Obesity continues to rise in the United States, and fortunately, more and more fitness professionals are playing a vital role in helping fight the obesity epidemic. Data collected in the National Health and Nutrition Examination Survey 2001-2004 found that nearly one in three US residents are obese.

    Health care providers generally determine obesity using a value of excess body weight or by calculating one's body mass index (BMI). If a client weighs 100 pounds over their ideal body weight, they are generally considered to be obese. Similarly, if their BMI is greater than or equal to 30, they are considered obese. See the table for standard BMI values to determine a client's weight status.

    Standard Body Mass Index Values
    BMI = weight (lb) ÷ [height (in)]2 x 703
    Weight Classification BMI
    Normal Weight 18.0 - 24.9 
    Overweight 25.0 - 29.9
    Obesity Class I 30.0 - 34.9 
    Obesity Class II 35.0 - 39.9
    Morbid Obesity 40 or greater

    Due to the rise in obesity, more people, along with their health care providers, are considering or advising weight loss surgery as an alternate option to fight the disease. Common types of weight loss (bariatric) surgeries include the gastric bypass or Roux-en-Y (RNY), LAP-BAND, gastric sleeve and duodenal switch. Having worked with hundreds of weight loss surgery clientele, I can honestly say that I'm a big advocate of the weight loss surgery, so long as the client meets all of these conditions:
    • Failed all other weight loss attempts
    • Currently 100 or more pounds overweight
    • Suffering from one or more co-morbidities (medical disorders associated with obesity, such as hypertension, diabetes, sleep apnea, low back pain, etc.)
    • Mentally and psychologically committed to adapting a physically active lifestyle and sustaining healthy eating habits

    Physical Activity Recommendations
    Excess body weight often restricts a client's ability to be physically active and, on a whole, will be the biggest obstacle when determining an appropriate exercise program. As fitness professionals, it is our responsibility to understand how to work around these mobility limitations. 

    Weight loss will always be the main objective initially, since decreasing weight will allow more mobility and put less stress on the joints. Additionally, the number-one reason your client had weight loss surgery was to lose weight, thus their exercise program should complement the effects of the surgery. Have your obese clients (BMI > 30.0) follow these physical activity recommendations:
    • Increase daily activity. For example, wash the dishes by hand, clean the house, park farther away, try using the stairs, etc.
    • Start slow, and gradually progress until you're exercising 60 minutes a day, six days a week.
    • If your BMI is greater than 35, make every effort to avoid exercises that would create greater stress on your joints. Avoid activities such as jogging, jumping and competitive contact sports.
    • Do aerobic exercise that is low to moderate in intensity.
    • Emphasize duration over intensity.
    • Select a modality of exercise that will work around any physical or medical limitation.
    • Strength training should consist of two to three sets of 12-15 repetitions. Use light to moderately heavy weights; the goal is to maintain lean muscle through the weight loss phase, not to bulk up muscle mass.
    • Joint pain is not healthy pain. If the exercise causes pain in the joint, modify the exercise.
    • If the client has any major joint limitations in the lower extremities, try to perform most, if not all, of the strength exercises from a seated position.
    • Always change up the exercise routine (i.e., flexibility, cardio, strength) every four to six weeks.

    Exercise Guidelines for Both Stages of Weight Loss Surgery
    The best thing weight loss surgery candidates can do to prepare themselves both before and after surgery is to increase their level of fitness. The better cardiovascular condition before surgery, the fewer complications they will experience during and after surgery.

    Preoperative Stage 
    • Make weight loss a primary goal of the exercise program. Excess fat can make it much more difficult for the surgeon to find the organs he/she is trying to operate on; it also can make the operation itself more challenging. In fact, some surgeons may even require that their patient lose a certain amount of weight before he/she will operate.
    • Focus on cardiovascular exercise to improve heart health, decrease body weight and help lose body fat before surgery.
    • Follow the exercise guidelines discussed previously.

    Postoperative Stage
    • If there are any postoperative complications, that is, physical problems following the weight loss surgery, your client should schedule an appointment with their bariatric surgeon and follow the surgeon's recommendations for an exercise program.
    • For the first four weeks after surgery, focus on flexibility exercises, deep breathing and getting your client back into performing normal daily activities.
    • Gradually incorporate low-intensity aerobic exercise (i.e. walking, biking or swimming).
    • If the surgery was laparoscopic, it is generally safe to start exercising up to the client's pain threshold two weeks after surgery.
    • If the surgery was incision (open-cut) surgery, it may take a few more weeks to recover; therefore:
      • During the first six weeks after surgery, do not lift any more than 15 pounds; otherwise, exercise up to pain threshold.
      • Avoid abdominal exercises for the first eight to 12 weeks to allow the incision to fully heal. This will help alleviate abdominal hernias near or around the incision.
      • Significantly reduce caloric intake. During the first few weeks to months after surgery, weight loss surgery patients should consume less than 500 calories a day (the surgeon will give specific instructions). This significant decrease in calories may initially cause some fatigue; therefore, do not perform high-intensity exercise. As weight is lost and the level of fitness is improved, your client will be able to take in a few more calories as well as exercise at higher levels of intensity. Follow the surgeon's dietary recommendations.
    • The bariatric surgeon may increase the caloric intake to 1,200-1,400 calories six to 12 months after surgery, particularly if, at this point, their patient has lost a large percentage of their excess weight. Follow the surgeo's and/or dietician's recommendations on food intake.
    • Regularly monitor and assess your client's exercise program to ensure continued compliance and continued weight loss that will ultimately lead to weight maintenance.
    • Several exercises may need to be modified in order to work around the excess weight and any other physical or medical limitations. Here are just a few ideas of how to modify an exercise for the weight loss surgery client:
      • Seated hamstrings stretch
      • Modified quadriceps stretch
      • Seated leg lift
      • Knee-taps
      • Modified push-up
      • Recumbent bike
    A lifelong exercise program is critical to a weight loss surgery client's long-term success. Bariatric surgery is a valuable tool for rapid weight loss; however, in two to three years, if a physically active lifestyle has not been adopted, the weight will be gained back. I have personally witnessed some patients gain back large amounts of weight because they stopped or never started exercising. Exercise becomes even more important postoperatively because the surgery itself, as well as the decreased intake of calories and rapid weight loss, dramatically lowers their metabolism and the body's fat-burning efficiency. This must be combated through regular exercise. If your client can stick to this advice, they'll be "cruising skinny" at a healthy weight and in good physical condition for years after their weight loss surgery.

    Julia Karlstad, M.Ed, CSCS, is the president and founder of JKFITNESS, LLC (www.jk-fit.com), headquartered in San Antonio, Texas. Previously, she developed and directed an exercise physiology program that consisted of two bariatric hospitals and three medically supervised weight loss clinics. Julia recently wrote a book on exercise as it relates to weight loss, called Rx Fitness for Weight Loss: The Medically Sound Solution to Get Fit and Save Your Life. Visit www.juliakarlstad.com for more information