Exercise Treatment Of The Obese Patient


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Exercise Treatment Of The Obese Patient

  1. 1. Exercise-Treatment of the Obese Patient Ayaz Virji, MD FAAFP Diplomate, American Board of Family Medicine Diplomate, American Board of Bariatric Medicine Diplomate, American Board of Phys Nutrition Specialists ABBM Review Course 2007
  2. 2. Definitions <ul><li>Physical Activity: any bodily movement produced by skeletal muscle resulting in EE (walking, running, household chores, playing sports) </li></ul><ul><li>Exercise: Physical activity that is planned or structured. Involves repetitive bodily movement aimed to improve physical fitness (CV endurance, flexibity, muscle strength). </li></ul><ul><li>Non-Exercise Activity: Physical activity involving non-volitional exercise. Leads to Non-Exercise Activity Thermogenesis (NEAT). Includes occupational activity, leisure time activity, and household activity </li></ul><ul><li>(US Dept HHS, Physical Activity and Health: A Report of the Surgeon General, 1996) </li></ul>
  3. 3. Skeletal Muscle Anatomy Myofibrils – Muscle fiber (cell) – Fascicle – Muscle Tissue
  4. 4. Skeletal Muscle Anatomy
  5. 5. Skeletal Muscle Physiology <ul><li>Type 1 fibers: aka = slow twitch/red muscle, OXIDATIVE, used for prolonged work (Posture-maintaining muscle, back,..) </li></ul><ul><li>Type 2 fibers: aka = fast twitch/white muscle, ANAEROBIC, used for quick bouts of work (extraocular muscles, hands,..) </li></ul><ul><li>Skeletal muscle has plasticity and subject to training </li></ul><ul><li>Marathon Runner: more Type 1 red fibers </li></ul><ul><li>Power Lifter: more Type 2 white fibers </li></ul><ul><li>(Ganong, 1995) </li></ul>
  6. 6. Skeletal Muscle Physiology <ul><li>Fuel </li></ul><ul><ul><li>At rest = 70% free fatty acids </li></ul></ul><ul><ul><li>With activity = depends upon intensity (low intensity = free fatty acids; high intensity = glucose) </li></ul></ul>
  7. 7. Skeletal Muscle Physiology <ul><li>Blood flow to resting muscle is low (2-4 ml/100g/min) </li></ul><ul><li>Muscle contraction leads to compression of blood vessel beginning at 10% of maximum tension. Flow completely blocked at 70% and burns intracellular storage of glycogen for fuel. </li></ul><ul><li>Reflexive vasodilation during resting phase – increase blood flow 100 X baseline rate </li></ul><ul><li>(Ganong, 1995) </li></ul>
  8. 8. Non-Weight Related Benefits <ul><li>24% reduction in all-cause mortality </li></ul><ul><li>36% reduction in CV mortality </li></ul><ul><li>Reduces emotional distress, depression, and anxiety </li></ul><ul><li>Improves glycemic control </li></ul><ul><li>Improves Immune system function (improves NK cells and T Cell function) </li></ul><ul><li>May reduce the risk of various cancers </li></ul><ul><li>(Hu, N Enlg J Med 2004) (Blumenthal, JAMA 2005) </li></ul><ul><li>(Paffenbarger, N Engl J Med 1993) (Keast, Sports Med 1988) </li></ul>
  9. 9. Physiologic Changes – Micro level <ul><li>Increase size and number of mitochondria </li></ul><ul><li>Increase capacity to store glycogen </li></ul><ul><li>Increase fatty acid utilization by muscle </li></ul><ul><li>Increase capillary number </li></ul><ul><li>Increase myoglobin levels </li></ul><ul><li>(Peterson, 2005) </li></ul>
  10. 10. Cardiovascular Adaptations – Macro level <ul><li>Improves contractility and stroke volume </li></ul><ul><li>Reduces Peripheral Vascular Resistance </li></ul><ul><li>Improves endothelial cell function </li></ul><ul><li>Improves Cardiac Compliance </li></ul><ul><li>Improves Cardiac Baroreceptor Reflex </li></ul>
