Watch this video of Luke Hart, Senior Strength & Conditioning Coach and Fitness Lab Lead at UPMC Sports Surgery Clinic, presenting on ‘The role of exercise post-op and why it is important for a healthy life’.
This presentation was recorded as part of SSC’s Public Information Meeting focusing on Orthopaedics in March 2021.
Thank you very much. So, tonight I’m going to present on the role of exercise postoperatively, and why it’s important for us to do them to lead a healthy and fit life.
Exercise really is critical to pre and post on exercise and fitness – preoperatively it’s really important to make sure that you build strength, so that post-op, you find you can get that strength back a little bit easier and we’ll go through why that is, but also for you leading a fit and healthy lifestyle postoperatively and I’ll show some details tonight, why that’s so important and why a lot of people do struggle to keep their fitness and health up after operations.
And so, an important fact to look at tonight is the fact that as we get older, the more important it is for us to stay strong and stay healthy.
Because as we get older, we start to drop off more and more in these qualities, and therefore it’s easier for us to lose strength quicker if we’re not using our muscles.
And after post-ops or after an operation, it’s obviously a period of where we’re not using those muscles and as we get older, we’ll lose them quicker. The old adverb ‘if we don’t use it we lose it’ definitely fits into this scenario, and so it’s a really important component that we’re going to talk through tonight.
So first off, why is it important and why is strength important currently?
Well, you can see here on the top left, we can see a 60-year-old woman with muscle mass – the dark part there is the muscle and the white part is the fat.
Then on the right-hand side, we can see an eighty-year-old woman with the dark part and the fat and we can see that that fat is starting to infiltrate into the muscle, so we can see more fat within the muscle and more fat around the muscle.
When we’re not using our muscle this is essentially what happens to it so after an operation, especially a lower limb operation, this is what will happen when we’re not using those muscles.
We can see on the graph below that as we age, as we kind of get to around about 30, we can start to see that decline in the muscles, what we call cross-sectional area, the amount of muscle that we have.
What that depicts is the amount of non-contractile elements to that muscle so that’s the fat, the adipose tissue the collagen, things that don’t help us in our day to day lives going up and down the stairs, standing up from a chair, etc.
Unfortunately, as I said, as we age we lose this.
Having said that, we can do a lot to make sure that we don’t lose it, or we’ve stifled the amount that we’re losing it by. And this has been showing up across the board and in cross populations. So even people who are even in hospital, have been shown to really improve their cross-sectional area, their strength and their function, and even people in care homes have been shown to short to 80% improvement in muscular strength when they start a strength training program.
So really is for everybody, not just for young fit and healthy people. And so it doesn’t have to be the case that we’ve seen this big drop off.
So it’s absolutely reversible and what we can see here is a picture that was done by a study called Wroblewski in 2011 that shows a 40-year-old triathlete at the top there. You can see the great muscle quality that he has with the slight little bit of fat around the outside.
We can then see a 74-year-old sedentary man who’s not doing much exercise below that. And what you can see there is that the fat around the muscle is much larger but the fat running through the muscle is also a much higher percentage.
And then at the bottom, we can see a 70-year-old triathlete. So we can see that the 70-year-old triathlete looks much the same as the 40-year-old triathlete, maybe not even better, and while he may not be as strong, or as fast his muscle quality is still just as good. And so it’s absolutely available for everybody to improve to this level, and it’s really important that we understand that.
But then why is strength itself so important?
Well, strength has a really strong correlation with mortality – the stronger we are, the less likely we are of essentially passing away or dying and so we can see that in big population cohorts – stronger people tend to live longer, tend to live healthier lifestyles and tend to do the things they love for longer.
So if we’re stronger, we tend to walk for longer we tend to play tennis for a few extra years, golf for a few extra years. So it’s really important that we make sure we maintain our strength. And strength has been shown to correlate with reduced risk in nearly every category, including cardiovascular disease and in terms of risk of mortality.
So it’s really important that we stay strong.
Lots of studies have shown that if we can keep the whole body strong, not just the upper body or not just the lower body but the total body is what’s really important to having a whole body workout – something that strengthens all the different regions of your body is really important.
But also, it reduces the risk of falls, and obviously subsequent fractures so after post-op, obviously that’s a slight risk is that we don’t have the strength and we don’t have the capabilities and function to move properly, then we’re going to be at higher risk after post-op.
