

Adult Obesity Rates

Obesity Prevalence Maps

Exercise Exercise ManagementManagement Obesity is a multifaceted disease, and may Obesity is a multifaceted disease, and may

involve hypothalamic, endocrine, and genetic involve hypothalamic, endocrine, and genetic disorders, environment, and behavior. disorders, environment, and behavior. Altered Altered insulin function may be the primary mechanism in the etiology insulin function may be the primary mechanism in the etiology (causation) and maintenance of obesity.(causation) and maintenance of obesity.

Obesity is not just about overeating. Most Obesity is not just about overeating. Most evidence suggest that it is a combination of evidence suggest that it is a combination of caloric dense, empty calorie diets, combined with caloric dense, empty calorie diets, combined with a sedentary lifestylea sedentary lifestyle Obesity is also complicated with the prospect Obesity is also complicated with the prospect that humans have evolved over many millennia that humans have evolved over many millennia from hunter-gather high energy expenditure from hunter-gather high energy expenditure lives to low energy expenditure high calorie lives.lives to low energy expenditure high calorie lives.

Exercise Exercise ManagementManagementDefining ObesityDefining Obesity (see Table 25.1, p.193, text)(see Table 25.1, p.193, text)

Exercise Exercise ManagementManagementAltered physiological responses in Altered physiological responses in

obesity includeobesity include:: increased fasting insulinincreased fasting insulin increased insulin response to glucoseincreased insulin response to glucose decreased insulin sensitivity,decreased insulin sensitivity, decreased growth hormone,decreased growth hormone, decreased growth hormone response decreased growth hormone response to insulin stimulationto insulin stimulation increased adrenocortical hormones increased adrenocortical hormones (glucocorticoids, mineralocorticoids, and androgens )(glucocorticoids, mineralocorticoids, and androgens ) increased cholesterol synthesis and increased cholesterol synthesis and excretionexcretion decreased hormone-sensitive lipasedecreased hormone-sensitive lipase

Exercise Exercise ManagementManagementThe primary difference between the The primary difference between the

identification, definition, and classification of identification, definition, and classification of obesity is the assessment of body fat.obesity is the assessment of body fat. The The following percentages of body fat are for men following percentages of body fat are for men and women:and women:


Exercise Exercise ManagementManagement Obesity increases not only the risk of disease Obesity increases not only the risk of disease

but alsobut also the severity of numerous diseases. the severity of numerous diseases. The distribution of body fat may contribute The distribution of body fat may contribute more to disease than total body fat. more to disease than total body fat.

Upper body fat distribution has been associated Upper body fat distribution has been associated with increased risk of coronary artery disease with increased risk of coronary artery disease (CAD), hypertension, hyperlipidemia, and diabetes, (CAD), hypertension, hyperlipidemia, and diabetes, and hormone / menstrual dysfunction.and hormone / menstrual dysfunction. Truncal adipocytes are more metabolically active Truncal adipocytes are more metabolically active than other adipocytes and secrete adipocytokines than other adipocytes and secrete adipocytokines (proteins) that control other metabolic functions (proteins) that control other metabolic functions including: increased insulin resistance, including: increased insulin resistance, hypertension via sodium retention, and increase hypertension via sodium retention, and increase sympathetic activation w/ smooth muscle sympathetic activation w/ smooth muscle hypertrophy in the vasculature.hypertrophy in the vasculature.

Exercise Exercise ManagementManagementAbdominal adipocytes are associated Abdominal adipocytes are associated

with increased very low density with increased very low density lipoprotein, triglyceride, and adipose lipoprotein, triglyceride, and adipose lipoprotein lipase activity. Thus, excess lipoprotein lipase activity. Thus, excess fat in specific deposits may contribute fat in specific deposits may contribute more to the diseases associated with more to the diseases associated with obesity.obesity.

------------------------------------------------------------------------------------------------------------------------------------ Body fat distribution can be estimated by the Body fat distribution can be estimated by the measurement of waist-to-hip ratios. measurement of waist-to-hip ratios. The most common and most often The most common and most often recommended technique may be the ratio of recommended technique may be the ratio of the minimal waist to the largest gluteusthe minimal waist to the largest gluteus


Exercise Exercise ManagementManagementEffects on the Exercise ResponseEffects on the Exercise Response

The obvious effect of obesity on exercise The obvious effect of obesity on exercise testing is low physical work capacity because testing is low physical work capacity because of excess body weight. of excess body weight. Because obesity is associated with other Because obesity is associated with other diseases, however, any of the confounding diseases, however, any of the confounding influences of these diseases may be involved influences of these diseases may be involved in exercise testing.in exercise testing.Social and behavioral factors associated with Social and behavioral factors associated with obesity, such as past experiences with and obesity, such as past experiences with and current fears of exercise should be considered.current fears of exercise should be considered.Prior to exercise testing, a comprehensive Prior to exercise testing, a comprehensive health and medical history should be obtained health and medical history should be obtained from obese patients.from obese patients.

