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The Role of Exercise The Role of Exercise inin

Obesity ManagementObesity Management

Dr. Dr. KirillKirill MicallefMicallef StafraceStafraceM.D.,MScSportsMed(Lond.),FFSEM(Ireland),FFSEM(UKM.D.,MScSportsMed(Lond.),FFSEM(Ireland),FFSEM(UK), MIM), MIM

EFSMAEFSMA--IPESIPES--SERCSERC--MOCMOC--MASEMMASEM

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Purpose of this talkPurpose of this talk

�� Outline recommendations for safe and Outline recommendations for safe and effective weight losseffective weight loss

�� Outline recommendations for prevention of Outline recommendations for prevention of weight regainweight regain--body weight maintenancebody weight maintenance

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Will not address issues:Will not address issues:

�� Weight loss related to sport and athletic Weight loss related to sport and athletic performanceperformance

�� Weight loss interventions specifically Weight loss interventions specifically targeting children and adolescentstargeting children and adolescents

�� Non exerciseNon exercise--related weight loss related weight loss interventionsinterventions

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DefinitionsDefinitions

�� OverweightOverweight and and obesityobesity are are defined by the WHO as defined by the WHO as abnormal or excessive fat abnormal or excessive fat accumulation that may impair accumulation that may impair health.health.

�� Body mass indexBody mass index (BMI): (BMI): index of weightindex of weight--forfor--height that height that is commonly used in is commonly used in classifying overweight and classifying overweight and obesity in adult populations obesity in adult populations and individuals. It is defined as and individuals. It is defined as the weight in kilograms divided the weight in kilograms divided by the square of the height in by the square of the height in meters (kg/m2).meters (kg/m2).

�� Underweight <18.5Underweight <18.5

�� Normal 18.5 Normal 18.5 -- 24.9 24.9

�� Overweight 25.0 Overweight 25.0 -- 29.929.9

�� Obesity Class I 30.0 Obesity Class I 30.0 -- 34.934.9

�� Obesity Class II 35.0 Obesity Class II 35.0 -- 39.939.9

�� Obesity Class III 40+ Obesity Class III 40+

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BMIBMI

�� BMI provides the most BMI provides the most useful populationuseful population--level level measure of overweight measure of overweight and obesity as it is the and obesity as it is the same for both sexes and same for both sexes and for all ages of adults. for all ages of adults.

�� However, it should be However, it should be considered as a considered as a rough rough guideguide because it may not because it may not correspond to the same correspond to the same degree of fatness in degree of fatness in different individuals different individuals

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�� WHOWHO’’s latest projections indicate that globally in s latest projections indicate that globally in 2005:2005:�� approximately 1.6 billion adults (age 15+) were approximately 1.6 billion adults (age 15+) were

overweight; overweight; �� at least 400 million adults were obese. at least 400 million adults were obese. �� At least 20 million children under the age of 5 years At least 20 million children under the age of 5 years

are overweightare overweight

�� WHO further projects that by 2015, WHO further projects that by 2015, approximately 2.3 billion adults will be approximately 2.3 billion adults will be overweight and more than 700 million will be overweight and more than 700 million will be obese.obese.

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What causes obesity and overweight?What causes obesity and overweight?

�� An energy imbalance between calories consumed on An energy imbalance between calories consumed on one hand, and calories expended on the other hand. one hand, and calories expended on the other hand.

�� Global increases in overweight and obesity are Global increases in overweight and obesity are attributable to a number of factors including:attributable to a number of factors including:�� a a global shift in dietglobal shift in diet towards increased intake of energytowards increased intake of energy--dense dense

foods that are high in fat and sugars but low in vitamins, minerfoods that are high in fat and sugars but low in vitamins, minerals als and other micronutrients; and and other micronutrients; and

�� a trend towards a trend towards decreased physical activitydecreased physical activity due to the due to the increasingly sedentary nature of many forms of work, changing increasingly sedentary nature of many forms of work, changing modes of transportation, and increasing urbanization. modes of transportation, and increasing urbanization.

