Sanjay Kalra  ( Department of Endocrinology, Bharti Hospital, Karnal, India. )
Anuradha Mandlekar  ( Head, Physiotherapy Services, Fitterfly Healthtech Pvt Ltd, Navi Mumbai )
Nitin Kapoor  ( Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore (TN) -632004, India, and Non Communicable Disease Unit, Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia. )

Exercise is an integral part of obesity management and health promotion. This brief communication shares practical and pragmatic tips as to how to initiate physical activity in an exercise-naïve person with obesity. This information will be useful for all health care professionals who manage patients with obesity, including physicians and physiotherapists. A step-wise initiation of physical activity starting from flexibility training, balance practice and then aerobic and resistance exercises would help to provide a long term sustainable pattern of physical activity.

Keywords: Exercise, Obese, Overweight, Obesity, Person-centered care, Physical activity, Workout.

 

Introduction

 

Exercise is an integral part of obesity management. Most guidelines and recommendations are concordant in their call for regular physical activity, including aerobic and resistance exercise.¹ The duration, intensity, and relative importance of both types of exercise may vary, according to needs and preferences. However, few experts describe how to begin exercise therapy in an exercise-naïve individual living with obesity.

 

Role of Exercise

 

About 30 minutes of moderate intensity physical activity for 5 days/week is required to maintain cardiovascular and metabolic health.² Aerobic exercise of at least 150 min/week to 300 min/week and Resistance exercise of at least 2 days/week will be required to reverse pre-existing conditions such as obesity and insulin resistance.³ Responsiveness to exercise also varies from person to person, and is influenced by age, gender, degree of obesity, adipose tissue topography, associated medical/metabolic comorbidities, concomitant therapy, and degree of caloric restriction.⁴

 In a person with obesity, 60 to 90 minutes of moderate intensity or 20 minutes of vigorous activity (50-75% of Target Heart Rate) is required for effective weight loss. Both exercise and calorie restriction, practiced together, offer the best chance of reducing weight, without losing fat free mass, and without causing nutrient deficiency.⁵

 

Types of Exercise

 

From a practical viewpoint, exercise can be classified as flexibility enhancing, aerobic and resistance exercises. These are defined and described in Table.

 

All types of exercise have their advantages, and a comprehensive combination is the best approach to weight loss.

 

Pre-Exercise Check-Up (Pre-Participation Screening)

 

A Pre-Participation Screening with a Qualified Physiotherapist must be conducted prior to prescribing exercise. This helps to identify musculoskeletal, medical, metabolic, monetary and mood related barriers to physical activity, so that they can be addressed appropriately.⁶ The risk of injury and other complications can also be gauged, so that they can be pre-empted by prescribing the correct mode of exercise therapy and gadgets. It is also important to identify a safe environment for performing these physical activities, such that the prescribed exercises can be customized to the available space and environment.⁷

 

Hierarchy of Exercise

 

Exercise regimens should be initiated gradually, and up titrated (in duration and intensity) at a slow speed. In an exercise-naïve person, one should begin with flexibility and balance exercises. These help to explore, and optimize, the range of movements at all joints, and allow the exercise physiologist to plan the course of further therapy.

Once the individual has become attuned to the concept of exercise, non-weight bearing aerobic exercise such as stationary cycling can be introduced. These are followed by low impact aerobic exercises (where at least one foot is firmly on the ground at any given time) and then by high impact aerobic exercises. The next step in the hierarchy is to introduce resistance exercises of gradually increasing intensity. All major muscle groups the trunk, upper limbs and lower limbs; proximal and distal; must be exercised to ensure and this should be taken into account while intensifying therapy (Figure).

 

 

Safety First

 

One should always start exercise with a Dynamic Warm Up.  This consists of a few minutes of activity that will slowly elevate the heart rate and the movements will move the joints in larger range of motion minimizing the risk of muscle injury during the main workouts. Small bouts of exercise may be practiced twice a day until endurance is built up to sustain activity for longer duration at one time.

Exercise should be discontinued temporarily, and then restarted at a lower intensity, in case of breathlessness, giddiness or muscle pain.

