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Okay…in Part I of this series I talked about the categorization and staging of obesity and in Part II I dropped a few fundamental thoughts (and some great resources) for preparing to train clients with obesity.  If you haven’t read these I’d suggest you go back and read them first.

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Goals

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Today I want to move forward and actually get into details about how I train people with obesity.  More specifically, I want to focus today on how I train clients with Class 2 and Class 3 obesity (BMIs over 35 and 40 respectively), but first I just want to touch on the subject of goals.  I read somewhere recently that when those with the higher classes of obesity are asked to define their weight loss goals it is common for many to desire and expect weight losses of as much as 50% of their current body weight.  In other words, if you’ve got a 500 pound man, his goal might be to reach 250 pounds.  If you’ve got a 300 pound woman, her goal might be to reach 150 pounds.

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Frankly, I don’t have any studies to back up this assertion, but based on my experience I can only say that there is certainly some truth to this.  As a human, I can certainly understand how someone with class 3 obesity might just want to be “normal”.  However, as a fitness professional I feel it is my responsibility to temper this belief with a delicately put explanation of reality.  The very real truth is that weight loss will likely be much less.  Even with bariatric surgery (eg: gastric bypass) the average weight loss is around 20-30% so the likelihood of weight losses this great with non-surgical methods are not great.  That certainly isn’t to say that they can’t happen (I’ve seen it with a couple of my own clients), but I think it is more prudent to emphasize the medical benefits of weight losses as small as 5-10%.  In fact, even without a body weight change, the addition of exercise alone can improve health markers, mobility, and wellbeing.

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I think the key here is to not prevent clients from making these goals for themselves (good luck if you try to do that), but to stress the benefits of lesser weight losses and applaud them as they achieve them.  Further to this point, with these clients in particular I would generally focus less on the outcomes and have them focus heavily on weekly behavioral goals instead.  As it will take a long time to lose this much weight, clients will get more consistent feelings of accomplishment from achieving small goals instead of looking at the overall goal (which can be discouraging).

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It is important to remember that two of the biggest predictors of long term adherence to an exercise program are the reality of their expectations and self efficacy (belief that they can do it).  Expecting too much and falling short obviously makes us want to give up which is why I try to emphasize realistic goals.  And giving them small weekly steps increases the belief that they can achieve the activity required which only sets them up for success.  Of course, you can probably see how this could work for non-obese clients as well…which it does.

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Side Note

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I chose to distinguish the training of Class 2 and 3 obesity from Class 1 or even just people in the overweight category because I think that goal setting should be different and the programs could actually be different between these groups to some degree (depending on the level of impact their obesity has on their movement).  I’ll talk more about this in my next post, but for now, I’d suggest employing the goal setting practices above for higher BMI clients.   But now that we’ve got that taken care of, let’s get into the training.

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*Note that the training I’m discussing here is if I am personally working with a client.  This is NOT the same as I’d recommend to an unsupervised person with obesity trying to get started on their own.*

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Assessments

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As many of you know, I’m big on assessments with clients.  However, in dealing with obese clients whether or not I use a formal movement assessment depends on their ability to actually move in the first place.  If they’re relatively young and otherwise healthy (Stage o or Stage 1 obesity) I’ll do a movement assessment as usual.  If their movement is greatly impaired or their obesity is really impacting their ability to move (due to pain, being deconditioned, etc) I skip it.  Of course, I could modify my assessment, but generally I don’t.  Someone in this position has bigger issues than whether they can dorsiflex their foot to X number of degrees or any other measure when it comes to movement.  Some may disagree and choose to assess anyway…and that is up to them.  Personally, I don’t always do it as I figure I can do it later when they’ve established themselves in some good nutritional and exercise patterns that will address their bigger issues.

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However, with clients that are in this category of obesity I think it is important to make sure to have their physician involved with doing some baseline and follow up assessments as well.  Measuring fasting glucose, lipid profiles, and various other health markers is wise to ensure that what you’re doing is actually making them healthier AND it serves as yet another marker of progress for the client.  And from a business perspective, their physician might notice what you’re doing and refer you more people…just sayin’.

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More to the point though, the doctor can also assess for sleep apnea (which can be related to depression and lack of weight loss) and other obesity related issues.  Free bonus tip:  If your client has sleep apnea make sure they get the mask refitted as they lose weight as it can become ineffective.