If we now kind of know that strength is really important and strength postoperatively is really important, you’re going to lose muscle mass on that one side, and we may lose function if we’re not really careful.
How is the best way to go about getting that strength back?
Well in this study they looked at people who did no exercise, endurance exercise, and then strengthening resistance training exercise.
What we can see is that the strengthening and resistance training with endurance had the best results.
So we can see that the top one there in green, had the best percentage improvement over 10 and 21 weeks and we can see nearly a 20% improvement in that group over 20 weeks, which is fantastic – percentage improvement, every single week when you’re doing some form of strength, endurance training, which is fantastic. And we can see that in both the lower body and in the upper body which is really important as well.
And then when we look at certain conditions we see that strength training is really important. Knee OA is probably one of the most prevailing, and we can see here that if we do some strength training with anybody who has knee osteoarthritis, which is a lot of people that have a knee replacement, we see that resistance training positively correlated with significant improvements in people’s function.
So people self-reported function the amount of walking they could do, stairs, hills going up and down hills massively improved with strength.
One of the common complaints that we have here is that people really struggle going up and downhill. Well, that is one of the key ones where strength will massively help you. So if you are stronger you will find it much easier coming downhill, than if you’re not strong, and that’s because when we go downhill we start to compress the joint we load the joint more going downhill, so we need to be stronger to deal with those forces.
We also saw decreases in pain as well as we get stronger and a 17.5% improvement in function.
Then the second study that was done on 500 people showed improved quadriceps strength actually improve people’s walking. That’s really important because a lot of people here struggle with their walking and actually pain may be secondary to the fact that they’re struggling with function. And if they’re struggling walking and going to the shops, strength is really the biggest port of call.
So if function is your problem and you’re finding it in the pain isn’t the biggest issue, that function is the issue that that’s where we can really help, and that’s where we can step in and get a strength program for you.
Strength also helps you to stop offloading onto the other leg. So sometimes what we see is if we start to get sore on one side, we offload onto the other leg and that’s how I get sore and that’s why strengthening is really important to make sure that doesn’t happen for you.
In a big meta-analysis of 2 million people it’s found that actually making sure your whole body was really strong was the biggest sort of way of reducing your risk of mortality, and actually was very comparable to actually just doing cardiovascular exercise, and obviously, we all know how important it is to do cardiovascular exercise, and we’ll touch on that in a minute, but not many people focus on strength.
|So there are some very positive effects of strength training pre-operatively, especially in hip replacements. In hip replacements it’s found that pre-op strength training – so doing a good bit of strength before you go into the operation, significantly improved your function post-operation, and people who had done pre-op strengthening got back quicker after the operation.|
So it’s a really good incentive if you’re thinking about a hip replacement at any point in the future, there are massive benefits to doing some strength training beforehand.
We found that pre-op quadriceps exercises and pre-op quadricep strength – so the muscle on the front of your thigh has a significant correlation with our post ACL quadriceps strength as well. So if you heard it before, it’s likely you’ll get it afterwards. But maybe it’s not so easy if you don’t have it before.
Then there were significant effects, one year postoperatively for those people who had knee replacements, especially when they were stronger.
So they were stronger had better post-op results at one year post and those that didn’t know didn’t have that strength. So it’s very, very important and there are lots of reasons why we should make sure we’re doing some form of strength, once or twice a week.
WHO Guidelines for maintaining healthy lifestyle
That brings me on to why the World Health Organization, approximately a couple of years ago changed their guidance and what they said was actually everyone was doing the cardiovascular side of things, but actually, we need strength in that and they recognize that without strength we can’t do the cardiovascular exercise because maybe we’re too sore, or maybe we have too much pain or we lose function.
So, what they’ve now suggested is that we do strength training twice per week.
And so they put out and this is the UK version – very, very similar to the World Health Organization, where they put out that two strength sessions a week, should be done for everybody to lead a healthy lifestyle.
Okay, and alongside that you’ll see a few other bits you’ll see 150 minutes of light, physical activity or 75 minutes of vigorous physical activity, some form of balanced training, and then to try and minimise, how much time you spend doing nothing, or just resting and trying to make sure we need just a generally healthy lifestyle.
