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 ®
Transcript
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
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
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?
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 [email protected] American Society of Bariatric
Physicians
52. Save your Questions & Lets Go Practice! Horn 2012