how physical therapists address obesity in clinical practice for obesity part ii conference.pdfhow...

How Physical Therapists Address Obesity in Clinical Practice

AudioconferenceSusan Scherer, PT, PhDIra Gorman, PT, MPSH

1 Regis University 2010 Scherer Gorman

Objectives } Understand the prevalence of obesity and the

implications for health and function} Describe methods for measuring obesity during

physical therapy screening and examination} Identify current guidelines for obesity management

related to physical activity and weight loss} Discuss risk factor monitoring for patients receiving

physical therapy who are overweight/obese} Identify ways of incorporating tracking of obesity in

PT outcome measurment} Describe opportunities for primary and secondary

prevention of obesity related problemsRegis University 2010 Scherer Gorman 2

Epidemiology} While US data are a concern, obesity is presently a global problem,

affecting 300 million people worldwide (Racette, Deusinger, & Deusinger, 2003).

} The total prevalence of overweight (BMI >25) which includes obesity, increased from 55.9% to 64.5% for the adult US population. These data demonstrated increases across men and women in all age groups and racial/ethic groups, although among women the prevalence was highest among non-Hispanic black women. (Flegal et. al. JAMA. 2002;288:1723-7).

} Approximately 127 million adults in the U.S. are overweight, 60 million obese, and 9 million severely obese.

} Obesity prevalence has increased across all education levels, and is higher for persons with less education Low SES has been shown tobe associated with obesity (Mokdad et al., 1999).

} Each year, obesity causes at least 300,000 excess deaths in the U.S., and healthcare costs of American adults with obesity amount to approximately $100 billion. (Mokdad AH, et al., 2001. JAMA 2003: 289:1: 76–9)3

Epidemiology of the problem in children(IOM, 2005, Ogden et al., JAMA 2008;299:2401–2405.)

} About 17.6 % of adolescents (ages 12 to 19), 17.0 % of children (ages 6 to 11) and 12.4% of children aged 2–5 years are obese.

} Presently-9 million children over age 6 are overweight} Obese children and adolescents are more likely to

become obese as adults.} 80% of children who were overweight at aged 10–15

years were obese adults at age 25 years.} 25% of obese adults were overweight as children.} Since the 1970s-} Ages 2-5, rate has more than doubled} Ages 12-19, rate has doubled} Ages 6-11, rate has more than tripled

IOM Report 2005 on Health Consequences of Obesity

Regis University 2010 Scherer Gorman 5

} Physical Health} Type 2 DM} Hypertension} Orthopedic and neurologic problems} Emotional health} Self esteem, body image, depression} Social Health} Stigma, discrimination, marginalization

Obesity and Physical Function


} Negative effect on performance} Children limited in standing long jump & vertical jump

(Riddiford, Steele & Baur, 2006)

} Slower gait speed and inability to adjust speed to conditions (Hills & Parker, 1992)

} Higher incidence of SCFE, Blount’s Disease, genu valgusand fracture risk in children (Chan & Chen, 2009)

} Difficulty in rising from chair (69% obese children needed assist) (Riddiford, Steele & Baur, 2006)

} Increased musculoskeletal pain limiting work (Peltonen, 2003)

} Increased frequency of total hip and knee surgery and poorer total knee outcomes (Foran et al, 2004)

} Increased association between obesity and back pain (Shiri, et al, 2010)

Chronic Diseases Share Common Risk Factors


Obesity Prevalence Changes

Increase in Prevalence (%) of Overweight (BMI > 25),Obesity (BMI > 30) and Severe Obesity (BMI > 40) Among U.S. Adults.

Overweight(BMI > 25)

Obesity(BMI > 30)

Severe Obesity(BMI > 40)

1999 to 2000 64.5 30.5 4.7

1988 to 1994 56.0 23.0 2.9

1976 to 1980 46.0 14.4 No DataSource: CDC, National Center for Health Statistics, National

Health and Nutrition Examination Survey. Health,

United States, 2002. Flegal et. al. JAMA. 2002;288:1723 -7..