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WhatWhat’’s the fuss?s the fuss?

�� Basically being obese has adverse health Basically being obese has adverse health implicationsimplications�� Diabetes, hypertension, Diabetes, hypertension, hypercholesterolaemiahypercholesterolaemia, ,

musculoskeletal problems, depression, certain musculoskeletal problems, depression, certain cancers etc.cancers etc.

�� Abdominal fatness is associated with an Abdominal fatness is associated with an even larger health riskeven larger health risk

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Magnitude of weight loss Magnitude of weight loss recommendationsrecommendations

�� Even modest reductions in body weight (5Even modest reductions in body weight (5––10%) will 10%) will significantly improve health. significantly improve health.

�� Thus, an initial weight loss goal should be to decrease Thus, an initial weight loss goal should be to decrease body weight by 5body weight by 5––10% and to sustain this magnitude of 10% and to sustain this magnitude of weight loss longweight loss long--term. term. WingWing 19981998

�� However, even though a weight loss of <10% is However, even though a weight loss of <10% is associated with initial improvements in risk factors, the associated with initial improvements in risk factors, the maintenance of a weight loss that is <10% may not result maintenance of a weight loss that is <10% may not result in the improvements in these risk factors being sustained in the improvements in these risk factors being sustained longlong--term. term. SjostromSjostrom 19981998

�� Therefore, longTherefore, long--term health benefits may be maximized term health benefits may be maximized with sustained weight loss of >10% of initial body weight.with sustained weight loss of >10% of initial body weight.

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Justification for inclusion of Justification for inclusion of exercise for weight loss.exercise for weight loss.

�� CombinationCombination of dietary modification and exercise is the of dietary modification and exercise is the most effectivemost effective behavioral approach for weight loss. behavioral approach for weight loss. NHLBINHLBI

�� MaintenanceMaintenance of exercise may be one of the best of exercise may be one of the best predictors ofpredictors of longlong--term weight maintenance. term weight maintenance. PronkPronk 1994, 1994, MillerMiller 1997, 1997, AvanellAvanell 2004, 2004, LangLang 2006. 2006.

�� Little evidenceLittle evidence that suggests that exercise alone that suggests that exercise alone produces magnitudes ofproduces magnitudes of weight loss that are similar to weight loss that are similar to what can be achieved withwhat can be achieved with dietary modification alone.dietary modification alone.

�� ““respondersresponders”” VsVs ““nonnon--respondersresponders”” BouchardBouchard 19941994

�� Effectiveness of exercise for weight managementEffectiveness of exercise for weight management may may also be influenced by gender. also be influenced by gender. WoodWood 19911991

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Components of a comprehensive Components of a comprehensive health evaluationhealth evaluation

�� Questionnaires Questionnaires screening formsscreening forms�� PARPAR--QQ

�� Signs & Symptoms of Signs & Symptoms of diseasedisease

�� Coronary risk factor Coronary risk factor analysisanalysis

�� Disease risk classificationDisease risk classification

�� Medical historyMedical history

�� Lifestyle evaluationLifestyle evaluation

�� Informed consentInformed consent

�� Clinical TestsClinical Tests�� Physical examinationPhysical examination

�� Blood chemistry profileBlood chemistry profile

�� Blood pressure Blood pressure assessmentassessment

�� 1212--lead ECGlead ECG

�� Graded exercise testGraded exercise test

�� Additional lab testsAdditional lab tests

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Classification of disease riskClassification of disease risk

�� Low RiskLow Risk�� Younger individuals (men <45, women <55) Younger individuals (men <45, women <55)

who are asymptomatic and have no more who are asymptomatic and have no more than one risk factor .than one risk factor .

�� Moderate RiskModerate Risk�� Older individuals (men>45, women >55) or Older individuals (men>45, women >55) or

individuals of any age having two or more risk individuals of any age having two or more risk factors .factors .

