What physiotherapy management should be provided for an adult with obesity aiming to lose 0.5–1 kg per week?

Physiotherapy Management of Obesity

Physiotherapists should prescribe a comprehensive exercise program consisting of 150-250 minutes per week of moderate-intensity aerobic activity combined with resistance training 2-3 times per week, integrated with dietary therapy (500-1000 kcal/day deficit) and behavioral strategies to achieve the target weight loss of 0.5-1 kg per week. 1

Core Exercise Prescription

Aerobic Activity

• Initially prescribe 30-40 minutes of moderate-intensity aerobic activity (such as brisk walking) 3-5 days per week, progressing to 150 minutes per week minimum 1
• For weight loss of 0.5-1 kg per week (1-2 lb/week), 150-250 minutes per week of moderate-intensity physical activity is required 2
• Greater amounts exceeding 250 minutes per week produce clinically significant weight loss and are necessary for long-term weight maintenance after initial loss 1, 2
• The American College of Sports Medicine evidence demonstrates that 150-250 min/week provides only modest weight loss when used alone, but becomes effective when combined with moderate caloric restriction 2

Resistance Training

• Prescribe resistance/strength training at least 2 times per week (up to 6 times weekly using different muscle groups with 48-hour rest between sessions) 1
• Resistance training during weight loss preserves lean body mass, increases muscle strength, and enhances fat mass loss, though it does not directly enhance weight loss 3, 2
• High-load resistance training combined with high-intensity aerobic training is superior to other modalities for decreasing abdominal adiposity and improving body composition 4

Progressive Approach for Exercise-Naïve Patients

For patients new to exercise, initiate with a stepwise progression: flexibility training → balance practice → aerobic exercise → resistance training to establish sustainable long-term physical activity patterns 5

Integration with Dietary Therapy

Exercise must be combined with caloric restriction to achieve the 0.5-1 kg weekly weight loss target 1:

• Create a 500-1000 kcal/day energy deficit through diet (typically 1,200-1,500 kcal/day for women; 1,500-1,800 kcal/day for men) 1
• Reducing dietary fat along with carbohydrates facilitates the necessary caloric reduction 1
• The combination of reduced-calorie diet plus increased physical activity produces weight loss, decreases abdominal fat, and increases cardiorespiratory fitness 1

Behavioral Therapy Component

All three components—diet, exercise, and behavioral strategies—must be included for effective comprehensive lifestyle intervention 1:

• Implement regular self-monitoring of food intake, physical activity, and body weight 1
• Provide structured behavior change programs with frequent contact (initially weekly sessions) 1
• Assess patient motivation and readiness to implement the weight management plan 1

Treatment Structure and Follow-Up

Initial Intensive Phase

• Provide frequent (initially weekly) on-site treatment for the first 6 months by trained interventionists in group or individual sessions 1
• This intensive approach produces average weight losses of up to 8 kg in 6 months (approximately 5-10% of initial weight) 1

Maintenance Phase

• Continue with weekly to monthly contact for another 6 months, then bimonthly or more frequent contacts beyond 1 year 1
• Follow-up ideally every 4-6 weeks to support lifestyle changes and monitor progress 1
• Expect gradual weight regain of 1-2 kg/year after initial loss, but long-term losses remain larger than usual care 1

Expected Outcomes

• Comprehensive lifestyle interventions (all 3 components) produce 5-10% weight loss, which translates to improved systolic BP by 3 mmHg, diastolic by 2 mmHg, and decreased HbA1c by 0.6-1.0% if prediabetes is present 1, 6
• Exercise alone produces only modest weight loss of a few kg, but provides substantial cardiovascular risk reduction regardless of weight changes 3, 2
• Physical activity improves cardiorespiratory fitness, helps maintain weight loss, and may decrease abdominal fat even without significant weight reduction 1, 3

Critical Implementation Considerations

Barriers to Address

• Identify and address specific barriers including motivation, major life stresses, psychiatric illness, and weight-promoting medications 6, 3
• Patients with obesity face numerous barriers to increasing physical activity that require individualized solutions 3
• The major challenge is improving adherence to new physical activity habits over time 3

Role Clarification

Canadian physiotherapists have reached consensus that physical activity prescription and assessment are both important and feasible components of physiotherapy practice for obesity management 7. Physiotherapists should function as direct-access practitioners or members of multidisciplinary teams in obesity care 7.

Common Pitfalls

• Do not prescribe exercise alone without dietary modification—the combination is essential for achieving 0.5-1 kg weekly weight loss 1
• Do not neglect behavioral therapy components, as behavior strategies are essential for achieving and maintaining weight loss 1
• Avoid prescribing insufficient exercise duration—150 minutes/week is the minimum, but 200-300 minutes/week is required for weight maintenance 1