US Cities- Highest Rate

Cities with the Highest Rateof Obesity among Adults

Cities Rate (%)

San Antonio, TX 31.1

Gary, IN 28.8

Jackson, MS 27.6

Ft. Wayne, IN 27.3

Shreveport-Bossier City, LA 28.7


US Cities- Lowest Rate

Cities with the Lowest Rateof Obesity among Adults

Cities Rate (%)

Denver, CO 14.2

Portland, ME 15.0

Santa Fe, NM 15.1

Burlington, VT 15.8

Bergen-Passaic, NJ 16.1


1999

Obesity Trends* Among U.S. AdultsBRFSS, 1990, 1999, 2008

(*BMI ≥30, or about 30 lbs. overweight for 5’4” person)

2008

1990

No Data <10% 10% –14% 15%–19% 20%–24% 25% –29% =30%

Obesity Trends* Among U.S. AdultsBRFSS, 2008

(*BMI =30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10% –14% 15%–19% 20%–24% 25% –29% =30%

BRFSS Trends} In 1990, 4 states had obesity prevalence rates of 15–19

percent and no states had rates at or above 20 percent.} By 1999, no state had prevalence less than 10%,

eighteen states had a prevalence of obesity between 20-24%, and no state had prevalence equal to or greater than 25%.

} In 2008, only one state (Colorado) had a prevalence of obesity less than 20%. Thirty-two states had a prevalence equal to or greater than 25%; six of these states (Alabama, Mississippi, Oklahoma, South Carolina, Tennessee, and West Virginia ) had a prevalence of obesity equal to or greater than 30%.


Measuring Obesity


} Obesity is caused by an imbalance of energy intake and expenditure

} Physiologically, obesity refers to excess fat or adipose tissue, not just weight. The gold standard for measuring the amount of body fat is using a process called dual X-ray absorptiometry (DXA).

} Ideal body weight

} Body mass index: weight(kg)/square of ht(m)2. If using pounds and inches you must then multiply weight(lbs)/height (in)2 by a conversion factor of 703 (IOM, 2005). ¨ Underweight Below 18.5¨ Normal 18.5 - 24.9 ¨ Overweight 25.0 - 29.9¨ Obesity 30.0 and Above(NIH, 1998) (WHO, 2003)

Obesity measurement in Children


} Children- ages 2-19 (Cole, Bellizzi & Flegal, 2000)

} Overweight = > 85th percentile for age and gender based on the 2000 CDC growth charts. (Ogden, Kuczmarski et al., 2002)

} Obese = > 95th percentile BMI for age and gender

} BMI measurements are non-invasive and BMI correlates with body fatness. While BMI is an accepted screening tool for the initial assessment of body fatness in children and adolescents, it is not a diagnostic measure because BMI is not a direct measure of body fatness.

(Mei, Z. Am J Clin Nutr 2002;978–985.)

CDC Growth chartshttp://www.cdc.gov/growthcharts/charts.htm


Central Adiposity


BMI > 25

Waist circum > 80 cm women or >90 cm men

HDL, cholesterol, Triglycerides, insulin resistance

Thomas GN, 2004

Waist Circumference


Abdominal adiposity is associated with increased risk for:} Type 2 diabetes

} dyslipidemia } hypertension } cardiovascular disease Jannsen, 2004

Insulin resistance

CV Risk factors

Waist Circumference


Evidence Statement: Waist circumference is the most practical anthropometric measurement for assessing a patient's abdominal fat content before and during weight loss treatment. Computed tomography and magnetic resonance imaging are both more accuratebut are impractical for routine clinical use. Evidence Category C.

} When BMI normal, waist circumference not enough} When BMI is overweight, waist circumference can

indicate whether weight is muscle or fat} Risk increases when waist

circumference measures} Women > 35 inches ( 88 cm)} Men > 40 inches ( 102 cm)

Source: NIH: NHLBI

Waist & Hip Circumference and Risk


} Waist circumference better marker of abdominal fat content

} However, waist: hip ratio} Waist hip ratio calculator

} Risk increase when ratio increases Male Female Health Risk Only on

WHR

0.95 or below 0.80 or below Low Risk

0.96 to 1.0 0.81 to 0.85 Moderate Risk

1.0 + 0.85 + High Risk

Causes Associated with Weight Gain

NHLBI Weight Loss Guidelines:Obesity


Reduce weight by 10% over 6

months

BMI 27-35

•? 300-500 kcal/day•Weight loss of 1lb/week

BMI > 35

•? 500- 1000 kcal/day•Weight loss of 1-2

lb/week

Negative Calorie Balance: 300 calories


http://aom3.americaonthemove.org/~/media/Tools

Exercise Prescription- Overweight/Obese (ACSM, 2010)


Maintenance of Weight Loss (ACSM, 2010)

} Optimal maintenance dose of physical activity = 2000 kcal/week } Physical activity 200-300 minute/week (5 days) } Aerobic and resistance exercise should be used

} Resistance exercise is recommended} 1-3 sets 8-12 reps } 2-3 non-consecutive days} > 50% of 1 RM