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Classification of disease riskClassification of disease risk

�� High RiskHigh Risk�� Individuals with one or more signs/symptoms for Individuals with one or more signs/symptoms for

CV and/or pulmonary disease or Individuals with CV and/or pulmonary disease or Individuals with know cardiac, pulmonary, or metabolic diseaseknow cardiac, pulmonary, or metabolic disease

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Exercise duration and weight loss. Exercise duration and weight loss.

�� VariousVarious public health recommendation for physical activity is public health recommendation for physical activity is forfor individuals to participate in at least 30 min to 1 hour of individuals to participate in at least 30 min to 1 hour of moderatemoderate intensity physical activity on most, preferably all, intensity physical activity on most, preferably all, days ofdays of the week the week ((WHO/FAO,ACSM,NHLBI,CDC)WHO/FAO,ACSM,NHLBI,CDC)

�� This recommendation has typically beenThis recommendation has typically been interpreted as a interpreted as a minimum of 150 min of physical activity perminimum of 150 min of physical activity per week and is week and is based primarily on the effectsbased primarily on the effects of exercise on cardiovascular of exercise on cardiovascular disease and other chronicdisease and other chronic conditions such as diabetes conditions such as diabetes mellitus. mellitus.

�� However, close examinationHowever, close examination of the scientific evidence of the scientific evidence suggests that levels ofsuggests that levels of exercise greater than this minimum exercise greater than this minimum recommended amountrecommended amount may be important for initial and long may be important for initial and long term weight loss weight loss .term weight loss weight loss .SchoellerSchoeller 1997,1997, JakicicJakicic 1999.1999.

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Exercise intensity and weight Exercise intensity and weight loss.loss.

�� There have been few studies There have been few studies that have adequately that have adequately examined the impact of various examined the impact of various intensities of exercise on intensities of exercise on weight loss. weight loss.

�� Thus, it appears that a Thus, it appears that a sufficient amount of moderatesufficient amount of moderate--intensity (55intensity (55––69% of maximal 69% of maximal heart rate) exercise can be heart rate) exercise can be beneficial for management of beneficial for management of body weight. body weight. DuncanDuncan 19911991

�� N.B. weight loss not fitness!N.B. weight loss not fitness!

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Intermittent exercise and weight loss. Intermittent exercise and weight loss.

�� There have been a few studies that have examined There have been a few studies that have examined the effectiveness of intermittent exercise in weight the effectiveness of intermittent exercise in weight loss programs. loss programs. DonnellyDonnelly 2000, 2000, JakicicJakicic 1995,1999.1995,1999.

�� Intermittent exercise has typically been defined as Intermittent exercise has typically been defined as accumulation of 30accumulation of 30––40 min of exercise per day 40 min of exercise per day through participation in multiple 10through participation in multiple 10-- to 15to 15--min min exercise sessions dailyexercise sessions daily

�� There has been interest in this form of exercise There has been interest in this form of exercise because early studies showed that intermittent because early studies showed that intermittent exercise effectively increased exercise effectively increased cardiorespiratorycardiorespiratoryfitness and favorably impacts coronary heart fitness and favorably impacts coronary heart disease risk factors. disease risk factors. DebuskDebusk 1990, 1990, EbisuEbisu 1985. 1985.

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��This resulted in the CDC and ACSM This resulted in the CDC and ACSM recommending the recommending the ““accumulationaccumulation”” of at of at least 30 min of moderate intensity least 30 min of moderate intensity activity per day. activity per day.

��The use of intermittent exercise may The use of intermittent exercise may be advantageous for individuals that be advantageous for individuals that dislike continuous exercise or perceive dislike continuous exercise or perceive barriers to continuous exercise.barriers to continuous exercise.

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Lifestyle activity and weight loss. Lifestyle activity and weight loss.

�� Lifestyle activity may be an effective option for Lifestyle activity may be an effective option for increasing fitness and modifying body weight in increasing fitness and modifying body weight in overweight adults. overweight adults. AndersenAndersen 1999, 1999, DunnDunn 19991999..

