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EXP 516L: Exercise in the Prevention and Rehab of Chronic

Diseases and Disabilities Laboratory


Josiah Schillinger
Lab Report 3
April 17, 2015

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1.
The purpose of this lab was to evaluate physiological and mechanical variables
in response to overweight and obesity conditions. Three subjects completed
various tasks under three weight conditions: normal, overweight (25 lb vest), and
obese (50 lb vest). Thirteen activities and exercises were preformed in each
weight condition including: oblique crunch, squat, flight of stairs, cycling, Nustep,
seated IT stretch, SNR stretch, crunch, tying shoes, functional reach, treadmill,
foam and Bosu balance. Between each condition body weight and BMI were
recorded. At the end of each completed exercise, HR, BP, RPE, dyspnea, and
any noted symptoms and/or changes in body mechanics were all measured and
documented.
Hemodynamics
Obesity is now considered an epidemic in the United States. According to the
Center for Disease Control and Prevention, 30.5% of Americans are considered
obese with a body mass index (BMI) greater than 30 kg/m2, and 4.7% of
Americans are considered morbidly obese (BMI > 40). Obesity is also affecting
children in the United States. The prevalence of overweight among children and
adolescents has increased from 10% in 1971 to 1974 to 31% in 1999 to 2000.
Obesity contributes to the development of many medical conditions and can also
lead to premature death (23).
Physiologically, morbidly obese patients have a higher intra-abdominal pressure
at two to three times than that of patients who are not obese. The increased
intra-abdominal pressure enhances venous stasis, reduces intraoperative portal
venous blood flow, decreases intraoperative urinary output, lowers respiratory
compliance, increases airway pressure, and impairs cardiac function (21).
In obese individuals, the cardiac workload is greater than those who are not, at
any level of activity. This is caused by an increased metabolic demand, which
produces an increment in total blood volume and cardiac output. The increase in
cardiac output is attributed to increased stroke volume. Another effect of obesity
is seen in an increase in left ventricular filling pressure and volume, which can
lead to the production of chamber dilation, a condition that causes increased wall
stress and predisposes to an increase in myocardial mass and left ventricular
hypertrophy (LVH ). Obese individuals also have a further increase in cardiac
filling pressures during exercise. Weight reduction causes a decrease in central
blood volume, as well as relief of some other conditions that are associated with
obesity (12, 28).
Weight excess is also a risk factor for progressive renal function loss, not only in
subjects with renal disease or renal transplant recipients, but also in the general
population. Considering the increasing prevalence of obesity worldwide, weight
excess may become the main renal risk factor on a population basis, all the more
so because the risk is not limited to morbid obesity, but is already apparent in the

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overweight range. The mechanism of the renal risk is multifactorial. In addition to
the role of comorbid conditions such as hypertension and diabetes, current
evidence supports a pathogenetic role for renal hemodynamics, specifically
glomerular hyperfiltration, and also glomerular hypertension. Weight excess is
associated with an elevated glomerular filtration rate and a less pronounced rise
in renal plasma flow, resulting in an elevated filtration fraction. This suggests
glomerular hypertension due to afferentefferent dysbalance, which impairs
glomerular protection from systemic hypertension. Data in renal transplant
recipients support the pathogenetic role of elevated glomerular pressure for longterm renal prognosis. Blockade of the reninangiotensinaldosterone system can
reverse the renal hemodynamic abnormalities. The obesity-associated renal risk
is unfavorably affected by high sodium intake. This may be due to the effects of
sodium on blood pressure, which is often sodium-sensitive in obesity, but direct
renal effects are also present. Interestingly, sodium restriction ameliorates
overweight-associated hyperfiltration in overweight subjects. Preventive
measures should focus on weight excess as well as on specific protection
against renal damage, by reninangiotensinaldosterone system-blockade and
moderate sodium restriction (17).
As seen and predicted in Appendix A and B, with weight added to each subject
for overweight and obese simulation, heart rate (HR) and blood pressure (BP)
both increased. Both progressively increased with additional weight placement
for each mode of exercise and physical activity. Implications may also be made
that more drastic increases in both HR and BP occurred for the more
deconditioned subjects (Subject 2, 3) compared to the more conditioned (Subject
1). Since subjects were not accustomed to this additional weight, HR elevated
due to the increase of demand on the body. However, in obese individuals, the
HR is unaffected. Left ventricular end-diastolic diameter is increased, dilatation,
as a result of the increased left ventricular stroke volume. In obese individuals the
left ventricular systolic function is depressed although left ventricular ejection
fraction is increased. Right ventricular function seems to be unchanged. Systemic
oxygen delivery is increased as a result of increased CO, serving the metabolic
demands of excess fat (18).
Alvarez et al. gave an overview of interacting factors that lead to cardiovascular
changes in the obese patient (2)

