“Incorporating a Gym Facility in a Lifestyle Medicine Practice for Patients with Diabetes Mellitus”

Abstract

Incorporating a gym or fitness facility into a lifestyle-focused clinic is potentially one of the most critical facets of the patient-focused care, especially for those with obesity, cardiometabolic disease, and all types of diabetes mellitus. The evidence for prioritizing physical activity and exercise as medicine is well-researched and universally recommended as first-line therapy plus prevention of many chronic disease states. Having a fitness center on-site as part of any clinic could improve patient utilization, reduce barrier to entry, and decrease hesitation to engage in exercise like resistance training. While the conceptualization may seem simple, the pragmatic application and implementation takes proper planning. Developing such a gym will depend upon gym size preference, program development, cost, and available personnel. Thought needs to be put into deciding which type of exercise and ancillary equipment, ranging from aerobic or resistance machines to free weights, will be included and in what format. Fee and payment options should be carefully considered to assure the budget works financially for both the clinic and patient population. Finally, graphic examples of clinical gyms are described to convey the potential reality of such an optimal setting.

Increased physical activity remains a first-line recommendation for all types of DM; it remains underutilized for many reasons, particularly a high barrier to initiation.

Introduction

Obesity prevalence continues to rise in the United States with large disparities across states and demographic groups.^1,2 With the rise of obesity, the prevalence of type 2 diabetes mellitus (T2DM) has increased with estimated prevalence of all types of diabetes mellitus (DM) up to nearly 10% via NHANES data. ³ While type 1 diabetes (T1DM) is not considered an adiposity-based risk disease, physical activity, exercise, and fitness are foundational priorities in the care for patients with T2DM along with those with T1DM. A recent issue of the American Journal of Lifestyle Medicine had a focused theme of physical activity due to the clearly established benefits for one and all based upon overwhelming data to support its inclusion as a primary pillar of lifestyle medicine. ⁴ An editorial in that issue eloquently articulated the need for progressing toward novel models of care, especially in the context of the COVID-19 pandemic. This includes improving patient health and reducing risk of succumbing to poor outcomes from a variety of disease by expanding healthcare to the health clubs, gyms, and fitness centers. ⁵

Lifestyle therapy is always first line in disease prevention and therapy where applicable; thus, having a clinic really focus on lifestyle treatment would be expected to succeed beyond the historical struggles of patient engagement for lifestyle change implementations. With the goal of developing an optimal lifestyle medical center, an imperative and recurrent theme is that exercise is a first-line medicine requiring improved application amongst the patients, especially the patient population suffering in the spectrum of dysglycemic disease. Providing a space, opportunity, guidance, supervision, and support for patients adhering to exercise or physical activity prescription is a tremendously crucial element to successful implementation of lifestyle medicine. This paper will propose basic considerations for designing and building a fitness center or gym as an integral part of a lifestyle medical center for patients with obesity and associated adiposity-based chronic disease (ABCD), cardiometabolic disease, T2D, and T1D (Figure 1).

Figure 1.

Exercise and physical activity prescriptions are first line for diabetes mellitus.

