Obesity, Exercise and Fitness

Article Author:
Grace Niemiro
Article Editor:
Amit Algotar
Updated:
4/8/2019 4:38:51 PM
PubMed Link:
Obesity, Exercise and Fitness

Introduction

Obesity represents a significant public health concern with one-third of adults classified as living with obesity in the United States and correlates with cardio-metabolic co-morbidities that can decrease the quality of life.[1][2] Researchers have proposed that exercise can be a vital sign in the healthcare setting, and this may be especially important in the context of obesity. This review will cover the role of exercise in obesity and fitness.

Function

The definition of obesity is excessive fat accumulation in adipose tissues, to the extent that health is impaired and defined by having a body mass index (BMI) greater than or equal to 30 kg/m.[3] Obesity correlates with to increasing an individual’s risk of cancers, stroke, metabolic disease, heart failure, and other cardiovascular conditions,[4][5][6], highlighting the need to reduce incidence and prevalence of obesity. Chronic low-grade inflammation associated with obesity is hypothesized to have associations with the adverse cardio-metabolic side effects.[7] Although short term inflammation is beneficial to initiate an immune response, chronically elevated levels of inflammation exhaust the immune system and contribute to immune dysfunction.[2] Researchers posit that this inflammation is stimulated by the excess adipose tissue, which has consistently shown to play a role as an active endocrine organ.[8]

Reducing adipose tissue is a means of reducing weight in individuals with obesity, and is necessary to mitigate negative cardio-metabolic co-morbidities in obesity. Two methods exist that can effectively decrease adipose tissue and include: 1. dietary modification and 2. Energy expenditure modification (i.e., exercise). Thus, increasing energy expenditure can help reduce excess adipose tissue and obesity. The current guidelines put out by the American College of Sports Medicine (ACSM) include either aerobic or anaerobic exercise. Aerobic exercise (i.e., running, cycling, rowing, etc.) is an exercise that exhausts the oxygen in the muscles, but oxygen consumption is sufficient to supply the energy demands placed on the muscles and does not need to derive energy from another source.[9] On the other hand, anaerobic exercise (or resistance exercise; i.e., weight lifting) is oxygen consumption that is not sufficient to supply the energy demands placed on the muscles, and your muscles must break down other energy supplies, such as sugars, to produce energy and lactic acid.[9] Physical activity (PA), is included in exercise, although it does not necessarily include structured exercise plans/sessions.

The measurement of exercise is conducted in “metabolic equivalent tasks” (METs), which roughly equate to the effort and energy expenditure it takes for an individual to sit quietly. Physical activity is frequently incorporated into different lifestyle interventions, highlighting the need for regular amounts of physical activity throughout the day. Physical activity in the general lifestyle includes goal-setting, problem-solving, leisure time physical activity, and activity used for commuting. Outcomes of interest include cardiorespiratory fitness, body composition, and muscular fitness. Recently, much literature has shown the positive effects of exercise on not only physical measures but also cognitive and emotional measures in people of all ages.[10]

Issues of Concern

Individuals living with obesity can partake in the same exercise prescriptions as individuals who are living at a normal weight. However, special considerations must be made, such as current co-morbidities that may be associated with obesity like orthopedic risk (i.e. arthritis), pulmonary, and/or cardiac co-morbidities. However, this should not deter individuals away from participating in exercise programs, as exercise is extremely important for overall health.[11][12] Currently, there are several exercise guidelines for individuals living with obesity and include the American College of Sports Medicine (ACSM), the Obesity Medical Association (OMA), and the Obesity Society (TOS); which are all clinically available to aid individuals in prescribing exercise. Here, we outline the general recommendations for individuals living with obesity and exercise.

