Notice I selected a picture of an obese person that didn't involve inaccurate stereotypes of them eating crappy food or being lazy.

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Over the past year or so a few fitness professionals (many of whom I respect) have written blog posts on how to train people with obesity.  As someone who is very familiar with this area, I figured I’d chime in with my own thoughts to add to the discussion and information about training this specific population for those who are interested in my take on the subject.

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As some of my readers know, I do some work for one of the very few government funded bariatric medical programs in my province providing evidence based (i.e., research backed) treatment for patients with obesity.  In our clinic we see hundreds of patients per year with weights ranging from 250 to 700 pounds.  My main role is to oversee the design and implementation of the exercise component of the program to get everyone exercising regardless of their physical, emotional, psychological, and economic limitations.  Combining that with my ongoing experience in the private sector in training people for fat loss (both online and in person), I feel that I’m in a good place to share my views on the topic.

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Definitions, Categorization, Etc.

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Before we can really talk about obesity though, we’ll need to clear up some definitions and lay down a foundation of understanding about how it is categorized.

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In short, obesity is defined and categorized primarily based on something called the Body Mass Index (BMI) which is essentially a height-weight scale.  In a publication in the early 1970′s it  scale was created as a proxy to determine body fatness in relation to height and weight, but more recent evidence suggests that this isn’t exactly true.  I’ll get into that in a bit, but for now you should know that BMI is the most widely used tool for the categorization of obesity in a medical setting.

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If you want to determine your BMI you can go HERE and use the calculator to let you know where you’re at.

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Categorization Based on BMI

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Under 18.5  -  Underweight

18.5 – 25  – Normal Weight

25 – 30  -  Overweight

30 – 35  -  Class I Obesity

35 – 40  -  Class II Obesity

Over 40  -  Class III Obesity

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Although this is the accepted World Health Organization categorization for obesity, it is pretty arbitrary and the divisions between most of the categories have no scientific explanation.  And since their are regional differences in “normal” body weights,  some places have different categorizations for obesity.  For example, the Japanese categorize anyone with a BMI of 23 as overweight and anyone with a BMI of 25 as obese.

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Of course, any astute fitness minded person will also note that BMI is limited in that it is not able to determine actual muscle and fat weight so someone who works out regularly and has a higher muscle mass might be categorized as obese while actually being quite lean.  In fact, the reverse can actually true as well which means that people with a “normal” body weight might actually carry an excess amount of body fat.  These are the people that we might call ”skinny-fat”, but are clinically defined as having normal weight obesity.

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Although I’m not sure this is universally agreed upon, having a body fat above 20% for males and 30% for females would make you obese regardless of your BMI.  And all of this leaves out the fact that where that fat is distributed may have an effect on cardiac health (i.e., fat around the waist = bad, fat around the hips = good) so you may be in danger regardless of whether or not you actually have a lot of fat.

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The Staging System

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So thus far we’ve talked about categorization of obesity based on weight and to some degree we’ve talked about body fat percentage without mentioning the methods used to measure body fat which is a different post entirely (Short version: Your home bathroom scale that measures body fat probably sucks).  However, to train people with obesity it is important not to just know how much they weigh, but the degree to which obesity is actually impacting their health, movement, etc.  To determine this it is helpful to determine the “stage” of obesity using something called the Edmonton Obesity Staging System (EOSS).  While I could type it all out for you, I’ll just swipe it from the site of Dr. Arya Sharma who is one of the creators of the system.

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STAGE 0: Patient has no apparent obesity-related risk factors (e.g., blood pressure, serum lipids, fasting glucose, etc. within normal range), no physical symptoms, no psychopathology, no functional limitations and/or impairment of well being.

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STAGE 1: Patient has obesity-related subclinical risk factor(s) (e.g., borderline hypertension, impaired fasting glucose, elevated liver enzymes, etc.), mild physical symptoms (e.g., dyspnea on moderate exertion, occasional aches and pains, fatigue, etc.), mild psychopathology, mild functional limitations and/or mild impairment of well being.

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STAGE 2: Patient has established obesity-related chronic disease(s) (e.g., hypertension, type 2 diabetes, sleep apnea, osteoarthritis, reflux disease, polycystic ovary syndrome, anxiety disorder, etc.), moderate limitations in activities of daily living and/or well being.

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STAGE 3: Patient has established end-organ damage such as myocardial infarction, heart failure, diabetic complications, incapacitating osteoarthritis, significant psychopathology, significant functional limitation(s) and/or impairment of well being.

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STAGE 4: Patient has severe (potentially end-stage) disability/ies from obesity-related chronic diseases, severe disabling psychopathology, severe functional limitation(s) and/or severe impairment of well being.