The evidence supporting the essential aspect of utilizing exercise and physical activity as medicine is well established and deeply embedded within the medical literature. Briefly reviewing the vast medically specific conditions, diseases or prevention of diseases should assist one in grasping the potentially enormous benefits of incorporating an accessible and patient-enticing fitness center or gym within a lifestyle medical clinic. A variety of clinical applications can and should be considered as all relevant evidence-based clinical practice guidelines put exercise and physical activity as a first-line therapy when it is a factor for chronic disease or rehabilitation. The most glaringly obvious disease along with comorbidities requiring exercise or physical activity and fitness is obesity. Obesity, defined as a chronic relapsing progressive disease of abnormal or excessive adiposity that may impair health, ⁶ is the epitome of a complex disease for which exercise, physical activity, and fitness is a central component of prevention and therapy. Central obesity specifically raises risk of dysglycemia, hypertension, and dyslipidemia, which are crucial to both treat and prevent in order to decrease risk of complications in all types of DM. Guidelines for obesity prevention and treatment consistently recommend prescription of aerobic activity, resistance training, and non-exercise physical activity as part of the therapy for addressing the primary focus of energy deficit to lose weight but for a more complex role in addressing the “adiposity-based chronic diseases” that are the principal concern of obesity.^7-11 While weight loss, per se, is not largely driven considerably by the exercise component of obesity therapy, it more importantly improves the clinical aspects including glycemic control and cardiometabolic risk, cardiorespiratory fitness, weight maintenance, strength, and likely mortality. Thus, physical activity prescription remains a first-line therapeutic recommendation in the most relevant clinical practice guidelines for T2D,^12-14 T2D prevention, ¹⁵ dyslipidemia,^16,17 hypertension,^18,19 and cardiovascular risk. ²⁰ Pragmatically getting patients with obesity and ABCD to adhere to a physical activity prescription is a frequently staggering hurdle; thus, a medically oriented fitness center as part of the clinic provides opportunity to overcome that barrier. Physical activity prescription initially under supervision is also necessary for cardiac rehabilitation following events or other cardiogenic disease. ²¹ T1D, autoimmune loss of pancreatic function generally requiring full insulin replacement therapy putting patients at long-term risk of microvascular ²² (including kidney disease, retinopathy and both autonomic and peripheral neuropathy) and macrovascular disease, presents unique challenges for clinician guidance and self-management of exercise, physical activity, and fitness. Challenges and barriers to overcome for patients with T1DM include risk plus accompanying fear of hypoglycemia and hyperglycemia in addition to all the same factors as the general population. Also like the general population, patients with T1D garner the cardiometabolic health benefits of fitness from physical activity and exercise while also mitigating some of the additional risks of complications secondary to T1D.

While prescribing exercise, physical activity, and physical rehabilitation requires its own emphasis and education, patient participation and compliance with the prescription may be the most difficult hurdle to clear. The first step in accomplishing participation is literally getting patients into the structure where physical activity prescription can be implemented. Integrating an efficient but comprehensive and inviting fitness center within a medical clinic is a key strategy in lowering this barrier to entry. This also provides sufficient opportunity to engage patients in education on exercise and fitness in a safe and supervised environment to ingrain why physical activity is so important while importantly guiding patients on how to perform a variety of exercise training options on their own. With this guidance and practice, patients will develop a decreased fear of exercise, especially resistance training, as this can often be a foreign concept to patients without experience leading to resistance of participation. The clinical aspect to a fitness center may also mitigate the so-called “gymtimidation” which is a term coined for the large proportion of people who view working out among others in a gym environment an unnerving prospect. Finally, incorporating exercise as medicine within a clinical fitness center increases overall patient contact with physicians and other members of the healthcare team to improve adherence to the prescribed program and serving as a support structure.

Incorporating a gym into a wellness clinic gives a plethora of opportunities to develop programs benefiting a wide variety of patients, as noted earlier in evidence-based guidelines. Not every wellness center will attempt to reach such a broad spectrum of clientele but the sky’s the limit to some degree. Potential programs specifically targeting disease states could include a variety of options. A structured intensive obesity treatment program focusing on lifestyle therapy beyond just weight loss could/should be a priority to encompass the full benefits of treating or preventing “adiposity-based chronic disease.” The robust accumulation of data incorporated into the clinical practice guidance cited early ultimately suggest that everyone, especially those with D, require some combination of aerobic plus resistance training prescription. While aerobic prescription is seemingly a simpler prescription for patients to develop at home, the all-important resistance training tends to be more unfamiliar and difficult to realize but has been clearly shown to be required for optimal cardiometabolic benefit.^23-26

A potentially overlooked aspect of ABCD and cardiometabolic disease is “sarcopenic obesity” which describes patients with excess adiposity but low skeletal muscle mass and function, likely resulting in much higher cardiometabolic risk and mortality ²⁷ which is clearly a condition undeniably requiring resistance training primarily. For T2D, different forms of resistance training have been shown to be clinically beneficial but working toward higher volume via endurance or hypertrophy training with the latter obviously being preferred for those with a sarcopenic phenotype.