That’s really important because obviously, we know how important our steps are our daily steps. We know that roughly we should be getting around about 7000 daily steps. Anything above that in the research seems to be not too much but doesn’t make as much benefit. But after 7000 steps it seems to be intensity is more important so make sure you’re doing intense steps or getting the heart rate up a bit higher seems to be more important 7000, is that is the amount that we want.
And so we can see that this is really important for managing stress, our weight, our mood and our sleep, which all have really important consequences, but also we can see there at the top on the right-hand side type two diabetes, cardiovascular disease, falls, depression, joint & back pain, and even cancer.
So we know it’s important to be strong. We’ve kind of gone through that and we’ve hashed that one out but now we want to have a look at cardiovascular fitness.
This has been very well documented but I just wanted to go through a couple of points, so we can see here that this is a study that looks at your V02 max – that’s the amount of oxygen you can use and is commonly used to kind of guide how fit you are, tell us how fit you are.
And we want to know how many mil’s of oxygen you can use per kilo of your body weight. And we can see the top category people that can use 37.1 mils per kilo – that is the lowest amount they can score, have the least number of deaths versus, people who are under maybe 27 had the highest amount of deaths.
So even a very small improvement in your V02 Max, aka your fitness can have massive effects on your risk.
Whether it’s a choice of you know maybe going out for a walk or maybe going for a little bit of extra exercise, we should always choose that option. No amount, however small it is, is a bad option.
And that’s why it’s really important why postoperatively, we get our strength back – If we get our strength back, we can start to do some cardiovascular fitness. And that’s also why, if maybe we have an ACL or we have a knee replacement, we should try and get back to maybe some arm bike or we should get back to swimming as quickly as we can, or back to cycling – finding an option that works for you, allows you to raise the heart rate and work on that cardiovascular fitness.
We would guide most of our patients here to be doing one low-intensity cardiovascular session a week. So it could be a long walk, it can be a very gentle cycle. It’s just something that takes the heart rate up a couple of per cent, maybe to around about 90 to 110 beats per minute but it’s individual for everyone.
One at medium intensity, so this could be a sport, it could be you know an easy sport: golf is a perfect example where we’re walking quite quickly. Then one high-intensity session – some examples of this that we use with all of our post-op patients would be bike based sprint’s, fast walking uphill, arm bike in the gym when they’re back open hopefully at some point, or maybe it was some sprint-based swimming where they do two lengths as fast as they can and rest after that.
We also have some people in the pool is doing aqua aerobics for working really hard for 30 seconds and relaxing for 30 seconds. So there are lots of different options out there for you to try and find that cardiovascular work that we may need.
So that brings me on to why is that important – keeping BMI, our body mass index and keeping your weight down after post-op is really important.
60 to 70% of people have been found to gain weight post hip replacement, and only 5% of people actually lose weight after a knee replacement.
It’s really important because within the replacement we can be incapacitated for a significant period – it’s really important that afterwards, we make sure that we’re conscious that we need to lose any weight that we may have gained pre-op or post up.
So, if we can make sure that after operations where we’re heading in the right direction we’re increasing our physical activity, we’re getting strong, we may be counting our calories to make sure we’re not eating too much because we’re not doing as much exercise – that would give us really positive effects.
If we can get the BMI down, or keep it the same throughout this period, it would be massively beneficial, but also adverse reactions postoperatively increase 35% if our weight is up towards maybe a quite heavier category – we really want to make sure that pre-op we are in a good place because that will minimize any chance of adverse reactions due to operation.
We can see here that this is lots of different graphs here. But what we can see is essentially on each of those individual graphs, if our BMI is higher – then our risk goes up. BMI is along the bottom of those small little graphs, and then the risk is on the left-hand side – you can look through yourselves and these slides will be around afterwards, for people to have a look at.
You can see that your risk does significantly increase if your BMI goes up, especially in the middle here of this table where you can see cardiovascular diseases, we can also see some of the cancers also not all, but some of them go up, especially our kidney cancer and other bits and pieces so it’s really important that we keep our BMI in a good place, or at least minimize it as best as we can, and really lead a fit healthy lifestyle there are so many positives to doing that.
Fit for life at SSC
So that’s what led us to start our Fit for Life – we had Fit for Life and we had done recently a Fit for Life, fit for golf campaign, and we also have our Fit for Life strength & conditioning programs – that’s to help people pre and post up to really try and improve their lifestyle, improve their wellness.