  11. 11. Treatment of Obesity <ul><li>May enhance caloric burn during a comprehensive weight loss strategy-but ineffective when used alone. </li></ul><ul><li>Inhibits malonyl CoA at level of myocyte (malonyl CoA inhibits fatty acid oxidation) </li></ul><ul><li>Overall role in weight loss is complicated and not fully understood. </li></ul><ul><li>(Visona, Obes Res 2002) (Ruderman 2006) </li></ul>
  12. 12. Exercise During Weight Loss <ul><li>Misperception of energy expenditure: patients burn far fewer calories than they think. May lead to over compensation during energy intake </li></ul><ul><li>Weight Loss Dishinhibition: </li></ul><ul><li>Restraint: ability to control energy intake </li></ul><ul><li>Disinhibition: loss of restraint </li></ul><ul><li>(include ETOH, dysphoric emotions, food commercials, and exercise) </li></ul><ul><li>Involvement of right pre-frontal cortex </li></ul><ul><li>(Visona, Obes Res 2002) (Alonso-Alonso JAMA 2007) </li></ul>
  13. 13. Exercise During Weight Loss <ul><li>Clearly stands out as an important component during weight loss maintenance (NWCR) </li></ul><ul><li>Increase in daily calorie burn (aerobic)– replaces loss of calorie burn during NEAT </li></ul><ul><li>Increase in lean muscle mass (anaerobic)-reduces loss of BMR from weight loss </li></ul>
  14. 14. Special Consideration in the Elderly <ul><li>Endurance and resistance exercise may improve physical function and ameliorate frailty during weight loss </li></ul><ul><li>Helps to counterbalance reduced bone mineral density </li></ul><ul><li>Combats sarcopenia during weight loss </li></ul><ul><li>(Villareal, Am J Clin Nutr 2005) </li></ul>
  15. 15. Energy Balance Equation <ul><li>TDEE = BMR + TEF + Activity </li></ul><ul><li>60-70% 5-10% 15-30% </li></ul><ul><li>TDEE – Total daily energy expenditure </li></ul><ul><li>BMR – Basal metabolic rate </li></ul><ul><li> TEF – Thermogenic effect of food </li></ul>
  16. 16. Aerobic vs Anaerobic <ul><li>Aerobic activity (Cardio): generally involves low intensity longer duration activity, uses fatty acids for fuel, and aimed toward improving cardiovascular fitness </li></ul><ul><li>Anaerobic activity (Resistance): generally involves high intensity, shorter duration activity, uses predominantly intacellular glycogen as fuel, and aimed toward muscle building </li></ul>
  17. 17. NEAT <ul><li>Non-Exercise Activity Thermogenesis (NEAT) also referred to at lifestyle activity </li></ul><ul><li>Calories burned through physical activity not involving volitional exercise (running errands, shopping, yard work, etc.) </li></ul><ul><li>Important source of total energy expenditure from physical activity. </li></ul><ul><li>Individual variation of NEAT in humans is 10 fold (equivalent to a marathon run) </li></ul><ul><li>(Andreson, JAMA 1999) </li></ul>
  18. 18. NEAT Studies <ul><li>Multiple Risk Factor Intervention Trial- (13,000 men followed over 7 years) showed leisure time activity (bowling, fighing, light walking, yardwork) lowered mortality risk from CVD by 20% </li></ul><ul><li>Health ABC Study- 30% reduction in all-cause mortality in highest quintile of NEAT activity (working, volunteering, vacuuming, lawn care,…) </li></ul><ul><li>(Levine, Am J Clin Nutr 2000) (Manini, JAMA 2006) (Leon, JAMA 1987) </li></ul>
  19. 19. NEAT Interventions <ul><li>Park car further away when out </li></ul><ul><li>Use stairs instead of the elevator/escalator </li></ul><ul><li>Avoid moving platforms </li></ul><ul><li>Pace while on the phone </li></ul><ul><li>Do your own house cleaning </li></ul>