Adjunctively or incorporated within that T2D program, a certified diabetes prevention program (DPP) could be utilized as well and would be an opportunity for involving and helping more of the community beyond those referred individually to the clinic.

Patients with T1D obviously benefit immensely from lifestyle optimization but are often hindered by the potential fear or realization of hypoglycemia when incorporating exercise into their lifestyles as previously noted. People with T1D are encouraged to engage in a combination of aerobic plus resistance exercise on most days, like everyone, to improve fitness, improve insulin sensitivity and reduced insulin requirement, reduce cardiovascular risk and mortality, likely reduce microvascular complications, and reduce risk of osteoporosis. ²⁸ Providing structured and monitored exercise therapy along with the education and experience would likely provide the confidence and ability for those patients to flourish beyond just the clinic. ²⁹ Utilization of continuous glucose monitoring under the supervision of diabetes education, exercise physiology, and a physician within the clinical setting could be a very powerful tool for providing personalized exercise prescription to those with T1D in a very safe but efficacious manner. ³⁰ Other programs could include focus on osteoporosis prevention/treatment, cardiac/pulmonary rehabilitation, and physical therapy.

Setting up a lifestyle medicine practice should include office-based considerations that reflect a clinician’s understanding of the needs of patients with obesity and other lifestyle-associated ailments as well as the near certainty that their experiences with healthcare providers have regularly included weight or other bias and stigma.

Though not all the suggestions here will be adoptable in every office, our hope is that reviewing them, regardless of whether you have plans to build an exclusively lifestyle medicine practice, some will be implemented. Perhaps the easiest way to explore a lifestyle medicine office with fitness component setup is to take a virtual walk through.

The Prescription Potential: Individualizing Exercise Plans

Published guidelines generally recommend a weekly accumulation of a minimum of 150 minutes of aerobic exercise at moderate intensity or 75 minutes of vigorous intensity (or a combination of the two) spread over a minimum of 3 days per week. Resistance exercise for muscle strengthening is also recommended at least 2 days a week which needs to clarify muscle groups involved and potential need to utilize resistance training daily if appropriately split. Flexibility training may complement other types of exercise and should be incorporated. Combining aerobic and resistance exercise within the same exercise session is recommended by most guidelines and can help improve efficiency and compliance.

A narrative review of international recommendations for T2D exercise prescription ³¹ proposed that exercise prescription for individuals with T2D include detailed education on the type, mode, duration, intensity, and frequency of exercise in addition to general physical activity guidance. They additionally conclude, consistent with guidance for all therapeutic modalities, that exercise prescription must be adapted for each individual, based on preferences, limitations, comorbidities, contraindications, and realistic personal goals.

Structural Aspects

Check-In and Waiting Area

The prevalence of weight stigma in public and among healthcare professionals results in several barriers to patients with obesity, leading these patients to be less likely to access care and follow-up over time. There are several considerations in the design, setup, and operation of a lifestyle medicine clinic in order to welcome patients and minimize the barriers and stigma they may have encountered in other healthcare contexts.

The patient’s experience begins with the check-in desk and waiting room. In many healthcare clinics, an initial obstacle for the patient with obesity is a lack of comfortable seating. Patients who are larger and their guests will feel welcomed by the presence of wide-seated bariatric chairs with armrests, longer benches, and/or high couches to provide a variety of seating options regardless of body size.

Health-related reading materials or televisions in the waiting area should not provide inaccurate, pseudoscientific, or additional stigmatizing content. For example, it is common to encounter magazines and tabloids promoting fad diets, weight loss supplements, or “quick weight loss” schemes, and a number of daytime television and talk shows that purport to discuss health-related topics also commonly promote inaccurate information or outright quackery. The simplest strategy involves providing reading or entertainment material that is entirely non-medical in nature and that does not become outdated requiring regular replacement.

