1. Deborah Bade Horn DO MPH FASBP ASBP Board of Trustees, Vice-President Medical Director, Center for Obesity Medicine & Metabolic Performance Asst. Professor, University of Texas Medical School Physical Activity Prescription: Assessment & treatment to improve functional & metabolic capacity. American Society of Bariatric Physicians

2. Objectives Results Typical Weight Maintenance & Metabolic Health Horn 2012

3. Road Map Results Typical: Review the Guidelines for Physical Activity Translate this into success for the patient with obesity Case Based Application: Discuss the provider approach & areas for improved treatment Creating an individualized PA prescription Reducing the risks involved with PA Interactive Delegate Experience

4. 5 Most Common Recommendations for PA A. Wait until you are at your goal weight. Right now just focus on your diet B. Walk 30 minutes per day 5 days per week C. Take the stairs and Park your car farther away D. Join a Gym E. No Pain, No Gain Whats your PA Rx for a patient with obesity?

5. How Much Physical Activity is Enough? General Health Benefit Moderate aerobic exercise 150min/wk (About 30 minutes 5x/wk) + Strength Training Prevent Weight Gain & Active Weight Loss 150-250 minutes per week 150-300 minutes per week Prevention of Wt Regain 200-300 minutes per week 300-420 minutes per week Donnelly J. Am College Sports Med. 2009. US Health and Human Services. 2008.

6. www.getirelandactive.ie

7. Waiting for the other shoe to ..

8. International Guidelines Ireland To avoid gaining weightat least 350kcal per day in PA. 60 min walking. Canadian Similar #s for Health benefit No specific recs for the Obese population UK Dept of Health 60-90min/d to prevent wt regain (2004) July 2011 rec new guidelines needed. Denmark WHO guidelines 300min/wk for additional benefit. Germany EU guidelines referenced at 150 min. Belgium, France, Finland all refer to CDC website on search. Bahrain Has Strategy, but no guidelines India New Recs

9. National Physical Activity Referral Program

10. 14 10 8 6 4 2 0 12 1 2 3 4 5 6 7 8 Treatment (Weeks) 8 18 Follow-Up (Months) WeightLoss/Gain(kg) Exercise Non-Exercise Exercise Non-Exercise Exercise for Weight Maintenance Pavlou KN. Am J Clin Nutr. 1989.

11. Look AHEAD Year 4: Success & Physical Activity Wadden TA. Obesity. 2011. 4-5 Mets for 60-70min/d Or Approx 420min/wk

12. 17 Observational Studies 3.62 kg greater mean wt loss 2.3x greater odds of unsuccessful wt loss if PA after surgery PA repeatedly an independent predictor of weight loss Next Steps FFM preservation (RYGB 31%, BPD 26%, Band 18% loss of FFM) Self reported questionnaires RCTs needed Optimal Rx unknown* Excellent Review: King and Bond. Exerc Sport Sci Rev., Vol 41(1) 2013

13. Self reported PA 5x from pre-op to post-op RT3 non-significant decline in post-op PA > 150min/wk MVPA compliance: Self report 55%, RT3 5%

14. Physical Activity Recs & Bariatric Surgery Pre-op ASMBS: Mild exercise 20min/d, 3-4d/wk AHA: Low-Moderate intensity PA at least 20 min/d, 3-4d/wk Post-op ASBMS/TOS/AACE: At least 30 min/d IOM, HHS, ACSM, IASO: All agree that 150min/week is insufficient for the prevention of weight regain. 250-420min/wk 60-90min/day ASMBS/ACSM expert panel assembled to develop specific pre/post operative recommendations. http://s3.amazonaws.com/publicASMBS/GuidleliStatesments/guildelines/asbs_bspc.pdfnes Poirer et al. Circ 2011, Mechanick et al. Obesity 2009 Donnelly Med Sci Sport Ex 2009, IOM 2002 Saris et al Obes Review 2003, http://www.health..gov/paguidelines/pdf/paguide.pdf

15. Physical Activity / Exercise History Historical benefit of exercise in their weight loss or weight maintenance? Past PA/Exercise participation Current and favorite PA/Exercise Previous and current barriers to PA/Exercise or

16. Basic Physical Activity Rx: FITTE Frequency Intensity Time Type Enjoyment This is NOT the beginning. This is the End!

