Promoting a Physically Active Lifestyle in Bariatric Patients

by Carol Ewing Garber, PhD, FAHA, FACSM

Dr. Garber is with Teachers College, Columbia University, New York, New York.

Introduction
It is clear that a physically active lifestyle is important for good health and promoting and maintaining weight loss.[1–4] Following bariatric surgery, patients who are physically active lose more weight,[5–7] and greater weight loss is associated with improved quality of life,[5] reduced all-cause mortality, and mortality due to cancer, diabetes, and cardiovascular disease, with the greatest impact on mortality due to the reduction in cancer deaths.[8] Exercise volumes of at least 1,000 to 1,200kcal per week (approximately 150 minutes per week) are ideal for most adults to attain the majority of substantial health and fitness benefits of exercise, but as much as 1,800 to 2,200kcal per week (>250 minutes per week) in purposeful exercise and physical activity may be needed to promote and maintain weight loss, especially among persons who spend much of their time in sedentary pursuits.[1,2,4]

There are many benefits of regular physical activity beyond weight loss that are particularly important to patients being treated with bariatric surgery, and that make physical activity a vital complementary health measure for these patients.

Regular physical activity—independent of body weight—delays all-cause mortality[9–11] and reduces the risk of developing cardiovascular disease,[12] stroke,[13] type 2 diabetes,[14] colon cancer,[15] and breast cancer.[15] Physical activity also lowers blood pressure,[16] improves lipid and lipoprotein profiles,[17] enhances insulin sensitivity,[18] and is associated with improvements in C-reactive protein.[19] Increasing physical activity also improves depression and anxiety,[3, 20–26] enhances quality of life,[27] cognitive function,[28] and energy,[29] and improves self esteem[30] and wellbeing.[31, 32]

Recently, the US government released the first Physical Activity Guidelines for Americans.[4] The reader is referred to this document for more specifics about the exercise recommendations and for educational materials that may be used with patients. Additional materials for healthcare providers and patients are available at the Exercise is Medicine website at www.exerciseismedicine.org/.

Briefly, the recommendations for adults, including obese adults, include the following:

• Five or more days per week of moderate aerobic exercise for a total of 30 to 60 minutes per day, or three or more days per week of vigorous aerobic exercise for 20 to 60 minutes per day, or a combination of vigorous and moderate aerobic exercise and physical activity 3 to 5 days per week.

• Daily exercise can be done in one continuous session or in multiple sessions of at least 10 minutes duration to accumulate the desired minutes of exercise per day.

• Shorter daily durations of exercise are beneficial, particularly in previously sedentary adults.

• Resistance exercises 2 to 3 sessions per week targeting all of the major muscle groups.

• Two to 4 sets of 8 to 12 repetitions per resistance exercise—the muscle should feel fatigued but should not be brought to failure—is appropriate for most adults. Sedentary, middle-aged, and older adults beginning a resistance-training program should begin at a lower intensity that permits 10 to 15 repetitions per set to reduce risk of musculoskeletal injury.

Discussion
In spite of the well-known benefits of a physically active lifestyle, a large proportion of the adult population in the US—and indeed in many countries throughout the world—fails to meet the recommended levels of activity, and physical inactivity is even more prevalent in persons who are overweight or obese.[33–35] It is challenging for all adults, and perhaps even more so for obese persons, to adopt and maintain a program of regular physical activity. Exercise interventions based upon behavior change theories, such as the Transtheoretical Model (i.e., “Stages of Change”),[36] have been successful in helping individuals adopt an exercise program over the short term.[37] However, behavioral interventions to increase physical activity have shown little, modest, or inconsistent effects on increasing long-term maintenance of regular physical activity.[37, 38] Illustrating the challenges of maintaining a physically active lifestyle, dropout rates for structured exercise programs range from 9 to 87 percent, but individualized, health behavior theory-based, physical activity programs may be an effective alternative to improve adherence to exercise for some individuals.[37]

Some aspects of physical activity interventions have been successful, and consideration of these factors will improve the effectiveness of counseling for physical activity.[37] First, it should be emphasized that receiving a clear, strong message from a healthcare provider can go a long way in assisting a person to increase physical activity.[37] However, it should be recognized that individuals go through complex processes of changing physical activity behavior that begins with thinking about making a change to actually making a change in behavior; thus, the healthcare provider need not feel that the lack of behavior change indicates that the counseling is not effective, as it may take some time for the patient to go through the processes that lead to behavior change. Relapse is common and should be expected. It is important that the message that is given to the patient be strong and supportive, and not prescriptive, threatening, or punitive. So a message such as, “As your healthcare provider, I must advise you that increasing exercise and physical activity can greatly improve your health, and it can help reduce the fatigue you have been experiencing,” is more effective than, “You need to become more physically active if you want to be healthy.” On the follow-up visit a statement such as “It is hard to exercise regularly, and it is great that you keep trying” can be more effective than “You have not done well with your exercise.”

Tailoring physical activity counseling to the individual’s gender, culture, lifestyle, and specific health concerns and readiness to change using behavioral theory improves the effectiveness of physical activity programs.[38, 39] Effective behavioral techniques to assist patients in adopting and maintaining a program of regular physical activity interventions include the following:

• Identify and clarify individual needs to establish the motive for exercise.

• Address concerns and correct misconceptions about exercise.

• Emphasize moderate intensity exercise (such as walking) that is perceived as pleasant or enjoyable.

• Identify community and home-based resources for exercise that are comfortable for obese persons.

• Identify safe, convenient, and well-maintained facilities for exercise.

• Increase social support for exercise (e.g., exercise with a friend or family member).

• Identify attainable goals and objectives for the individualized exercise program.

• Use motivational self-monitoring techniques such as pedometers, exercise diaries, and waist circumference measurement.

• Use reminders such as calendars, prominent exercise prompts (e.g., post-it notes, prominent placement of exercise clothing, etc.).

• Emphasize a regular schedule of exercise that includes variety and enjoyment in the exercise program.

Referral to qualified, personable, and enthusiastic exercise professionals may also be helpful, particularly in the adoption phase for new exercisers.[40] Exercise professionals most qualified to work with the obese, sedentary patient will generally hold an advanced certification from an organization such as the American College of Sports  Medicine or the National Strength and Conditioning Association, and/or have a college degree in kinesiology, exercise science, or a related field. These professionals may be found in a cardiac rehabilitation program, a health club, YMCA, community recreation center, or other fitness facility. Some health insurers will pay for a part of the cost of a membership to a gym or for visits to a personal trainer, so this can provide an incentive to access these resources. Where access to facilities and/or human resources are limited, there are many good websites that can be helpful, as noted previously. The ultimate goal is to assist the bariatric patient in incorporating physical activity into his or her life, and it is important that healthcare providers encourage their patients to be as active as possible.

Conclusion
A physically active lifestyle is important for good health, and it is of particular importance in obese persons due to their increased risk of cardiovascular and metabolic disease.  However, becoming active and maintaining a regular program of physical activity is difficult.  Behavior change strategies derived from health behavior theories can enhance the effectiveness of a program of physical activity. Health care providers can provide the stimulus and support for physical activity by discussing  the importance of physical activity with  their patients and providing referrals to community resources to support a physically active lifestyle.

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Category: Past Articles, Review