Inside the Clinic

Similar accommodations and considerations are needed within clinic hallways, examination rooms, restrooms, phlebotomy areas (if applicable), and any areas used for more specialized care (e.g., procedure or gynecologic exam rooms). These illustrate to patients that their needs have been fully considered, and will likely improve engagement with care.

Walking from the waiting room to the next stage in the outpatient visit involves passing through doors and hallways. These should be wide enough for individuals to comfortably walk past one another, inclusive of any assistive devices they may require (e.g., rolling walkers, wheelchairs, or scooters). Wide ramps and/or elevators can provide access to multiple floors in the clinic if necessary.

The initial assessment typically involves checking vital signs and updating a variety of basic health information. Blood pressure measurement is very sensitive to appropriate cuff size, and thus, a variety of larger arm cuffs or thigh cuffs should be available to improve measurement accuracy. Similarly, weight scales should have handles for support, a wide platform that is easy to step on and off, and a high load capacity (ideally at least 350 kg). Scales should also be placed and used in a way that maintains patients’ privacy regarding their weight (i.e., out of sight and earshot of other patients and staff).

In the exam room, wider, high-capacity exam tables are needed, and should be bolted to the floor or wall in order to avoid tipping over as a patient sits on one end. Stools or steps will facilitate getting on and off the exam table. Bariatric chairs like those found in the waiting area should also be available for patients and guests. Larger-sized patient gowns are needed for more thorough physical examination or procedural interventions.

Similar considerations should be applied to any specialized equipment that may be needed for patient encounters (e.g., larger gynecologic specula, longer needles for phlebotomy, injections, or other procedures). If the clinic is equipped with laboratory capabilities, larger phlebotomy chairs and tourniquets will be needed.

Bathroom toilets should be raised, floor-mounted (instead of wall-mounted), and have both handles and appropriate bariatric seats to accommodate patient needs. If urine specimen collection is required, split seats and specimen collectors with handles are helpful.

Fitness Area

The fitness side of the clinic can be divided into a changing room and the exercise area. The changing area and locker room should be equipped with sturdy bariatric chairs and wide, bolted-down benches. Grab bars aid in standing up and for support during ambulation, if needed. Extra-wide shower stalls with curtains will help to maintain privacy and comfort for patients.

There are a number of important factors in the design and implementation of a gym. These include considerations of gym size and space efficiency, cost-effectiveness, staffing, exercise format (i.e., individual vs small group coaching vs “open gym”), and the patient population/scope of practice (e.g., general fitness alone vs inclusive of rehabilitative treatment) (Figure 2).

Figure 2.

Example graphic of an intermediate size fitness area.

Gym Size

Gym size and capacity determines what is possible with respect to equipment, exercise format, and the types of patients who are appropriate for this setting. The amount of available space may range from less than 1000 square feet to larger sizes of 10 000 square feet and beyond.

A smaller gym space limits the capacity for patients and limits the amount of equipment that can be acquired. This results in a need to prioritize equipment with the greatest versatility and range of possible uses. It becomes less feasible to acquire a specific exercise machine for each individual muscle group, for example, and more practical to consider multi-modal machines and/or free weights that can be utilized in a variety of ways. A smaller gym space can also have benefits in terms of lower costs, staffing, and maintenance needs, and can provide a more comfortable setting for 1-on-1 coaching for clients who experience significant intimidation and apprehension from large, busy gym facilities.

A larger gym space provides much greater capacity for patients and allows for a wider range of exercise options. It also facilitates larger group exercise sessions or an “open gym” option, where an individual may come in and perform a self-guided exercise session. Conversely, a larger gym space will be more expensive, require more staffing and maintenance, and can be more intimidating for certain patients, although this can be ameliorated by sub-dividing the space into smaller rooms or having a separate studio area for 1-on-1 or small group sessions (Table 1).

