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SCOPE School Dublin - Deborah Horn

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  • 1. Deborah Bade Horn DO MPH FASBP ASBP Board of Trustees, Vice-President Medical Director, Center for Obesity Medicine & Metabolic Performance Asst. Professor, University of Texas Medical School Physical Activity Prescription: Assessment & treatment to improve functional & metabolic capacity. American Society of Bariatric Physicians®
  • 2. Objectives “Results Typical” Weight Maintenance & Metabolic Health © Horn 2012
  • 3. Road Map  “Results Typical”: Review the Guidelines for Physical Activity Translate this into success for the patient with obesity  Case Based Application: Discuss the provider approach & areas for improved treatment Creating an individualized PA prescription Reducing the risks involved with PA  Interactive Delegate Experience
  • 4. 5 Most Common Recommendations for PA A. Wait until you are at your goal weight. Right now just focus on your diet B. Walk 30 minutes per day 5 days per week C. Take the stairs and Park your car farther away D. Join a Gym E. No Pain, No Gain What’s your PA Rx for a patient with obesity?
  • 5. How Much Physical Activity is Enough? General Health Benefit  Moderate aerobic exercise 150min/wk (About 30 minutes 5x/wk) + Strength Training Prevent Weight Gain & Active Weight Loss  150-250 minutes per week  150-300 minutes per week Prevention of Wt Regain  200-300 minutes per week  300-420 minutes per week Donnelly J. Am College Sports Med. 2009. US Health and Human Services. 2008.
  • 6. www.getirelandactive.ie
  • 7. Waiting for the other shoe to ……..
  • 8. International Guidelines  Ireland – To avoid gaining weight…at least 350kcal per day in PA. 60 min walking.  Canadian – Similar #’s for “Health benefit” No specific recs for the Obese population  UK Dept of Health 60-90min/d to prevent wt regain (2004) July 2011 rec new guidelines needed.  Denmark – WHO guidelines 300min/wk for additional benefit.  Germany – EU guidelines referenced at 150 min.  Belgium, France, Finland all refer to CDC website on search.  Bahrain – Has Strategy, but no guidelines  India – New Recs
  • 9. National Physical Activity Referral Program
  • 10. 14 10 8 6 4 2 0 12 1 2 3 4 5 6 7 8 Treatment (Weeks) 8 18 Follow-Up (Months) WeightLoss/Gain(kg) Exercise Non-Exercise Exercise Non-Exercise Exercise for Weight Maintenance Pavlou KN. Am J Clin Nutr. 1989.
  • 11. Look AHEAD Year 4: Success & Physical Activity Wadden TA. Obesity. 2011. 4-5 Mets for 60-70min/d Or Approx 420min/wk
  • 12.  17 Observational Studies  3.62 kg greater mean wt loss  2.3x greater odds of unsuccessful wt loss if  PA after surgery  PA repeatedly an independent predictor of weight loss Next Steps  FFM preservation – (RYGB 31%, BPD 26%, Band 18% loss of FFM)  Self reported questionnaires  RCTs needed  Optimal Rx unknown*  Excellent Review: King and Bond. Exerc Sport Sci Rev., Vol 41(1) 2013
  • 13.  Self reported PA  5x from pre-op to post-op  RT3 – non-significant decline in post-op PA  > 150min/wk MVPA compliance: Self report 55%, RT3 5%
  • 14. Physical Activity Recs & Bariatric Surgery Pre-op ASMBS: Mild exercise 20min/d, 3-4d/wk AHA: Low-Moderate intensity PA at least 20 min/d, 3-4d/wk Post-op ASBMS/TOS/AACE: At least 30 min/d IOM, HHS, ACSM, IASO: All agree that 150min/week is insufficient for the prevention of weight regain. 250-420min/wk 60-90min/day ASMBS/ACSM expert panel assembled to develop specific pre/post operative recommendations. http://s3.amazonaws.com/publicASMBS/GuidleliStatesments/guildelines/asbs_bspc.pdfnes Poirer et al. Circ 2011, Mechanick et al. Obesity 2009 Donnelly Med Sci Sport Ex 2009, IOM 2002 Saris et al Obes Review 2003, http://www.health..gov/paguidelines/pdf/paguide.pdf
  • 15. Physical Activity / Exercise History  Historical benefit of exercise in their weight loss or weight maintenance?  Past PA/Exercise participation  Current and favorite PA/Exercise  Previous and current barriers to PA/Exercise or
  • 16. Basic Physical Activity Rx: FITTE Frequency Intensity Time Type Enjoyment This is NOT the beginning. This is the End!
