Exercise… The Key to Weight Loss Success

by Sharon Zarabi, RD, CDN, CPT
Ms. Zarabi is the Bariatric Dietitian at Lenox Hill Hospital in New York.

Introduction
Obesity is a growing health concern that has prevailed our country in recent years. Between the years 2000 and 2005, morbid obesity and super obesity increased two- and three-fold, respectively, than that of obesity alone.1 Many patients have turned to weight loss surgery as a means for long-term weight loss after several failed diet attempts and exercise programs. As a result, it is estimated that the rates of bariatric procedures have increased to decrease the mortality rates of obese individuals.

In a study of the National In-patient Survey (NIS), Pope et al reported that the rate of bariatric surgery procedures increased from 2.7 to 6.3 per 100,000 adults from 1990 to 1997. During the same period, gastric bypass surgery as a percentage of all bariatric surgeries in the US increased from 54 to 84 percent.2 Unfortunately, after having the gastric bypass—or any other weight loss surgery for that matter—is not the cure all. It is still the responsibility of the patient as well as any other individual to use diet and exercise as a means of weight management due to the fact that both diet and exercise are effective complementary roles, which, in the longterm, work better than either component alone.3

Despite the benefits of weight loss, exercise has been proven to help lower blood pressure, alleviate uncontrolled blood sugars, reduce cholesterol, improve quality of life, and increase sex drive.4-7 Weight training, a counterpart of exercise, helps increase fat-free mass, increases resting metabolic rate, increases bone density, and decreases the risk of osteoporosis along with preventing many other chronic diseases.8 Most often, women shy away from weights, believing the myth that fat turns into muscle, thus creating a wider frame or “bulky physique.” But muscle is active tissue that requires energy or calories for sustenance. Hence, increased muscle composition burns more energy at rest, leading to a higher resting metabolism.9 Stretching should also be made a priority to enhance flexibility of joints and reduce the risk of injury.

Exercise Recommendations
Exercise recommendations are based on the type of activity, including mode, frequency, intensity, and duration. (A sample exercise program is listed at the end of this article). While focusing on postoperative bariatric patients, recently speaking, there are no recommended guidelines for the amount of physical activity needed to maximize weight loss after surgery.10 Currently, The American Heart Association recommends the following: “30 to 60 minutes on most, if not all, days of the week, (which) need to be individualized and are generally targeted to expend a total of 100 to 200Kcal” for exercise.11 In 2001, the American College of Sports Medicine (ACSM) suggested further guidelines of a minimum of 150 minutes (2.5 hours) of moderate intensity exercise weekly for overweight and obese individuals, leading to an energy expenditure of 300 to 500/Kcal/day or 1,000 to 2,000Kcal/week.12 These are suggestions that need to be adjusted based on total caloric intake daily. Please be aware that as the postoperative diet progresses over time and calories consumed increase, it is important to consider adjusting calories expended to calories consumed. Protein needs will change depending upon calorie intake due to the fact that protein provides 4cal/g. It is important that the bariatric patient follow up with a registered dietitian to formulate adequate needs as muscles burn protein for energy when fuel is scarce.

Medical Evaluations
Prior to implementing any activity recommendations, it is of utmost importance that a thorough medical evaluation be completed. This can help minimize the risk of injury, stroke, and/or heart attack. The ACSM guidelines for Exercise and Testing Prescription state that “medical and exercise testing may not be necessary if the physical activity is at a moderate level. Overweight or obese patients can begin an exercise program with a gradual increase in physical activity without undergoing diagnostic tests.”13 However, it is further suggested that if the patient has symptoms of heart disease, hypertension, or history of metabolic, cardiac, or pulmonary disease, formal testing is highly recommended.

Such testing can help the exercise professional prescribe the proper workout protocol. There are several methods to consider when recommending and monitoring the intensity of the activity. Such modalities include heart rate (HR) or rate of perceived exertion (RPE).

When implementing an exercise prescription, the clinician must assess the patients maximum heart rate. The predicted equation of 220-Age is the most common formula to predict maximum heart rate. In order to burn the stored carbohydrates as fuel, it is recommended that avid exercisers achieve a target HR of 55 to 80 percent of their maximum HR. To find out more information on appropriate zones, visit www.americanheartassociation.org.
Miller et al examined the relationship of oxygen consumption and HR in obese individuals compared with adults of normal BMI and further developed a more accurate equation to predict max HR for obese individuals to be 220-0.5 x Age.14

Fifty percent of this equation can be a basic starting point for beginner exercisers focusing more on the duration of their workouts rather than high intensity, and adjustments may be made based on any medical conditions—hence the importance of medical clearance by a doctor. Heart medications, beta blockers, and angiotensins have an effect on lowering resting HR, which can decrease exercise capacity, while calcium channel blockers and vasodilators trigger hypotension; therefore, a cool down session must be emphasized.13

Patients can also monitor their own HR by measuring their pulses. This can be done by placing their three fingers on their radial pulse (inside of the wrist) or by using their index and middle finger to monitor their carotid pulse (below the neck). They then count the beats in 10 seconds and multiply that number by 6—which will give them their beats per minute (bpm).

