Preoperative Progressive Resistance Training Exercise for Bariatric Surgery Patients

| May 19, 2010

by Samuel B. Wollner, BA; James D. Adair, MD; Daniel B. Jones, MD, MS; George L. Blackburn, MD, PhD

Mr. Wollner is from the Center for the Study of Nutrition Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts. Dr. Adair is from the Section of Minimally Invasive Surgery, Beth Israel Deaconess Medical Center. Dr. Jones is from the Section of Minimally Invasive Surgery, Beth Israel Deaconess Medical Center and the Department of Surgery, Harvard Medical School, Boston, Massachusetts. Dr. Blackburn is from the Center for the Study of Nutrition Medicine, Beth Israel Deaconess Medical Center and the Division of Nutrition, Harvard Medical School.

Funding: This research was supported by the Harvard Center for Healthy Living and the Boston Obesity Nutrition Research Center (grant no. P30DK46200).

Bariatric Times. 2010;7(5):11–13

Abstract
Objective: To test the strength and functional fitness outcomes of a four-week progressive resistance training exercise program in a small cohort of patients with Class III obesity who are preparing for bariatric weight loss surgery. Setting: A fitness center within a major medical center in Boston, Massachusetts. Participants: Four patients were recruited from the weight loss surgery clinics at Beth Israel Deaconess Medical Center. Participants were men (n=2) and women (n=2) aged 18 to 65 years (mean=44 years) with a body mass index of >40kg/m2 who are considering weight loss surgery at Beth Israel Deaconess Medical Center. Measurements: Exercise testing measurements included the chest press and leg press 1-repetition maximum, chest and leg press fatigability (70% and 80% 1-repetition maximum, respectively) and the six-minute walk test (30 meter course). Exercise testing was completed at baseline—prior to exercise training and within 90 days of surgery—and then again after four weeks of training (8 sessions) just prior to surgery. Results: Results in both strength (1-repetition maximum and fatigability) and fitness (6-minute walk test ) showed a generally positive trend in all four subjects. Performance in the six-minute walk test improved on average by 8 percent (+3%) from baseline after four weeks of progressive resistance training exercise. Conclusion: While the results of this study are very preliminary, we hypothesize that progressive resistance training represents a new evidence-based approach to improve strength and functional fitness in Class III obese, weight loss surgery patients. The progressive resistance training protocol demonstrated a trend toward improved strength and fitness in our trial run. A larger, randomized, control trial is necessary to confirm these trends. Clinicaltrials.gov number: NCT01100450

Introduction
Physical activity (PA) is one important component in optimizing the long-term effectiveness of weight loss surgery (WLS).[1] Most patients with extreme obesity are, however, markedly sedentary compared to individuals of normal weight.[2,3] Initial research efforts revealed that approximately 80 percent of weight loss surgery patients fail to respond to doctors’ recommendations to perform 150 minutes or more of moderate-intensity PA per week.[4] New interventions are necessary to improve fitness and PA levels in surgical candidates with Class III obesity. The preoperative period may represent a “teachable moment” to increase patient engagement in PA routines.[2]

Progressive resistance training (PRT) is a promising alternative form of exercise. PRT is characterized by short bouts and intensive bursts of muscular exertion against a given resistance.[5] Although resistance training has long been accepted as a means for developing and maintaining muscular strength, endurance, power, and muscle mass (hypertrophy), its beneficial relationship to health factors and chronic disease has been recognized only recently.[6] PRT is now advocated as an important part of exercise for general fitness and well being.[7] It is recommended as an appropriate PA strategy for weight loss by the American College of Sports Medicine,[8] and for secondary prevention of coronary heart disease[9] and management of type 2 diabetes.[10] The latest Physical Activity Guidelines for Americans, released by the Department of Health and Human Services, cites resistance exercise as critical for improving fitness.11 Extensive data demonstrate that PRT is safe, effective, well-accepted, and potentially more feasible than aerobic exercise in many complex patient groups, including the elderly and individuals with disability or disease.[12]

More research is necessary to determine effective exercise interventions to improve fitness, reduce disease risk, and improve weight loss outcomes in bariatric surgery patients. In order to test the feasibility of a preoperative PRT program for patients with Class III obesity, we recruited a small cohort of weight loss surgery (WLS) candidates at Beth Israel Deaconess Medical Center (BIDMC) and assessed the strength and functional fitness outcomes after a four-week PRT protocol. This brief report presents preliminary descriptive data from a small preoperative pilot study.

Methods
Subjects. Four patients were recruited from the weight loss surgery clinic at Beth Israel Deaconess Medical Center in Boston, MA. Participants were men (n=2) and women (n=2) aged 18 to 65 years (mean=46) with a BMI of greater than or equal to 40kg/m[2] who were considering WLS at BIDMC. All patients participated in the BIDMC multidisciplinary, preoperative program consisting of information sessions, nutritional counseling, and medical screening. Patients were then cleared by a physician to participate in a voluntary exercise regimen. Patients were required to disclose pre-existing orthopedic issues that might prohibit them from performing PRT. All exercise testing and training was performed under the direct supervision of a certified exercise physiologist.