Exercise Exercise ManagementManagementEffects of Exercise TrainingEffects of Exercise Training

Exercise training is effective in reducing body weight Exercise training is effective in reducing body weight ininmoderate obesity, but may not be as effective in moderate obesity, but may not be as effective in morbidmorbidobesity.obesity. Fat loss through exercise is more efficient for Fat loss through exercise is more efficient for individuals withindividuals withupper body fat distribution. upper body fat distribution. Physical activity combined with diet is more effective Physical activity combined with diet is more effective in fat loss than either alone. Physical exercise can: 1) in fat loss than either alone. Physical exercise can: 1) preserve lean mass; 2) improve insulin sensitivity; 3) preserve lean mass; 2) improve insulin sensitivity; 3) improve lipid profiles; 4) reduce blood pressure; 5) improve lipid profiles; 4) reduce blood pressure; 5) improve mood, and, possibly; 6) make positive improve mood, and, possibly; 6) make positive improvements on satiety levelsimprovements on satiety levels Exercise training has profound effects on glucose Exercise training has profound effects on glucose metabolism in both the moderately and the morbidly metabolism in both the moderately and the morbidly obese. These includeobese. These include

decreased fasting glucosedecreased fasting glucosedecreased fasting insulindecreased fasting insulinincreased glucose toleranceincreased glucose tolerancedecreased insulin resistance.decreased insulin resistance.

Exercise Exercise ManagementManagementManagement via exerciseManagement via exercise

The individual who is most likely to be The individual who is most likely to be successful in weight loss:successful in weight loss: is slightly or moderately obeseis slightly or moderately obese has upper body fat distributionhas upper body fat distribution has no history of weight cyclinghas no history of weight cycling has a sincere desire to lose weight has a sincere desire to lose weight became overweight as an adult.became overweight as an adult.

(FYI – Pharmacology and Bariatric (FYI – Pharmacology and Bariatric Surgery)Surgery)

Exercise Exercise ManagementManagementRecommendations for Exercise Recommendations for Exercise

Testing Testing (Table 25.5, p.197, also below)(Table 25.5, p.197, also below)

Evaluation of the client who is obese Evaluation of the client who is obese includes more than just exercise testing. includes more than just exercise testing. Additional assessments include:Additional assessments include: medical and weight histories, medical and weight histories, motivation and readiness for change, motivation and readiness for change, nutrition and eating habits, nutrition and eating habits, body composition. body composition. Body composition Body composition assessment includes a measure of the extent of assessment includes a measure of the extent of obesity, distribution of body fat, and a reasonable obesity, distribution of body fat, and a reasonable target weight.target weight.


TestingTesting

The primary objective of exercise The primary objective of exercise testing with individuals who are obese is testing with individuals who are obese is developing a safe and effective exercise developing a safe and effective exercise prescription. prescription. Disease diagnosis is a secondary Disease diagnosis is a secondary objective.objective.Exercise testing should also take into Exercise testing should also take into consideration any comorbidities, consideration any comorbidities, orthopedic limitations, and current orthopedic limitations, and current medications.medications.Important considerations include the Important considerations include the increased risk for orthopedic injury, increased risk for orthopedic injury, CAD, and heat intolerance.CAD, and heat intolerance.



Programming Programming (Table 25.6, p.198, follows)(Table 25.6, p.198, follows)

Mode:Mode:Non-weight-bearing exercise - WalkingNon-weight-bearing exercise - WalkingIncrease in daily living activitiesIncrease in daily living activitiesResistance trainingResistance training

Frequency: Frequency: Daily or at least 5 sessions/weekDaily or at least 5 sessions/week

Duration: Duration: 30 to 60 min/day or 20 to 30 min twice daily30 to 60 min/day or 20 to 30 min twice daily

Intensity:Intensity:50 to 70% of peak oxygen consumption (VO50 to 70% of peak oxygen consumption (VO22,peak). ,peak). Exercise intensities of 70 to 85% of VOExercise intensities of 70 to 85% of VO22,peak can ,peak can be prescribed providing the risk of injury is be prescribed providing the risk of injury is minimalminimal


Programming Programming (Table 25.6, p.198)(Table 25.6, p.198)

The focus of the exercise prescription is The focus of the exercise prescription is to increase energy expenditure and to increase energy expenditure and minimize the risk of injury.minimize the risk of injury.For some patients two or more sessions For some patients two or more sessions per day with less duration may be more per day with less duration may be more tolerable and may result in exercise at a tolerable and may result in exercise at a higher intensity.higher intensity.Most important is to increase caloric Most important is to increase caloric expenditure at or above 2000 kcal /wk. expenditure at or above 2000 kcal /wk. Progression to the longer duration and Progression to the longer duration and total caloric expenditure should be total caloric expenditure should be gradual.gradual.


ProgrammingProgramming The following considerations and guidelines The following considerations and guidelines are relevant for exercise programming in are relevant for exercise programming in obese populations:obese populations: Prevention of overuse injuryPrevention of overuse injury Injury historyInjury history Adequate flexibility, warm-up, and cool-down Adequate flexibility, warm-up, and cool-down sessionssessions Gradual progression of intensity and Gradual progression of intensity and durationduration Use of low-impact or non-weight-bearing Use of low-impact or non-weight-bearing exercisesexercises ThermoregulationThermoregulation Time of day – should be coolTime of day – should be cool Adequate hydrationAdequate hydration Clothing (e.g., should be loose fitting)Clothing (e.g., should be loose fitting)



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Exercise Management Obesity Chapter 25. Exercise Management OBESITY Obesity is the excessive accumulation of body fat and is associated with numerous