Dyspnea and RPE


The major respiratory complications of obesity include a heightened demand for
ventilation, elevated work of breathing, respiratory muscle inefficiency and
diminished respiratory compliance. The decreased functional residual capacity
and expiratory reserve volume, with a high closing volume to functional residual
capacity ratio of obesity, are associated with the closure of peripheral lung units,
ventilation to perfusion ratio abnormalities and hypoxemia, especially in the
supine position.

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Resting alterations in lung volumes and gas exchange become attenuated during
exercise in the obese, while oxygen cost of breathing and dyspnea are
increased. Respiratory muscle function also seems to be impaired, such that
inspiratory muscle strength is reduced and respiratory drive is increased.
Furthermore, while there is no reduction in the absolute values of maximal
oxygen uptake compared with normal-weight subjects, oxygen uptake at a given
workload is increased and maximal workload is reduced in the obese, caused by
increases in body mass and basal metabolic rate (8).
An important respiratory abnormality in obesity is a decrease in total respiratory
system compliance, which is supported by the work of Naimark and Cherniack
(20). They have demonstrated that total respiratory compliance is reduced by as
much as two-thirds of the normal value in obese individuals. This is due, in part,
to a decrease in lung compliance that may relate to the increased pulmonary
blood volume seen in obese individuals. However, the primary reason is due to a
decrease in chest wall compliance associated with the obese individuals
accumulation of fat in and around the ribs, the diaphragm and the abdomen.
Total respiratory compliance is markedly reduced by recumbence in obese
individuals compared with non-obese individuals. This reduction is almost entirely
due to the decreased compliance of the chest wall, although it may also be due
to an increase in respiratory resistance (30).
Although many spend considerable amounts of time overcoming the reduction in
chest wall compliance, it accounts for only one-third of the increased work of
breathing. The remaining increase is likely due to an increase in non-elastic work
and inefficiency of the respiratory muscles (20). Non-elastic work may be
performed to overcome the airflow limitation and the airway resistance that are
reportedly increased in patients with obesity. In addition, forced expiratory
volume in 1 s (FEV1) of men and women are lower in obese patients compared
with non-obese subjects (31).
Both respiratory resistance and airway resistance rise significantly with the level
of obesity, which is inversely related to changes in functional residual capacity
(FRC). This suggests that in addition to the elastic load, obese individuals must
overcome increased airway resistance resulting from a reduction in lung volumes
due to obesity.
Because an obese individuals respiratory muscles must work constantly against
a less compliant chest wall and higher airway resistance, it would be expected
that they could generate increased pressures. Kelly et al (16) examined the
maximum inspiratory and expiratory pressures at different lung volumes in 45
morbidly obese patients, who on average weighed 183% of their predicted
weights. These were compared with the pressures of 25 non-obese age-matched
individuals. At all lung volumes, the pressures generated by the obese patients
were lower than those of the non-obese patients, despite increased demands for
diaphragmatic work. This may result from diaphragm dysfunction due to

