obesity epidemic part 1...• coronary heart disease • cerebrovascular accidents • liver and...

12/6/11

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The Obesity Epidemic: Implica8ons for the Physical Therapist

Part 1

LeeAnn Eagler, PT, DPT, GCS, CLT Sara Knox, PT, DPT Lynchburg College Lynchburg, Virginia

Objec8ves •  Describe the current epidemiology and related costs of obesity in the United States

•  Iden8fy physiological changes and co‐morbidi8es specific to the obese pa8ent

•  Discuss considera8ons in determining the prognosis of obese pa8ents

•  Describe mobility techniques that incorporate pa8ent and physical therapist safety

•  Discuss special considera8ons when trea8ng the bariatric pa8ent across the con8nuum of care

•  Iden8fy op8ons in bariatric equipment

Defini8ons •  Adults – Overweight:

•  Body mass index (BMI) of 25 to 29.9 kg/m2 – Obese

•  BMI of 30 kg/m2 or greater •  Equivalent to 221lbs in a 6”0” person or 186lbs in a person 5”6”

Na$onal Ins$tute of Health Clinical Guidelines on the Iden$fica$on, Evalua$on, and Treatment of Overweight and Obesity in Adults 1998

•  Children (aged 2‐19 years old) – Overweight

•  BMI at or above the 85th percen8le and lower than the 95th percen8le for children of the same age and sex

– Obese •  BMI at or above the 95th percen8le for children of the same age and sex

Centers for Disease Control and Preven$on, Basics on Childhood Obesity, 2011

Obesity Epidemic

•  Epidemic= New cases of a certain disease, in a given human popula8on, and during a given period, substan8ally exceed what is expected based on recent experience.

•  Declara8on on Obesity as an epidemic – 1997: World Health Organiza8on – 2003: United States Surgeon General – 2010: US Childhood obesity now an epidemic

U.S. Department of Health and Human Services. The Surgeon General’s call to ac8on to prevent and decrease overweight and obesity. [Rockville, MD]: U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General; [2001]. Available from: U.S. GPO, Washington.

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Epidemiology Prevalence rates of Overweight and Obesity in United States Adults

1970 1999 2010

Overweight 32% 34% 34%

Obese 17% 27% 33%

TOTAL 49% 61% 67%

Prevalence rates of Overweight and Obesity in United States Children

1980 1999 2008

Overweight 4% 16% 30%

Obese 5% 10% 19%

TOTAL 9% 26% 49%

Dispari8es •  Women

–  Higher in women who are members of racial and ethnic minority popula8ons

•  Men –  Mexican Americans have a higher prevalence of overweight and obesity than non‐Hispanic whites or non‐Hispanic blacks. For non‐Hispanic

–  Prevalence of overweight and obesity among whites is slightly greater than among blacks

•  Children –  Mexican American boys tended to have a higher prevalence of overweight than non‐Hispanic black and non‐Hispanic white boys.

–  Non‐Hispanic black girls tended to have a higher prevalence of overweight compared to non‐Hispanic white and Mexican American girls

The Surgeon General’s Call To Ac$on To Prevent and Decrease Overweight and Obesity 2001

Dispari8es con8nued

•  Age – Prevalence of overweight and obesity increases with advancing age un8l the sixth decade aler which it starts to decline.

•  Socioeconomic status – Women of lower socioeconomic status (income < 130 percent of poverty threshold) are approximately 50 percent more likely to be obese than those with higher socioeconomic status


Economic Consequences •  Direct Costs –  Preventa8ve care –  Diagnos8c tes8ng –  Treatments

•  Indirect Costs –  Lost wages –  Lost future earnings –  Lost work force

•  Es8mates of Costs –  1995 ~ 99 billion –  2000 ~ 117 billion (61 billion direct, 56 billion indirect) –  2010 ~ 270 billion **Most costs are associated with Type II DM, Coronary Heart Disease and Hypertension

Obesity and its Rela$on to Mortality and Morbidity Costs, Society of Actuaries 2010


Na8onal Health Ini8a8ves •  Healthy People 2020

–  Nutri8on and Weight Status Objec8ves •  Na8onal Ini8a8ve for Children’s Health Care Quality

–  Be our Voice •  Na8onal Ins8tute of Health

–  We Can! •  Center for Disease Control

–  BAM! Body and Mind –  Kids Walk to School –  Lean Works!