  • 17.  Current PA level  Readiness + Patient Goals (C/I, Stage of Change)  Co-morbidities  Physical exam  Medication Adjustment  Diagnostic testing needs  Mobility/Fitness Assessment  Special Equipment needs/modifications  FITTE  Optimal Default Put it all in a PA Contract! Medical Physical Activity Rx Top Ten © Horn 2012
  • 18. Readiness Rulers  Why are you a _____ and not at a lower number?  What would it take to get you from a ___ to the next higher number? Adapted from Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change. Public domain.
  • 19. Physical Activity Prescription Form © Horn 2012
  • 20. Physical Activity and Mets….What’s your intensity?
  • 21. MET Categories Light < 3 METs Driving your automobile = 2 Moderate = 3-6 METs Walking 4 mph, brisk pace = 5 Vigorous > 6 METs Carrying 25-49pds upstairs = 8
  • 22. Resting VO2 by Age & BMI Byrne et al. J Appl Physiol 2005 Sept 99:1112-1119
  • 23. RPE Scale Correlates with HR Adapted from Borg RPE Scale Gunnar Borg 1998
  • 24. Trainers, Physiologists, and Therapists…..Oh My! Trainers/Physiologists Highly Recommended: Graduate Level training ACSM, NSCA or ACE = Nat’l Certs CSEP Equivalents Subspecialized Certifications Physical Therapists – Key role in orthopedically complicated patients – Revisit periodically
  • 25. Start with the Fundamentals  Low/No Impact & Low Risk Activities – Aqua classes, water walking – Recumbent bikes / elliptical trainers – Walking – Chair aerobics  Balance training  Strength training
  • 26. Low Risk, High Yield Physical Activity Tools © Horn 2012
  • 27. What’s “The Best” Rx Doc? “LIVE IT!” Long Term – What activity will produce adherence? Intensity Volume Enjoyment Including Transitions Together they need to meet the guidelines Optimal Default + Life changes © Horn 2012
  • 28. Case Study Orthopedic Issues
  • 29. Patient Profile  66 year old, female  Weight 189.5 kg (416.8)  BMI 59.8  WC 64in  Architect  Single, 1 adult child Q: Why does the patient want to lose weight? A: Needs Bilateral Total Knee Replacement
  • 30. Weight & Physical Activity History  Max Weight 192.kg (424lbs)  Onset: >15 yrs ago  Regained 100lbs since last weight loss effort  Repeated rebound weight regain  Eats due to stress, extensive snacking, & eating out  Ongoing struggle with PA & bilateral knee pain 2nd to OA.  Previously a Tennis Pro, preferred activity  No PA at time of admission  Very motivated by need for knee replacements.  Low confidence due to pain.
  • 31. Past Medical History  NIDDM >10 years  Severe Bilateral Knee DJD  Depression/Anxiety  Sitagliptin 100mg  Pioglitazone 45mg  Bupropion-XL 300mg  Diclofenac, gabapentin, oxyc odone, propoxyphene both combined with acetaminophen. Medications
  • 32. Physical Exam  BP 126/68  Ht. = 70in, Wt. = 189.5 kg (416.8 lbs)  BMI = 59.8 WC = 64in  PE within normal limits except as noted below.  Balance: Unable to complete tandem gate  Utilizing walker intermittently  Msktl: Decreased ROM in shoulders, back, hips, and knees R knee: no crepitus, tenderness or inflammation  Phys. Therapy – initially declined by patient
  • 33. The Starting Point…
  • 34. Sept 8, 2011 None, Ambulating with walker for long distances. ADLs only X 10/10 2/10 The Starting Point… Patient Described Goals: – Accelerate Weight Loss – Improve conditioning in preparation for bilateral TKR
  • 35. CVD Risk Factors  Age  Diabetes  Overweight  Sedentary Lifestyle Any additional diagnostic testing or physical assessment?
