How do you start the training program for severely obese clients?

Tricks of the Trade:

The more deconditioned people are, the more important it is to get the first few weeks of exercise right. The underlying psychology of obese clients’ beliefs about exercise is as important as the physiology of obesity. Typically, weight loss is the main goal—bordering on an obsession. My exercise programs for this type of client proceed from two main objectives: (1) to use what they already have in order to (2) change their expectations of what they will experience with exercise.

Usually, with a weight loss goal for severely obese individuals, the emphasis is on endurance training. In my opinion, this emphasis is a mistake. When people weigh several hundred pounds, they commonly lack endurance. [Considering] the possible embarrassment from performing poorly on even small amounts of aerobic activity, a different approach is in order.

Obese clients possess surprising levels of strength in exercises relating to everyday movements. The need to carry around significant body mass in day-to-day life naturally develops a certain degree of strength in the absence of any structured exercise program.

My programs for obese clients focus primarily on strength exercises that mimic everyday movements and on very limited amounts of endurance activities. “Feel better first” is my driving concept in program design. I want clients to feel better in their bodies and enjoy a more capable day-to-day movement experience. Once you provide that, their abilities and their outlook on exercise often improve, and the likelihood of program adherence goes up.

By using the strength they already possess on exercises like squats, lunges, upper-body pushes and pulls, they experience greater self-efficacy. I also introduce body awareness exercises to reconnect them with what is “under their head,” as they’ve often lost track of it! This frequently involves exercises where their aim is to prevent movement (stability) while I apply a gentle external force. If necessary, I will avoid putting them on the floor if this is overly difficult for them.

For endurance activity, whatever they can do at first is enough for me. If they can walk only for a few minutes initially, I’m fine with that. A few minutes are the stepping stone to 5 minutes and beyond. Overreaching in this area provides a negative physical and mental experience during the early days of a program.

Progressions are added in small increments in the first few weeks and then in larger steps later on, after those essential first few weeks are over. At this point, the program can begin to look more like a traditional program.

Jonathan Ross
Owner, Aion Fitness
Personal Training Director, Sport Fit
Total Fitness Club
Bowie, Maryland

When meeting with new clients who are heavily overweight, do not jump too quickly into the physical without first assessing the mental. Take time to get to know your clients, and build individual profiles of their previous experiences with exercise and food. Here are some areas that will help you get a better understanding of the clients and allow you to assist them in getting great results.

Previous Experience With Exercise. Clients may have deep-rooted issues with exercise that go back to childhood. By understanding these issues, you can help clients overcome them and change clients’ perception of exercise. It is important that you understand what types of exercise your clients feel positive/negative about. For example, many obese clients don’t like running, and may prefer cycling. Finding exercises that clients enjoy, especially in the early days of training, allows them to start to have a positive experience with exercise and to build strong foundations for later work. Into every training session build an opportunity for success, where clients can achieve a challenging but realistic goal.

Barriers to Change. Barriers are anything that gets in the way or is perceived to get in the way of clients exercising. Look at things such as lack of childcare, time management issues and no motivation. By understanding barriers, you can help clients devise strategies to overcome them. For example, if clients say that they can’t find time to exercise, you could go over their diaries with them and look at activities that they may be able to use as exercise, such as shopping (suggest they walk around the shops faster). Be creative.

Building these client profiles allows you to use motivational and support systems that will actually work for each individual. These support systems are vital in the achievement of clients’ goals.

Tom Godwin
Managing Director, Foresight
Personal Training
Manchester, United Kingdom

I think of three important areas when working with severely obese clients. First are behavioral change and goal-setting objectives. Second are the psychological concerns regarding the training environment. Third are the cardiovascular training principles of frequency, intensity, duration and modality (FITT Principles). Core exercises are equally important in the initial training period as clients often have a “disconnect” between their abdominal and back muscles and their importance to structural integrity in maintaining a fitness program.

Behavioral change and goal setting are the first tools that I use. Obese clients need to see what they are doing well and what they want to improve. If their goals are specific, and if they write out barrier prevention strategies before initiating exercise, then they will be better able to visualize their goals and be motivated to work toward them.

I keep core exercises to four initial exercises that improve postural integrity: modified front planks, glute bridges, bird dogs and back extensions. While getting down and up from the floor is an essential life skill, initially I work with clients on a surface that is above ground level so that they become more confident. I use a Pilates rehab reformer for their core and resistance training, as the carriage is 22.5 inches off the floor and 24 inches wide. This strategy helps them feel comfortable with the exercises because they don’t feel like their bodies are too wide for a weight training bench, and they don’t have to get up from the floor.

