The American College of Sports Medicine (ACSM), the American Heart Association (AHA), and the US Department of Health and Human services released guidelines for physical activity/exercise in 2008. Before the guidelines are discussed the difference between physical activity and exercise must be clearly defined.

• Physical activity: any bodily movement produced by the contraction of skeletal muscle that increases energy expenditure above a basal (rest) level. This includes personal grooming/hygiene, feeding oneself, standing, walking from parking lot to entrance of building, family care, household chores, occupational requirements, gardening, and so on.

• Exercise: is structured physical activity specifically designed to improve one’s cardiovascular fitness, muscular strength/endurance, flexibility, and body composition (lean mass/fat mass).

• All exercise is physical activity but not all physical activity is exercise.

Cardiovascular Recommendations:
Most if not all days of the week (3-5 days/week) for at least thirty minutes per day. Moderate intensity level: Working hard enough to raise your heart rate and break a sweat, yet still being able to carry on a conversation (talk test).

METs: A metabolic equivalent or MET is a unit useful for describing the energy expenditure for a specific activity. A MET is the ratio of the rate of energy expended during an activity to the rate of energy expended at rest. Example: 1 MET is the rate of energy expenditure at rest, expressed as 3.5 ml/kg/min or 1 kcal/kg/h or 4.184 kj/kg/h. A 4 MET activity expends four times the energy used by the body at rest.

Two methods of assessing aerobic intensity:
1. Absolute Intensity (Overall guide)
Light: are defined as 1.1 to 2.9 METS
Moderate: are defined as 3.0 to 5.9 METS. Walking at 3.0 mph requires 3.3 METS of energy expenditure
Vigorous: are defined as > 6.0 METS. Running at 10 minute/mile pace is a 10 MET activity

2. Relative Intensity (Specific to individual): Intensity expressed in terms of percent of maximal heart rate, heart rate reserve or aerobic capacity reserve.
Moderate: 40-59% of aerobic capacity reserve (0% resting and 100% maximal) or a 5-6 on a scale of 0-10 (0=sitting, 10=maximal effort)

Vigorous: 60-84 % of aerobic reserve capacity or a 7-8 on a scale of 0-10

Four classifications of cardiovascular exercise:
Inactive: no activity beyond baseline activities of daily living.

Low Activity: <150 minutes (2.5 hours) of moderate intensity exercise or 75 minutes (1.25 hours) of vigorous intensity exercise per week.

Medium Activity: 150-300 minutes (2.5-5 hours) of moderate intensity activity or 75-150 minutes (1.25-2.5 hours) of vigorous intensity exercise per week.

High Activity: > 300 minutes (> 5 hours/week) of moderate intensity exercise.
A good rule of thumb is that vigorous intensity exercise requires only 50% of the weekly duration (time) of moderate intensity exercise to obtain the same health benefits.

The greater the amount of regular exercise (moderate or vigorous) performed on a weekly basis the greater the health benefits. Examples below:
Lower risk for premature death (17-28 years)
Lower risk for coronary heart disease (CHD)
Lower risk of stroke
Lower risk for hypertension (High blood pressure)
Lower risk for dyslipidemia (High cholesterol)
Lower risk for Type 2 diabetes mellitus
Reduced depression
Improvement in cognitive function
Reduction in the number of falls

Cardiovascular Activity
Any activity where the body’s large muscles move in a rhythmic manner for a sustained period of time (i.e. brisk walking, running, cycling, jumping rope, swimming, and hiking).

Three components to consider when selecting an activity (FIT Principle):
Frequency: how often on a weekly basis is the exercise performed.
Intensity: how hard to work during the activity. Moderate = brisk walking, vigorous = jogging/running.
Time: how long (duration) each session should last (i.e. 10-60 minutes).

Greg Stanley, MS, CSCS, HFS
Exercise Physiologist

Most likely, every person reading this knows someone affected by obesity, whether it is a family member or a friend. The Obesity Action Coalition, American Society for Metabolic and Bariatric Surgery (national and TN chapters) and New Life Center for Bariatric Surgery are bringing the Walk From Obesity to Knoxville (well, Farragut actually). The money raised from the walk helps support OAC and the ASMBS Foundation in research, education, public awareness and advocacy for obesity. This is the first year our office has helped to host the walk and we are very excited about it. It will take place on the 24th of September at 10 am at McFee Park in Farragut. The event will consist of a short walk to raise money for obesity awareness and research. There will be lots of activities for children, too!

In the last 20 years Tennessee’s rate of adult obesity has risen from 10-14% to over 30%; more than doubling the percentage! In addition, 10-15% of children in the state of Tennessee are obese. It’s time for ACTION! We have an opportunity to raise awareness about the epidemic and to educate our kids about obesity. Will you join our staff in the Walk From Obesity?

I challenge each of you to participate to the utmost of your ability. My goal is to have 120 participants. If each participant raises $50 we would raise over $5000 for the cause. If each of our past patients give $10, we would raise over $300,000! That would be amazing! Please help us in whatever way you can, whether by walking, raising money, donating a door prize, or donating money. Your help is greatly appreciated.