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Looking at the list above, you might discover that as a client you have a person who is actually has Class III obesity, but is a stage zero and has no related health or mobility problems.  This could be a guy who was a lineman on his college football team, maybe he’s actually still fairly active, and he’s not sick.  This guy might thrive with hard training and a slowly integrated nutritional program.

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Training this guy might be different than working with someone with class I obesity that is a stage 3 and has disabling arthritis making it difficult to move let alone hit up some heavy squats.  This person would obviously require a drastically different program which is why I get worried when I see generalized recommendations for training obese folks.

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And if YOU are an “offseason” bodybuilder or you just train regularly and don’t have a solid nutrition program you might have gotten off easy before with the old mantra that “BMI doesn’t take into account my muscle mass so I’m not really obese”, but now you know that if your body fat is breaking 20% (or 30% for women) you ARE obese.  And you might actually be a class 1 or 2 on the staging system too.  You know that heartburn you’ve been getting and the slightly elevated blood pressure that you’re not paying attention to?  Those are potentially obesity related issues.

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So if you wonder why I spend so much time talking about obesity on my blog it isn’t because I’m talking about someone who is vastly overweight.  In my experience, most people who see themselves as having “only a few extra pounds” are actually clinically obese…and this includes those who exercise regularly and even fitness professionals themselves (we are not immune).

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Now that we’ve covered the basics and some definitions, in my next couple posts I’ll come back and drop some information about how I would go about training someone with different classes and stages of obesity.

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Check out Part II of the series HERE.

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PS:  If this post helped you or you think it would benefit others please share it.

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PPS:  Please feel free to join me on Facebook and Twitter.

Let’s face facts for a second here.  The vast majority of people that lift weights do so for primarily aesthetic reasons.  Sure, many of us want to be stronger, faster, and healthier.  And there are certainly those who train exclusively to improve their sports performance, but in the end I’d be willing to bet that training to simply look better is the single biggest motivation for the average trainee.

So why do many strength coaches crap all over bodybuilding?  I could speculate that it has something to do with the rampant steroid use among high level competitors or the fact that some of them have more oil in their muscles than I do in my car.  Or it could be the mental image of a bunch of oiled up, tanned, men and women posing on a stage in their bathing suits.  I can’t really say for sure.

But what about people who aren’t interested in competing?  What about those who are purely interested in gaining the leanest, most muscular physique possible within their own biomechanical and physiologial framework while keeping an eye on structural balance and joint health?  Is bodybuilding training really so bad for the body that we need to crap all over their methods?

I guess the question I’m really asking is whether it is possible to create a lean and exceptionally muscular physique without sacrificing structural balance and joint health.

And in line with that question, is there room for exercises that are deemed my many coaches as unfriendly for the joints (such as the guillotine bench press) or useless (direct arm training)?

As with everything, I think it comes down to assessment.  If you’ve read my blog you’re probably aware that I am a big fan of movement based testing with such as Assess and Correct, but beyond that I feel that it is really important to use the appropriate assessments to inform your decisions for each individual goal.

For dealing with obesity I use the Edmonton Obesity Staging System, for performance I look at the demands of the sport, and when training for aesthetics I like to do a true visual assessment to direct training.  I should note here that I don’t care much for body fat testing in leaner individuals as this is less important than the physical appearance changes.  I could care less what the number says if a client’s appearance doesn’t reflect it.

Here is a sample of a simple client assessment I use for evaluating a physique in which I can comment on muscle size or relative proportion:

- Upper traps:
- Front delts:
- Lateral delts:
- Rear delts:
- Biceps:
- Tricep long head:
- Tricep lateral head:
- Forearms
- Lower chest:
- Upper chest
- Upper back width:
- Upper back thickness:
- Lower/Mid back erectors:
- Abdominals:
- Obliques:
- Quads:
- Glutes:
- Hamstrings:
- Calves:
 
Highlights:
 
Needs Work:

General Impression & Plan:

Combining this with the movement based screen I should now know what muscles need to be worked (yes, I sometimes work muscles not movements…I know…blasphemy) and which movements should be contraindicated for that person.  If arm training is warranted, I’ll do arm training because I’m not in the business of sticking to a “training arms is for wussies” paradigm because it is popular.  I’m in the business of getting results.

Would I use the guillotine bench press, sissy squats, or upright rows?  Probably not.  But this is primarily because these are not the most effective movements in the first place and I can find exercises to hit the same muscle groups with less risk.

Are joint health and building a muscular physique mutually exclusive?  I would have to say no.  Do you agree?  Feel free to share your thoughts below!

And thanks to my blog reader Rob for putting the idea for this post in my head.  I hope I answered your question.