We offer sessions here that people come in for pre-op and post-op to really make sure they’re maximizing their strength, and really improving their fitness – we run that here for anybody who would be interested in, that’s something that we run here at the clinic or in the sports medicine building, and you can enquire using the email today as well.
Fitness Lab Target Sheet
But on that we’ve also created a fitness lab weekly guidance and targets that you can all download after this, you can stick up on the wall, or you can pop in the diary, and you can tick off when you get everything done and what you see there is 150 minutes of low-intensity exercise, or 75 minutes of moderate, or vigorous-intensity exercise, two strength sessions per week, a little bit of balance and mobility, so that could be Pilates, that could be yoga, even your golf could count as that, or tennis.
An 80/20 diet – what I mean by that is, if 80% of the time in our week, we are choosing the right decisions with our diet that allows us or affords us 20% of the time to go slightly off-piste – have that little bit of extra carrot cake maybe on the weekend, or something along those lines.
So, the 80/20 days a really good rule of thumb to use if we’re doing the right thing, every eight out of 10 meals, then two out of 10 meals a week or maybe choose something that’s a little bit off the script.
7000 steps, each and every day is a baseline, and then a little bit of extra protein with lunch or dinner – this helps support muscle strength.
This helps support muscle function and muscle growth, so if we’re doing our strength training, we’re looking to recover post-op and make sure our muscles are back into good quality – protein is essential.
And if we’re doing that through meat, cheeses and eggs that’s fine but if we’re doing that through vegetarian sources, we want to make sure that we’re mixing lots of different vegetables like beans with lentils to make sure we get the complete protein profile – that’s really important as well. We can go through that with anyone.
If you have any questions on that, please feel free to ask at the end, or if anyone’s really interested they can absolutely book an appointment with me and we can go through that and go through diet as well.
So thank you very much for listening. If you have any questions, I’ll be more than happy to answer them, or you can email email@example.com.
We have health and fitness testing available to lots of people with VHI, Irish Life and Laya Healthcare.
We also offer it privately as well if you’d be interested and a lot of people have been availing of that recently.
Fiona Roche (FR) Business Development Manager at SSC put some of the audience’s questions to Luke Hart (LH)
FR: Katie has torn her MCL – what should she be doing to get back on the rugby pitch as soon as possible? She has been out for a year now and hopes to get back soon.
LH: With our MCL, we want to make sure that the quadriceps and hamstring muscles are as strong as possible after the injury.
Often we will see some waste away of those muscles and we can see some weakness after the injury, so it is really important that you get those back to full strength after the injury, but also looking at the hip strength, so with medial collateral ligament on the inside of the knee, we have got to make sure the hip strength is really as strong as it can be to try and prevent that inwards motion of the knee which causes some of that strain the MCL.
So if the legs are equally as strong as each other, so the non-injured side is equally as strong as the injured side, and the hip strength is equally strong, then that is probably our markers to head back onto the pitch as well. But she has to make sure that we are as strong in the quads and the hamstrings to really help protect that MCL going forward.
After a year there should not really be any contraindications on the MCL – again, I presume that’s noted by potentially a surgeon or the sports physician but otherwise, just making sure the muscles are as strong as possible would be the best guidance.
FR: Kristina asks if trampolining is a good exercise?
LH: It is great to keep up the heart rate, trampolining is a fantastic exercise for that side of things for sure. It can also help with lower limb strength, there is some evidence there as well.
It wouldn’t be the only exercise I would do, but absolutely you could use that to increase the heart rate and to strengthen the lower limb.
You may still want to add a few more exercises on top, but I think it is a fantastic exercise and a lot of people find it is great fun.
FR: Tom is saying: is there any exercise which should get rid of a severe limp after a hip replacement? He has good function in the hip, just a bit of a limp.
LH: Often if we have a good range of motion but we don’t necessarily have the full strength back in the hip – that is when we will see the limp kind of occur.
Making sure that the side of the hip muscles are really strong because they are the ones that are often cut through, so you want to make sure that the side of the hip muscles are really strong to provide stability to that hip so that you can prevent that limp.
Also making sure that you do some gait re-education training. Our physios at the clinic will do a lot to make sure your gait cycle is back to normal. Often the limp can be a learnt pattern, so it’s making sure that we train that gait pattern.