•  Let’s Move! (First Lady Michelle Obama) •  Partnership for a Healthier America (Private Non‐Profit) •  Campaign to end Obesity (Private Non‐Profit)

Pathophysiology and Comorbidi8es of Obesity

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Causes of Overweight and Obesity

•  Essen8ally an Energy imbalance – High intake to low output

•  Gene8c, metabolic, environmental, behavioral, & socioeconomic factors – 30% asributed to gene8cs and 70% to environment

•  Metabolic predictors of weight gain – Low adjusted sedentary energy expenditure – High respiratory quo8ent – Low level of spontaneous physical ac8vity

Sunyer FX. Obesity Research (2002) 10, 97S–104 The Obesity Epidemic: Pathophysiology and Consequences of Obesity

Obesity is a Risk Factor for….. •  Hyperinsulinemia •  Insulin resistance •  Type 2 diabetes

•  Hypertension (high blood pressure) •  Dyslipidemia (for example, high total cholesterol or high levels of triglycerides) •  Coronary heart disease •  Cerebrovascular Accidents

•  Liver and Gallbladder disease

•  Sleep apnea and respiratory problems

•  Osteoarthri8s (a degenera8on of car8lage and its underlying bone within a joint)

•  Cancers (endometrial, breast, and colon)

•  Gynecological problems (abnormal menses, infer8lity)

Centers for Disease Control and Preven$on 2011

Fat pasern distribu8on

•  Gluteofemoral pasern – Primarily occurs in women

•  Abdominal or Upper Body – Men (women aler progression) –  Increased risk of diabetes, cardiovascular disease, HTN, insulin resistance, hyperinsulinemia, arthri8s, gallbladder disease

Physiological changes •  Altera8ons in hormone produc8on and metabolism – estrogen produc8on – circula8ng testosterone – Excre8on of cor8coid metabolites – Insulin secre8on – Insulin effec8veness – Blunted growth hormone – Blunted prolac8n responsiveness

Onset of Hyperinsulinemia & Insulin Resistance set off a cascade of metabolic events that result in…….. Diabetes Mellitus, Hypertension, Hypercoaguability, and Cardiovascular Disease

Hyperinsulinemia & Insulin resistance Cellular level  Insulin binds to a receptor

 Leads to intracellular signaling  Culminates in cellular responses

 Allow glucose uptake for use & glycogen storage

 Enzyma8c process for glucose use

Steps in the cycle that are defec8ve in pa8ents who are obese


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Increased Free Fasy Acids

 Increased Body Fat increases the rate of lipolysis  Increases the mobiliza8on & oxida8on of Free Fasy acids in muscle

 Increased hepa8c glucose use due to increased lipolysis  Hyperglycemia & Impaired glucose tolerance

Effect of increased lipolysis on glucose use and gluconeogenesis.


Dyslipidemia

•  Abnormal amount of lipids in the blood •  Increased Free Fasy Acids affects lipid metabolism – Very‐low‐density lipoprotein produc8on by liver – High density lipoprotein cholesterol levels – Small dense, low‐density lipoproteins

•  Beser able to penetrate the arterial wall •  More readily undergo oxida8on & glyca8on •  More atherogenic

Atherogenic risk Coronary Heart Disease Sunyer FX. Obesity Research (2002) 10, 97S–104 The Obesity Epidemic: Pathophysiology and Consequences of Obesity

Hypertension •  Mechanisms –  Blood Pressure is the product of cardiac output and systemic vascular resistance. •  Cardiac output is increased due to increased blood flow to adipose 8ssue

•  Systemic vascular resistance is normal or slightly reduced due to the increased cross sec8onal area of the vascular bed –  Arterial pressure –  Heart rate –  Cardiac Output –  Renal sympathe8c ac8vity –  PRA –  Na+ balance –  Tubular reabsorp8on –  GFR

Systemic Vascular Resistance

Coronary Heart Disease

•  Obesity is an independent predictor of coronary artery disease

•  Obesity accelerates atherosclerosis decades before there are clinical manifesta8ons

•  Increased adverse affects post coronary bypass surgery in obese pa8ents – Thromboembolism, infec8ons of the sternum, infec8ons of the saphenous vein harvest site.