The Borg RPE is another method in assessing how hard an individual feels based on breathing rate, HR, sweat, and muscular fatigue during physical activity.15 The scale ranges from 6 (no exertion at all) to 20 (extreme exertion). Moderate intensity can be considered on a scale of 12 to 14 (somewhat hard). This scale, while subjective, has been shown to correlate with actual HR and can be a good tool to help postoperative patients assess their own individual intensities.16

When using cardiovascular equipment, such as a treadmill, elliptical, or stair climber, patients gauge their workouts with the total calories burned, allowing themselves to eat more later in the day. But the calories burned are overestimated, despite adding age, gender, and weight.17-19 Ceesay et al concluded that the most accurate and cheapest means of calculating calories burned is with a HR monitor or increased steps measured by a pedometer. It is easy to find Polar Heart Rate Monitors®™ or Nike®™ accessories at sportswear stores, ranging in price from $60 to $200 depending on their functions and capabilities.20, 21

In addition to the aerobic element, light resistance training is also encouraged to help correct posture, improve balance and coordination, build fat free mass, and increase self esteem.22 When working with bariatric patients, it is a major responsibility to ensure the safety of the patients by maintaining them in a supported position during all exercises. Using machines is recommended, but is often a challenge due to their large stature. A second alternative to machines is the use of free weights, which are encouraged to help challenge smaller muscles in the body while focusing on larger muscles, but may also be high risk due to the range of free motion that may lead to injury if correct form is not instituted. The pain they endure is less likely to help them continue a resistance training workout, instead leading them to associate pain with exercise.23

In the longterm, the physical activity should progress to an exercise prescription to reduce body fat with cardiovascular activity and preserve fat free or lean body mass with resistance or strength training routines. Whereas some patients may be willing to attempt to follow the recommended guidelines of 60 to 90 minutes, the immediate postoperative patient may not be able to achieve such goals, and duration of activity can be broken into four 15-minute sessions throughout the day. Moreover, therapeutic lifestyle changes may begin with simple exercises, such as yoga, martial arts, pilates, or group exercise classes. Exercise should always be fun to promote compliance.

By interviewing patients, one can easily adopt an appropriate exercise program that suits their needs and lifestyle. Important questions that need to be addressed in order to achieve their goals include past exercise history, perceived obstacles and barriers of past attendance, and comfort level of exercising in public places, such as a health club, or more private settings, such as in their own homes. Patients should be encouraged to walk extra steps throughout the day. Taking the stairs may be difficult due to joint issues, but other daily activities, such as carrying their own groceries, getting off the train a stop ahead, or taking a walk during their lunch break, can all have a significant impact on their long-term success if done consistently.

Technology has made it easy for all to engage in an exercise program. With the increasing use of computers and advancement in technology, clinicians are branching out to alternative modes of engaging clients by phone and internet. In the short term, Tate et al found a weight loss internet website to produce a 1.7kg weight loss over three months compared to a 4.0kg weight loss produced with an internet behavior program that had weekly lessons, emails, and therapist feedback.24 After six months, the total weight loss was almost the same. A few user-friendly websites that are free of charge are listed in Table 1. Although patients are aware of the health benefits, encouraging them to maintain exercise as part of their renewed lifestyle can be quite challenging.

Zografakis et al evaluated the attendance of postoperative patients who were enrolled in a surgical weight loss program and were required to participate in group exercise sessions. Results of this study concluded that despite patients having pre-paid for the exercise classes, only 17 percent attended.26 Bond et al demonstrated the relationship between physical activity readiness and physical activity (PA) among gastric bypass patients.27,28 They concluded that 46 percent of the subjects were prepared to participate in PA, while 34.5 percent actually engaged in PA for less than six months, and 13.8 percent have been in the maintenance phase of performing PA for more than six months. This study portrays the renewed sense of responsibility that a patient is willing to take for his or her health, but pursuing these goals must be achieved with the help of the bariatric allied health team, including the surgeon, nutritionist, psychologist, nurse, and exercise specialist. I remind my patients that there will not be any more hours added to the day after patients leave the hospital to make time for the gym; it is all in their desire to make the changes now. Table 2 (on page 32) provides some daily activities and their caloric expenditures.

