Exercise Treatment Of The Obese Patient

Exercise-Treatment of Exercise-Treatment of the Obese Patientthe Obese Patient

Ayaz Virji, MD FAAFPAyaz Virji, MD FAAFPDiplomate, American Board of Family MedicineDiplomate, American Board of Family Medicine

Diplomate, American Board of Bariatric MedicineDiplomate, American Board of Bariatric MedicineDiplomate, American Board of Phys Nutrition SpecialistsDiplomate, American Board of Phys Nutrition Specialists

ABBM Review Course 2007ABBM Review Course 2007

DefinitionsDefinitions Physical Activity: any bodily movement produced by Physical Activity: any bodily movement produced by

skeletal muscle resulting in EE (walking, running, skeletal muscle resulting in EE (walking, running, household chores, playing sports)household chores, playing sports)

Exercise: Physical activity that is planned or Exercise: Physical activity that is planned or structured. Involves repetitive bodily movement structured. Involves repetitive bodily movement aimed to improve physical fitness (CV endurance, aimed to improve physical fitness (CV endurance, flexibity, muscle strength).flexibity, muscle strength).

Non-Exercise Activity: Physical activity involving Non-Exercise Activity: Physical activity involving non-volitional exercise. Leads to Non-Exercise non-volitional exercise. Leads to Non-Exercise Activity Thermogenesis (NEAT). Includes Activity Thermogenesis (NEAT). Includes occupational activity, leisure time activity, and occupational activity, leisure time activity, and household activityhousehold activity

(US Dept HHS, Physical Activity and Health: A Report of the Surgeon General, 1996)(US Dept HHS, Physical Activity and Health: A Report of the Surgeon General, 1996)

Skeletal Muscle AnatomySkeletal Muscle AnatomyMyofibrils – Muscle fiber (cell) – Fascicle – Muscle TissueMyofibrils – Muscle fiber (cell) – Fascicle – Muscle Tissue

Skeletal Muscle AnatomySkeletal Muscle Anatomy

Skeletal Muscle PhysiologySkeletal Muscle Physiology

Type 1 fibers: aka = slow twitch/red muscle, Type 1 fibers: aka = slow twitch/red muscle, OXIDATIVE, used for prolonged work (Posture-OXIDATIVE, used for prolonged work (Posture-maintaining muscle, back,..)maintaining muscle, back,..)

Type 2 fibers: aka = fast twitch/white muscle, Type 2 fibers: aka = fast twitch/white muscle, ANAEROBIC, used for quick bouts of work ANAEROBIC, used for quick bouts of work (extraocular muscles, hands,..)(extraocular muscles, hands,..)

Skeletal muscle has plasticity and subject to Skeletal muscle has plasticity and subject to trainingtraining

Marathon Runner: more Type 1 red fibersMarathon Runner: more Type 1 red fibersPower Lifter: more Type 2 white fibersPower Lifter: more Type 2 white fibers

(Ganong, 1995)(Ganong, 1995)

Skeletal Muscle PhysiologySkeletal Muscle Physiology

FuelFuel At rest = 70% free fatty acidsAt rest = 70% free fatty acids

With activity = depends upon intensity With activity = depends upon intensity (low intensity = free fatty acids; high (low intensity = free fatty acids; high intensity = glucose)intensity = glucose)

Skeletal Muscle PhysiologySkeletal Muscle Physiology Blood flow to resting muscle is low (2-4 Blood flow to resting muscle is low (2-4

ml/100g/min)ml/100g/min)

Muscle contraction leads to compression Muscle contraction leads to compression of blood vessel beginning at 10% of of blood vessel beginning at 10% of maximum tension. Flow completely maximum tension. Flow completely blocked at 70% and burns intracellular blocked at 70% and burns intracellular storage of glycogen for fuel.storage of glycogen for fuel.