  • 36. Recommendations for Stress Testing Prior to Exercise Risk Stratification – Low Risk: Asymptomatic and ≤1 CVD Risk Factor – Moderate Risk: Asymptomatic and ≥ 2 CVD risk factors – High Risk: Known cardiovascular, pulmonary or metabolic disease or major signs of disease Alternative Guidelines: 2010 ACCF/AHA Guideline for Assessment of Cardiovascular Risk in Asymptomatic Adults. Thompson WR, Ed. ACSM’s Guidelines for Exercise Testing & Prescription. 2010. Greenland P. J Am Coll Cardiol. 2010.
  • 37. Age • Men ≥ 45 yrs • Women ≥ 55 yrs Smoking • Smoker • Quit < 6 mo ago Sedentary • < 30 min of mod. exercise on at least 3 d/wk for previous 3 mo. Obesity • BMI ≥ 30 • WC > 40in men >35in women HTN • Systolic ≥ 140 and/or • Diastolic ≥ 90 • Antihypertensive Meds Dyslipidemia • LDL ≥ 130 • HDL < 40 • Lipid Lowering Meds PreDM • Fasting Glucose ≥ 100 • Abnormal IGT HDL • ≥ 60 • Negative Risk Factor Risk Factor Thresholds Thompson WR, Ed. ACSM’s Guidelines for Exercise Testing & Prescription. 2010.
  • 38. Stress Testing Based on Risk Stratification Risk Low Risk Mod Ex  No Vig Ex  No Intermediate Risk Mod Ex  No Vig Ex  Yes High Risk Mod Ex  Yes Vig Ex  Yes Thompson WR, Ed. ACSM’s Guidelines for Exercise Testing & Prescription. 2010.
  • 39. What are the key components to consider in your physical activity prescription? Let’s Write It!
  • 40. What did you choose? Oct 14, 2012 ADL’s with assistance RPE 2-8 10/10 PT-2 X X X X Strength and H2O H2O - 3 Needs Stress Test/Phys Therapy Eval for falls eval prior to initiation. When cleared:170min/wk. 2 weeks Personal Trainer 2/10 X PCPA Mod 1-2 Leg Ext, Crunch, Deborah Bade Horn DO MPH PCPA-3 1 28 13 NA NA © Horn 2012
  • 41. Exercise Prescription  Falls precautions  Initially: – Pool work: anti-gravity – Personal training – PCPA  No DM Med changes, but begin monitoring  Eventually – Physical therapy – Review presurgical approach  Begin Pain journal to facilitate medication adjustment 1st Goal: >170 min at RPE ≥ 4, minimal joint pain Optimal Goal: >250 min, RPE ≥ 5, Doubles Tennis?
  • 42. Progress: Ortho/ Pain Meds  During the course of obesity treatment: – Bilateral Total Knee Replacements – 1 TKR revision  Pain med adjustments – Pain Mgmt consult – Weaned off controlled substances – Ultimately, Ibuprofen occasionally
  • 43. Progress – Weight & PA Maintenance  Lost and maintained 54.5kg (120 lbs). weight loss throughout 3 surgeries over 18 months.  Physical Activity?
  • 44. Long Term Planning What would you do?
  • 45. Long Term Planning  After bilateral TKR and 1 revision: – Off walker after extensive pre and post surgery PA – Minimal intermittent pain
  • 46. Putting it into Long Term Practice Step 1: Complete your PA Top 10 for EVERY patient. Step 2: Develop an Exercise prescription SPECIFIC to individual needs. Step 3: Monitor progress & update Ex Rx every visit Step 4: Revise goals at least every 3 months. Step 5: Be Creative & think outside the treadmill! © Horn 2012
  • 47. Engineering PA Back into Life
  • 48. Expose Unexpected Barriers
  • 49. Swimming Up Stream © Horn 2012
  • 50. Using Your Environment © Horn 2012
  • 51. Deborah Bade Horn DO MPH FASBP ASBP Board of Trustees, Vice-President Medical Director, UT Center for Obesity Medicine and Metabolic Performance (COMMP) Asst. Professor, University of Texas Medical School debbiebhorn@yahoo.com American Society of Bariatric Physicians®
  • 52. Save your Questions & Let’s Go Practice! © Horn 2012