Article Text

Exercise prescription for the overweight and the obese: how to quantify and yet keep it simple
  1. R Ehrsam1,
  2. U Hoerler-Koerner2,
  3. S Stoffel2,
  4. T Melges2,
  5. B Ainsworth3
  1. 1
    Sports Medicine and Rehabilitation Division, Zinman College of Physical Education and Sport Sciences, Wingate, Israel
  2. 2
    Institute for Exercise and Health Sciences, University of Basel, Basel, Switzerland
  3. 3
    Department of Exercise and Wellness, Arizona State University, Politechnic Campus, Mesa, Arizona, USA
  1. Correspondence to Dr R Ehrsam, Sports Medicine and Rehabilitation Division, Zinman College of Physical Education and Sport Sciences, Wingate 42902, Israel; Rolf.ehrsam{at}unibas.ch

Abstract

An activity point system (APS) is presented that assists healthcare providers and health professionals with a way to prescribe exercise in a semiquantitative manner and to motivate their patients to begin an exercise programme. Activity points are specific to one’s body weight, body mass index and activity intensity for 10-minute bouts of activity performed. With a goal of accumulating 100–300 activity points per week, the APS provides a simple yet quantitatively accurate way to prescribe exercise for overweight and obese adults.

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With overweight and obesity on the rise, new treatment strategies to reduce overweight and obesity must be improved further. Besides caloric restriction, medication and surgery, regular exercise as part of a behaviour modification programme is highly effective, especially in patients with a metabolic syndrome, ie, in people with hypertension, dyslipidaemia, impaired glucose metabolism or diabetes mellitus type 2 and coronary heart disease.1 2 In terms of cost to the healthcare system, exercise is inexpensive and almost universally available.

Whereas many people get a lot of pleasure out of exercise, sports and games, overweight and obese patients quite often do not enjoy such activities. Overweight and obese patients are frequently affected with medical conditions and functional limitations. Therefore, they need well-designed exercise programmes and a careful introduction on how to exercise.3 For exercise prescriptions to be effective, physical activity programmes should be designed and modified for the overweight and the obese with the following points in mind:

  • The aims of the exercise programme should be discussed with the patient: metabolic fitness, establishing an exercise habit, improving physical fitness and weight loss. Quite frequently weight loss may not be a prime target in the beginning of a programme. Instead, managing a metabolic condition, such as diabetes, may be a primary aim of the exercise programme.

  • Medical problems, functional limitations and disabilities.

  • Physical activity history: activities a person has performed in the past or when he/she was young, activities he/she has always wanted to learn and/or feels capable of performing.

  • Actual physical activity status with respect to the stages of readiness to begin an exercise programme, according to the transtheoretical model.4

  • Barriers to regular exercise such as lack of time, social influence, lack of energy, lack of willpower, fear of injury, lack of skill, lack of resources, weather conditions, travel, family obligations or retirement years.3

Healthcare providers often lack formal training in prescribing exercise to patients. To assist with assigning and monitoring exercise, we have developed an activity point system (APS) for overweight and obese adults that takes into consideration the body mass index (BMI), body weight and exercise intensity for a variety of lifestyle activities, conditioning and sports activities.

The activity point system

The APS for exercise prescription is a simple way to prescribe and monitor physical activity programmes. The system assigns points based on a patient’s BMI, body weight and the intensity of an activity for 10-minute bouts. The APS should be helpful by meeting the following requirements: to motivate patients to become and remain physically active; to allow quick exercise prescription and programme modification; to allow quantification of physical activities; and to relate the amount of exercise performed and calories expended to changes in body weight and clinical variables such as plasma glucose and triglyceride levels, cholesterol and hypertension, among others.

As shown in an example of the APS system (table 1), the points assigned vary by BMI category (class I, 25.0–29.9 kg/m2; class II, 30.0–39.9 kg/m2 and class III, ⩾40.0 kg/m2), body weight (⩽90 kg; >90 kg, etc) and the type of activity performed. An example of the APS is provided in table 1. The complete APS is presented as supplemental material (see supplemental table 2 available online only).