 

Motivation

 

Motivation is of utmost importance for exercise initiation, intensification and maintenance. This is especially true for the exercise-naïve person. A supportive social environment, characterized by empathy and understanding, contributes to better adherence to therapy.^8,9 A person-friendly choice of exercise regimens, exercise environment and exercise partner is essential for long term persistence. Modern technology, such as wearable monitors, and exercise aids, such as resistance bands are helpful in promoting regular exercise.¹⁰

 

Nutrition and Hydration

 

Nutrition and hydration are important aspect of a fitness regimen. A fruit or a high protein pre-workout snack, coupled with adequate intake of electrolyte containing beverages, are helpful in improving exercise tolerance. From a South Asian perspective, suitable snacks include boiled eggs, grilled cottage cheese, roasted nuts and pulses, and savoury snacks made of gram flour.⁵ Beverages such as lemonade, buttermilk (salted), Cumin water (jaljeera), water balls(panipuri) water and kokum juice are useful in maintaining fluid and electrolyte balance.¹⁰ A post-workout meal should be consumed preferably  after a Cool Down. There are 3 R's of a post workout meal:

1. Rehydrate - Drink 1-2 glasses of water after exercise. It will make up for fluid and electrolyte losses during workout.

2. Replenish - replenish your glycogen stores with a fruit or take an appropriate advice from your nutritionist as per your body requirements.

3. Repair - A good protein rich meal will carry out its repair work and prevent tissue microdamage.

Charity Begins at Home, So Does Exercise

The best motivator is one who practices what he preaches. We request all exercise — naïve readers to begin regular physical activity, exercise and sports. For those who do exercise, we request you to intensify it, by increasing the duration and intensity.

 

Summary

 

Well begun is half done. This brief communication focuses on initiating exercise in exercise-naïve persons. The simple description and tips mentioned herein are useful in getting obese persons to begin physical activity and exercise. Once this is achieved at an individual and a community level, one of the major barriers to managing obesity will be overcome.

 

References

 

1.       Kapoor N, Kalra S, Kota S, Das S, Jiwanmall S, Sahay R. The SECURE model: A comprehensive approach for obesity management. J Pak Med Assoc. 2020; 70:1468-9.

2.       Obesity Management for the Treatment of Type 2 Diabetes: Standards of Medical Care in Diabetes-2021. Diabetes Care. 2021; 44 (Suppl 1): S100-s10.

3.       Kapoor N. Thin Fat Obesity: The Tropical Phenotype of Obesity. In: Feingold KR, Anawalt B, Boyce A, Chrousos G, de Herder WW, Dungan K, et al., editors. Endotext. South Dartmouth (MA): MDText.com, Inc.; 2000.

4.       Kalra S, Kapoor N, Bhattacharya S, Aydin H, Coetzee A. Barocrinology: The Endocrinology of Obesity from Bench to Bedside. Med Sci . 2020; 8:51.

5.       Kapoor N, Sahay R, Kalra S, Bajaj S, Dasgupta A, Shrestha D, et al. Consensus on Medical Nutrition Therapy for Diabesity (CoMeND) in Adults: A South Asian Perspective. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy. 2021; 14:1703.

6.       Kalra S, Kapoor N, Kota S, Das S. Person-centred Obesity Care - Techniques,Thresholds, Tools and Targets. Eur Endocrinol. 2020; 16: 11-13.

7.       Kalra S, Kapoor N. Environmental Endocrinology: An Expanding Horizon. In: Feingold KR, Anawalt B, Boyce A, Chrousos G, de Herder WW, Dungan K, et al., editors. Endotext. South Dartmouth (MA): MDText.com, Inc.; 2000 Copyright© 2000-2021, MDText.com, Inc.; 2000.

8.       Kapoor N, Lotfaliany M, Sathish T, Thankappan KR, Tapp RJ, Thomas N, et al. Effect of a Peer-led Lifestyle Intervention on Individuals With Normal Weight Obesity: Insights From the Kerala Diabetes Prevention Program.Clin. Ther. 2020;42:1618-24.

9.       Kapoor N, Lotfaliany M, Sathish T, Thankappan KR, Thomas N, Furler J, et al. Prevalence of normal weight obesity and its associated cardio-metabolic risk factors — Results from the baseline data of the Kerala Diabetes Prevention Program (KDPP). PloS one. 2020; 15:e0237974.

10.     Salis S, Joseph M, Agarwala A, Sharma R, Kapoor N, Irani AJ. Medical nutrition therapy of pediatric type 1 diabetes mellitus in India: Unique aspects and challenges.Pediatr Diabetes. 2021; 22:93-100.