Obesity rehabilitation

Exercise has to start at a level the joints currently tolerate, which is why water and body-weight-supported work are used early. Starting where a programme would like to start is how knees are aggravated in week one.

The dietitian is part of the same plan rather than a separate appointment, because the exercise dose and the nutrition plan have to be written against each other.

Function, not a number on a scale. Walking distance, stair capacity, getting up from a chair and the joint pain that limits all three.

Weight change is recorded, but it is not the measure the programme is judged by.

The clearest trial in this area randomised 454 adults over 55 with knee osteoarthritis and a body mass index of 27 to 41 to eighteen months of diet plus exercise, diet alone, or exercise alone. Diet plus exercise produced the most weight loss (10.6 kg, 11.4% of body weight) and, more to the point, less pain and better function than either component on its own 1.

Exercise alone produced 1.8 kg, or 2.0% 1. That single number is why the dietitian sits inside this programme rather than in a separate appointment: for this group, exercise on its own is not a weight intervention, and diet on its own leaves function behind.

People whose weight has begun to cost them movement: walking distance, stairs, getting out of a chair, joint pain that limits all three. Also people preparing for bariatric surgery, and people in the year after it.

Where an eating disorder, uncontrolled cardiac or respiratory disease, or a joint that needs surgical assessment is present, that is dealt with first. We say so rather than enrolling someone into a programme that cannot address the thing actually limiting them.

Eight to sixteen weeks, one to three hours a day — longer than most programmes on this site, because what has to change here is a routine rather than a block of therapy. Walking distance, sit-to-stand count, pain score and weight are recorded at the start and repeated at the end.

Function usually improves before the scale does, and it is worth knowing that in advance. Someone who has added two hundred metres to their walking distance and lost three kilograms has had a good eight weeks, even though only one of those numbers is the one they came to change.

Before an operation the work is building the exercise capacity and the daily habits that make the year afterwards productive. Rehabilitation does not decide whether surgery is appropriate — that is the bariatric team's assessment — but it does determine how much of the weight lost afterwards is fat rather than muscle.

After it, the priority is protecting muscle while weight falls quickly, through resistance training and adequate protein agreed with the dietitian. Without that, a person can reach a target weight and still be unable to climb the stairs they came in unable to climb.