Impact of Exercise on Obesity Management

Topic Outline The Role of Physical Activity in Obesity Management for: Weight loss Weight loss maintenance Prevention of obesity Reducing general health risks Mechanisms of Action Current Recommendations for Physical Activity in Obesity Therapy Translating Physical Activity Recommendations into Increased Physical Activity in Patients

Weight Loss: What Works? Effect of Physical Activity Without Diet on Body Weight Loss1 Mode Frequency Weight Loss Epstein and Wing Walk/run 2 - 5x/wk 0.09 kg/wk Ballor and Kessey Walk/run/cycle 3 - 4x/wk 0.1 kg/wk Garrow and Summerbell Hadjiolva, et al Various Daily (10 hrs/day) 1.8 kg/wk Lee, et al Military Training 5x/wk 0.6 kg/wk 1Zachwieja JJ. Endocrinol Metab Clin North Am 1995;25:965-988.

Physical Activity Usually Does Not Increase Short-Term Diet-Induced Weight Loss Blonk 1994 Sweeney 1993 -15 -10 -5 Weight Loss (kg) * Diet only Diet + exercise Wadden 1997 Ross 1996 Marks 1995 Ross 1995 Bertram 1990 Each study ranged from 4 to 6 months *P < 0.05 vs diet-only group Wing. Med Sci Sports Exerc. 1999;31(suppl):S547.

Physical Activity and Weight Loss Most studies suggest a reasonable amount of physical activity does not produce weight loss Exercise alone - 0.06 to 0.1 kg/week Dose response relationship does not significantly increase initial weight loss over what is obtained by caloric restriction alone

Dr. Steve Blair - Cooper Institute “Do not judge the impact of physical activity by weight loss” Dr. Steve Blair - Cooper Institute September 20, 2004

Weight Loss Maintenance: What Works? Adapted from Pavlou KN, et al. Am J Clin Nutr. 1989;49:1115-1123.

Weight Loss Maintenance: What Works? * ** n = 84 n = 102 n = 87 n = 76 n = 80 Jeffery RW et al AJCN 2003;78:684-9.

Physical Activity and Weight Loss Maintenance Data from case studies, correlation studies and randomized control trails have all concluded that high levels of physical activity facilitate maintenance of weight loss long-term

Prevention: What Works? Freshman and Sophomore Women at the University of Kansas Donnelly J, Jacobsen D, Hill JO. Archives of Internal Medicine 163:1343-1350, 2003.

Freshman and Sophomore Women at the University of Kansas 225 minutes/week prevented weight gain in women at risk (2.3 kg/16 months) 225 minutes produced a weight loss in men at risk (5.2 kg/16 months) Women 439 kcal/session (5.4 kcal/kg) Men 667 kcal/session (6.7 kcal/kg) Donnelly J, Jacobsen D, Hill JO. Archives of Internal Medicine 163:1343-1350, 2003.

Physical Activity and General Health Moderate levels of cardiorespiratory fitness substantially reduce mortality risks associated with overweight and obesity Moderate levels of cardiorespiratory fitness can be developed in 30 minutes of activity at least 5 days per week

HERITAGE Family Study * Pre-Training Post-Training 100 90 80 70 60 50 40 30 20 10 High TG Low HDL-C High BP High Glucose High WC Metabolic Syndrome Pre-Training Post-Training * Prevalence of individual risk factors before and after 20 wk of aerobic exercise training in the HERITAGE Family Study among 105 participants with the metabolic syndrome at baseline. *P < 0.05 pre- versus post-training. Katzmaryck PT, Leon AS, Wilmore JH, et al. Med Sci Sports Exerc, 2003; Vol. 35, No. 10, 1703–1709.

Why the difference in impact for physical activity between weight loss and weight loss maintenance?