17. Current PA level Readiness + Patient Goals (C/I, Stage of Change) Co-morbidities Physical exam Medication Adjustment Diagnostic testing needs Mobility/Fitness Assessment Special Equipment needs/modifications FITTE Optimal Default Put it all in a PA Contract! Medical Physical Activity Rx Top Ten Horn 2012

18. Readiness Rulers Why are you a _____ and not at a lower number? What would it take to get you from a ___ to the next higher number? Adapted from Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change. Public domain.

19. Physical Activity Prescription Form Horn 2012

20. Physical Activity and Mets.Whats your intensity?

21. MET Categories Light < 3 METs Driving your automobile = 2 Moderate = 3-6 METs Walking 4 mph, brisk pace = 5 Vigorous > 6 METs Carrying 25-49pds upstairs = 8

22. Resting VO2 by Age & BMI Byrne et al. J Appl Physiol 2005 Sept 99:1112-1119

23. RPE Scale Correlates with HR Adapted from Borg RPE Scale Gunnar Borg 1998

24. Trainers, Physiologists, and Therapists..Oh My! Trainers/Physiologists Highly Recommended: Graduate Level training ACSM, NSCA or ACE = Natl Certs CSEP Equivalents Subspecialized Certifications Physical Therapists Key role in orthopedically complicated patients Revisit periodically

25. Start with the Fundamentals Low/No Impact & Low Risk Activities Aqua classes, water walking Recumbent bikes / elliptical trainers Walking Chair aerobics Balance training Strength training

26. Low Risk, High Yield Physical Activity Tools Horn 2012

27. Whats The Best Rx Doc? LIVE IT! Long Term What activity will produce adherence? Intensity Volume Enjoyment Including Transitions Together they need to meet the guidelines Optimal Default + Life changes Horn 2012

28. Case Study Orthopedic Issues

29. Patient Profile 66 year old, female Weight 189.5 kg (416.8) BMI 59.8 WC 64in Architect Single, 1 adult child Q: Why does the patient want to lose weight? A: Needs Bilateral Total Knee Replacement

30. Weight & Physical Activity History Max Weight 192.kg (424lbs) Onset: >15 yrs ago Regained 100lbs since last weight loss effort Repeated rebound weight regain Eats due to stress, extensive snacking, & eating out Ongoing struggle with PA & bilateral knee pain 2nd to OA. Previously a Tennis Pro, preferred activity No PA at time of admission Very motivated by need for knee replacements. Low confidence due to pain.

31. Past Medical History NIDDM >10 years Severe Bilateral Knee DJD Depression/Anxiety Sitagliptin 100mg Pioglitazone 45mg Bupropion-XL 300mg Diclofenac, gabapentin, oxyc odone, propoxyphene both combined with acetaminophen. Medications

32. Physical Exam BP 126/68 Ht. = 70in, Wt. = 189.5 kg (416.8 lbs) BMI = 59.8 WC = 64in PE within normal limits except as noted below. Balance: Unable to complete tandem gate Utilizing walker intermittently Msktl: Decreased ROM in shoulders, back, hips, and knees R knee: no crepitus, tenderness or inflammation Phys. Therapy initially declined by patient

33. The Starting Point

34. Sept 8, 2011 None, Ambulating with walker for long distances. ADLs only X 10/10 2/10 The Starting Point Patient Described Goals: Accelerate Weight Loss Improve conditioning in preparation for bilateral TKR

35. CVD Risk Factors Age Diabetes Overweight Sedentary Lifestyle Any additional diagnostic testing or physical assessment?