Reflexive vasodilation during resting phase Reflexive vasodilation during resting phase – increase blood flow 100 X baseline rate– increase blood flow 100 X baseline rate

(Ganong, 1995)(Ganong, 1995)

Non-Weight Related BenefitsNon-Weight Related Benefits

24% reduction in all-cause mortality24% reduction in all-cause mortality 36% reduction in CV mortality36% reduction in CV mortality Reduces emotional distress, depression, Reduces emotional distress, depression,

and anxietyand anxiety Improves glycemic controlImproves glycemic control Improves Immune system function Improves Immune system function

(improves NK cells and T Cell function)(improves NK cells and T Cell function) May reduce the risk of various cancersMay reduce the risk of various cancers

(Hu, N Enlg J Med 2004)(Hu, N Enlg J Med 2004) (Blumenthal, JAMA 2005) (Blumenthal, JAMA 2005) (Paffenbarger, N Engl J Med 1993) (Keast, Sports Med 1988)(Paffenbarger, N Engl J Med 1993) (Keast, Sports Med 1988)

Physiologic Changes – Micro levelPhysiologic Changes – Micro level

Increase size and number of Increase size and number of mitochondriamitochondria

Increase capacity to store glycogenIncrease capacity to store glycogen Increase fatty acid utilization by muscleIncrease fatty acid utilization by muscle Increase capillary numberIncrease capillary number Increase myoglobin levelsIncrease myoglobin levels

(Peterson, 2005)(Peterson, 2005)

Cardiovascular Adaptations – Macro levelCardiovascular Adaptations – Macro level

Improves contractility and stroke Improves contractility and stroke volumevolume

Reduces Peripheral Vascular Reduces Peripheral Vascular ResistanceResistance

Improves endothelial cell functionImproves endothelial cell function Improves Cardiac ComplianceImproves Cardiac Compliance Improves Cardiac Baroreceptor Improves Cardiac Baroreceptor

ReflexReflex

Treatment of ObesityTreatment of Obesity May enhance caloric burn during a May enhance caloric burn during a

comprehensive weight loss strategy-but comprehensive weight loss strategy-but ineffective when used alone.ineffective when used alone.

Inhibits malonyl CoA at level of myocyte Inhibits malonyl CoA at level of myocyte (malonyl CoA inhibits fatty acid oxidation)(malonyl CoA inhibits fatty acid oxidation)

Overall role in weight loss is complicated Overall role in weight loss is complicated and not fully understood.and not fully understood.

(Visona, Obes Res 2002) (Ruderman 2006)(Visona, Obes Res 2002) (Ruderman 2006)

Exercise During Weight LossExercise During Weight Loss Misperception of energy expenditure: Misperception of energy expenditure:

patients burn far fewer calories than they patients burn far fewer calories than they think. May lead to over compensation during think. May lead to over compensation during energy intakeenergy intake

Weight Loss Dishinhibition:Weight Loss Dishinhibition:Restraint: ability to control energy Restraint: ability to control energy

intakeintakeDisinhibition: loss of restraintDisinhibition: loss of restraint(include ETOH, dysphoric emotions, (include ETOH, dysphoric emotions,

food food commercials, and exercise)commercials, and exercise)Involvement of right pre-frontal cortexInvolvement of right pre-frontal cortex

(Visona, Obes Res 2002) (Alonso-Alonso JAMA 2007)(Visona, Obes Res 2002) (Alonso-Alonso JAMA 2007)

Exercise During Weight LossExercise During Weight Loss

Clearly stands out as an important Clearly stands out as an important component during weight loss component during weight loss maintenance (NWCR)maintenance (NWCR)

Increase in daily calorie burn (aerobic)– Increase in daily calorie burn (aerobic)– replaces loss of calorie burn during NEATreplaces loss of calorie burn during NEAT

Increase in lean muscle mass Increase in lean muscle mass (anaerobic)-reduces loss of BMR from (anaerobic)-reduces loss of BMR from weight lossweight loss

Special Consideration in the ElderlySpecial Consideration in the Elderly

Endurance and resistance exercise Endurance and resistance exercise may improve physical function and may improve physical function and ameliorate frailty during weight lossameliorate frailty during weight loss

Helps to counterbalance reduced Helps to counterbalance reduced bone mineral densitybone mineral density

Combats sarcopenia during weight Combats sarcopenia during weight lossloss

(Villareal, Am J Clin Nutr 2005)(Villareal, Am J Clin Nutr 2005)

Energy Balance EquationEnergy Balance Equation

TDEE = BMR + TEF + ActivityTDEE = BMR + TEF + Activity

60-70% 5-10% 15-30%60-70% 5-10% 15-30%

TDEE – Total daily energy expenditureTDEE – Total daily energy expenditure

BMR – Basal metabolic rateBMR – Basal metabolic rate

TEF – Thermogenic effect of foodTEF – Thermogenic effect of food

Aerobic vs AnaerobicAerobic vs Anaerobic

Aerobic activity (Cardio): generally involves Aerobic activity (Cardio): generally involves low intensity longer duration activity, uses low intensity longer duration activity, uses fatty acids for fuel, and aimed toward fatty acids for fuel, and aimed toward improving cardiovascular fitnessimproving cardiovascular fitness

