Special Considerations for Weight Management

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This chapter discusses special considerations relevant to exercise testing, prescription, and progression for individuals who are overweight or obese. The case study focuses on a middle-aged woman with obesity who was screened prior to participation in a 4-month exercise training program. She completed baseline testing, including anthropometric measurements, a submaximal exercise test, and assessments of muscular fitness and flexibility. This case study presents direction for the formulation of an appropriate exercise prescription to result in weight loss and a reduction in chronic disease risk factors for a patient with obesity.

Case Study 18-1

Ms. Case Study-WM

Ms. Case Study-WM is a 48-year-old woman who works 5 days per week as a bank executive. She previously walked up the stairs to her third floor office but has started to use the elevator because in the past month, she has experienced shortness of breath when walking up the stairs. The patient was physically active throughout college as a club lacrosse player but has not exercised regularly since she gave birth to her children who are now 16 and 14 years old. Ms. Case Study-WM is 167.6 cm (66 in), weighs 102.7 kg (226 lb), and drinks one to two glasses of wine per day due to the stress of her job and divorce 1 year ago. Lab results from her physical examination 1 month ago revealed total blood cholesterol: 230 mg ∙ dL⁻¹, low-density lipoprotein (LDL): 150 mg ∙ dL⁻¹, high-density lipoprotein (HDL): 48 mg ∙ dL⁻¹, and blood glucose: 110 mg ∙ dL⁻¹. Her blood pressure (BP) was recorded as 132/84 mm Hg at this doctor’s visit. Ms. Case Study-WM has a family history of heart disease with her father dying at 53 years of age of a myocardial infarction and her brother’s coronary revascularization at 48 years of age. She is a nonsmoker. Current medications for Ms. Case Study-WM include Atorvastatin (Lipitor) for hypercholesterolemia and Lisinopril for high BP.

Ms. Case Study-WM’s body fat percentage was obtained using bioelectrical impedance analysis (BIA). Waist circumference (WC) was measured at the narrowest circumference above the umbilicus and below the xiphoid process. Height was measured using a wall-mounted stadiometer, and weight was measured on a calibrated balance beam scale (Box 18.1). Submaximal exercise test results obtained from a modified Balke protocol are presented in Table 18.1. Muscle strength, seen in Box 18.2, was assessed by a five repetition maximum (5-RM) protocol using plate-loading resistance training machines. Flexibility testing results are shown in Box 18.3.

Box 18.1	Anthropometric Measurements for Ms. Case Study-WM with Obesity
Following are anthropometric measurements for Ms. Case Study-WM with obesity:
Height: 167.6 cm
Weight: 102.7 kg
BMI: 36.5 kg ∙ m⁻²
Body fat: 32.4%
Waist circumference: 98 cm

Table 18.1

Submaximal Exercise Test Results from a Modified Balke Protocol

Stage	Minute	Grade (%)	Speed (mph)	HR (bpm)	BP (mm Hg)	Rating of Perceived Exertion (6–20 Borg Scale)
1	1	0	3.0	98
1	2	0	3.0	102	152/86	11
2	3	2.5	3.0	126
2	4	2.5	3.0	127	164/86	14
3	5	5	3.0	140	180/88	16

Preexercise HR: 78 bpm; preexercise BP: 134/86 mm Hg; recovery BP: 152/82 mm Hg.

Box 18.2	Five Repetition Maximum, Muscular Fitness Testing Results for Ms. Case Study-WM with Obesity
Following are 5-RM, muscular fitness testing results for Ms. Case Study-WM with obesity:
Chest press: 35 lb
Leg press: 165 lb
Biceps curl: 12.5 lb
Leg extension: 50 lb
Latissimus dorsi pull-down: 35 lb
Leg curl: 30 lb
Triceps extension: 15 lb

Box 18.3	Flexibility Testing Results for Ms. Case Study-WM with Obesity
Following are flexibility testing results for Ms. Case Study-WM with obesity:
Trunk forward flexion using a sit-and-reach box: 21 cm
Shoulder and upper arm flexibility: fail for both right (−7 cm) and left (−10 cm) sides