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increased abdominal and visceral adipose tissue deposition. It has been
suggested that the additional load causes a length-tension disadvantage for the
diaphragm due to fiber overstretching, which is particularly worse while the
individual is supine (27).
Obese individuals tend to have a rapid, shallow breathing pattern. The oxygen
cost of breathing is less for given ventilation when the respiratory rate is high and
the tidal volume is small. However, because the oxygen cost of breathing rises
relatively with the respiratory rate and because the relative dead space
increases, rapid breathing ultimately is inefficient. This may explain why obese
individuals commonly perform poorly on pulmonary function tests that require
high levels of breathing effort.
The most common pulmonary function abnormality in obese subjects is a
reduction in the expiratory reserve volume (ERV) (25). This occurs because the
mass loading effect of obesity decreases FRC. Because FRC is reduced and the
residual volume (RV) is not, ERV declines. ERV reduction is greatest in the
supine position when the diaphragm ascends in the chest, and the weight of the
lower thorax and the abdomen is applied to the lungs. At this point, the ERV may
approach or be exceeded by the closing volume and gas may be trapped in the
chest (5).
While the decrease in ERV and FRC are proportionate to the degree of obesity,
dynamic lung volumes including VC and total lung capacity (TLC) are often
normal (24). In a study of 43 obese but otherwise healthy nonsmoking young
adults, Ray et al (24) observed that the lung function of most individuals was
within the generally accepted 95% confidence limits for the predicted values.
The pattern of body fat distribution may also influence the effect of obesity on
lung function. It is generally believed that upper body obesity carries a higher risk
of cardiovascular and metabolic disease than lower body obesity. Collins et al (6)
demonstrated that multiple measures of adiposity showed a significant inverse
relationship with both spirometry and static lung volumes. The best measure of
fat distribution was the biceps skinfold, which is a measure of upper body fat
distribution. Another study (19) showed that the ratio of abdominal circumference
to hip breadth and subscapular skinfold thickness were negatively associated
with FEV1 and FVC. This suggests that central abdominal obesity has a greater
impact on spirometric measures compared with back or lower body obesity.
Breathlessness on exertion is a very common symptom in obese individuals (13),
and has been reported in almost 80% of subjects. In another study (4) of obese
patients with type II diabetes mellitus, one-third reported abnormal breathing that
became more prevalent with increasing BMI. The cause of dyspnea in these
patients was likely due to a variety of factors related to the abnormal
physiological effects of being overweight and the obesity itself, and to
comorbidity related to obesity such as diastolic dysfunction, coronary artery

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disease, pulmonary hypertension and gastro esophageal reflux disease. In
healthy obese subjects, the sensation of dyspnea may originate from an increase
in the work of breathing to overcome decreases in pulmonary compliance and
increases in resistance. Airway obstruction at low lung volumes may also
stimulate flow receptors to increase the sensation of breathlessness (22, 26).
Respiratory muscle weakness and fatigue may lead to dyspnea through an
increase in effort (sensed in the somatosensory cortex) and chemoreceptor
activity responding to increasing CO2 production and hydrogen ion release.
There is evidence that healthy obese individuals with a normal FEV1 and FEV1
to FVC ratio are more likely to experience dyspnea at rest with increasing BMI,
reduced maximum expiratory mouth pressure, and peripheral airway obstruction
compared with obese individuals without dyspnea (26).
In summary, the major respiratory complications of obesity with or without
hypoventilation include a heightened demand for ventilation, elevated work of
breathing, respiratory muscle inefficiency and diminished respiratory compliance.
The decreased FRC and ERV with a high closing volume to FRC ratio of obesity
are associated with the closure of peripheral lung units, ventilation to perfusion
ratio abnormalities and hypoxemia, especially in the supine position. The major
circulatory complications are an increased total and pulmonary blood volume, a
high cardiac output and elevated left ventricular end-diastolic pressure. Patients
with obesity commonly develop hypoventilation and sleep apnea syndromes with
attenuated hypoxic and hypercapnic ventilatory responsiveness. The final result
is increasing hypoxemia, pulmonary hypertension and progressively worsening
disability. Obese patients have increased dyspnea and decreased exercise
capacity, which are vital to quality of life. Decreased muscle, increased joint pain,
and skin friction are important determinants of decreased exercise capacity in
addition to the cardiopulmonary effects of obesity. Weight reduction and physical
activity are effective means of reversing the respiratory complications of obesity.
As seen and predicted in Appendix A and B, with weight added to each subject
overweight and obese simulation, dyspnea increased. Dyspnea progressively
increased with additional weight placement for each mode of exercise and
physical activity, which resulted in how hard the client self-reported they were
working as well. Among the physiological variables used to prescribe
individualized exercise intensity in obese or overweight patients, the HR is most
often selected, which is expressed in a percentage of HRmax or HR reserve.
However, as previously described, HR can vary when taking certain drugs, betablockers. Thus it is preferable, in obese patients treated with these drugs to use
another method to prescribe adapted exercise intensity. A potential alternative
would be to use the target RPE range (7).
The Borg RPE scale is a valid and reproducible tool that can be used in obese
patients. However, before using it, it is essential to follow some
recommendations, such as reading the instructions, deliver information to the
patient or implement perceptual anchors. Afterwards, it is possible to use the