36. Recommendations for Stress Testing Prior to Exercise Risk Stratification Low Risk: Asymptomatic and 1 CVD Risk Factor Moderate Risk: Asymptomatic and 2 CVD risk factors High Risk: Known cardiovascular, pulmonary or metabolic disease or major signs of disease Alternative Guidelines: 2010 ACCF/AHA Guideline for Assessment of Cardiovascular Risk in Asymptomatic Adults. Thompson WR, Ed. ACSMs Guidelines for Exercise Testing & Prescription. 2010. Greenland P. J Am Coll Cardiol. 2010.

37. Age Men 45 yrs Women 55 yrs Smoking Smoker Quit < 6 mo ago Sedentary < 30 min of mod. exercise on at least 3 d/wk for previous 3 mo. Obesity BMI 30 WC > 40in men >35in women HTN Systolic 140 and/or Diastolic 90 Antihypertensive Meds Dyslipidemia LDL 130 HDL < 40 Lipid Lowering Meds PreDM Fasting Glucose 100 Abnormal IGT HDL 60 Negative Risk Factor Risk Factor Thresholds Thompson WR, Ed. ACSMs Guidelines for Exercise Testing & Prescription. 2010.

38. Stress Testing Based on Risk Stratification Risk Low Risk Mod Ex No Vig Ex No Intermediate Risk Mod Ex No Vig Ex Yes High Risk Mod Ex Yes Vig Ex Yes Thompson WR, Ed. ACSMs Guidelines for Exercise Testing & Prescription. 2010.

39. What are the key components to consider in your physical activity prescription? Lets Write It!

40. What did you choose? Oct 14, 2012 ADLs with assistance RPE 2-8 10/10 PT-2 X X X X Strength and H2O H2O - 3 Needs Stress Test/Phys Therapy Eval for falls eval prior to initiation. When cleared:170min/wk. 2 weeks Personal Trainer 2/10 X PCPA Mod 1-2 Leg Ext, Crunch, Deborah Bade Horn DO MPH PCPA-3 1 28 13 NA NA Horn 2012

41. Exercise Prescription Falls precautions Initially: Pool work: anti-gravity Personal training PCPA No DM Med changes, but begin monitoring Eventually Physical therapy Review presurgical approach Begin Pain journal to facilitate medication adjustment 1st Goal: >170 min at RPE 4, minimal joint pain Optimal Goal: >250 min, RPE 5, Doubles Tennis?

42. Progress: Ortho/ Pain Meds During the course of obesity treatment: Bilateral Total Knee Replacements 1 TKR revision Pain med adjustments Pain Mgmt consult Weaned off controlled substances Ultimately, Ibuprofen occasionally

43. Progress Weight & PA Maintenance Lost and maintained 54.5kg (120 lbs). weight loss throughout 3 surgeries over 18 months. Physical Activity?

44. Long Term Planning What would you do?

45. Long Term Planning After bilateral TKR and 1 revision: Off walker after extensive pre and post surgery PA Minimal intermittent pain

46. Putting it into Long Term Practice Step 1: Complete your PA Top 10 for EVERY patient. Step 2: Develop an Exercise prescription SPECIFIC to individual needs. Step 3: Monitor progress & update Ex Rx every visit Step 4: Revise goals at least every 3 months. Step 5: Be Creative & think outside the treadmill! Horn 2012

47. Engineering PA Back into Life

48. Expose Unexpected Barriers

49. Swimming Up Stream Horn 2012

50. Using Your Environment Horn 2012

51. Deborah Bade Horn DO MPH FASBP ASBP Board of Trustees, Vice-President Medical Director, UT Center for Obesity Medicine and Metabolic Performance (COMMP) Asst. Professor, University of Texas Medical School debbiebhorn@yahoo.com American Society of Bariatric Physicians

52. Save your Questions & Lets Go Practice! Horn 2012