Anaerobic activity (Resistance): generally Anaerobic activity (Resistance): generally involves high intensity, shorter duration involves high intensity, shorter duration activity, uses predominantly intacellular activity, uses predominantly intacellular glycogen as fuel, and aimed toward muscle glycogen as fuel, and aimed toward muscle buildingbuilding

NEATNEAT Non-Exercise Activity Thermogenesis (NEAT) also Non-Exercise Activity Thermogenesis (NEAT) also

referred to at lifestyle activityreferred to at lifestyle activity

Calories burned through physical activity not Calories burned through physical activity not involving volitional exercise (running errands, involving volitional exercise (running errands, shopping, yard work, etc.)shopping, yard work, etc.)

Important source of total energy expenditure Important source of total energy expenditure from physical activity.from physical activity.

Individual variation of NEAT in humans is 10 fold Individual variation of NEAT in humans is 10 fold (equivalent to a marathon run)(equivalent to a marathon run)

(Andreson, JAMA 1999)(Andreson, JAMA 1999)

NEAT StudiesNEAT Studies Multiple Risk Factor Intervention Trial- Multiple Risk Factor Intervention Trial-

(13,000 men followed over 7 years) (13,000 men followed over 7 years) showed leisure time activity (bowling, showed leisure time activity (bowling, fighing, light walking, yardwork) lowered fighing, light walking, yardwork) lowered mortality risk from CVD by 20%mortality risk from CVD by 20%

Health ABC Study- 30% reduction in all-Health ABC Study- 30% reduction in all-cause mortality in highest quintile of NEAT cause mortality in highest quintile of NEAT activity (working, volunteering, activity (working, volunteering, vacuuming, lawn care,…)vacuuming, lawn care,…)

(Levine, Am J Clin Nutr 2000) (Manini, JAMA 2006) (Leon, JAMA 1987)(Levine, Am J Clin Nutr 2000) (Manini, JAMA 2006) (Leon, JAMA 1987)

NEAT InterventionsNEAT Interventions

Park car further away when outPark car further away when out Use stairs instead of the Use stairs instead of the

elevator/escalatorelevator/escalator Avoid moving platformsAvoid moving platforms Pace while on the phonePace while on the phone Do your own house cleaningDo your own house cleaning

2005 HHS Dietary Guidelines2005 HHS Dietary Guidelines To Prevent Chronic Disease: Accumulate 30 minutes or To Prevent Chronic Disease: Accumulate 30 minutes or

more of moderate-intensity physical activity on most, more of moderate-intensity physical activity on most, preferably all, days of the week.preferably all, days of the week.

To Prevent Gradual Weight Gain: Accumulate 60 minutes of To Prevent Gradual Weight Gain: Accumulate 60 minutes of moderate to vigorous activity on most days of the week.moderate to vigorous activity on most days of the week.

To Sustain Adult Weight Loss: Accumulate 60-90 minutes To Sustain Adult Weight Loss: Accumulate 60-90 minutes of moderate to vigorous activity on most days of the week.of moderate to vigorous activity on most days of the week.

(http://www.healthierus.gov/dietaryguidelines/)(http://www.healthierus.gov/dietaryguidelines/)

Practice GuidelinesPractice Guidelines Utilize a STEPS approach to establishing an Utilize a STEPS approach to establishing an

activity regimen for your patients.activity regimen for your patients.

Overly aggressive initial recommendations will Overly aggressive initial recommendations will cause a zero sum attitude and damage self cause a zero sum attitude and damage self efficacy.efficacy.

Gradually build an exercise regimen for the Gradually build an exercise regimen for the individual patient that is exclusive to him/her and individual patient that is exclusive to him/her and compatible with lifestylecompatible with lifestyle

The best regimen for overall health and The best regimen for overall health and weight management is that which is most weight management is that which is most sustainablesustainable

(Tanasescu, JAMA 2002) (Jakicic, JAMA 2003)(Tanasescu, JAMA 2002) (Jakicic, JAMA 2003)

Practice GuidelinesPractice Guidelines Best time to Exercise—”More important to exercise Best time to Exercise—”More important to exercise

regularly than to worry about morning vs evening”regularly than to worry about morning vs evening”(AHA Position Statement - (AHA Position Statement - Circulation 2007Circulation 2007).).