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RPE scale during GXT and/or during rehabilitation program. The Borg RPE scale
is thus a useful and reliable tool in the care management of obese patients (7).
As seen and predicted in Appendix A and B, with weight added to each subject
overweight and obese simulation, RPE increased. How hard each subject felt
they were working progressively increased with additional weight placement for
each mode of exercise and physical activity.
3.
Although medically significant obesity exists in most patients who seek medical
care, only a small portion present requesting medical help with weight reduction.
Increasing the awareness of those not aware of the relationship between their
weight and medical problems is an effective way of helping them become
determined to address their weight. Compassion and understanding coupled with
flexible and practical weight loss recommendations are essential to building
rapport with obese patients. Most individuals seeking professional help with
weight loss have a BMI of 38 or more, and invariably they have attempted to lose
weight several times in the past. Proper assessment of the barriers to and
benefits of weight loss should be the initial step in the clinical evaluation of the
obese patient. Comprehensive assessment of obesity can lead to appropriate
treatment and effective long-term control of obesity and its related comorbidities
(9).
Obesity poses a number of risks to your health and well-being, and in many
cases can affect your posture. Bending and rotating the hips and trunk are part of
the normal movements required in everyday life, such as getting dressed,
cleaning the house or doing laundry. The "International Journal of Obesity" found
that obese individuals who performed tasks from a sitting position had less
forward flexing motion from the trunk than participants of a normal weight. The
same obese group also used more hip movements when performing tasks from a
standing position. The repetitiveness of hip flexing could put strain on the hips
from overuse. Both findings can contribute to muscle stiffness and pain in some
people. Obesity may cause spinal changes in some people due to the excess
strain that is put on the muscles, vertebrae and other supportive structures in the
back. This is referred to as passive strain, according to the journal "Physical
Therapy." One of the common changes to posture brought on by obesity is
hyperlordosis. Physical therapy is often used to correct hyperlordosis and other
postural abnormalities to decrease stiffness that occurs during activities of daily
living. Carrying oneself with proper or neutral posture allows them to participate
in activities of daily living with ease. Obesity can interfere with such activities in
some people due to limited flexibility and range of motion. Exercising regularly
can help people who are obese reach an ideal body weight and BMI, as well as
loosen stiff tissues (1, 14, 30).

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Laboratory testing should screen for diabetes, elevated cholesterol and
triglycerides as well as LDL and HDL cholesterol levels, and clinical or subclinical
hypothyroidism. Comprehensive chemistry profiles can assess for nonalcoholic
fatty liver and renal disease. Electrocardiograms are rarely necessary except to
evaluate specific cardiovascular problems such as elevated BP or palpitations
(9).
Routine exercise testing in the overweight and obese population is not indicated.
And it has been suggested that pharmacological stress testing using
dipyridamole is preferred for evaluating obese individuals (Poirier, 2006). When
performed, the purpose is primarily to assess for the presence of CAD (Fletcher,
2001). Exercise testing may also be performed to determine functional capacity,
develop an exercise prescription based on HR, and assess for risk related to
bariatric surgery (McCullough, 2006). Several studies demonstrate that obese
and morbidly obese patients can exercise to maximal exertion on a variety of
treadmill protocols (Fletcher, 2001, Fornitano, 2010).
Although walking is the preferred mode of exercise for testing, it is not always
practical in those who are obese. Patients in this group, especially those with
BMI values greater than 40 kg/m2, often have concomitant gait abnormalities and
joint-specific pain during weight-bearing exercise. Seated devices such as upper
body ergometers, stationary cycles, or seated stepping machines offer
alternatives that allow patients to achieve maximal exercise effort in a nonweight-bearing mode. Despite this, McCullough et al. reported that in a group of
43 consecutive patients referred for bariatric surgery, only one could not perform
a walking protocol (McCullough, 2006). Testing should be performed with the
normal routine, Prediction equations for METs from the work rate achieved on an
exercise device are typically inaccurate in people who are obese. Assessment of
cardiopulmonary gas exchange provides an accurate measurement of exercise
ability. Gallagher et al. reported a peak oxygen consumption level of 17.8 3.6
ml/kg/min in a morbidly obese group of patients who achieved peak respiratory
exchange ratio (RER) values greater than 1.10 (Gallagher, 2000). No
complications related to exercise testing were reported in this cohort, suggesting
that exercise testing is safe in this extremely obese population.
The American College of Sports Medicines Guidelines for Exercise Testing and
Prescription recommends that an exercise program focus on physical activities
and intentional exercise for 60-90 min/week to promote and maintain weight loss
(ACSM). These recommendations are beyond the general recommendation of
1,000 to 2,000 kcal expenditure per week (30 min on most days) for general
health benefits. Exercising for 250 to 300 min/week (or ~ 60 min/day) is
equivalent to about 2,000 kcal energy expenditure per week. But this figure is
less than the 2,500 to 2,800 kcal per week expenditure recommended by the
National Weight Control Registry. Therefore, ACSM recommendations for obese
populations are based on a weekly caloric expenditure of 2,000 to 2,800 kcal per
week. This goal range is appropriate for all obese individuals, although some