�� Lifestyle activity appears to be a promising Lifestyle activity appears to be a promising alternative to structured forms of exercise. alternative to structured forms of exercise.

�� Therefore, overweight adults should be Therefore, overweight adults should be encouraged to engage in activities that are at encouraged to engage in activities that are at least moderate in intensity as part of physically least moderate in intensity as part of physically active lifestyle. active lifestyle.

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Resistance exercise Resistance exercise &&

weight loss.weight loss.

�� Although most research studies have examined the effect of Although most research studies have examined the effect of endurance exercise on weight loss, the inclusion of endurance exercise on weight loss, the inclusion of resistance training in weight loss programs has clear resistance training in weight loss programs has clear advantages. advantages.

�� Resistance training is a potent stimulus to increase fatResistance training is a potent stimulus to increase fat--free free mass (FFM), muscular strength, and power and thus may be mass (FFM), muscular strength, and power and thus may be an important component of a successful weight loss program an important component of a successful weight loss program by helping to preserve FFM while maximizing fat loss. by helping to preserve FFM while maximizing fat loss. BallorBallor 1988, 1988, PavlouPavlou 1989, 1989, GarrowGarrow 1995, 1995, MarksMarks 1995, 1995, RossRoss 1995, 1995, GeliebterGeliebter 1997, 1997, KraemerKraemer 1999, 1999,

�� However, when resistance exercise is combined with dietary However, when resistance exercise is combined with dietary energy restriction, there appears to be little benefit in terms energy restriction, there appears to be little benefit in terms of of absolute weight loss. absolute weight loss. SweeneySweeney 19931993, Krauss, Krauss 20002000. .

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�� No scientific evidence to suggest that resistance No scientific evidence to suggest that resistance exercise is superior to more commonly used forms exercise is superior to more commonly used forms of endurance exercise for weight loss. of endurance exercise for weight loss.

�� However, the ability of resistance exercise to However, the ability of resistance exercise to improve muscular strength and endurance may be improve muscular strength and endurance may be especially beneficial because of the impact on especially beneficial because of the impact on functional tasks (e.g., getting out of a chair, lifting functional tasks (e.g., getting out of a chair, lifting oneone’’s own body weight), which may facilitate the s own body weight), which may facilitate the adoption of a more active lifestyle in sedentary adoption of a more active lifestyle in sedentary overweight and obese individuals.overweight and obese individuals.

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Exercise to Exercise to Improve Health and Extend LifeImprove Health and Extend Life

��Harvard Alumni Study (Classes of Harvard Alumni Study (Classes of 1920 1920 -- 1954)1954)�� Exercise improved health and reduced Exercise improved health and reduced

mortalitymortality

�� HypertensivesHypertensives: Reduced death rate by 50%: Reduced death rate by 50%

�� Individuals with parents who died prior to age Individuals with parents who died prior to age 65: Reduced death rate by 25%65: Reduced death rate by 25%

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Harvard Alumni StudyHarvard Alumni Study

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60

5 5 to

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10 to

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15 to

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20 to

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25 to

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30 to

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Miles Walked / Run per Week

% Death Risk Reduction

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Exercise to Improve Health and Exercise to Improve Health and Extend LifeExtend Life

�� Epidemiological evidence:Epidemiological evidence:�� Studies have shown a cause Studies have shown a cause -- effect relationship effect relationship

between physical inactivity and CHD (sedentary between physical inactivity and CHD (sedentary person = 2Xperson = 2X’’s risk)s risk)

�� Protective association just as strong as hypertension, Protective association just as strong as hypertension, smoking, and high cholesterol.smoking, and high cholesterol.

�� Physical inactivity is the Physical inactivity is the GREATESTGREATEST risk factor for risk factor for heart disease...more people are physically inactive heart disease...more people are physically inactive than possess than possess ALLALL other CHD risk factors!other CHD risk factors!

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The Figure shows the relative risks associated with The Figure shows the relative risks associated with the different categories of fitness measured.the different categories of fitness measured.