Table 1

The APS

In an exercise programme for overweight and obese patients, 100–300 activity points should be collected weekly according to the individual’s goals. On the basis of accepted recommendations for the promotion and maintenance of health, the optimum accumulation is between 200 and 300 activity points per week.1 2 3 5 6 As the total weekly amount of energy expended and the amount expended at higher intensities is also of prime importance in the prevention and treatment of health risks during exercise,2 7 8 9 10 it is beneficial to accumulate more activity points and/or at higher intensities if safely possible.

The activity points are based on the equations published by Ainsworth and colleagues11 12 in the Compendium of physical activities. The energy expenditure for 60 daily and sports-related activities is calculated as follows:

Energy expenditure (kcal/minute)  =  factor × body weight (kg) × (number of minutes/60 minutes)

where the “factor” denotes exercise intensity as metabolic equivalent intensities and is a multiple of one metabolic equivalent, ie, an oxygen intake of 3.5 ml/minute per kilogram. This we did for three BMI classes including overweight, obese classes I and II, and obese class III categories. As body weight varies substantially within one BMI class, each class was subdivided into two weight groups to account for the added energy cost of moving more body weight.

To make things practical, the energy requirements were based on 10 minutes’ duration of each activity, with the exception of stair climbing, which was limited to one minute. As we felt that overweight and obese people should not have to think in terms of calories, which relate to dieting and therefore to an area fraught with failure, and again to make the system easy to handle, the calories were divided by 10 to yield “activity points”. Patients are thus encouraged to collect activity (and “health”) points rather than estimate calories expended. If desired, the calories expended in various activities can easily be obtained by multiplying the activity points by 10 or they can be calculated using the equation presented for computing energy expenditure from the activity intensity, duration and the individual’s body mass.

The APS can be personalised by inputting the corresponding table into a computer for each patient and printing it out. However, the points provided for the two weight groups within each BMI class, eg, 90 kg or less and over 90 kg, are of sufficient accuracy to account for the energy expended by most patients. As shown in fig 1, an additional table with weekdays, eg, in the form of a personal booklet, can be used to provide patients with an easy way to make a note of the daily activity points collected. As a rule patients should only keep a book of activities in addition to routine activities of daily living and light intensity, such as self-care, casual walking, or less than 10 minutes’ duration such as walking to the parking lot. A blank personal booklet is presented as supplemental material (see supplementary fig 2 available online only).

Figure 1

Example of a personal booklet that can be used to provide patients with an easy way to make a note of the daily activity points collected with the activity point system. In the upper section, patients record the activity performed in the first column, an abbreviation for the activity (first letter of the activity) recorded in the second column, and the number of points assigned according to their body mass index and body weight level for each multiple of a 10-minute activity bout recorded in the remaining columns. On the right side of the form, patients record the week dates for the activity period and comments regarding their activity during the week. In the bottom section, patients record the abbreviation for the activity performed in the columns labelled (A for activity) and record the associated points earned for the duration of the activity in the columns labelled (P for points). The daily total points are computed by summing all activity points completed each day and recording them in the column labelled daily total. The total weekly activity points are computed by summing the daily activity points and recording them in the box labelled activity points, weekly total. The patient’s goal is to accumulate between 100 and 300 activity points per week.

In discussing the need for physical activity with overweight and obese adults, healthcare providers can refer to the book, Promoting physical activity: a guide for community action, published by the US Department of Health and Human Services3 and to the article, Self-efficacy, decision making and the stages of change: an integrative model of physical exercise, by Marcus et al.4 These resources are practical guides for identifying strategies to increase physical activity.

Conclusion

The APS assists in simplifying and improving exercise prescription, and patients quickly learn to use it correctly. But they must be reminded, time and again, that collecting activity points is not just a matter of calories but improves health and fitness even in periods when body weight does not decrease. Also, health professionals must provide exercise programmes that are so well adapted and interesting that, eventually, their patients start to enjoy physical activities, however simple or limited these may be.

REFERENCES

Supplementary materials

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