– Higher incidence of atrial arrhythmias

Boban et al, 2008

Cerebrovascular Accidents •  Increased BMI and waist–hip ra8o are independent risk factors for stroke

–  Even aler adjus8ng for hypertension, hypercholesterolemia, and diabetes. •  Physician's Health studied a cohort of 21,414 men

–  Mul8ple adjusted rela8ve risk of total stroke compared to men with BMI <25 •  BMI between 25 and 30= 1.32 (95% CI, 1.14‐1.54) •  BMI >30= 1.91 (95% CI, 1.45‐ 2.52)

–  Rela8ve risk of ischemic stroke •  BMI between 25 and 30= 1.35 (95% CI, 1.15‐ 1.59) •  BMI > 30= 1.87 (95% CI, 1.38‐2.54) •  With each 1 unit increase in BMI score, the mul8ple adjusted rate of ischemic stroke

increased by 4% –  Rela8ve risk of hemorrhagic stroke

•  BMI between 25 and 30 = 1.25 (95% CI, 0.84–1.88) •  BMI > 30= 1.92 (95% CI, 0.94–3.93) •  With each 1 unit increase in BMI score, the mul8ple adjusted rate of hemorrhagic stroke

6%. •  The underlying mechanism by which increased BMI score affects stroke

risk. Independent of established risk factors such as hypertension and diabetes is not fully understood.

Boban et al, 2008

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Gastrointes8nal Disease •  Gallbladder Disease

–  Increased cholesterol turnover related to total body fat •  Cholesterol produc8on is linearly related to body fat •  20 mg of addi8onal cholesterol are synthesized for each kilogram of extra body fat.

•  The increased cholesterol is, in turn, excreted in the bile. •  High cholesterol concentra8ons rela8ve to bile acids increase the likelihood of of gallstones

•  Increased fat in the Liver –  Increased steatosis is characteris8c of the livers of overweight individuals

–  May reflect increased VLDL produc8on associated with hyperinsulinemia.

–  The accumula8on of lipid in the liver suggests that the secre8on of VLDL in response to hyperinsulinemia is inadequate to keep up with the high rate of triglyceride turnover.

Bray, 2004

Respiratory Disorders

 Increased adipose 8ssue around the chest wall  Decreased Func8onal Residual Capacity  Decreased Expiratory Reserve Volume

% % % % %%  Increased Risk of expiratory flow limita8ons and airway closure

% % % % % %  Decreased O2 Satura8on

Osteoarthri8s •  Mechanism of how obesity causes osteoarthri8s is unknown.

•  Possible mechanisms – Biomechanical (Received lisle asen8on in epidemiological studies) •  Increased weight increases joint reac8on forces •  Studies looking at rela8onship of knee adduc8on moment and medial 8bial plateau

•  Excess stresses on patella with knee bend – Metabolic •  Specula8ons but the majority of studies have not been able to iden8fy a causal rela8onship

Teichtahl et al 2008

Introduc8on to Cases

Examina8on/Evalua8on Considera8ons

Guide to Physical Therapist Prac$ce 2nd Edi$on

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Examina8on •  History

–  Race, Ethnicity –  Cultural beliefs/values –  Caregiver support –  Current and Prior work/leisure ac8vi8es –  Devices/Equipment availability (Are they bariatric?) –  Living environment –  General Health Percep8on –  Psychological func8on –  Behavioral health risks (over ea8ng) –  Level of fitness –  Medical History (cardiovascular, endocrine/metabolic, integumentary, musculoskeletal, respiratory)

–  Chief complaint –  Pa8ent/Caregiver expecta8ons –  Current/Prior func8onal status


Examina8on •  Systems Review

–  Cardiovascular/pulmonary system •  Heart rate, respiratory rate, blood pressure, oxygen satura8on, and edema

–  Integumentary system •  Pliability(texture), presence of scar forma8on, skin color, and skin integrity (skin folds)

–  Musculoskeletal system •  Gross symmetry, gross range of mo8on, gross strength, height, and weight

–  Neuromuscular system •  Gross coordinated movement (eg, balance, gait, locomo8on, transfers, and transi8ons) and motor func8on (motor control and motor learning)

–  Communica8on ability


Examina8on •  Tests and Measures –  Body Mass Index Calcula8ons – Dyspnea Scales

•  Borg Dyspnea scale •  Modified Dyspnea Index

–  Borg Ra8ng of Perceived Exer8on –  Cardiac Health Profile – Outcome Expecta8ons for Exercise – Quality of Well‐being self administered –  Respiratory rate, rhythm, and pasern –  Skin fold measurements – Waist to Hip Ra8o