�� Healthy adults who are the Healthy adults who are the least fit have a mortality least fit have a mortality risk that is 4.5 times that of risk that is 4.5 times that of the most fit. the most fit.

�� Surprisingly, an Surprisingly, an individualindividual’’s fitness level s fitness level was a more important was a more important predictor of death than predictor of death than established risk factors established risk factors such as smoking, high such as smoking, high blood pressure, high blood pressure, high cholesterol, and diabetes. cholesterol, and diabetes.

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What Are the Risks of Exercise?What Are the Risks of Exercise?

�� During exercise, there is a transient increase in During exercise, there is a transient increase in the risk of having a cardiacthe risk of having a cardiac--related complication. related complication.

�� Risk is extremely small. Risk is extremely small. �� For adults without existing heart disease, the risk For adults without existing heart disease, the risk

of a cardiac event or complication ranges of a cardiac event or complication ranges between 1 in 400 000between 1 in 400 000––800 000 hours of 800 000 hours of exercise. exercise.

�� For patients with existing heart disease, an For patients with existing heart disease, an event can occur an average of once in 62 000 event can occur an average of once in 62 000 hours.hours.

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�� Importantly, the risk of a cardiac event is Importantly, the risk of a cardiac event is significantly lower among regular exercisers.significantly lower among regular exercisers.

�� Evidence suggests that a sedentary personEvidence suggests that a sedentary person’’s s risk is nearly 50 times higher than the risk for a risk is nearly 50 times higher than the risk for a person who exercises about 5 times per week. person who exercises about 5 times per week.

�� Stated simply, individuals who exercise regularly Stated simply, individuals who exercise regularly are much less likely to experience a problem are much less likely to experience a problem during exercise. during exercise.

�� Moreover, contrary to popular view, the majority Moreover, contrary to popular view, the majority of cardiac events (approximately 90%) occur in of cardiac events (approximately 90%) occur in the resting state, not during physical activity. the resting state, not during physical activity.

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Starting an Exercise Starting an Exercise ProgrammeProgramme

�� Motivation Motivation –– why?why?�� Weight Loss Weight Loss

�� Social Affiliation Social Affiliation

�� Physical Appearance Physical Appearance

�� Competition Competition

�� Health Benefits Health Benefits

�� Stress Relief Stress Relief

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Factors in Choosing Workouts Factors in Choosing Workouts

�� Time of Day Time of Day ��Choose the most convenient time of day Choose the most convenient time of day

�� Available Facilities Available Facilities ��Fitness Centre Fitness Centre

��Home Home

��Outdoors Outdoors

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�� Mode of Workout Mode of Workout ��Enjoyable activities Enjoyable activities

��Conducive to goalsConducive to goals

�� Social Setting Social Setting ��With a partner With a partner

��In a group In a group

��Alone Alone

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Components of Health Related Components of Health Related Physical FitnessPhysical Fitness

�� Body Composition Body Composition

��Refers to the proportion of body fat to Refers to the proportion of body fat to lean body tissue lean body tissue

��% Fat vs. total body weight % Fat vs. total body weight

��Male vs. female Male vs. female -- % fat % fat recommendation recommendation

�� Flexibility Flexibility

��Extent and range of motion around a Extent and range of motion around a joint joint

�� Injury prevention Injury prevention

��Static stretchingStatic stretching

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�� Strength and Endurance Strength and Endurance ��StrengthStrength-- amount of force exerted by a group of muscles amount of force exerted by a group of muscles

��EnduranceEndurance-- ability to maintain a contraction over a period of ability to maintain a contraction over a period of time time

�� CardiorespiratoryCardiorespiratory Fitness Fitness •• Body's ability to consume and process O2 Body's ability to consume and process O2

•• Aerobic activities Aerobic activities

•• Components of a workout Components of a workout �� Frequency Frequency -- 33--5 days/wk 5 days/wk

�� <3 days less improvement in VO2 max (fitness)<3 days less improvement in VO2 max (fitness)