  20. 20. 2005 HHS Dietary Guidelines <ul><li>To Prevent Chronic Disease: Accumulate 30 minutes or more of moderate-intensity physical activity on most, preferably all, days of the week. </li></ul><ul><li>To Prevent Gradual Weight Gain: Accumulate 60 minutes of moderate to vigorous activity on most days of the week. </li></ul><ul><li>To Sustain Adult Weight Loss: Accumulate 60-90 minutes of moderate to vigorous activity on most days of the week. </li></ul><ul><li>(http://www.healthierus.gov/dietaryguidelines/) </li></ul>
  21. 21. Practice Guidelines <ul><li>Utilize a STEPS approach to establishing an activity regimen for your patients. </li></ul><ul><li>Overly aggressive initial recommendations will cause a zero sum attitude and damage self efficacy. </li></ul><ul><li>Gradually build an exercise regimen for the individual patient that is exclusive to him/her and compatible with lifestyle </li></ul><ul><li>The best regimen for overall health and weight management is that which is most sustainable </li></ul><ul><li>(Tanasescu, JAMA 2002) (Jakicic, JAMA 2003) </li></ul>
  22. 22. Practice Guidelines <ul><li>Best time to Exercise—”More important to exercise regularly than to worry about morning vs evening” </li></ul><ul><li>(AHA Position Statement - Circulation 2007 ). </li></ul><ul><li>Let the patient decide when and where works—but you document the specifics so patient can be held accountable. </li></ul><ul><li>Use a specific exercise prescription—either on script pad or in chart that notes frequency/time/duration of prescribed exercise regimen. </li></ul><ul><li>Try to blend some aerobic (improve CV fitness) and anearobic (improve basal metabolic rate) but be flexible. </li></ul>
  23. 23. Practice Guidelines <ul><li>Remember to tailor your activity regimen to your patient not vice versa. Must be realistic with your goals. </li></ul><ul><li>Sometimes the perfect/ideal regimen is unknown (What is the best dose of Aspirin325, 161, 81, 75 mg). Work with what we know. </li></ul><ul><li>The best regimen for overall health and weight management is that which is most sustainable </li></ul>
  24. 24. Grading Exercise Intensity <ul><li>Metabolic Equivalent (MET) level: </li></ul><ul><li>-Measure the amount of oxygen used by the body during physical activity </li></ul><ul><li>-MET= 3.5 ml O2/ KG/ min </li></ul><ul><li>= 1Kcal/ Kg/ hr </li></ul><ul><li>-1 MET generally equals the energy used by the body as you sit quietly </li></ul><ul><li>-Moderate Activity- burns 3 to 6 METs </li></ul><ul><li>-Vigorous Activity- burns > 6 METs </li></ul>
  25. 25. Grading Exercise Intensity <ul><li>Perceived Exertion (Borg Scale) </li></ul><ul><li>-How hard you feel your body is working </li></ul><ul><li>-subjective rating, but appears accurate </li></ul><ul><li>-ranges from 6-20 </li></ul><ul><li>-(6) no exersion </li></ul><ul><li>(7-11) light intensity </li></ul><ul><li>(12-14) moderate intensity </li></ul><ul><li>(15-20) Vigorous intensity </li></ul>
  26. 26. Risks of Exercise <ul><li>Musculoskeletal injury: most common risk of exercise </li></ul><ul><li>Arrhythmia more pronounced in patients with heart disease. </li></ul><ul><li>Risk of Sudden Cardiac Death during vigorous physical activity 1 per 1.51 million episodes of exercise. </li></ul><ul><li>Recommendations for Stress Testing </li></ul><ul><li>(Albert, N Engl J Med, 2000) </li></ul>
  27. 27. Odds and Ends <ul><li>Warm-up phase prior to exercise: increases blood flow, may reduce injury </li></ul><ul><li>Cool down phase post-exercise: improve removal of lactate from muscles </li></ul><ul><li>Stretching prior to exercise does not seem to confer benefit in reducing soreness or injury. </li></ul><ul><li>(Herbert, BMJ 2002) </li></ul>