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obesity class II patients and most class III patients will have to progress gradually
to these higher levels of daily energy expenditure. As the exercise physiologist, I
will provide counseling about physical activity that will help individuals develop
realistic goals, establish appropriate exercise progression schedules, and gain
control of their exercise programs.
Initially, exercise and physical activity should focus on cardiovascular modes. The
primary reason for this approach is to focus on the greatest amount of energy
expenditure possible in a given period of time. To achieve the target of 2,000 to
2,800 kcal per week expenditure, exercise must be predominantly aerobic.
Although resistance training may provide added benefits, the caloric expenditure
of resistance training is less than that of aerobic exercise because is it not
performed continuously, a single training session incorporates less exercise time
than an aerobic session does, and resistance training should be performed on
only 2 or 3 days/wk. Exercise mode selection is important for enhancing
adherence and reducing the risk of injury. Some individuals have preexisting
musculoskeletal issues that could prevent certain modes of cardiovascular
exercise. These issues often relate to pain in the lower back, hip, nee and ankle
joints that may be chronic. However, these problems may improve, as weight is
lost. As the exercise physiologist, I will assess any painful conditions and make
recommendations to avoid this type of pain.
In general, aerobic exercise should be categorized as either weight bearing or
non-weight bearing. When possible, walking is the best form of exercise for
several reasons. Walking has few disadvantages; all patients have experience
with the activity and a goal to remain functional and independent. Walking is an
excellent, low-intensity activity with little risk of injury. It is available to most
patients and does not require special facilities. Neighborhoods, parks, walking
trails, shopping malls, fitness centers, and so on offer walking opportunities. If an
obese patient wants to walk on the treadmill, care should be taken to assess the
weight limits of the treadmill. Many are rated to handle only 350 lbs. Treadmills
especially designed for obese individuals up to 500 lbs are available. Jogging
should usually be avoided, especially in patients with no previous jogging history
or individuals who have a preexisting musculoskeletal issue that may be
aggravated by jogging. Some class I patients may be appropriate candidates for
jogging. Non-weight bearing exercise options include stationary cycling,
recumbent cycling, seated stepping, upper body ergometry, seated aerobics, and
water activities. These activities are useful at any time but are particularly useful
for those with joint injury or pain. When central adiposity is present,
understanding that exercises such as squats, cycling, and use of the Nustep may
not be appropriate. Data retrieved from the lab shows subjects self-reporting their
knees hitting their overweight and obesity vests. These findings suggest that
some exercises that are performed anteriorly and include the knees moving
proximally toward the chest may not be appropriate for obese individuals. As the
exercise physiologist, I will adapt these modes of exercise by providing larger
seats and stable equipment. Individuals who are obese often have difficulty