Below are a few strength training exercises with brief descriptions as devise by the Womens Heart Foundation.29
1) Side shoulder raise—for outer portion of the shoulders (Figure 1)
• Start with arms hanging in front of thighs, elbows slightly bent, and palms facing each other
• Raise both dumbbells outward simultaneously to shoulder heights, keeping elbows slightly bent
• Lower dumbbells to starting positions and repeat

2) Front shoulder raise—for front portion of the shoulders (Figure 2)
• Begin with arms hanging in front of thighs and palms facing thighs
• Raise one dumbbell straight in front to shoulder height
• Lower dumbbell to starting positions and repeat using other arm
• Alternate arms

3) Upright row—for shoulders, neck and upper back (Figure 3)
• Stand with arms hanging in front of thighs, palms facing thighs, and dumbbells close together
• Keeping palms close to the body, raise dumbbells simultaneously to the chin
• Lower dumbbells to starting position and repeat

4) Biceps curl—for biceps or front of arm (Figure 4)
• Commence the exercise with arms hanging at sides and palms facing away from body
• Keeping the elbows close to sides, curl both dumbbells upward to the shoulders
• Lower and repeat

5) One-arm dumbbell triceps curl—for triceps (Figure 5)
• Stand erect, head up, feet 16 inches apart
• Hold dumbbell in right hand; raise overhead to arm’s length, upper arm close to head
• Lower dumbbell in semicircular motion behind head until forearm touches biceps
• Return to starting position and repeat with left arm
• Inhale down, exhale up

6) Alternated dumbbell press—for front and outer deltoids (Figure 6)
• Raise dumbbells to shoulder height, palms and elbows in
• Press one dumbbell straight up to arm’s length
• Lower to starting position and press other dumbbell up
• Keep body rigid; do not lean from side to side
• Do all work with shoulders and arms
• Inhale up, exhale down

As a certified trainer by the International Fitness Professional Association, and with permission of Dr. John Bell, below I provide the current recommendation of an exercise prescription for an overweight individual.

Cardiovascular (Aerobic) Prescription
Frequency: 3 to 7 days/week
Intensity: 40 to 85 percent of maximum heart rate (MHR). Depending on the individual, remember to start out slow and use interval training of going from high to low MHR for 30 second intervals.
Time: 10 to 60 minutes. Initially, the deconditioned patient may only be able to handle 10 minutes. If so, plan on 3 to 10 minute sessions/day until conditioning improves.
Type: Walking, stationary bike, water aerobics (low/non-impact activities to begin). It is important to consider that the excess body mass may limit range of motion, agility, balance, and coordination

Strength Training Routine
Frequency: 2 to 3 days/week
Intensity: 15 to 20 repetitions
Time: 1 set per muscle or muscle group (i.e., upper body: arms, biceps, shoulders, triceps, chest) in Weeks 1 & 2; 2 sets per muscle or muscle group in Weeks 3+
Type: Circuit training on machines. Shorten rest intervals as conditioning progresses

Flexibility
Frequency: 5 to 7 days/week, multiple sessions/day
Intensity: low only to a point of tight, never until pain
Time: 1 or 2 sets per muscle group
Type: static stretches of holding the stretch for 30 counts

Simply put, a one-day workout may look something like this:

Interval Training
• five minutes on stationary bike
• alternating with two sets of 12 to 15 repetitions of a single joint exercise, such as leg extension, seated curl, cable pushdown, dumbbell bicep curl, and stretching
• Hip opening exercises and core basics
• As patient becomes more comfortable, increase to three sets of 12 to 15 reps, and add longer cardio sessions
• Add balance challenges, such as performing bicep curls on one leg or using a balance disc
• Progress by introducing elliptical or treadmill intervals and multi-joint strength moves.

As your patient’s fitness level and self image improve, continue to challenge him or her.

Conclusion
Many research studies have concluded that the only way patients are successful in the longterm with managing their weight is through diet and exercise.30-32 Maintaining weight loss and prevention of future weight gain imparts physical activity as a way of life.33, 34
As a healthcare provider to the weight loss surgery patient, you need to be reminded that not only are you physically changing the natural anatomy of their digestive tract, but you are also a lifestyle coach for them. Helping them maintain a positive attitude is crucial to their success. Only by imparting physical activity, proper diet, and future education can our postoperative patients be in control of their journey to healthy lives.

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