Before I begin their fitness programs, I complete a thorough health screening, seeking information on injuries, equipment likes/dislikes and risk-factor identification. From this set point, the objective is to increase cardiovascular endurance to reach the minimum of 150 minutes a week by the second week of cardiovascular training. To maintain interest and variety, I recommend three 15-minute periods three times a week on the treadmill, recumbent bicycle and rower or arm ergometer (arm cycling) machine. Blood pressure is taken pre- and postworkout to monitor improvement and to provide automatic feedback on the benefits of exercise. Endurance is built up over the first 2 weeks so that clients gain confidence, muscular strength and self-esteem from their accomplishments. My goal for them is to complete the workouts thinking they could have done more and eager to come back, until the desire for exercise as a lifestyle modification is established.

Pedometers are an invaluable tool for monitoring physical activity outside of the structured training environment because they provide measurable feedback. I ask clients to increase their total steps by 50–100 steps every day until they reach the 10,000 steps/day goal. Gradually increasing the steps they take motivates clients and is something they can do with friends, co-workers and family members.

Once they accomplish 150 minutes a week in the gym, they increase the duration spent on each cardiovascular setting until they can maintain a minimum of 30 minutes of consistent heart rate intensity on each piece of equipment. Once duration goals are met, we increase frequency to a minimum of 4 days a week, preferably 5. Only after duration, frequency and modalities are all monitored, and physical responses (heart rate, skeletal and muscular) are observed, do we increase intensity. Remember that many severely obese clients may have muscular/skeletal concerns due to [excessive] weight. Overuse symptoms may occur sooner than with clients of lower weight. The knees, hips and back are primary areas of concern.

Obese clients are often initially afraid and unwilling to watch their form in a mirror while working out. In resistance training, they turn sideways or turn away from the mirrors all together. However, after they improve self-confidence, they begin to see their bodies as amazing, functioning assets. Then they will independently turn to face the mirrors, watching their bodies and checking form. When I see this magic “a-ha” moment of taking ownership and becoming awakened to the beauty of their bodies, I know they have made that next big leap into their level of wellness.

Sarah Collins, MS
Exercise Physiologist, St. Vincent’s
Medical Center
Owner, Fit Solutions by Sarah LLC
Trumbull, Connecticut

Each client, obese or not, has a unique personal background, as well as exercise, injury and psychological profiles. Until these factors are considered, you can’t create the most effective approach and program for obese clients.

Determining the psychological triggers of severely obese clients is the most important factor in helping them create lifelong change. All the exercise in the world will not create long-term change unless clients have dealt with the personal, professional, lifestyle and social factors that led them to put on so much weight. While trainers must be careful to stay within their scope of practice and not offer “counseling” services, having clients “open up” and share their feelings, fears, concerns and frustrations with you will provide valuable insight into their mindset and the psychological barriers they are facing.  Depending on the client and situation, working with a psychologist or qualified counseling professional can help overcome these barriers.

Anybody can make someone sweat for a few training sessions, but the true change comes from connecting with clients’ “hot buttons” and motivational triggers. Until this happens, the behavior change will be subject to myriad external factors and interference. Clients can hire the world’s best trainers and nutritionists and follow the most customized programs ever made, but if psychological, social or physical barriers are stopping clients from actually following the program, then the work and effort are wasted. Figure out what makes [your clients] tick, and you will have the key to creating virtually any change they want.

From an exercise standpoint, severely obese clients vary as much as nonobese clients in ability levels and modifications that are needed. While there are some specific modifications necessary because of sheer size, it generally isn’t the size as much as the movement skills of the client that determine the greatest modifications needed. I’ve worked with some obese people who have better movement skills than some fit-looking clients. A lot of it has to do with exercise history, current or previous injuries, medical conditions and psychological perspective on exercise and health.

Tim Borys, CSCS
President/CEO, FRESH! Fitness
Calgary, Alberta

© 2010 by IDEA Health & Fitness Inc. All rights reserved. Reproduction without permission is strictly prohibited.

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April 2010

© 2010 by IDEA Health & Fitness Inc. All rights reserved. Reproduction without permission is strictly prohibited.

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