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getting on or off these types of equipment or moving through the range of motion
required by a given piece of equipment. For some individuals, seated aerobics
may be an excellent option to reduce the typical orthopedic limitations that some
experience, including back, hip, knee, and ankle pain. Another advantage is that
seated or chair aerobics can be performed in the comfort of a persons home. In
extremely obese individuals, it is important to use a chair that is rated to handle a
very heavy body weight. An experienced exercise leader can make a workout
session fun and effective. For example, the resistance of the water can be used
creatively to increase intensity. Many patients do not consider water activities
because of the effort necessary to get into and out of the pool and because of
their concern about their appearance in a bathing suit. As the exercise
physiologist, I will work to overcome these issues by using zero-entry pools and
locations where the public does not have a direct view of the aquatic facility (9).
CRF
Frequency
All individuals who are obese can exercise daily, typically from the beginning of a
program. Key factors are to minimize the duration and intensity initially to avoid
excess fatigue or muscle soreness that may interrupt the patients willingness to
exercise the next day. Altering the exercise mode may also help reduce the risk
of injury.
Intensity
The intensity of exercise must be adjusted so that the patient can endure up to
one hour of activity each day. For those who have never exercise previously,
intensity in the range of 50-60% of peak VO2 (50-60% HRR) is typically low
enough for sustained exercise. However, an intensity closer to 40% may be
required by some individuals, particularly those who have not exercised recently.
As an individual progresses, a goal of 60-80% of HRR is adequate. Individuals
without significant comorbid conditions can perform at these intensities in either a
supervised or a non-supervised setting. Many individuals who are obese are
hypertensive and may be taking a B-blocker. This possibility must be considered
when intensity is prescribed using HR. Typical RPE values of 11-15 (6-20 scale)
may be substituted when assessing HR is not convenient.
Duration
For those with little or no previous recent exercise history, beginning with 20-30
min each day is appropriate. Breaking this exercise time into two or three
sessions per day of shorter duration (5-15 min) may be required for highly
deconditioned people. Progression of approximately 5 minutes every one to two
weeks, until the individual can perform at least 60 min of exercise, is usually
appropriate. This progression is intended to increase compliance to the duration
of each session as well as to daily exercise. An accumulation of time over several
sessions in a day is as beneficial as one continuous work bout with respect to
total caloric expenditure. All individuals who are obese should be continuously
encouraged to maximize daily physical activity by considering all options. For

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instance, they could park at the far end of the parking lot when visiting a store or
get off one or two stops early when taking public transportation. The duration of
daily physical activity should typically not be restricted unless the individual
appears to be suffering from effects of excessive activity. But the contribution of
incidental exercise to total caloric expenditure is significant and may be as
beneficial as that of the planned exercise (3). Intensity and duration must be
manipulated so that the intensity is low enough to allow suitable duration to
expend the recommended caloric energy. For many obese patients, the intensity
will not be great enough to improve cardiovascular fitness. The initial focus,
however, should be on weight loss and therefore caloric expenditure. As the
exercise progresses and the individual is able to better tolerate the exercise
routine, higher intensity activities should be encouraged. Patients should be
encouraged to increase the duration from 20 min per day to 60 min or more per
day on every day of the week so that they expend > 2000 kcal per week. An
exercise program for obese patients should include both the supervised and nonsupervised phases with adaptations in modes, intensity, duration, and frequency
to provide adequate calorie expenditure while preventing soreness and injury.
Patients with existing comorbidities should preferably participate in a supervised
exercise program 3-5 days/week with a prescribed intensity and duration to treat
their comorbidities. Patients should be physically active a minimum of 60 min
each day, including the days of supervised exercise; therefore, they may have to
supplement with walking to accumulate 60 minutes. The remaining days of the
week (2-4 days) can be non-supervised with self-reported exercise to accumulate
60 min of physical activity each day. Special considerations for aerobic training
with obese populations include non-weight bearing modes needing to be
considered if joint pain or injury exists. In addition, watching for indications of
hyperthermia and providing guidelines on water consumption during exercise is
recommended.
Resistance Training
If resistance training is incorporated, careful attention must be given to beginning
this type of program. Strength equipment may not be an option for some morbidly
obese individuals. As the exercise physiologist, for obese individuals I will include
resistance intensity in the range of 60-80% of an individuals one-repetition
maximum performed for 8-15 repetitions for two sets each; with 2-3 min of rest
after each bout. This will allow the individual to perform 6-10 exercises in a 20-30
min session. Resistance exercises can be performed maximally on 2 or 3
days/week. These exercises should focus on the major muscle groups of the
chest, shoulders, and upper and lower back, abdomen, hips, and legs. The
primary acute benefit of the prescribed resistance program is to improve muscle
endurance; the secondary benefit is to increase muscle strength. For obese
individuals, the long-term benefit may be related to a higher resting metabolic
rate and protection of lean mass loss during rapid weight loss attempts. Special
considerations for resistance training with obese populations include keeping in
mind that because of range of motion limitations, some equipment may be