Table 1.

Example Descriptions of Gym Size and Comprehensiveness

Minimal or Focused	Intermediate	Comprehensive
Small space	Medium space	Large space
< 1000 square feet	1000–10 000 square feet	> 10 000 square feet
Individual or small group	Multiple rooms	Some > 100 000 feet
Low cost	Many individuals and small group sessions	Many individuals and large group sessions
Solo or small group practice	Large group practice	High cost
Minimal equipment	Modest cost	Associate with medical system
Minimal personnel	Several modalities	Variety of modalities
	Weight room	Weight room
	Aerobic room	Aerobic room
	Focused studios	Focused studios
	Rehabilitation	Track
	Variety personnel	Pool
	± Personal trainers	“Functional” area
	± Physical therapists	Rehabilitation
	Custodial staff	Variety personnel
	Maintenance	Personal trainers
	± Child care	Physical therapists
	Financial	Custodial staff
	± Locker room	Maintenance
	Minimal luxuries	Child care
		Financial
		Locker room
		Luxuries
		Televisions

Approach to Exercise and Equipment Selection

There are several considerations when determining the equipment needs of a gym. As noted above, the available space is the primary limiting factor. Beyond this, other factors include financial resources and the patient/client population of interest.

Before planning the exercise equipment for a gym space, a variety of non-exercise equipment such as seating, flooring, sanitation equipment, and water fountains should be considered. As discussed elsewhere, in the clinic, bariatric chairs and wide, bolted-down benches are needed for rest areas during exercise sessions. Flooring is important in the context of resistance exercise, particularly where free weights may be dropped or repeatedly lifted and set down on the floor. Dense, rubberized flooring can provide stability for ambulation while also protecting underlying floors from damage from free weights. Other luxuries may include entertainment devices such as televisions or music equipment. Finally, although mirrors are a common finding in many public gyms, they should likely be avoided in the context of the fitness center focused on patients with obesity. Many individuals struggle with body image concerns and viewing themselves in the mirror during their exercise sessions is unlikely to be beneficial (Table 2).

Table 2.

Exercise Equipment to Consider Based Upon Gym Size and Comprehensiveness.

Equipment	Minimal	Intermediate	Comprehensive
Aerobic	Few options Air resistance bike Treadmill Rowing machine Stair machine	Several options with higher quantity Air resistance bikes Treadmills Rowing machines Stair machines	Several options with high quantity to accommodate large numbers Air resistance and spin bikes Various treadmills Several stair machines Rowing machines Lap pool Track
Dumbbells	Adjustable dumbbells For example, powerblock adjustable bench	Partial dumbbell rack 5s–50s lbs 2–3 adjustable benches	Complete dumbbell rack from 5s–100s lbs Several adjustable benches
Barbells	Barbells with 200 lbs of plates	Barbells with 300 lbs of plates and a squat stand and padded bench	Several barbells with 500 lbs of plates, few squat racks and few padded benches (including incline)
Leg press	Air resistance bike	Standard leg press machine	Multiple types of leg press machines
Cable combination	Universal cable machine	Universal cable machine	Dual-sided universal cable machine
Major muscle group Resistance machines	Singe hybrid or combo machine	Few hybrid or combo machines Some variety of specific movements	Multiple press and row machines = Variety of specific movements
Focused muscle resistance machines		Hip-thrust/glute-raise station	Variety of hip-thrust/glute-raise options
		Combination leg extension and curl machine	Multiple leg extension and curl machines
		Combination hip abduction and adduction machine	Multiple hip abduction and adduction machines
Miscellaneous	Efficient use of resistance bands for space and cost-effectiveness	Resistance bands Exercise balls	Resistance bands Exercise balls “Functional equipment” like tires for “flipping” and sleds for pushing
Pool		Perhaps a small exercise pool	Possibly a large pool for group water aerobics, laps, etc

Aerobic Exercise

The aerobic component of the physical activity guidelines recommends 150–300 minutes per week of moderate-intensity aerobic activity (3.0–5.9 METs), 75–150 minutes per week of vigorous-intensity physical activity (> 6.0 METs), or a combination of moderate- and vigorous-intensity aerobic activity to achieve a target of 500–1000 MET-minutes per week. The majority of patients entering the clinic will be well below these targets at first, and many will not be performing any significant physical activity at all. Given that there is no minimum threshold for benefit to physical activity, the goal is to initiate some amount of regular aerobic activity, and gradually progress from there over time.