We often focus on picking the knees up, making sure you almost do a mini marching pattern to retrain the gait, so the muscles need to be strong first because no amount of gait retraining will retrain the muscles if they are not strong, but then afterwards we can do some gait re-training where we focus on lifting the knees up a little bit higher to try and prevent that limp.
FR: I have two questions now that came from Ruth’s talk on shoulders last month. Gay Nolan asked: what exercise would you recommend for a return from a rotator cuff injury, and I think there was another one about rotator cuff: he’d had surgery on rotator cuff, having similar symptoms and wondering what exercises that he could do other than having surgery?
LH: So with the rotator cuff, it kind of activates in any of our shoulder strengthening exercises, so any kind of pressing movement overhead, especially will make sure the rotator cuff’s doing some work.
If we are limited in terms of the range of motion and that is where we might be some of our banded rotator cuff exercises, so anything where the upper body is rotating – so in these sorts plains through here would definitely help. On that one I would definitely speak to a physio, to try and get specific rotator cuff exercises because the rotator cuff is a fairly large component to the shoulder.
You could work rotator cuff exercises for the front of the shoulder and the back of the shoulder and both would have completely different effects.
So a little bit of specificity is required, and that is where you might get some help from a physio, but any kind of pressing movements overhead if you can are fantastic for strengthening rotator cuff, any ones where your arms are moving out to the side like a lateral raise can also be very good.
But there are also some specific banded ones we’d want to look at, especially if you have had surgery before, there might be some specific deficits after that surgery, so we want to make sure that they are kind of tidied up, so that would be my answer there.
FR: Ann says: can you please recommend exercises to build up strength and flexibility in the hip, prior to a hip replacement?
LH: So we want to make sure that the back of our Glute muscles are very strong, so hip bridges are fantastic for building strength in the backside muscles.
With the side of the hip muscles as well, you want to focus on laying on the side and lifting the leg up to the side of the hip muscles to get some good strengthening as well.
An exercise such as a step up on the bottom step of the stairs would also really help to strengthen the hip muscles as well.
These are three easy ones that you can do at home. They will also help with the flexibility – we would really recommend getting strong. The surgery will help some of the flexibility as well, but really getting stronger in those muscles is the biggest priority prior to going into the surgery because they are the muscles you’re going to lose the quickest, so if we can get them strong pre-surgery, they will get stronger, easier and better after the surgery as well and that is probably one of the most important points – if we don’t have it before the surgery it’s going to be really hard for us to get it after the surgery.
FR: How long should the high-intensity session last?
LH: Generally we would say about 20 minutes.
If we are doing high intensity and really pushing, we won’t be able to do longer than you know 15-20 minutes, so just how comfortable you feel pushing high-intensity kind of conditioning, so usually we would say you know if we’re doing 10 to 20 intervals roughly taking a minute per interval, that would be perfect, but it just depends on what exercise and how you’re doing – so something like a rower might be slightly longer, whereas if we’re doing a lot of bike work it might be a little bit shorter intensity.
So generally around about 15 to 20 minutes is more than enough to get the high intensity so it is really time efficient and you just obviously push yourself quite hard when you’re working and then the rest of it is really relaxed – that should be perfect for most people.
FR: Kathy says: what causes the hip to give way with the pain occasionally on a side step lunge or a simple twist rotation in a very fit and active individual? Is it a sign of weakness or something more?
LH: It’s hard to tell – I mean if there is a specific range of motion that you will always find is giving way, then that is definitely something to investigate a little bit further, because that shouldn’t be happening.
Especially if you are getting pain first then giving way. The giving way there would most likely be due to the pain so we need to find out the root cause is that is causing the pain. Is there a pathology in the hip that we maybe need to MRI or look at and assess? Especially if it is always the exact same movement. That is when I am definitely getting to see maybe one of the sports doctors or a physio to have a look at that.
If it is completely different movements, then I think that could be a weakness. But if it is always the same movements if it’s always rotations or always in the same movement pattern then definitely I would get that looked at, just because we would want to see why that is the case.
FR: Eric Boyle is just saying: it is difficult to keep up exercise during the lockdown when all exercise classes we have been attending have been are closed. Do you have any advice on that?
LH: There are Zoom classes on going – a lot of places are still doing zoom classes. So that is definitely something to look at because staying accountable is really important during this period.
