Obesity

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Obesity is excess body fat for a given age or gender and can increase the risk of coronary heart disease two-fold (BHF, 2004). Body Mass Index (BMI) is an accepted method of estimating a person's relative weight. BMI is calculated by dividing weight in kilograms by the square of height in metres. The following are the differing ranges of BMI:

BMI 20-24.9kg/m2 = healthy, stable, weight range BMI 25-29.9 kg/m2 = overweight BMI 30-39.9 kg/m2 = obese BMI 40kg/m2 and above = severely obese

In the last ten years the percentage of obese adults has increased by more than 50%, from 14% of the population to 22% (BHF, 2004). This has many serious implications for cardiac rehabilitation, as obesity is a significant risk to the primary cause and secondary prevention of CHD.

The management of weight loss is a controversial area. At present there is inconclusive evidence regarding the relative effectiveness of physical activity combined with diet, versus diet alone or physical activity alone (Mulvihill and Quigley, 2003). As adipose tissue contains about 7000kcal/kg, with physical activity alone it is difficult to lose much weight (BHF, 2004). Therefore, management of obese participants should include advice on diet, physical activity and a behavioural modification component in order to be comprehensive and effective. The most favourable alterations in body composition will occur with low-intensity, long duration aerobic exercise and aerobic exercise combined with high repetition resistance training (Mulvihill and Quigley, 2003).

If the goal is to use exercise as a strategy for obesity reduction, exercise programmes require prescribed energy expenditure of 3000-3500 kcal per week. This would require approximately 45-60 minutes of exercise, for example, purposeful walking performed at a moderate intensity (70% HRmax) on most days of the week (Mulvihill and Quigley, 2003).

Frequency

The frequency remains at 3 to 5 exercise sessions per week, integrating activity into everyday life.

Intensity

The intensity for weight management is between 50 and 75% HRmax. Type

Combined cardiovascular (CV) and RE should be included with the aim to increase lean tissue (muscle), as this is more metabolically active.

For overweight patients, avoid high-impact exercises in order to prevent excess stress on joints. Alternatively, non-weightbearing activities could be prescribed, e.g. swimming/water-based activities/cycling. Some obese patients may be embarrassed to do these and some exercise bikes will have a weight restriction. Special consideration should also be given to the individual's ability. (See pp. 117-18 on water-based activities.)

Always ensure alternative exercises are given to accommodate those in the class who are physically unable to carry out certain exercises. In addition, adipose tissue may restrict positions for stretching or the ability to partake in floor-based exercises. Obese patients may have issues with low self-esteem and poor body image. Therefore, the exercise leader should be aware of this and take it into account when prescribing activity to encourage adherence. When monitoring an obese patient it may be difficult to palpate a pulse at the wrist or neck areas, and RPE scales may be the mode of monitoring.

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Increase duration and frequency according to the participant's capacity and aim to increase total energy expenditure.

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