Applying these guidelines to individual patients involves working through the behavior change process and using individualized assessment to account for their preferences, abilities, and limitations. Limitations may include medication effects (such as achieving a target heart rate while taking beta-adrenergic blockers), post-operative limitations, as well as comorbid diseases such as obstructive pulmonary disease, cardiovascular disease, lower extremity neuropathy, or musculoskeletal pain issues, among others.

A variety of activities may serve to introduce patients to aerobic exercise. A very common place to start is simply walking. A walking program may be initiated using a treadmill, or in a medium- to large-sized facility, an indoor or outdoor track may be available. Walking can be done in a continuous, “steady-state” fashion, or can be done in shorter intervals depending on individual tolerance. Assistive devices such as a rolling walker may be used if needed. Stair steppers are similar to treadmills, but require the individual to continuously climb a revolving set of stairs rather than walk along a flat track. These can offer a much greater challenge to patients while also improving the strength and endurance of the hip and knee extensor musculature. Both treadmills and stair steppers should include side handles for support, and be rated for high loads for the gym-clinic population.

For some patients, baseline strength, balance, orthopedic limitations, cardiorespiratory fitness, or individual preferences may preclude the use of a regular walking program to meet aerobic exercise goals. There are other ways to introduce aerobic activity for individuals in this situation, such as ellipticals, stationary bikes, rowers, and stair climbers, each of which have pros and cons.

Stationary bikes offer an excellent aerobic modality for patients, including those with strength, mobility, or other limitations that preclude the use of a walking program as described above. Even for patients who are able to walk independently, bikes offer another option for aerobic activity that can be increased in intensity and performed in a steady-state or interval-based fashion, while requiring a minimal footprint in the gym. Bikes also offer an option for those with musculoskeletal pain issues such as advanced knee osteoarthritis that may be more tolerable at higher volumes of exercise. Arm ergometers are analogous to stationary bikes, but utilize the arms for “cycling” instead of the legs, and can be applied in a similar fashion. A limitation with stationary bikes and arm ergometers may be the weight rating of the device, and the size and comfort of the seat; many stationary bikes have a relatively small seat that will be impractical or uncomfortable for patients with obesity. Some device designs include a wider, larger seat and these would be preferable for this patient population.

Rowers offer another option for aerobic exercise that simultaneously trains the whole-body, as it mimics rowing a boat using both the legs and hip musculature to drive the seat across a rail, while also pulling the handle/chain attachment with the arms and back musculature. These devices commonly use a fan, water, or a magnet to provide resistance as well as an adjustable damper to further alter the resistance for a given individual. As with the other equipment in the gym, attention should be paid to the weight rating of the device; there are some options with weight ratings as high as 225 kg and these would be preferable for the gym-clinic.

Resistance Exercise

The physical activity guidelines also recommend resistance training of moderate or greater intensity involving all major muscle groups on 2 or more days per week. Despite the dramatic health and functional benefits that can be attained through regular resistance exercise, this component of the guidelines is much more often overlooked. The 2017 National Health Interview Survey found that while 53.1% of adults age 18 and over met aerobic physical activity guidelines, only 23.5% met guidelines for both aerobic and muscle-strengthening activities. ³² Several common barriers to regular engagement in physical activity, especially resistance exercise, have been identified, including low self-efficacy, low education, low perceived health, fear of injury, apprehension or intimidation in the gym environment, and many others.^33-35 These barriers will need to be assessed and addressed with each patient individually as part of their intake process. For some patients whose baseline strength or cardiorespiratory fitness limits their ability to perform prolonged aerobic activity, resistance exercise may actually be more practical to introduce early as a strategy to build the necessary capacity for longer bouts of aerobic activity.