Exercise testing and training. The study followed a protocol previously described by Adair et al.[13] Exercise testing was completed at baseline—prior to exercise training and within 90 days of surgery—and then again after four weeks of training (8 sessions) just prior to surgery. Exercise testing measurements included the following: 1) one-repetition maximum (1-RM) leg and chest press tests, which were used to determine changes in maximal strength in the quadricep and pectoralis muscle groups, respectively, by measuring the greatest resistance that can be moved through the full range of motion; 2) chest and leg press fatigability tests, which were used to determine changes in quadriceps and pectoralis endurance by measuring total repetitions performed at a load equal to a percentage (70% chest press, 80% leg press) of the initial 1RM; and 3) six-minute walk test (30 meter course), which measured total distance walked, and was used to reflect changes in functional capacity to undertake day-to-day activities.[14]

Patients trained at the Tanger Be Well Center at BIDMC twice-per-week for four weeks following baseline exercise testing (8 total sessions). In training Weeks 1 and 2 (4 sessions), subjects gradually increased intensity of training and completed moderate resistance exercises yielding a perceived effort of 11 to 13 on the Borg Rated Perceived Exertion scale (i.e., 2 sets of 8–12 repetitions each). In training Weeks 3 and 4, subjects worked on increasing resistance as tolerated (typically 5–10% of previous load for upper body and 10–20% of previous load for lower body) until a subject was able to complete two sets of 12 repetitions for a given exercise over two consecutive training sessions. The resistance training program comprised nine exercises that addressed major muscle groups. All exercises were performed on the Nautilus Nitro® (Nautilus Inc., Vancouver, Washington) strength fitness machines or with free weights (Figure 2).

Results
Training attendance. Two patients were unable to complete all eight training sessions (Subject 1 missed 2 training sessions; Subject 2 missed 1 training session). Reasons given for missed training sessions were due to illness or work-related conflicts.

Strength and fatigability tests. All four patients completed the 1-RM and fatigability testing. One patient could not complete the leg press tests due to lower back discomfort. Due to small cohort size, subject strength, and fatigability, test results are exhibited individually as percent change from baseline to post-training (Table 1).

Discussion
To our knowledge, this is the first study to report strength and fitness outcomes from a preoperative PRT exercise program in bariatric surgery candidates with Class III obesity. Consistent with previous reports in other vulnerable cohorts, PRT seems to be a feasible alternative form of exercise intervention to boost functional capacity.[12] Because levels of PA play an integral part in the long-term success of weight loss surgery,1 innovative interventions are necessary to provide optimal care to surgical candidates with Class III obesity. The preoperative period may represent a “teachable moment” to increase patient engagement in PA routines.[2] (Figure 1).

Effective exercise protocols for patients with Class III obesity must consider the unique physical and psychological barriers faced by such patients. These patients often suffer from locomotive handicaps and muscle quality deterioration.[15,16] Because PRT does not require a high level of cardiorespiratory fitness to commence, this form of exercise represents a logical starting point for patient engagement in this highly sedentary cohort.[17] Preliminary evidence suggests patients with obesity respond adversely to aerobic exercise compared to patients with normal weight and patients who are overweight.[18] The repetitive movements and prolonged bouts of aerobic exercise training may not be feasible in this cohort of patients. We have found that approximately 80 percent of weight loss surgery patients fail to respond to doctors’ recommendations to perform 150 minutes or more of moderate-intensity PA per week.[4] The short-bout, intense bursts of PRT exercise combined with the direct supervision of an exercise physiotherapist may help address the unique biomechanical and psychological issues presented by these patients.

Given the small sample size with incomplete participation, the scope of this paper is limited to very preliminary descriptive data. However, we present this brief report in hopes of encouraging more centers to investigate best practices in pre- and postoperative care to optimize WLS outcomes. Because of its powerful weight loss effects and health benefits, WLS can often be perceived as a “quick fix.” Patients must be aware that exercise is a lifestyle change necessary for the long-term success of surgery. Our hope is that by engaging with exercise preoperatively, patients will be more likely to exercise postoperatively. We are also encouraged by the trend that PRT exercise translated into improved functional capacity as demonstrated by the 6MWT. If ambulatory ability improves after PRT, patients may be better capable of performing aerobic activity. Combined modalities of resistance training and aerobic training are necessary to promote optimal health improvements.[17]

Based on our preliminary findings, we hypothesize that PRT represents a new evidence-based approach to improve strength and functional fitness in weight loss surgery patients with Class III obesity. A larger follow-up study needs to be performed to validate the trends observed in this report. Since attendance was an issue at times, lifestyle barriers may be a hindrance to regular exercise. By standardizing a PRT protocol for distribution to local fitness centers, healthcare providers may avoid some of the convenience issues of commuting to a medical center for exercise training. Additionally, body composition analyses and blood serum tests for metabolic markers could be helpful for understanding the underlying physiological adaptations to PRT.

The authors would like to thank Marelene DaCosta, MA; Carine Corsaro, BS; Ricardo DiScipio, MEd; and the Tanger Be Well Center at BIDMC for supporting the authors’ research and testing and training the patients. The authors also thank Linda S. Trainor, RN, and the Weight Loss Surgery Center at BIDMC for their support in recruiting patients to the study. Lastly, a special thanks to Renee Miciek, MS; Thomas W. Storer, PhD; Caroline M. Apovian, MD; Joanne B. Krasnoff, PhD; the Nutrition and Weight Management Center; and the Exercise Physiology Research Lab at Boston Medical Center for their help in developing the exercise testing and training protocol.

References

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