Implications for Physical Therapists


} Measure BMI in all clients} Consider other measures of obesity risk } Waist circumference

} Waist: hip ratio

} Prescribe appropriate exercise for weight loss and other musculoskeletal limitations

} Counsel and refer for dietary interventions for weight loss

} Evaluate effect of obesity on physical therapy outcomes

Prescribe Exercise


Assumptions underlying Estimation of Calorie Expenditure during Exercise

Regis University 2009 Scherer28

} HR and VO2 have linear relationship at HR between 120-150 beats/minute

} Oxygen consumption for any given workload does not vary between subjects

} Energy expenditure (calories) is estimated at 5 kcal/min for each liter of oxygen consumed.

} Energy consumption is reported in relative units of oxygen consumption (ml/kg/min)

} Calorie expenditure is reported in absolute units of oxygen consumption (L/min)

} To lose 1 lb of body weight, you need to burn 3500 calories } (same with weight gain)

Energy Expenditure relationships


Heart Rate Workload

Oxygen Consumption Kcal s


Calorie Expenditure Estimated for 30 minutes

90

lbs. 100 lbs.

110 lbs.

120 lbs.

130 lbs.

140 lbs.

150 lbs.

160 lbs.

170 lbs.

180 lbs.

190 lbs.

200 lbs.

220 lbs.

240 lbs.

260 lbs.

280 lbs.

300 lbs.

Aerobic dancing (low impact) 104 115 127 138 149 161 172 184 195 207 218 230 253 276 299 322 345

Bicycling,10 mph 112 125 138 150 162 175 188 200 213 225 237 250 275 300 325 350 375

Bicycling, 13 mph 180 200 220 240 260 280 300 320 340 360 380 400 440 480 520 560 600

Walking, 2 mph (30 minutes/mile)

54 60 66 72 78 84 90 96 102 108 114 120 132 144 156 168 180


72 80 88 96 104 112 120 128 136 144 152 160 176 192 208 224 240


90 100 110 120 130 140 150 160 170 180 190 200 220 240 260 280 300

Estimating Calorie Expenditure


Workload and Calories Body weight (kg) speed (mph) Grade VO2 in ml VO2 in L Calories/min

90 1.5 0 7.52 0.6768 3.384100 2 0 8.86 0.886 4.43100 2 2 9.82 0.982 4.91

2 5 11.26 0 02.5 0 10.2 0 02.5 2 11.16 0 02.5 5 12.6 0 0

3 0 11.54 0 03 2 12.5 0 03 5 13.94 0 0

3.5 0 12.88 0 03.5 2 13.84 0 03.5 5 15.28 0 0

Exercise Prescription for Weight Loss} Select workload for exercise that will expend 200-

300 calories per session.


200 lb person walking 4 mph 30 minutes = 200 cal

200 lb person walking 2 mph60 minutes = 240 cal

BEFORE You Exercise

} Measure risk of cardiovascular event during exercise


ProceedNeeds more

evaluation

Cardiovascular Risk Stratification


Cardiovascular Risk Stratification


ACSM, 2010

ACTION: Moderate Risk

} Recommend follow up for existing risk factors} Measure HR/BP prior to physical activity } DO NOT exercise if: } Heart rate: > 120 or < 50 bpm} Resting SBP: > 200 mmHg or < 100 mmHg} DBP: > 110 mmHg} O2 Sats: < 90% unless indicated

} Monitor HR/BP, and RPE during physical activity (SaO2 if indicated or available)

} Monitor HR/BP for 3-5 minutes after exercise

36

ACTION: High Risk

} Determine whether current condition is stable

} Consult physician for current disease status if needed

} Measure HR/ BP prior to physical activity

} Measure baseline status relevant to condition:} Asthma (peak flow) OR DM (blood glucose)

} Monitor HR/ BP, (SaO2) and RPE during physical activity

} Monitor HR/BP 5 minutes after activity

} Limit exercise intensity: monitor using HR or RPE37

When Not to exercise


� DO NOT start exercise if: � Heart rate: > 120 or < 50 bpm� Resting SBP: > 200 mmHg or < 100 mmHg� DBP: > 110 mmHg� O2 Sats: < 90% unless indicated� Symptoms

� Unstable angina � Mental confusion� Leg pain at rest� Cyanosis� Increasing SOB� Severe fatigue

� Acute Illness� Other exercise limitations (i.e. peripheral neuropathy)

Check CV response to Exercise


HR rises with

exercise

} SBP rises with exercise

DBP stays ± 10 mmHg

Compare HR to age-predicted maximal

208- (0.70 x age )