Muscle-strengthening exercises can range from tasks involving low external loads such as bodyweight movements (e.g., squats to a chair) to loaded activities on machines (e.g., leg press, chest press, cable row or pulldown) or free weights (e.g., barbell deadlifts and dumbbell overhead presses). The exercises that provide the greatest benefit for individuals’ health and physical independence tend to train muscles and joints through relatively long ranges of motion, and tend to focus on more proximal musculature (i.e., the hip girdle, shoulder girdle, and knees).

The general movement patterns to be trained can be broken down into three basic categories:

• 1. “Pushing”-type movements, such as bench presses and overhead presses,

• 2. “Pulling”-type movements, such as rows, pulldowns, and deadlifts,

• 3. “Squatting”-type movements, such as leg presses, squats, and lunges.

There are also a variety of movements that do not fit neatly into this classification system such as biceps curls, triceps extensions, calf raises, and other movements that train more distal musculature in an isolation-type fashion. These movements should carry significantly lower emphasis in a resistance training program for these patients.

Bodyweight Exercise

Bodyweight strength training may be appropriate as an initial strategy for certain individuals who already have sufficient strength to perform the movements while maintaining balance. For example, a bodyweight squat can train the musculature of the hip girdle and knee extensors, while also challenging balance—all of which are critical components for physical independence and activities of daily living. Range of motion may be adjusted based on individual ability and progressed over time, or may be modified to squat to a chair or bench. These prescriptions can also be offered as a way to translate exercise prescription from the gym to the home setting. As strength and range of motion improves, external load may be introduced in a variety of ways. For individuals whose baseline strength does not permit such activities, machines offer a strategy to provide lower loads and build strength over time.

Machines

As mentioned above, decision making about the acquisition of machines for resistance exercise is heavily influenced by variables such as the available space, supervision, and financial resources. If machines are to be acquired, priority should be given for those that facilitate the training of more proximal muscle groups (hip/shoulder girdle and knee extensors) through relatively long ranges of motion, as these are likely to provide the greatest effects for the amount of space they require.

An example of a reasonably comprehensive setup for this purpose could include a leg press machine, chest press machine, overhead (shoulder) press machine, as well as horizontal row and vertical pulldown machines. These machines may be either “plate-loaded” (involving the use of individual weight plates), or may be “selectorized,” involving a built-in weight stack with load selection by moving a pin. Plate-loaded machines typically offer a wider range of loading options, although are less convenient in that they require manual loading and unloading of plates—which may not be feasible for all patients and require additional supervision and assistance. Conversely, selectorized machines typically offer a narrower range of loading options, but are more convenient for selecting and adjusting loads. Where space and cost efficiency is a concern, the “bilateral” versions of these machines would be preferred over iso-lateral/“unilateral” machines; bilateral machines can always be used with a single extremity in case of a need for unilateral training. Other machines that offer more isolation-type exercises (e.g., bicep curl or tricep extension focused machines, calf raise machines, leg adduction/abduction, and shoulder adduction/abduction) should not be prioritized over the above-mentioned equipment in a space- or cost-limited setup (Figure 3).

Figure 3.

Dumbbell rack.

Free Weights

Free weights are the most versatile option for resistance exercise, since they can be picked up and moved in any way to train a wide variety of movement patterns under load. Free weights also tend to be the type of equipment that offers the most cost and space-efficiency, given that they can be localized to one station while offering this versatility, compared to individual machines for each desired exercise that must be spread out across the gym floor. Despite these benefits, free weight training tends to require more coaching and supervision, particularly of the beginner, and thus raises the need for experience and expertise among the staff with these modes of training.