Description, Prevalence, and Etiology

Data suggest that obesity continues to be a significant public health concern in the United States, with 68.5% of adults in the United States classified as overweight or obese (body mass index [BMI] ≥25.0 kg ∙ m⁻²) and 34.9% categorized as obese (BMI ≥30.0 kg ∙ m⁻²) (9). Overweight and obesity are associated with an increased risk of Type 2 diabetes, hypertension, dyslipidemia, coronary heart disease (CHD), stroke, some forms of cancer, musculoskeletal problems, respiratory problems, and elevated risk of all-cause and cardiovascular disease (CVD) mortality (7). Additionally, there are negative psychosocial, biomedical, and economic implications of overweight and obesity for the U.S. population (7). Maintenance of body weight is primarily determined by the energy balance equation (Energy Intake = Energy Expenditure) (1). Although this concept of weight management appears to be straightforward, there is a constellation of causes contributing to overweight and obesity. Contributing factors include, but are not limited to, genetic, epigenetic, social and physical environment, biological, and psychological variables that can lead to positive energy balance (9). Evidence suggests that even a minimal weight loss of 2%–3% can reduce cardiovascular risk factors (3,7,9). Furthermore, maintaining a weight loss of 3%–5% may result in the lowering of risk factors associated with overweight and obesity comorbidities (e.g., blood glucose and glycolated hemoglobin [HbA1C] test levels) (7). Physical activity is a target focus of interventions that are linked to an improvement in health outcomes and increased success with weight loss when combined with caloric restriction (5,7). Additionally, physical activity is found to be one of the best predictors of long-term weight maintenance after weight loss (1,2,5,7). Through increasing physical activity levels, individuals who are overweight or obese can expend more calories, thus aiding in a negative energy balance. Table 18.2 contains American College of Sports Medicine (ACSM) recommendations on physical activity and weight loss (4).

Table 18.2

American College of Sports Medicine Recommendations on Physical Activity and Weight Loss

Physical Activity Amount	Potential Magnitude of Weight Loss
<150 min ∙ wk⁻¹	Minimal weight loss
>150 min ∙ wk⁻¹	~2–3 kg
>225–420 min ∙ wk⁻¹	5–7.5 kg

Preparticipation Health Screening, Medical History, and Physical Examination

Minimally, in order to be consistent with ACSM’s updated exercise preparticipation health screening recommendations, individuals with overweight and obesity should be assessed first for current exercise participation; known cardiovascular, metabolic, or renal disease or signs or symptoms of these diseases; and planned exercise intensity level (1,11).

In order to individualize treatment appropriately, other pertinent information to collect prior to initiating an exercise program for an individual who is overweight or obese may include a thorough medical history due to an increased risk of associated comorbidities (e.g., hypertension, dyslipidemia, diabetes, CHD, stroke, gallbladder disease, osteoarthritis, sleep apnea, respiratory problems, and certain cancers) (7).

Additional information to collect as part of the preparticipation exercise screening would be height, weight, BP, heart rate (HR), waist circumference, medications, musculoskeletal/orthopedic problems, psychological conditions, and amount of sedentary time (7,11). Supplementary factors for the clinician to assess prior to program participation for individuals with overweight or obesity are history of weight gain and loss over time, dietary habits, physical activity history, family history of obesity, barriers to weight loss (e.g., low social support, readiness for change, low self-efficacy, time constraints, financial concerns), and individual weight and physical activity goals (7). Because of the complex etiology of overweight and obesity, considering a multitude of factors in prescreening will provide the health care provider with useful information to create a safe and effective exercise prescription. Based on the ACSM’s Guidelines for Exercise Testing and Prescription, 10th edition (GETP10) (1), perhaps some of the most important information to obtain from this group of individuals is a clear understanding of the person’s current level of physical activity and the presence of signs; symptoms; and/or known cardiovascular, metabolic, or renal disease.

Case Study 18-1 Quiz:

Preparticipation Health Screening, Medical History, and Physical Examination

1. Is medical clearance recommended for this individual prior to exercise testing and prescription? Why or why not?

2. What additional information is important to consider from the review of this patient’s case study for the exercise preparticipation health screening?

3. What further questions would be helpful prior to initiating an exercise program?

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