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difficult to use such as machines. In addition, because of high incidence of
hypertension, considering reducing breath hold or Valsalva maneuver is
recommended. Types of core and abdominal exercises need to be considered in
exercise prescriptions for overweight and obese populations. As seen in lab,
improper mechanics such as stomach continuously hitting the thighs and feelings
of back strain may occur.
ROM
Obese patients may have a reduced range of motion as a result of increased fat
mass surrounding joints of the body (11), in conjunction with a lack of stretching.
As a result, these patients often respond slowly to changes in body position and
have poor balance. Persons who are obese are also at a greater risk of low back
pain and joint-related osteoarthritis because of their condition (10, 29). Therefore,
range of motion may improve spontaneously with weight loss (15). Still, to the
degree possible, patients should perform a brief flexibility routine focused on the
legs, lower back, and arm and chest regions. Normal flexibility routines are
recommended as tolerated. Special considerations for ROM exercises with
obese populations include keeping in mind that certain stretching techniques may
be difficult for some because of poor balance, coordination, and inability to sit on
the floor. Modifying stretches for the client will be important due to decreased
range of motion. Adjusting exercise prescriptions for obese populations is crucial
in reducing risk of injury.
Behavioral Therapy
Providing any level of exercise advice without behavior change is typically futile.
Most medically significant weight loss efforts require frequent contact and
support in order for people to adopt the healthier weight behaviors necessary for
weight loss and maintenance of weight loss. Regular accountability, problem
solving, and skill building are necessary over a 20-week period to establish longterm success. Such behavioral change can be supported by individual or group
therapy and augmented by phone and Internet follow-up. Weight loss efforts
typically move from pre-contemplation to contemplation to determination and
then the action phases. Maintenance efforts must follow action steps in weight
loss; otherwise, relapse is common. Motivation and realistic goal setting must be
supported in a compassionate environment focused on measurable progress (9,
Miller, 2012).
Record keeping and review predicts success because most people make better
choices when they are made aware of the significance of those choices. Stimulus
control helps patients identify stress and emotional eating cues and make other
choices. Unhealthy eating behaviors like eating while driving or eating in front of
a television or computer screen should be discouraged. Increased intentional
exercise or lifestyle activity should be planed and monitored. Cognitive
restructuring is used to detect black-and-white thinking and to help patients avoid

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an all-or-nothing pattern. Addressing emotional issues such as depression and
shame with supportive therapy is essential, and referral for significant mental
health or eating disorders may be necessary. Nutrition education and planning for
maintenance, including relapse, can help reduce recidivism and the need for
treatment (9, Brownell, 1987).
According to many experts including a study done by Dong et al. obesity is
associated with the increased risk for depression across gender and racial
groups. Exercise professionals who work with patients with depression may find
the experience both challenging and rewarding. Symptoms of depression such
as fatigue and loss of interest in people and activities may adversely affect a
patients ability to adhere to an exercise program. Patients with depression often
require more attention by the exercise professional than do non-depressed
individuals. The exercise professionals consideration may be especially
important during the initiation phase of an exercise program. For example, many
patients with depression feel a lack of self-worth and may not believe in their
ability to participate successfully in an exercise program. The loss of energy that
occurs with depression may further contribute to a patients reluctance to begin
exercising. Thus, depressed patients may need more reassurance and positive
reinforcement when they begin the program. In addition, the cognitive symptoms
of depression, such as indecisiveness and difficulty in concentrating, may lead to
problems with recalling the exercise prescription or remembering to set exercise
goals. Occasional reminders of such exercise information can be helpful.
Depression often is accompanied by social problems, such as family conflict and
unemployment. The exercise professional should be aware that such stressful
life situations might present barriers to participation in an exercise program. For
example, a depressed patient who is going through a divorce and is between
jobs may be less likely to consider exercise a priority. When clinicians encounter
patients with depressive symptoms that interfere significantly with exercise
participation, the appropriate approach may be to refer them to a mental health
provider for treatment to improve quality of life and, potentially, to achieve
motivation to exercise. Several treatments for depression have shown success,
including antidepressant medication and cognitive-behavioral therapy. Patients
with depression should also be informed that exercise training has been shown
to reduce depressive symptoms in both healthy and medically ill populations.
Because depression is associated with increased risk of dropout from exercise
programs, staff should closely monitor depressed clients and refer them for
specialized treatment when appropriate.
Disturbed sleep is a defining feature of depression, and the presence of
disturbed sleep among depressed patients predicts poor response to treatment
and future depressive episodes (Manber, 2009). Furthermore, many medications
used to treat depression may also lead to sleep disruption (Argyropoulos, 2005).
There is now evidence to suggest that exercise, known to be an effective
treatment for depression, may also improve disturbed sleep. Epidemiological