�� >5 days subject to injury >5 days subject to injury

�� IntensityIntensity-- 5050--80% VO2 max/MHR :80% VO2 max/MHR :

�� < 70 WMP, >70 increase fitness< 70 WMP, >70 increase fitness

�� Duration Duration -- goal 20goal 20--30 min continuous activity 30 min continuous activity

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Elements of a Cardiovascular Program:Elements of a Cardiovascular Program:

�� WarmWarm--up 5up 5--10 min 10 min

�� Conditioning 20Conditioning 20--60 min 60 min

�� CoolCool--down 5down 5--10 min 10 min

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Principles of TrainingPrinciples of Training�� Specificity Specificity

��Specific activities elicit specific adaptations creating specifiSpecific activities elicit specific adaptations creating specific c training effects training effects

�� Reversibility Reversibility �� If training ceases, strength and endurance diminishes If training ceases, strength and endurance diminishes

�� Progression Progression ��Gradual increase in "work" over a period of training Gradual increase in "work" over a period of training

�� Overload Overload ��Strength and endurance will increase only if muscles and the Strength and endurance will increase only if muscles and the

cardiovascular system are systematically subjected to cardiovascular system are systematically subjected to workloads greater than those to which they are accustomed workloads greater than those to which they are accustomed

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Workout EquipmentWorkout EquipmentShoesShoes

•• QualitiesQualities�� Shock Shock

absorption absorption

�� Cushion Cushion

�� Support Support

•• FunctionFunction�� Cross training Cross training

�� Running Running

�� Walking Walking

�� Aerobic Aerobic

�� Court Court

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ClothingClothing

•• warm weather warm weather �� Thin, light Thin, light

�� Loose fitting Loose fitting

�� Porous Porous

�� Allow for heat evaporation Allow for heat evaporation

•• cold weather cold weather �� Layers Layers

�� GortexGortex

•• water proof water proof

•• heat escapes heat escapes

�� Head, hand protection Head, hand protection

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�� Most important factors:Most important factors:�� Patient must understand that weight loss is Patient must understand that weight loss is

not only goalnot only goal

�� EnjoyabilityEnjoyability

�� SafetySafety

�� PersistancePersistance

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Thank youThank you

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REFERENCESREFERENCES

�� ACSM Position Stand on the Appropriate Intervention Strategies fACSM Position Stand on the Appropriate Intervention Strategies for Weight Loss and Prevention of Weight Regain for Adults. or Weight Loss and Prevention of Weight Regain for Adults. Med. Med. SciSci. Sports. Sports ExercExerc.., Vol. 33, No. 12, , Vol. 33, No. 12, 2001, pp. 21452001, pp. 2145––2156.2156.

�� ANDERSEN, R. E., T. A. WADDEN, S. J. BARTLETT, B. ZEMEL, T. J. VANDERSEN, R. E., T. A. WADDEN, S. J. BARTLETT, B. ZEMEL, T. J. VERDE, and S. C. FRANCKOWIAK. Effects of lifestyle activity ERDE, and S. C. FRANCKOWIAK. Effects of lifestyle activity vsvs structured aerobic exercise in structured aerobic exercise in obese women: a randomized trial. obese women: a randomized trial. JAMA JAMA 281:335281:335––340, 1999. 340, 1999.

�� ASHLEY, F. W., and W. B. KANNEL. Relation of weight change to chASHLEY, F. W., and W. B. KANNEL. Relation of weight change to changes in anges in atherogenicatherogenic traits: the Framingham Study. traits: the Framingham Study. J. J. ChronChron.. Dis. Dis. 27:10327:103––114, 1974.114, 1974.�� AVANELL A,BROWN T, AVANELL A,BROWN T, McGEEMcGEE M, CAMPBELL M, GRANT A, BROOM J, What interventions should we M, CAMPBELL M, GRANT A, BROOM J, What interventions should we add to weight reducing diets in adults with obesity? A systematiadd to weight reducing diets in adults with obesity? A systematic c

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