The overarching goal in individuals living with obesity and exercise includes reducing excess fat mass, increasing muscle mass, and increasing overall PA. Therefore, the following guidelines for individuals with obesity to exercise are summarized as follows:

  1. Patients must be cleared by their healthcare provider for any comorbid conditions by history and physical examination in order to maximize patient safety.[13]
    1. Examples include Physical Activity Readiness Questionaire (PAR-Q) and Health/Fitness Facility Preparticipation Screening Questionnaire.[14][15].
  2. Minimum of 150 to 300 minutes of moderate physical activity per week or 75 to 150 minutes of vigorous physical activity weekly as a minimum to prevent weight regain, increase weight loss, and fitness improvement.[13] However, for individuals who wish to lose weight, at least 200 to 300 minutes of moderate to vigorous physical activity each week is recommended to encourage long-term weight loss.[13][16]
    1. Examples of moderate include walking briskly, swimming, active yoga, ballroom or line dancing, etc. 
    2. Examples of vigorous include running, jogging, jump rope, high-intensity interval training, heavy yard work that increases heart rate, etc.
    3. In order to increase PA, ensure that it is increased gradually over time. The recommendation for inactive individuals is “start low and go slow” by starting with lower intensity activities and gradually increasing frequency and duration of activity. This is especially important in individuals who are living with obesity and these individuals tend to be less fit.
    4. It is a good idea to spread out aerobic activity over the week, versus all the time in one day.
    5. Utilize appropriate gear and sports equipment and chose safe environments.
      1. That being said, obesity disproportionately affects individuals with a lower socioeconomic status, and these individuals may not have access to a safe exercising space, may not understand the importance of exercise, or may not have the time during the day to exercise due to other obligations. Therefore, the relationship between the physician, healthcare group, and the patient becomes extremely important in implementing exercise in individuals with obesity.
    6. Adjust exercises as necessary to decrease orthopedic risk or is non-ambulatory (if applicable). This can include cycling instead of running if an individual has arthritis.
      1. In the event that individuals are not ambulatory or may have to modify exercise due to special circumstances, the aforementioned exercise guidelines still apply. However, the patient can get creative to find ways to achieve them, such as utilizing limbs that are more ambulatory than others (e.g. moving arms faster in order to get the heart rate up if legs are not able to be used, upper body ergometer, etc.)
    7. Anaerobic training can be implemented and may even increase muscle mass. Anaerobic exercise has not been shown to be effective in altering energy expenditure or absolute weight loss.[16] However, if the goal of the patient is to increase muscle mass, then anaerobic exercise is highly encouraged.
      1. In order to increase muscle mass, each muscle group should be exercised at a minimum of 10 sets per week, with one set consisting of 8 to 10 reps.
      2. Ensure proper form to avoid injuries.
      3. Individuals who are not ambulatory or may have limited movement are still able to participate in an anaerobic exercise. Individuals must ensure proper form but can modify exercises as needed, such as upper body only exercises, lower body only exercises, using a neutral grip, keeping stable movements, etc.)

Enhancing Healthcare Team Outcomes

The healthcare team (nurse practitioner, primary care provider, internist, endocrinologist, bariatric surgeon) should implement many strategies to increase physical activity and fitness for individuals living with obesity and includes utilizing “exercise vital signs,” tracking exercise, motivational interviewing, and periodic check-ins. Currently, the following could potentially be implemented into practice to encourage patients living with obesity to exercise:

  1. Utilizing exercise as a vital sign in individuals with obesity.
    1. Obtaining current exercise and physical activity habits from patients could serve as another vital sign and would include understanding the intensity, mode, and duration of exercise performed weekly by the patient. Physicians could have electronic medical records (EMRs) to prompt patients who are living with obesity to have discussions with the patient regarding their physical activity. These prompts on the EMR can be input by the medical assistants who may ask at the beginning of the appointment, just like taking blood pressure and pulse.
  2. Utilizing exercise trackers
    1. Today, technology can track heart rate, motion, exercise, MVPA, and beyond. Physicians could potentially use these data to ensure that the patient is exercising, and could point towards potential problems that may arise due to abnormal heart or exercise responses.
    2. Examples include smartwatches, cellular smartphones, pedometers, heart rate monitors, etc.
  3. Motivational Interviewing
    1. To drive the point home further, nurses, CNAs, physicians, and anyone else involved in the healthcare setting for this patient could employ/use motivational interviewing techniques with the patient to reflect, plan, and execute different action plans to ensure that patients are meeting their exercise goals.
  4. Check-Ins
    1. Technology is allowing individuals to interact now more than ever. Physicians and patients could potentially use these technological advances to develop relationships further. Utilizing technology to have doctor-patient check-ins regarding their exercise may increase adherence of individuals living with obesity to exercise programs.
    2. These could include developing an app that alerts patients and/or the doctor when exercise habits are not sufficient, thus prompting a check in from the physician using motivational interviewing asking why the patient has or hasn’t exercised according to plan.