The simplest and most versatile free weight option involves a barbell, which can be plate-loaded and lifted from the floor (as in a deadlift or row-type exercise) or placed into a rack to facilitate other exercises (such as a bench press, squat, overhead press, or other variations of these). Benches should be wide and sturdy to support patients appropriately, and racks should ideally be bolted down into the floor for stability. Barbell movements require an element of balance and grip, while also challenging strength and joint range of motion, and can therefore improve all of these parameters at once. As a corollary, patients with limitations in these parameters will require modification to the exercise prescription to account for their specific limitations, for example, performing overhead presses while seated, squatting to a bench or box, or deadlifting from an elevated height in the rack instead of from the floor to name a few.

Other free weight options include dumbbells and kettlebells, which similarly offer a variety of potential exercise options in both bilateral and unilateral formats. There are also many other forms of equipment commonly found in gyms, such as resistance bands, exercise balls, and other “stability” equipment that generally are of lesser utility and return on investment compared to the modalities described above. Much of this is due to the limited options for loading and progression offered by these tools, as progressive loading is essential to elicit adaptation in patients—particularly those with sarcopenia and anabolic resistance (Figures 4 and 5).

Figure 4.

Adjustable dumbbell rack.

Figure 5.

Example of a machine which incorporates both pushing and pulling upper-body resistance exercise.

Combination Training

Finally, there is no obligation to restrict patients to one modality of resistance-type exercise. A variety of different modalities can be combined in a variety of ways, whether separated on different days, or combined within the same session in sequence or alternating fashion (so-called “Circuit” training). These strategies can be individualized based on patient preferences, abilities, and limitations while building a broad base of physical capacity to improve their function in daily life, while also improving muscular strength, bone mass, and improving cardiometabolic health.

Specialized Situations

There are also several unique situations and options that may be accounted for, particularly in a larger facility with a broader range of clinicians and staff. These may include rehabilitation programs such conventional physical and occupational therapy. Many patients with obesity experience mobility limitations, as well as medical complications and comorbidities that require specialized approaches. For example, individuals may experience:

• 1. Sarcopenia and frailty

• 2. Diabetic neuropathy and amputations, increasing risk of falls

• 3. Cardiovascular complications such as stroke with residual neurological deficits

Many of these (and other) adiposity-based chronic diseases and their associated complications benefit from formalized physical and occupational therapy. As a result, typical equipment such as training stairs, sit-to-stand assist and other patient transfer devices, and handheld dynamometers may be useful for clinicians participating in the assessment and treatment of these patients.

Other programs such as cardiac rehabilitation, pulmonary rehabilitation, or neuro-rehabilitation each come with their own unique needs and considerations that fall outside the scope of the present article.

Clinical and Support Staff

Perhaps the most important consideration beyond any of the physical infrastructure and design of the clinic is adequate training of the clinical staff and support personnel. Given the high likelihood that patients have already had negative experiences with the healthcare system due to stigma, the ways in which they interact with patients are critical in order to demonstrate compassion, empathy, and to show respect for the patients as humans. Staff should be educated on the common barriers to care faced by people with obesity, their unique needs, fears, and concerns, and the types of language that are preferred in clinical encounters regarding obesity. Consistent use of non-stigmatizing person-first language, eliciting information about individuals’ prior history with the healthcare system, and individualizing treatment approaches accordingly is likely to improve adherence and outcomes.

Conclusion and Summary

Increased physical activity remains a first-line recommendation for people with all types of DM, yet it continues to be underutilized for a variety of reasons, one of which is a high barrier to initiation. Incorporating a gym into a clinical setting could increase utilization by lowering this barrier and improve care for those with, or at risk of, DM. While there are no substantial data suggesting that physical activity participation within a medical facility under supervision would increase participation beyond home prescription, ³⁶ per se, we suspect patients without exercise experience would appreciate this model and bridge that gap. Opportunity exists for this novel model, although careful planning and consideration is important to address the unique needs of these patients. If implemented effectively, such a model may prove very beneficial for both physicians and patients.