Discussion of Case #1

Discussion of Case #2 Discussion of Case #3

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Factors to Determining Prognosis

•  Medical diagnosis & prognosis (if applicable) •  Comorbidi8es and past medical history •  Prior level of func8on/ac8vity level •  Current level of func8on based on tests and measures of the examina8on

•  Pa8ents outlook and goals

Factors Predic8ng Prognosis for the Obese Pa8ent

Pre‐weight Loss Predictors •  Ini8al body weight •  Body image •  Ea8ng & exercise self‐efficacy •  Psychopathology •  History of diet asempts •  Realis8c goals •  Less perceived barriers to exercising •  Self mo8va8on •  Abdominal fat distribu8on

Factors Predic8ng Successful Prognosis for the Obese Child

•  Weight management that is mul8disciplinary •  Includes cogni8ve and behavioral aspects of weight loss

•  Degree of obesity •  Age of child •  Feelings of self worth •  Family dynamics

Prognosis Considera8ons for Pa8ent with Asthma

•  Link between obesity and development of asthma

•  Weight loss creates a decrease in asthma symptoms

Poor Func8onal Prognosis Considera8ons for Pa8ent with CVA

•  Func8onal outcome predictors in first 12 hours following ICU admission (Jeng et al)

•  Ini8al stroke severity (NIH Stroke Scale) •  Ven8lator dependence •  Advanced age •  Previous stroke •  Total anterior circulatory infarct •  Mul8ple co‐morbidi8es (Turhan et al) •  Poor func8onal level prior to CVA (Turhan et al)

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Prognosis Considera8ons of Obese Elderly Pa8ent

•  Obesity related to medical comorbidi8es thus increasing the risk of mul8ple hospitaliza8ons and death

•  Decreased basic func8onal abili8es, earlier onset of disability – includes even walking across the room, bathing, ge~ng out of bed, etc.

•  More likely to rate quality of life low, more depression

Exercise Prescrip8on

Formula for exercise prescrip8on: •  Intensity •  Dura8on •  Frequency •  Mode •  Progression

Intensity

•  Heart rate •  BORG RPE •  Dyspnea Scales •  Oxygen satura8on •  Blood Pressure •  Time to Complete Task •  1 Rep. Max.

Intensity – Heart Rate

•  HR Max (bpm)= (210‐50% age)‐ (5% body(lbs))+4 if male or + 0 if female www.howtobefit.com/determine‐maximum‐heart‐rate.htm

•  ACSM recommends exercising 60‐80% of maximum heart rate

Obese pa8ents have a blunted heart rate during exercise and recovery = decreased exercise capacity

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BORG Rate of Perceived Exer8on •  6 No exer8on at all •  7 Extremely light (7.5)

8 •  9 Very light •  10 •  11 Light •  12 •  13 Somewhat hard •  14 •  15 Hard (heavy) •  16 •  17 Very hard •  18 •  19 Extremely hard •  20 Maximal exer8on •  Borg RPE scale

© Gunnar Borg, 1970, 1985, 1994, 1998

BORG Rate of Perceived Exer8on

•  Nega8vely related to intensity and exercise in obese but not related to METs

Dyspnea Scales

Pa8ents who are obese may become short of breath at a low rate of exercise

Exercise Intensity

•  Other vitals to consider: •  Oxygen satura8on •  Blood pressure – Normal response to exercise = rise in systolic bp 20‐30 mmHg, diastolic bp should remain about the same

– Return to normal BP and HR within 5 mins of si~ng

•  Time to complete a task

Intensity for Strength Training

The 1 Rep Max •  Most healthy adults can strength train at the 70‐80% of 1 rep max

•  Strongly supported by evidence •  Studies in obese children support training using 50%‐97% of the 1 rep max – 1 study found compliance with strength training high (96%)

Dura8on for Strength Training

•  Exercise to fa8gue •  Healthy adults should perform 8‐12 reps at the intensity of 70‐80% of 1 rep max

•  If lower intensity, 30‐60% of 1 rep max, 12‐25 reps

•  No research supports the 3 set tradi8onal method

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Dura8on

•  Adults: 2 hours 30 mins/week moderate or 1 hour 15 mins/week intense cardiovascular exercise & 2 days/week muscle strengthening

•  Children: 60 minutes accumulated through the day

U.S. Department of Health and Human Services Physical Ac8vity Guidelines, American Heart Associa8on and Expert Commisee Recommenda8ons on Childhood Obesity

How long should the pa8ent exercise?