Let the patient decide when and where works—but Let the patient decide when and where works—but you document the specifics so patient can be held you document the specifics so patient can be held accountable.accountable.

Use a specific exercise prescription—either on Use a specific exercise prescription—either on script pad or in chart that notes script pad or in chart that notes frequency/time/duration of prescribed exercise frequency/time/duration of prescribed exercise regimen.regimen.

Try to blend some aerobic (improve CV fitness) Try to blend some aerobic (improve CV fitness) and anearobic (improve basal metabolic rate) but and anearobic (improve basal metabolic rate) but be flexible.be flexible.

Practice GuidelinesPractice Guidelines

Remember to tailor your activity regimen Remember to tailor your activity regimen to your patient not vice versa. Must be to your patient not vice versa. Must be realistic with your goals.realistic with your goals.

Sometimes the perfect/ideal regimen is Sometimes the perfect/ideal regimen is unknown unknown (What is the best dose of Aspirin325, (What is the best dose of Aspirin325, 161, 81, 75 mg). Work with what we know.161, 81, 75 mg). Work with what we know.

The best regimen for overall health The best regimen for overall health and weight management is that which and weight management is that which is most sustainableis most sustainable

Grading Exercise IntensityGrading Exercise Intensity

Metabolic Equivalent (MET) level: Metabolic Equivalent (MET) level:

-Measure the amount of oxygen used by the -Measure the amount of oxygen used by the body during physical activitybody during physical activity

-MET= 3.5 ml O2/ KG/ min-MET= 3.5 ml O2/ KG/ min

= 1Kcal/ Kg/ hr= 1Kcal/ Kg/ hr

-1 MET generally equals the energy used by -1 MET generally equals the energy used by the body as you sit quietlythe body as you sit quietly

-Moderate Activity- burns 3 to 6 METs-Moderate Activity- burns 3 to 6 METs

-Vigorous Activity- burns > 6 METs-Vigorous Activity- burns > 6 METs

Grading Exercise IntensityGrading Exercise Intensity

Perceived Exertion (Borg Scale)Perceived Exertion (Borg Scale)-How hard you feel your body is working-How hard you feel your body is working-subjective rating, but appears accurate-subjective rating, but appears accurate-ranges from 6-20-ranges from 6-20-(6) no exersion-(6) no exersion (7-11) light intensity(7-11) light intensity (12-14) moderate intensity(12-14) moderate intensity (15-20) Vigorous intensity(15-20) Vigorous intensity

Risks of ExerciseRisks of Exercise

Musculoskeletal injury: most Musculoskeletal injury: most common risk of exercisecommon risk of exercise

Arrhythmia more pronounced in Arrhythmia more pronounced in patients with heart disease.patients with heart disease.

Risk of Sudden Cardiac Death during Risk of Sudden Cardiac Death during vigorous physical activity 1 per 1.51 vigorous physical activity 1 per 1.51 million episodes of exercise.million episodes of exercise.

Recommendations for Stress TestingRecommendations for Stress Testing

(Albert, N Engl J Med, 2000)(Albert, N Engl J Med, 2000)

Odds and EndsOdds and Ends

Warm-up phase prior to exercise: Warm-up phase prior to exercise: increases blood flow, may reduce injuryincreases blood flow, may reduce injury

Cool down phase post-exercise: improve Cool down phase post-exercise: improve removal of lactate from musclesremoval of lactate from muscles

Stretching prior to exercise does not seem Stretching prior to exercise does not seem to confer benefit in reducing soreness or to confer benefit in reducing soreness or injury. injury.

(Herbert, BMJ 2002)(Herbert, BMJ 2002)

ConclusionConclusion

““All parts of the body which have a All parts of the body which have a function, if used in moderation and function, if used in moderation and exercised in labours in which each is exercised in labours in which each is accustomed, become thereby accustomed, become thereby healthy, well-developled and age healthy, well-developled and age more slowly, but if unused and left more slowly, but if unused and left idle they become liable to disease, idle they become liable to disease, defective in growth, and age quickly.defective in growth, and age quickly.

Hippocrates (460-377 BC)Hippocrates (460-377 BC)

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