Exercise/physical activity is a proven modality for treating the disease of overweight and obesity. Individuals living with obesity can certainly exercise and increase their fitness in the same way. However, management of this disease is best through dietary interventions and regular exercise. Exercise is an integral part of not only weight loss, but overall health as well. Individuals living with obesity can increase exercise in their daily lives with the help of their medical team to increase exercise and PA in their daily routine.


References

[1] Ogden CL,Carroll MD,Kit BK,Flegal KM, Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA. 2014 Feb 26;     [PubMed PMID: 24570244]
[2] Hotamisligil GS, Inflammation and metabolic disorders. Nature. 2006 Dec 14;     [PubMed PMID: 17167474]
[3] Caterson ID,Gill TP, Obesity: epidemiology and possible prevention. Best practice     [PubMed PMID: 12468409]
[4] Asghar A,Sheikh N, Role of immune cells in obesity induced low grade inflammation and insulin resistance. Cellular immunology. 2017 May;     [PubMed PMID: 28285710]
[5] de Heredia FP,Gómez-Martínez S,Marcos A, Obesity, inflammation and the immune system. The Proceedings of the Nutrition Society. 2012 May;     [PubMed PMID: 22429824]
[6] Craft MK,Reed MJ, Immunologic changes in obesity. Critical care clinics. 2010 Oct;     [PubMed PMID: 20970048]
[7] Asztalos BF,Horan MS,Horvath KV,McDermott AY,Chalasani NP,Schaefer EJ, Obesity associated molecular forms of C-reactive protein in human. PloS one. 2014;     [PubMed PMID: 25299074]
[8] Adamczak M,Wiecek A, The adipose tissue as an endocrine organ. Seminars in nephrology. 2013 Jan;     [PubMed PMID: 23374889]
[9] Bateman LA,Slentz CA,Willis LH,Shields AT,Piner LW,Bales CW,Houmard JA,Kraus WE, Comparison of aerobic versus resistance exercise training effects on metabolic syndrome (from the Studies of a Targeted Risk Reduction Intervention Through Defined Exercise - STRRIDE-AT/RT). The American journal of cardiology. 2011 Sep 15;     [PubMed PMID: 21741606]
[10] Bechara RG,Kelly ÁM, Exercise improves object recognition memory and induces BDNF expression and cell proliferation in cognitively enriched rats. Behavioural brain research. 2013 May 15;     [PubMed PMID: 23439217]
[11] Ozemek C,Laddu DR,Lavie CJ,Claeys H,Kaminsky LA,Ross R,Wisloff U,Arena R,Blair SN, An Update on the Role of Cardiorespiratory Fitness, Structured Exercise and Lifestyle Physical Activity in Preventing Cardiovascular Disease and Health Risk. Progress in cardiovascular diseases. 2018 Nov - Dec;     [PubMed PMID: 30445160]
[12] Cotman CW,Berchtold NC, Exercise: a behavioral intervention to enhance brain health and plasticity. Trends in neurosciences. 2002 Jun;     [PubMed PMID: 12086747]
[13] McQueen MA, Exercise aspects of obesity treatment. The Ochsner journal. 2009 Fall;     [PubMed PMID: 21603430]
[14] Thomas S,Reading J,Shephard RJ, Revision of the Physical Activity Readiness Questionnaire (PAR-Q). Canadian journal of sport sciences = Journal canadien des sciences du sport. 1992 Dec;     [PubMed PMID: 1330274]
[15] American College of Sports Medicine Position Stand and American Heart Association. Recommendations for cardiovascular screening, staffing, and emergency policies at health/fitness facilities. Medicine and science in sports and exercise. 1998 Jun;     [PubMed PMID: 9624663]
[16] Donnelly JE,Blair SN,Jakicic JM,Manore MM,Rankin JW,Smith BK, American College of Sports Medicine Position Stand. Appropriate physical activity intervention strategies for weight loss and prevention of weight regain for adults. Medicine and science in sports and exercise. 2009 Feb;     [PubMed PMID: 19127177]