The American College of Sports Medicine, the Medical Fitness Association, and numerous other organizations have long recognized the value that exercise can have on health outcomes. The challenge has been how to successfully integrate exercise into the medical community. At Florida Hospital Celebration Health (FHCH), we have not only integrated into the medical community but also provided one of the critical elements for our Bariatric Department to be reviewed as a Center of Excellence in 2005.
The Bariatric Program at FHCH is more than just a surgical center. It is a multidisciplinary program that has been designed to help the patients progress from their initial decision-making process to modifying their lifestyles postoperatively. Obesity has no known cure; surgery is only the beginning of the journey for bariatric patients. The rest of the journey depends on how successfully the patients can integrate their nutrition and exercise into their lifestyle.
Exercise Challenges and Opportunities
Gastric bypass patients are often plagued by barriers to physical activity and need to make substantial lifestyle changes if they are going to achieve long-term weight loss success. A recent 5-year study done by Virginia Commonwealth University showed that patients who exercised and followed their dietary guidelines maintained more than 70% of their weight loss (1). Patients who did not follow their exercise or diet guidelines maintained only about 40% of their weight loss (1). Research done at Baylor University revealed that about 78% of bariatric patients were not compliant with their recommended lifestyle changes (2). Approximately 41% did not incorporate exercise, and 37% did not follow their prescribed diet (2).
Furthermore, the bariatric candidate is often a high-risk patient before surgery. Table 1 shows the prevailing medical conditions revealed by the profile of our bariatric population, whereas Table 2 shows the activity habits of this population identified by our profile.
We now have a profile of a sedentary high-risk patient with slight to severe orthopedic constraints who needs to incorporate exercise for long-term success. Before surgery, almost 100% of bariatric patients have fatty liver syndrome, an increased chance of postoperative complications, and the possibility of longer hospital stays. After surgery, this patient profile also would indicate a greater risk of muscle loss, bone loss, lowering of resting metabolic rate (RMR), and a premature weight plateau.
Florida Hospital Celebration Health Bariatric Program
The success of our bariatric exercise program at FHCH is based on the fact that it is a critical component of the overall program and not an afterthought. Patients are informed from their initial information session that obesity is a multifactorial disease and that major changes in lifestyle are required for the procedure to be successful. Before surgery, patients have almost a full day of information that includes a detailed medical description of the procedure and follow-up medical care. There also is a detailed presentation on diet that outlines their nutrition from presurgery to maintenance. Last but not least, each patient is given a metabolic profile and education about exercise's role in his/her metabolism and how physical activity will be a key component of his/her success.
Before surgery, all patients also are given an exercise prescription designed to address the previous preoperative concerns: 1) a breather is prescribed for daily use to increase lung volume and diaphragm strength, and 2) daily walking for 20 to 30 minutes, if the patient's joints and health will allow. Daily activity, along with the patient's presurgery diet, will help reduce fat around the liver much more effectively than diet alone. This prescription needs to be implemented at least 10 to 14 days before surgery to be effective.
During the patients' hospital stay, they are required to walk up to 10 times per day, use an incentive spirometer 3 times per day, and do some daily lower-limb exercises to avoid deep vein thrombosis. Upon discharge, they are encouraged to start doing a daily walk until their one-month follow-up.
Follow-up metabolism tests are administered at one month, three months, and six months and at year's end. The metabolic profile uses the Medgem device and a bioimpedance body fat analysis. This information will help the patients better understand where the majority of their weight loss is coming from. If the Medgem detects that the patient's RMR is slowing down, it indicates that most of his/her weight loss is starting to come from lean body tissue, and a possible weight loss plateau looms around the corner. Conversely, if the patient's RMR is increasing, it indicates that the patient is increasing his/her lean body mass, and his/her activity level is helping him/her overcome some of the challenges of a low-calorie intake. Regular metabolism checks serve several functions: 1) it provides an ideal situation to present the need for physical activity or to get patients to a higher fitness level, and 2) the results of each test also are given to the physician and nutritionist. This helps the bariatric team to both support and reinforce the same message to the patient.
Tailored Exercise Prescription
We also have a clinical integrated exercise program called Exercise Right. This program is a six-week individualized exercise prescription. It provides an initial assessment to help identify muscle imbalances, core stability, and baseline fitness measurements. This information is essential for designing a proper exercise prescription. A postevaluation is administered at the end to measure the patients' progress and establish new goals and objectives. Upon completion of the six-week program, patients are given a workout schedule to continue on their own. Follow-up assessments and counseling are scheduled either on a quarterly or semiannual basis, to continue to monitor the patients' overall health status.
Patients are usually given more details about the Exercise Right program at their one-month postsurgery appointment. This is usually the time when most patients have recovered sufficiently from surgery and are advised to begin a more structured strength training program to help avoid excessive muscle loss. All patients transitioning into the program are given an exercise referral form from their surgeon that lists any medical restrictions that they may have. The program also provides an insurance worksheet along with a letter of medical necessity for the patients to submit for possible reimbursement.
Obesity is a lifelong, progressive, life-threatening disease of excess fat storage. There is no known cure. Just telling people to eat better and exercise more is not specific enough for most of our population. Time is too valuable. People need to know more specific information and exactly what to expect from their efforts. The seeds for lifestyle change need to be integrated from the beginning of a bariatric program and not put in as an afterthought. At FHCH, we integrated the lifestyle changes from the introductory first step through preoperative screening and education to postoperative follow-up.
1. Bond, D., and R.M. Shannon. A conceptual application of health behavior theory in the design and implementation of a successful surgical weight loss program. Obesity Surgery
2. Elkins, G., and T. Cook. Noncompliance with behavioral recommendations following bariatric surgery. Obesity Surgery