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Foam Rolling

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As a general rule, if a client can do this, we’ll do it.  If they can’t get down to the floor and up again without a big struggle, we skip it.  I do believe it is important, but not important enough to humiliate a client.  As they’re able, we’ll add it in.  The Stick may be an option for those who can’t get down to the floor if it is absolutely necessary.

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For those who can get down to the roller, remember that they’ll be putting a lot more weight onto a focused spot on their body and it can hurt.  If this is their first encounter with fitness that might be discouraging.  For this reason, we have 3 different foam rollers of increasing density with one being quite soft, and a little harder, and being the normal foam roller most would use.  I’ve found this helps.  My buddy Nick Tumminello also once mentioned putting a couple rollers under the area being rolled to increase the surface area and decrease pressure to get the same effect.  Nick is smart!

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Mobility Work

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For those clients I’ve done a formal movement assessment on, I will normally design the mobility program based on that.  For those I haven’t assessed, I make an assumption based on educated guesses as to what is typically tight/weak/etc.  This may be a crappy approach, but in the end, I’m getting people moving.  For many, breaks will be needed between drills and for some the drills alone can actually be the exercise session.

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Early in my career I used to try to make sure the client achieved their “planned workout”, but these days I think it is more important to just “roll with the punches” and work within the limits the client has.  Push a little.  Gain a little progress.  Show them small successes.  Then STOP!  Don’t force it.  Just encourage them and keep them coming back for more.  This will do infinitely more for anyone than breaking them down with hard workouts that make them overly sore and sick.

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Resistance Training

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Here’s the thing – with obese clients in these categories muscle will be lost with weight loss.  You can work to prevent it, but ultimately, it is going to go down.

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Here’s the other thing – many of these clients will have never worked out in their lives.  For most, it has at least been a long time.  Which ultimately means, it doesn’t really matter what you do (unless you do something completely idiotic) because they are going to get results (i.e., some muscle retention, strength, etc).

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I generally start these clients with 1-3 sets of 10-15 repetitions on 5-6 exercises in a whole body workout 2-3 times per week.  So on their first day (and for each workout for a few weeks) I might do 1 set of 10-15 on each of 6 exercises.  Over time I’ll bump it up to two sets.  And finally up to 3 sets.  Then I’ll probably move towards pairing antagonist exercises (like a row and a bench press), but keeping the same set/rep scheme.  Over time I may substitute in new exercises, but keep everything else the same.  In short, I keep it wicked simple.  My goal is to create CONSISTENCY as I think this is the most important factor for these folks.

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With increasing length of training time, strength, mobility, and weight loss their programs will start to look increasingly like my “normal” training programs, but at the start (and by start I mean first 3, 6, or even 9 months) their programs are pretty basic.

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Cardio

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While interval training may be faster and debatably “better” than steady state cardio (although I’m hard pressed to believe the second statement), I think it is probably the worst choice for a novice obese client.  I’ll often have them do as little as 10 minutes of moderate intensity cardio after a session and aim for a couple of extra walks (5-30 minutes depending on mobility, etc) during the week.  Ultimately, I tend to see walking as the gateway drug of fitness and while it isn’t necessarily the best exercise for weight loss, there are some remarkable health outcomes that can be brought about by walking alone.

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Over time I’ll increase the time (for the person who can only walk short distances) and intensity of cardiovascular activity for these clients.  Eventually I might include some more interval type protocols in the interest of time, but this would be far down the line and subject to client tolerance and interest in this type of training.  But the big thing you’ll notice in these programs is that resistance training is only typically 2 days per week (3 days max) and that my goal is to build up to 150-200 minutes of weekly physical activity by adding increasing amounts of cardiovascular activity (which can be as simple as walking).  Keep in mind that going from zero minutes of physical activity to 200 can take a LONG time…so patience is key and it is important to focus on the aforementioned small weekly steps forward.  Encouragement is paramount!

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Summary

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And that’s about it.  Pretty simple really.  I’m sure I’ve overgeneralized here as there are definitely cases where obese clients have done much less than this (only walking) and others have done much more.  Looking back, I’m not really happy with the article as I feel there are many more qualifiers and exceptions I should have included, but this would easily end up being a novel.

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In my next post I’ll discuss the differences between training those in these categories of obesity and class 1 obesity, and the following post will cover a discussion of nutrition for both groups.

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In the meantime, if you have a specific question related to this post, please ask in the comments section below and I’ll be happy to address it.

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Check out Part IV of this series HERE.

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If this article has helped you or you think it might help others please share it via Facebook, Twitter, or whatever social media you like or simply hit the “like” button below.

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