Differences Between Weight Loss and Weight Loss Maintenance Maintenance of Weight Loss Time limited Requires a negative energy balance Reduced caloric intake is critical Physical activity not required for success Common Life-long Requires energy balance at a reduced body weight Physical activity is critical for success Rare

Why Is Physical Activity Critical Mechanism of Action Why Is Physical Activity Critical for Long-Term Success? Makes it more likely for patients to remain in Energy Balance at a reduced body weight Why? Possibilities include: Direct compensation for diet indiscretions Prevent or attenuate metabolic efficiency associated with weight loss Improved self-efficacy or mood Improved satiety/hunger Allows better “physiological” matching of intake and expenditure to occur

Potential Effects of Increasing Physical Activity vs Potential Effects of Increasing Physical Activity vs. Decreasing Intake on Encouraging Physiological Energy Balance Obesity Conducive Environment Energy Balance Energy Intake Physiological Control Maximized Activity B A Intake C Cognitive Control Required Energy Expenditure

Physical Activity Recommendations: How Much is Enough? A Common Patient Misconception “30 minutes of physical activity every day is all I need to do to manage my weight”

How Much is Enough? Current PA Recommendations Minimal public health recommendations to improve health related outcomes 30 min moderate activity most days of the week (150 minutes/week) CDC - Centers for Disease Control ACSM - American College of Sports Medicine SG - Surgeon General Maximize weight loss and prevent weight regain 45-60 minutes/day IOM - Institutes of Medicine 60-90 minutes/day IASO - International Assoc for Study of Obesity 60 minutes/day (300 minutes/week) ACSM - American College Sports Medicine Preventing general weight gain Unclear

Weight Loss Maintenance: How Much is Enough? Schoeller et al, AJCN 1997;66:551-6.

Weight Loss Maintenance: How Much is Enough? Women in the physically active group gained the least weight after reaching their target for weight loss Retrospective analysis: Threshold of 11 kcal/kg of body wt/day 80 minutes of moderate intensity activity or 35 minutes of vigorous activity Supports that body weight is better regulated at a higher energy flux Schoeller et al, AJCN 1997;66:551-6.

Average Energy Expended in Physical Activity in the NWCR Klem et al, AJCN 1997;66:239-46.

What About Intensity? Studies suggest the intensity of physical activity may have limited impact on weight control when total energy expenditure (TEE) is fixed High levels of energy expenditure (EE) improve weight management So if vigorous intensity results in greater EE weight loss outcomes will improve So if moderate intensity results in greater EE weight outcomes will improve Moderate intensity provides health benefits while presenting low to moderate health risks

Planned vs Lifestyle Activity Planned Activity- completed in a discrete period of time, moderate to high intensity 30 to 60 minutes Walking, swimming, biking Lifestyle Activity- completed during everyday tasks Parking further away, taking stairs, walk to meetings

Mean Changes in Body Weight for Lifestyle Activity vs Aerobic Exercise Anderson et al. JAMA 1999; 281: 337.

Long vs Short Bouts Multiple short bouts are as effective as one long bout and perhaps may facilitate efforts to increase activity Helps address the barrier of perceived lack of time Multiple short bouts increase adoption of physical activity during first 6 months Long-term impact is less clear Jakicic JM et al. JAMA 1999;282(16):1554-60. Jacobsen DJ et al. Int J Sports Med 2003;24:459-64.

Physical Activity - The “Magic Pill” What Patients Want… Currently available Safe, cheap and effective Increase my “metabolism” Burn fat as fuel Allow me to eat more food without gaining weight Make me “healthier”

How to Get Your Overweight Patients to Be More Active

How to Get Your Overweight Patients to Be More Active For many individuals, starting a structured exercise program is not possible Therefore: Implement small lifestyle changes to increase daily physical activity Park at end of lot when driving to store Only have one phone in house so patient has to walk to use it Find the stairs! Walk to a co-worker’s office at work instead of calling on the phone Use elevators only if going up more than 2 floors Decrease sedentary activity

Lifestyle Activity Program Wear a pedometer every day for a week to determine baseline Increase steps by 500 steps/day /week Ultimate goal 10,000 - 15,000 steps/day 500 steps = 5 minutes walking moderate Helps set goals and gives instantaneous feedback Do all those little changes add up?

www: Americaonthemove.org

Then What? After these lifestyle alterations are in place, start on a structured exercise plan Start slow - perhaps as little as 5 - 10 min of activity per day (whatever they enjoy and will continue to do) Total amount of activity is what counts

Conclusions Physical activity recommendations of 30 minutes most days of the week are based on improving cardiovascular health - a good initial or minimal goal 60 - 80 minutes of physical activity may be what is necessary to prevent regain following a weight loss (long-term goal) Risk factors associated with Metabolic Syndrome improve with physical activity How to get patients to do what we know it takes is the real problem Lifestyle changes and short bouts of activity in sedentary individuals may be the place to start Gradual increase over 1 - 2 years may be necessary Long-term adherence is the most important goal