Telling patients with high body mass index (BMI) to go to the gym and exercise is like telling patients with hypertension to go to the pharmacy and get medication — but not telling them the name, dosage or frequency of the medication prescribed. According to Cleveland Clinic sport and exercise medicine specialist Matthew Kampert, DO, MS, most patients don’t know how to improve cardiorespiratory fitness or muscular strength on their own and may be intimidated by the task.
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“Exercise is medicine,” he says. “And the best exercise prescription is relative to each individual.”
Increasing cardiovascular fitness decreases the rate of adverse cardiovascular events, according to an American Heart Association position statement published in 2016.
“The statement said that cardiorespiratory fitness is as strong a predictor of mortality as smoking, hypertension, diabetes and high cholesterol,” says Dr. Kampert. “The healthcare community does a lot to help patients address those last four factors, but it hasn’t done much to address cardiorespiratory fitness. Exercise prescriptions are still quite uncommon.”
Soon after that AHA statement was released in 2016, Dr. Kampert, then a family medicine resident at Cleveland Clinic, began work on an exercise prescription pilot study. Called THE BRIDGE PROJECT (Targeted Healthcare Efforts to Bridge Resources, Improve the Development of Guideline-Based Exercise Prescription and Reduce Obesity by Joining Education, Community and Technology), the effort included designing and evaluating intensive behavioral therapy for obesity. It produced some striking outcomes (see below).
Now, in a second phase of THE BRIDGE PROJECT, Dr. Kampert intends to expand the use of intensive behavioral therapy with first-of-its-kind technology that makes exercise prescriptions easier for patients to follow and simpler for providers to assess. Cleveland Clinic’s Orthopaedic & Rheumatologic Institute is working with digital technology to develop a unique “smart gym” workout facility at Cleveland Clinic South Pointe Hospital. At the facility:
- Patients check in to receive a pre-assigned personalized exercise regimen.
- Smart exercise equipment automatically adjusts to the patient and prescription.
- Software tracks each patient’s performance and sends data to their electronic medical record for providers to review.
“This new concept, a cross between sports medicine and endocrinology, could make great strides in reducing health risks for patients who need weight management,” says Dr. Kampert, formerly an exercise physiologist who now has dual appointments in Cleveland Clinic’s Orthopaedic & Rheumatologic Institute and Endocrinology & Metabolism Institute. The effort is in addition to the Get Ready program that Cleveland Clinic introduced in 2021 to medically optimize patients with obesity or diabetes for orthopaedic surgery.
The Endocrinology & Metabolism Institute is developing a second and possibly third exercise facility modeled after the one at South Pointe Hospital.
Outcomes of intensive behavioral therapy for obesity
During the first phase of THE BRIDGE PROJECT, Dr. Kampert recruited patients with BMI over 30 (mean BMI 37, mean age 42, 85% Black, 66% female). Patients performed a cardiopulmonary exercise test at baseline, then again six and 12 months later to measure change in fitness as indicated by VO2 max (maximum rate of oxygen consumption during exercise). All patients were provided heart rate monitors and YMCA memberships.
Throughout the 12 months, Dr. Kampert counseled patients on nutrition and prescribed exercise regimens. He trained YMCA staff to guide patients in correctly using exercise equipment and provided personalized spreadsheets listing assigned exercises and goals. Patients would record their performance on the spreadsheets and return the sheets to Dr. Kampert.
Patients who completed the 12-month study improved their cardiorespiratory fitness by a mean of 1.21 METs. (MET is metabolic equivalent, a measurement of oxygen consumed at rest. It is equal to 3.5 mL of oxygen per kilogram of body weight per minute, or VO2 max divided by 3.5.) Those patients also lost a mean of 10.9% of their body weight over the 52 weeks. In comparison, injectable medication liraglutide combined with intensive behavioral therapy has been shown to reduce body weight 9.1% over 56 weeks.
“My study and the liraglutide study likely had similar clinical care costs [for intensive behavioral therapy encounters], but in my study, the cost for 1% of weight loss per person over 12 months was $38, the cost of the annual YMCA membership,” says Dr. Kampert. “The cost of using liraglutide combined with intensive behavioral therapy for 1% of weight loss per person over 12 months is over $1,800.”
But weight loss does not mean improved fitness, notes Dr. Kampert.
“You don’t get changes in mortality merely with changes in weight. It’s fitness that is most important,” he says. “There are people with obesity who have perfect metabolic panels, with no diabetes and no hypertension, but they have low exercise capacity.”
Advantage of smart workout equipment
While clinically effective, the first phase of THE BRIDGE PROJECT had some challenges:
- Cleveland Clinic paid for full-year YMCA memberships even when patients dropped out of the program early.
- Only changes in cardiorespiratory fitness were tracked, as there were no resources to assess changes in strength or body composition.
- Patients recorded their exercise performance on paper, and Dr. Kampert manually entered the data into each patient’s electronic medical record.
The next iteration of the program will address those challenges. Not only will patients exercise at Cleveland Clinic-owned gyms rather than third-party facilities, they will use smart workout equipment that tracks body composition, strength and cardiorespiratory data, and sends it directly to the patient’s medical record.
Dr. Kampert will serve as director of exercise medicine at each facility. Cleveland Clinic patients with obesity will be referred to him for assessment and medical optimization. He will develop personalized exercise prescriptions and program them into the technology at Cleveland Clinic gyms. Patients will exercise at the gyms and have regular follow-ups, possibly as shared medical appointments with Dr. Kampert or an exercise physiologist.
At the gyms, patients will check in at a kiosk that tells them which exercise machines (e.g., treadmill, bike, resistance machine) to use and in what order. The machines will adjust resistance, seat height, arm height and other settings; direct the number of repetitions or duration, as prescribed; and digitally record performance data, including heart rate and compliance with exercise prescription.
“With this ‘smart gym’ technology, we now can have patients perform a one-rep max, so we can get baseline and follow-up strength measurements as well,” says Dr. Kampert.
Improving patient wellness could improve industry wellness
What will this program do better than standard exercise regimens? Everything, says Dr. Kampert.
“Right now, patients with obesity are being told to eat less and exercise more,” he says. “They’re being told to walk more and increase their number of steps per day. But they are not being taught how to exercise. Some may not have access to exercise equipment. There’s no baseline assessment, no resistance training, no exercise prescription, no follow-up. They just get on a scale and pay no attention to whether they’re losing fat or muscle.”
Building what Dr. Kampert calls “human performance labs” could completely change how providers address obesity, and possibly wellness for all patients, he notes. Even cardiopulmonary rehabilitation may benefit from the use of these facilities with smart exercise equipment.
“There was a paper published in 2019 that showed, for a person with average weight, improving fitness by one MET would result in more than $3,000 of healthcare cost savings for every year the fitness level was maintained,” says Dr. Kampert. “Savings increased to over $4,000 per year for a person with higher weight and over $6,000 per year for a person with obesity. Increasing fitness not only improves the wellness of individuals, it could improve the financial wellness of the entire healthcare industry.”