•  Depends on how long the pa8ent can exercise at baseline at the beneficial intensity

•  Gradually build up to the recommended exercise guidelines – ACSM recommends 30‐40 minutes/day – Can benefit from short dura8on, mul8ple 8mes during the day

Exercise Frequency

•  3‐7 days/week cardiovascular, 2 days/week strength training

•  Since obese pa8ents have mul8ple co‐morbidi8es and most are sedentary, may want to begin low and build up

•  Monitor for adverse effects

Mode of Exercise

•  Mul8ple studies have been done to determine effec8veness of many different types of exercise –  Ex. Krasilshcikov et al found that a combo of cardiovascular and strength training resulted in decreased knee pain in obese women

•  Choose a type of exercise the pa8ent may enjoy long term

•  May have to build the pa8ent up to the ac8vity

Mode

•  Mul8ple ar8cles wrisen on interval and circuit training

•  Campbell et al found no difference in weight loss between the interval training vs. the con8nuous training group

•  Obese pa8ents may not tolerate con8nuous •  Interval training also effec8ve in obese popula8on

Mode In Children

•  Radon et al studies the use of video games that promote ac8vity – The children started high but by 4th week, no exercise

•  Asthma pa8ents have beser results in pa8ents with intermisent rest – Swimming, baseball, wrestling, biking, walking – hsp://www.webmd.com/asthma/guide/exercising‐asthma

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Ac8vity Recommenda8ons in Children With BMI 85‐94th%

•  Brisk walking, treadmill •  Field sports •  Roller blading •  Hiking •  Racketball/tennis •  Mar8al Arts •  Skiing •  Jump rope •  Indoor sports •  Swimming •  Dancing •  Tag

Ac8vity Recommenda8ons in Children With BMI >95th%

•  Swimming •  Cycling •  Strength or aerobic circuit training •  Recline biking •  Interval walking •  Start at low level and gradually increase

Ac8vity Recommenda8ons in Children With BMI >97th%

•  Exercise needs to be prescribed and supervised by a trained professional

•  Swimming •  Walking •  Light resistance training

Mode Strength Training •  Mul8ple studies demonstrate effec8veness in strength training in addi8on to cardiovascular exercise in physical well being of the obese pa8ent

•  Results: strength gains, weight reduc8on, and decreased in severity of co morbidi8es

•  The Presidents Council on Physical Fitness & Sports supports strength training in addi8on to other forms of exercise in obese youth

Types of Exercise •  Many choices •  Elas8c bands •  Machines – study: weight machines allow for safety using 1

rep max principles but know weight restric8ons on machines

•  Body weight – keep in mind balance issues •  Weighted bars •  Medicine balls •  Pulleys •  Body blade •  Func8onal ac8vi8es – sit to stand ac8vity •  Consider circuit training

Progression

Strength Training •  70‐80% 1 rep max – 12 reps or more – increase weight 5%

•  30‐60% 1 rep max – 25 or more reps – increase weight 10%

•  Cardiovascular – Adjust the ac8vity to meet intensity requirements – Add 8me to meet dura8on requirements

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Equipment Prescrip8on and Use

Using equipment that is not meant to hold that persons weight can cause poten8al

•  Damage to equipment •  Injury to the pa8ent •  Embarrassment to the pa8ent

Bariatric Equipment Considera8ons in Hospital/SNF

•  Recliner/chair •  Ceiling lil •  Beds/Masresses •  Blood pressure cuff •  Commodes •  Gait equipment •  Wheelchairs •  Gait belt •  Transfer equipment

Bariatric Equipment Considera8ons in Home

•  Blood pressure cuffs •  Bed/Masress •  Commodes •  Gait equipment •  Wheelchairs •  Secure grab bars •  Ramp •  Lil •  Gait belt

Bariatric Equipment Considera8ons in Outpa8ent

•  Extra wide plinths/mat tables •  Step stool •  Blood pressure cuffs •  Gait equipment •  Wheelchairs •  Exercise equipment •  Gait belt

obesity epidemic part 1...• coronary heart disease • cerebrovascular accidents • liver and...

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