Exercise HR ÷ max HR x 100 50-70% of maximal

Replaces 220-age

When to Stop Exercise

} Decrease in heart rate with increase in activity

} Stable heart rate as workload increases

} SBP > 220 mmHg or decrease > 10 mmHg with activity

} DBP >110 mmHg or ± 10 mmHg over baseline

} O2 Sats < 90% unless otherwise indicated

} Symptoms

40

Examination of the Obese Client

41Regis University 2010

Summary for PT Practice


Equipment Needed for Obese Patients } Large Size BP cuff

} Clinic Scale to weight limit

} Exercise equipment appropriate for weight ranges (i.e up to 350 lbs)

} Pulse oximeter


Prevention (U.S. Preventive Services Task Forces’ Guide to Clinical Preventive Services (2d edition, 1996)


} Primary prevention

} Prevent the onset of a targeted condition } Same intervention for all, Can do risk assessment to see if safe} Ex: immunizations, helmets, seat belts, ski fitness

} Secondary prevention

} Identify if disease exists, Early detection- screening} Targeted interventions} Ex: pap smears, mammograms, EMS, health fairs

} Tertiary prevention

} Care of established disease, with attempts made to restore to highest function, minimize the negative effects of disease, and prevent disease-related complications. Ex: Rehab, PT

Ecological Model

IndividualFamily

communitysociety

Compliance Sustainability

} Clinician focus} Avoid victim blaming} Assure long term success} “Bang for the buck”- public health model

Health Promotion is Part of Physical Therapist Practice


} HEALTH PROMOTION AND WELLNESS BY PHYSICAL THERAPISTS AND PHYSICAL THERAPIST ASSISTANTS HOD P06-93-25-50 (Program 32) [Position]The American Physical Therapy Association recognizes that physical therapists are uniquely qualified to assume leadership positions in efforts to prevent injury and disability, and fully supports the positive roles that physical therapists and physical therapist assistants play in the promotion of healthy lifestyles, wellness, and injury prevention.

Health Promotion Practice Patterns of Physical Therapists


Rea, 2004Survey of 417 PTs in CA, NY, TN

How do we improve?


Public Health Medical Care

PT Role in Community based health promotion

} Health fairs- Screening} Exercise Classes} Educational Information} Consultants to programs/research} Fall prevention} Physical Activity

Task Force on Community Preventive Services Recommendations-2002

} Individual Behavior Change Programs} Point of decision prompts} Community wide campaigns} School Based PE} Social Support} Enhanced access to places for physical activity

Regis University 2010 Scherer Gorman

How do PT’s get involved?1. Identify activities/resources in community2. Identify skills PT bring to table3. What is the evidence re: issue4. Who can you contact? 5. How would you measure success?

________________} Prevention is part of public health initiatives and

Guide to PT practice} Multiple ways to get involved} Role of PT is to get out of office and into

community and see where you can make a contribution

Exercise Calculations for oxygen consumption and calorie

expenditure

The following few slides gives an example of the mathematical calculations for walking on a treadmill and

calorie expenditure

Regis University 2010 Scherer Gorman57

Find the VO2

} A person is walking on a treadmill at 2.5 mph and a 5% grade.

What is the oxygen consumption in ml x min-1 x kg-1?

VO2 = 3.5 + 2.68(speed) + 0.48(speed)(grade)VO2 = 3.5 + 2.68(2.5) + 0.48(2.5)(5)VO2 = 3.5 + 6.7 + 6.0VO2 = 16.2 ml x min-1 x kg-1

To convert to METs16.2 ml x min-1 x kg-1 ÷ 3.5 = 4.6 METs


Estimate Calorie Consumption� You want a female patient who weighs 180 lbs to

exercise at 4 METs as part of a weight loss program. How many calories will she be burning at this workload?

4 METs x 3.5 ml/kg/min = 14.0 ml/kg/min[14.0 ml/kg/min x 180lbs ÷2.2 lb/kg ] ÷ 1000 ml/L L/min = 1.14

1 Liter of oxygen consumed expends 5 kcal of energy

1.14 L/min x 5 kcal/L = 5.7 kcal/min


Weight loss programs � You want a female patient who weighs 180 lbs to

exercise at 4 METs as part of a weight loss program. She burns 5.7 kcal/min at this level.

5.7 kcal/min } How many calories does she burn in 30 minutes activity?

172 calories

} How many days of exercise at this level to lose 1 lb? } 3500 kcal burned to lose 1 pound

= 20 days to lose 1 lb.


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