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

8. Waiting for the other shoe to ……..

9. 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

11. National Physical Activity Referral Program

12. 14
10
8
6
4
2
0
12
1 2 3 4 5 6 7 8
Treatment (Weeks)
8 18
Follow-Up (Months)
Weight
Loss/Gain
(kg)
Exercise
Non-Exercise
Exercise
Non-Exercise
Exercise for Weight Maintenance
Pavlou KN. Am J Clin Nutr. 1989.

13. Look AHEAD Year 4: Success & Physical Activity
Wadden TA. Obesity. 2011.
4-5 Mets for
60-70min/d
Or
Approx
420min/wk

14.  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

15.  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%

16. 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

17. 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

18. Basic Physical Activity Rx: FITTE
Frequency
Intensity
Time
Type
Enjoyment
This is NOT the beginning.
This is the End!

19.  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

20. 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.

21. Physical Activity
Prescription
Form
© Horn 2012

22. Physical Activity and Mets….What’s your intensity?

23. 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

24. Resting VO2 by Age & BMI
Byrne et al. J Appl Physiol 2005 Sept 99:1112-1119

25. RPE Scale
Correlates with HR
Adapted from Borg RPE Scale
Gunnar Borg 1998

26. 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

27. 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

28. Low Risk, High Yield Physical Activity Tools
© Horn 2012

29. 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

30. Case Study
Orthopedic Issues

31. 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

32. 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.

33. Past Medical History
 NIDDM >10 years
 Severe Bilateral Knee DJD
 Depression/Anxiety
 Sitagliptin 100mg
 Pioglitazone 45mg
 Bupropion-XL 300mg
 Diclofenac, gabapentin,
oxycodone, propoxyphene
both combined with
acetaminophen.
Medications

34. 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

35. The Starting Point…

36. 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

37. CVD Risk Factors
 Age
 Diabetes
 Overweight
 Sedentary Lifestyle
Any additional
diagnostic testing
or physical
assessment?

38. 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.

39. 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.

40. 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.

41. What are the key components to consider in your
physical activity prescription?
Let’s Write It!

42. 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

43. 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?

44. 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

45. Progress – Weight & PA Maintenance
 Lost and maintained 54.5kg (120 lbs). weight loss
throughout 3 surgeries over 18 months.
 Physical Activity?

46. Long Term Planning
What would you do?

47. Long Term Planning
 After bilateral TKR and 1 revision:
– Off walker after extensive pre and post surgery PA
– Minimal intermittent pain

48. 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

49. Engineering PA Back into Life

50. Expose Unexpected Barriers

51. Swimming Up Stream
© Horn 2012

52. Using Your Environment
© Horn 2012

53. 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®

54. Save your Questions & Let’s Go Practice!
© Horn 2012