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investigations support a significant link between engaging in exercise and better
sleep (Youngstedt, 2005). Several interventional studies have demonstrated that
acute bouts of exercise are generally associated with small, but significant,
improvement in total sleep time among normal sleepers (Youngstedt, 2005,
Youngstedt, 1997). Montgomery et al. set out to conduct a meta-analytic review
of chronic exercise interventions for insomnia among non-depressed older
adults. However, they were able to identify only one study that met their inclusion
criteria (King, 1997). In that study of 48 male and female community-dwelling
adults, participants assigned to a 16 week exercise intervention scored better on
a standardized sleep scales than wait-list control, and exercise was associated
with an average improved sleep duration of 42 minutes per night. In a recent
study of 17 non-depressed adults with insomnia, participants who completed a
16 week aerobic exercise program plus sleep hygiene reported that their sleep
duration improved by an average of 75 minutes per night, compared to 13
minutes for the attention control plus sleep hygiene condition (Reid, 2010).
Singh et al. reported that an 8 week strength training intervention was associated
with greater improvement in both depressive symptoms and sleep, compared to
an attention control (Singh, 2005), and that a high intensity 8 week strength
training intervention was associated with greater improvement in both depression
and sleep compared to a low intensity strength training intervention (Singh,
2005). However, data regarding aerobic or resistance training exercise as a
treatment for disturbed sleep among depressed adults are limited; ultimately,
there is no definitive evidence that regular aerobic or resistance training exercise
improves sleep among depressed persons. Evening exercise has been
associated with sleep disturbances in some studies (Tworoer, 2003), but this
issue has not been investigated among patients with clinical depression. When
formulating an exercise prescription for depressed patients with sleep
disturbance, the EP is encouraged to prescribe daytime exercise, as evening
exercise may disrupt sleep for some patients.
There are many strategies for improving exercise adherence in patients with
depression. Most importantly, exercise professionals need to work to establish
good rapport with patients. Positive feedback and empathy from exercise staff
can go along way toward promoting adherence. At the beginning of an exercise
program, review with patients their unique barriers to participation. The barriers
should then be discussed with patients to find ways to overcome or minimize
these obstacles. The EP needs to educate patients about the benefits of exercise
for physical health and depression. Elicit from patients other benefits of exercise
specific to them periodically remind them of those benefits. Patients are more
likely to adhere to exercise training if the experience is enjoyable. Work with
patients to increase their satisfaction with the program. Helping patients develop
realistic exercise goals is also important such as gradual increases in number of
exercise session per week. In addition, the EP needs to encourage patients to
reward themselves for participation in exercise. Emphasize the importance of
positive reinforcement for accomplishments. Even simple rewards can be

16
powerful motivators. In addition, it is suggested to recommend to patients that
they talk to family members and friends about their exercise program and goals.
Such people are often a valuable resource in offering encouragement for
patients participation in exercise. An EP must remember that untreated or
undertreated depression is likely to have a negative effect on adherence to
exercise. Encourage patients to seek treatment for depression if symptoms
appear to interfere with exercise participation.
In conclusion, exercise and behavioral modification are cornerstones of sound
weight management programs. Clinical exercise physiologists, especially those
who have a strong background in behavioral or lifestyle counseling, are playing
an increasing role in the primary prevention, treatment phase, and secondary
prevention of overweight and obesity. Patients benefit from seeking out exercise
physiologists who are providing services in weight management programs. Given
the number of overweight individuals in the United States and worldwide, it is
important to continue to advance clinical exercise physiologists to work with
overweight patients (9).

17
APPENDIX A

18

19
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