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1. Physical activity should be seen as an integral part of any prescription for fat loss except where this may be contra-indicated or is difficult because of injury or other problems.

2. Physical activity should be seen as vital to the long term maintenance of fat loss.

3. The primary recommended form of physical activity for fat loss and long term maintenance of fat loss is long, low to medium intensity, gentle continuous aerobic exercise.

4. The appropriate level of intensity of physical activity for fat loss with optimal safety in someone who is fat and unfit is 40-60 per cent VO2 max.

5. Intensity of physical activity may increase with increasing fat loss and fitness, although this should be prescribed by a relevant medical or exercise specialist.

6. Physical activity prescription in the initial stages of a program is perhaps best based on distance covered in the case of walking, cycling, swimming, etc. With increasing fitness, heart rate and then perceived rate of exertion (PRE) can be used to determine the intensity of physical activity.

7. The frequency with which ‘planned’ activity needs to be carried out for significant fat loss is daily, or at least 6 days a week

8. Duration of planned physical activity will affect total calorie use as well as substrate utilisation and therefore no upper limit on duration at low intensity needs to be imposed. Upper limits would be determined by the level of comfort of the individual, as well as limiting medical and physical factors.

9. Non-weight-bearing activities such as cycling, swimming or rowing should be given less support in fat loss programs, except where patients may need this initially for comfort or motivation.

10. Anaerobic activity should never be prescribed for fat loss, particularly in cases where fitness levels and medical contraindications are unknown.

11. Variety in physical activity routines is recommended to maintain motivation and ensure a slower rate of energy adaptation to a single exercise form.

12. It may be necessary to allow time for physical adaptations to introduced forms of physical activity, such as sore knees, provided these problems do not get worse. Referral to appropriate professionals is necessary if problems persist.

13. Where planned physical activity is not possible as part of a fat loss prescription, more attention needs to be given to the control of amount and type of energy input.

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All this suggests that the area of weight control is going through a major paradigm shift. The older, simplistic notions of ‘change in weight = energy in (food) – energy out (exercise)’, are no longer applicable. On the food side of the equation, there has been a shift away from total energy, or total calories, as being solely important, to a greater emphasis on the importance of dietary fat. Energy balance has thus become ‘fat balance’ and ‘dieting’ has given way to food planning and lifestyle eating patterns. Similarly, the role of vigorous, organised exercise has given way to a greater emphasis on fat use through longer duration, lower intensity activity, along with an increase in the type of ‘incidental movement’ that can be added to daily life.

The environment, biology and behaviour are also vital in any assessment of causes, and whilst these are mediated through the energy balance equation, no detailed discussion of fat loss management can be considered without them. Finally, more account needs to be taken of the body’s physiological adjustment mechanisms. Static equations relating to energy intake and energy expenditure which do not consider the dynamic adjustment of the body to changes in body composition and energy balance are no longer realistic. A more appropriate paradigm would attempt to take account of these adjustments. Hence, the old ‘physics’ style weight control paradigm is slowly giving way to a new, more personalised ‘ecological’ approach. After examining the health and physiological effects of fat and how it is measured, we spell out such a paradigm for use in the practical situation. The remainder of the book is then centred around explaining the components of this paradigm and their implications for dealing with overfatness and obesity.

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