Call me, Sarah, at 865.694.9676 or email me at sgrimes@premiersurgical.com if you wish to donate a door prize or gift. Go to www.walkfromobesity.com to register.

Sarah Grimes, RN, CBN
Bariatric Coordinator
New Life Center for Bariatric Surgery

This is the question many doctors and patients are starting to ask.  With obesity on the rise, even in our children, why aren’t more things being done to treat and prevent it?  Also, why aren’t more insurance companies paying for the diagnosis?  One of the answers I believe is the stigma associated with obesity.  Another reason may be they don’t want to hurt a patient’s feelings.   Obesity like other diseases has a genetic factor, you see families that are obese and are raising obese children.   These same families also have diabetes, hypertension, sleep apnea, and heart disease to name a few comorbidities that most likely “run in the family.”   These comorbidities and others all have medical interventions to treat the disease.  Although we have medical interventions for obesity, they are not covered well by insurance the majority of the time, if they are covered at all.  In our country we consider smoking, drug addiction, and alcohol addiction all diseases that are treatable.  We don’t tell the person, you just need to stop using, and expect them to quit and be treated.  So, why do we expect to do that to the obese?  I know I have raised a lot of questions, probably more that even the experts can answer, but I am going to share my “perfect world” in which lies some, but not all of the answers.

We need to start with our school children, for the first time the current younger generation have a lower life expectancy than their parents.  Adolescents are on blood pressure medication and diagnosed with Type 2 or adult onset diabetes.  To help this we need more fruit and vegetables to be available in student cafeterias.  Less soda pop, high carbohydrate juices, and chips and candy should be available.  We need to teach our children to play outside, and go with them and do it.  I swung on a swing and went off a diving board for the first time in close to 20 years a couple weeks ago, and I had fun, we as adults need to play more.  We need to encourage schools to have gym class, not cut out recess to have gym, but have both.  This need continues into high school as well.  I had great physical education classes in high school (gymnastics, circus stunts, and self defense) and I still broke a sweat but had fun doing it.  I know these things may not have funding, but remember this is my Perfect World.

After high school comes college and the freshman 15, or 20 or 30, depending on lifestyle, of course.  This is when it gets challenging because parents have no control, and this age group is very self conscientious.   By diagnosing overweight and obesity, more can be done to help at this age level.  Also, by learning in younger years the proper way to eat, and by staying active we can decrease or eliminate that extra weight the first years away from home bring on.  It is difficult when you go from a situation where limited foods are available to one where there are many different types of food available in abundance.  This is also a time where gym is no longer a necessity to graduate; and those that were athletes in high school may not be in college.  All these bring on the extra pounds, and to prevent it, it comes again to watching what you eat and increasing activity.

Now on to adulthood, this is where the circle ends and begins.   Many people I run into have very different obesity stories.  Some have been obese all their lives, some became overweight during college and then obese after marriage and children.  Some were normal weight their whole lives and then became obese later in life.  No matter the story the outcome becomes the same, co morbid conditions, difficulty with activity, low self esteem, depression, and this can go on.  It is important for us to understand that nothing can be fixed overnight, no one goes to bed one day normal weight and wakes up the next obese, so it can not come off that quickly either.   Having surgery to fix the obesity is not the end all, be all, it takes dedication to lifestyle change to be successful as well.  I believe this is why it is difficult to diagnose obesity as a disease.  Many other problems we have medication for, but even those you still have to have a lifestyle change to make it last.  A newly diagnosed diabetic may have good control with one oral medication, but eventually it goes to two or three or even to insulin use if the person does not adapt good dietary and exercise habits.  But with obesity, there are not many medications that have long term results, you can not build on them, if they are not working you stop the medication, and any weight the person might have lost comes back on.  To properly lose weight, you need dietary and exercise counseling, but for the majority of people, these are not covered services and most people can not pay out of pocket for them as well.  There is also the downside to diet and exercise counseling, it is normally not successful long term for the morbidly obese population, and surgery for weight loss is the only proven successful long term treatment for morbidly obese.  So to properly use diet and exercise counseling it needs to be done when a pt is overweight, not wait until the patient is morbidly obese and has co morbid conditions.  By treating at a lower weight, there is a higher chance of being successful and thus a lower chance of advancing to obesity or morbid obesity.  By treating obesity in adulthood, even with surgery your goal needs to be to teach the younger generations how to eat properly, how you eat after surgery, not how you ate prior to surgery.  I hear many times how patients make 2 suppers, one for them and one for their family, because their spouses or children just won’t eat what they eat.  By passing on healthy eating information now, you will help prevent complications later.

So, in my perfect world there is less “junk food,” more affordable fruits and vegetables, more activity and family play time, and generalized good health.  Primary care physicians will sit down and have a discussion with patients when they are slightly overweight and not obese with co morbid conditions.  If a patient is obese, doctors will diagnose obesity as a disease and insurance companies will pay for treatment for obesity. Treatment can be diet and exercise counseling alone or combined with surgical or pharmaceutical intervention.   I know these ideas are not perfect, nor complete.  It is just some ideas to get you started.  Remember in the end, it is up to each individual to determine their commitment.  If you choose us or have chosen us to help you, we will commit with you (a spin off of one of Dr Boyce’s favorite sayings.)    Take time out to play each day, it really is as fun as the kids make it look, and you will burn calories while doing it.