Either having a buddy who you do the exercises with, who make sure you do them at a specific time, and don’t slack off – I think is really important.
Finding a class where you can sign up and book in and that just holds you accountable – that is definitely one part because it’s too, especially during lockdown, to forget about exercise and after a tiring day, it’s very easy.
So either having a partner that you do the exercise with where you meet up on zoom is a really good idea. Secondly to that let’s have a look at some of the zoom classes because they are excellent as well and then it’s just a case of trying to make it a habit and make it something you do in your week without even thinking, you already have that timeboxed off and go and make it as easy as possible.
|That’s where doing exercise earlier in the day is often better because as you get through the day you have more mental fatigue and you’ll be more likely to find the excuses, so if you can do it early in the day before you start your working day that’s generally one of the best bits of advice we can give if you struggle with that motivation|
Try and take away any of the kind of resistance of the day before we have a million and one things to do. That is generally a good one but look at the classes on zoom, they are really good and lots of people have been very imaginative with the ways that they are going about them now.
FR: Denise talks about strengthening exercises, she had surgery for cancer. She is finished treatment but she feels very unfit, so I suppose where does she start?
LH: Really we want to start with the basics, so even just being physically active after cancer is really important even during the process there has been massive benefits shown.
We need to be careful obviously sometimes bone mineral density might be lower afterwards and after treatment. We want to start very simply and efficient, so some of the exercises we would have done in the past on the website would be perfect.
I think some sort of guidance maybe from a professional would be fantastic as well but just basic exercises looking at some lower body exercises such as squats, lunges if you can manage them, stepping up on small stairs if lunges are a little bit too hard, some upper body exercises would be fantastic as well, like incline push-ups against the wall and its juts like getting the body moving again and so making sure we are doing daily walks up until what you feel that you can do as well – maybe on a bike as well a resistance bike if you have that option available would be fantastic.
So it is just about getting moving again and starting to build the strength back up as best as we can, but the benefits have been shown to be fantastic. I think it is definitely an important one to start.
FR: What exercises do I do pre-surgery for a knee replacement?
LH: With this one, we want to make sure those quadriceps muscles are as strong as possible, so squatting to a height that you can do without pain is really good, making sure that we do an exercise called a straight leg raise because that shouldn’t cause your knee any pain at all and you can look that one up online and that is very easy to do.
Those two are two key ones that are quite comfortable. Also, we’d often use the wall hold. You’ll have seen it on the TV recently in Ireland’s fittest families, but just adjusting it for yourself where you can do it without any pain is really important.
If you can use a bike or even one of the small bikes that you can get, that just go on the floor to keep the knee moving is really important as well so if you can get strengthening into the leg, those would be the four ones that I would go for at the moment and you don’t need any real equipment apart from the small bike that you can buy online.
I think we have them at the clinic as well that you can get in there – those four would be my key four without a gym at the moment.
FR: One person is asking: should they consider Bariatric Surgery to reduce their BMI? Two people have asked about gastric bypass surgery, they do need a hip replacement at some stage and they were a very high BMI. So I suppose just some advice there maybe?
LH: I think there is good evidence to support Bariatric surgery in reducing weight – however, we need to put the habits in place that are really important post-surgery.
So we will just want to see a trend in the right direction in the BMI. If our BMI is trending in the right direction pre-surgery, the evidence would be that it will continue to go that way post-surgery when we have got better function, so it is really about putting the right habits place pre-surgery so making sure our physical activity is higher.
Now there are some people who may be in pain walking, but walking as best as you can, also may be using things like the arm bikes that you can buy online, or in our shops again at the clinic. There are lots of places you can get them, and we want to try and increase physical activity, increase heart rate to burn calories and also to make sure our diet is as good as possible as well and really get those good habits in place, so once we have had the surgery, we are in a good place and we have already formed those habits and we continue them going afterwards because obviously, we will have a little bit of a period post-surgery where it is hard to exercise.
So I think yes surgery is a good option and that has shown to be very effective but I think also we can’t rely on that – we need to put habits in place you know the strengthening exercises are a very good way of doing exercise as well which will help after surgery as well so I think that we can’t just rely on that – we need to make sure we’re putting good habits in place, increasing our physical activity, making our muscles stronger, so they can handle more as well is vital – so even just losing the weight isn’t the only thing to focus on.