  28. 28. Conclusion <ul><li>“ All parts of the body which have a function, if used in moderation and exercised in labours in which each is accustomed, become thereby healthy, well-developled and age more slowly, but if unused and left idle they become liable to disease, defective in growth, and age quickly. </li></ul><ul><li>Hippocrates (460-377 BC) </li></ul>
  29. 29. References <ul><li>US Department of Health and Human Services. Physical Activity and Health: a report of the Surgeon General. Atlanta: US Department of Health and Human Services, Center for Chronic Disease Prevention and Health Promotion, 1996. http://www.cdc.gov/nccdphp/dnpa/physical/terms/index.htm . [Accessed 3/15/05] </li></ul><ul><li>Ganong WF. Review of Medical Physiology . Appleton & Lang:East Norwalk. 1005.56-67,577-578. </li></ul><ul><li>Hu FB, Willett WC, Li T, et al. Adiposity as compared with physical activity in predicting mortality among women. N Engl J Med 2004;351:2694-703. </li></ul><ul><li>Blumenthal JA, Sherwood A, Babyak MA, et al. Effects of Exercise and stress management training on markers of cardiovascular risk in patients with ischemic heart disease. JAMA 2005 293(13):1626-34. </li></ul><ul><li>Paffenbarger RS, Hyde RT, Wing AL, et al. The association of changes in physical-activity level and other lifestyle characteristics with mortality among men. N Eng J Med 1993;328:538-545. </li></ul><ul><li>Keast D, Cameron K, Mortan AR. Exercise and the immune response. Sports Med 1988; 5:248. </li></ul><ul><li>Peterson DM. Overview of the risks and benefits of exercise. UptoDate. Available at www.uptodate.com . [Accessed 3/15/05] </li></ul>
  30. 30. References <ul><li>Visona C and George VA. Impact of dieting status and dietary restraint on post exercise energy intake in overweight women. Obes Res 2002 10:1251-1258. </li></ul><ul><li>Ruderman NB, Saha AK. Metabolic Syndrome: Adenosine monophosphate-activated protein kinase and malonyl coenzyme A. Obesity Res 2006; 14(S):25S-33S. </li></ul><ul><li>Alonso-Alonso M, Pascual-Leone A. The right brain hypothesis for obesity. JAMA 2007; 297: 1819-1822. </li></ul><ul><li>Villareal DT, Apovian CM, Kushner RF, et al. Obesity in older adults; technical review and position statement of the Amercian Society of Nutrition and NAASO, The Obesity Society. Am J Clin Nutr 2005 82:923-934. </li></ul><ul><li>Tanasescu M, Leitzmann MF, Rimm EB, et al. Exercise type and intesity in relation to coronary artery disease. JAMA 2002;288:1994-2000. </li></ul><ul><li>Jacicic JM, Marcus BH, Gallagher KI, et al. Effect of exercise duration and intensity on weight loss in overweight, sedentary women. JAMA. 2003;290:1323-1330. </li></ul>
  31. 31. References <ul><li>US Department of Health and Human Services: Dietary Guidelines for Americans 2005. Available at:http://www.healthierus.gov/dietaryguidelines/ [Accessed 3/15/05]. </li></ul><ul><li>Levine, JA, Schleusner, SJ, Jensen, MD. Energy Expenditure of nonexercise activity. Am J Clin Nutr 2000; 72:1451. </li></ul><ul><li>Anderson RE, Wadden TA, Bartlett SJ, et al. Effects of lifestyle activity vs structured aerobic exercise in obese women, JAMA. 1999;281:335-340. </li></ul><ul><li>Leon AS, Connett J, Jacobs DR, et al. Leisure-time physical activity levels and risk of coronary heart disease and death: the multiple risk factor intervention trial. JAMA. 1987;258:2388-2395. </li></ul><ul><li>Manini TM, Everhart JE, Patel KV, et al. Daily activity energy expenditure and mortality among older adults. JAMA. 2006;296:171-179. </li></ul><ul><li>Albert CM, Mittleman MA, Chae CU, et al. Triggering of sudden death from cardiac causes by vigorous exertion. N Engl J Med 2000; 343:1355. </li></ul><ul><li>Herbert RD and Gabriel M. Effects of stretching before and after exercising on muscle soreness and risk of injury: systematic review. BMJ 2002; 325:468. </li></ul>