Hope everyone is having a great start to the new school year, a new beginning for some, a re-commitment for others.

 1. Walking/Jogging, Cycling, and Hiking: there are miles and miles of Green ways and hiking trails in Knoxville and the surrounding counties that are perfect for walking/jogging, cycling, and hiking. You can visit http://www.connectwithtn.com/index.php to find the Green ways and hiking trails closest to you. Take advantage of the beauty East Tennessee has to offer that is unique to this part of the country! Use this time of year to get involved in your local walking/jogging community by training for and completing a 5K road event (that’s 3.1 miles for those of us that do not use the metric system). You do not have to be a runner to get involved in a 5K road event; many people walk the courses, too! The Knoxville Track Club, in partnership with many area businesses and organizations, organize 15+ road events per month that are appropriate for any fitness level. You can visit www.ktc.org for a calendar of events and contact and registration information for each road event.

2. Yard Work: this is the time of year where everything grows, blooms, and invites us to spend time outside in our yards and gardens. Patients ask me all the time if they can count their yard work as exercise. It depends on the type of yard work that you are performing and what the physical demands are. If you are push mowing and/or weed eating by hand, you can count these two yard activities toward your exercise time during the day. Other yard activities, such as light to moderate gardening, raking, light trimming, etc all fit into the “activity” category, but should not be the only form of “exercise” you get for your day or week. Push mowing can burn, on average, 400+ calories per hour based on a 145 pound person, so pull out the push mower and offer to mow your neighbor’s yard, too!

3. Swimming, Canoeing, or Kayaking: East Tennessee has miles of rivers and lakes to enjoy this time of year and canoeing or kayaking is a great way to spend your time on the water and exercise too. Swimming is another form of excellent water exercise. Spending time at the pool with friends and family is a great summer activity (not to mention a great way to get relief from the heat and humidity) and you do not have to swim laps to exercise in the pool. Water walking is a fantastic form of cardiovascular exercise that you can do in the shallow end of the pool while you are watching your children or grandchildren play. The water creates resistance that helps get our heart rates up while we are walking in the pool. Walking at a moderately out of breath pace (where you can carry on a conversation, but it is a “labored” conversation) for two sessions of 15 minutes during your day at the pool will meet the American College of Sports Medicine’s exercise recommendation of 30 minutes of exercise a day.

4. Recreational sports such as Soccer, Basketball, Softball, Frisbee, or Golf: There are numerous opportunities to join recreational leagues to play any number of sports or you can go to your local park and participate in these activities on your own. You do not have to be an athlete to reap the benefits of playing basketball or soccer and don’t worry if you’re not the best golfer. The goal is to add variety to your exercise routine and walking the golf course as you play 9 holes of golf or playing a pick-up game of basketball is a great way to exercise!

 As with any outdoor activity, remember to wear sunscreen and remain properly hydrated. Variety is a key to success in maintaining a regular exercise and fitness routine and getting that variety from what each season has to offer is a great way to enjoy each one as it comes!

Rebecca Johnson, Exercise Physiologist, BS, CPT.

Early on in the journey motivation is high, compliance is great and weight loss is at its peak. Later on, as weight loss slows (naturally), daily routine takes priority, old habits can gradually creep back in at times and exercise may even dwindle somewhat. If this seems to be happening with you, think back to what motivated you to have surgery and write down the goals that you had at that time. See how many of them you have accomplished and see which ones are yet to be realized. Maybe even set new goals.

Your number one goal was probably to get healthy. The second one was probably to lose weight, or maybe it was a combination of the two; to get healthier and lose weight. If your goal was to get healthy, realize that the only way to get healthy is to eat healthy foods most of the time (a great majority of the time) and to exercise regularly, get quality sleep, manage stress, and do things that make you happy. Make sure that you set yourself up to be successful at eating the right amount of foods and the right types of foods that have been recommended to you. In addition, make sure that you are making time to exercise five or more days per week.

Sometimes things happen that interfere with your routine, but do not let this interference become a long term hindrance to exercise. You have to figure out for yourself how you can make your circumstances allow for regular exercise and healthy eating. Use an exercise record sheet to stay on track and a food journal for your diet as needed. For example, if your work schedule changes and you have to work overtime and this is cutting into your exercise time, don’t quit, modify your exercise routine and do what you can as often as you can until your schedule permits returning to your old routine. Remember 10 minutes of vigorous exercise is better than none and you can always divide your total exercise time between two different sessions throughout the day. For example, if your goal is to exercise for 30 minutes each day, but there are several days where you do not have 30 minutes at once to exercise, complete two 15-minute sessions with appropriate intensity and you will have 30 minutes of exercise for the day. When you are sick you need to rest, but during that time continue to use your record sheet and document that you are sick. Return to more exercise as tolerated.

Make it happen. Be healthy. Be fit.