A good rule of thumb is that one's waist size should not exceed half their height. More specifically, men with a waist size greater than 40 inches and women with a waist size greater than 35 inches are at higher risk. Other health risk considerations include associated risk factors such as blood pressure and level of physical activity.
The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) reports that approximately 32 percent of U.S. adults are obese and 66 percent of adults are either overweight or obese. The Centers for Disease Control and Prevention (CDC) reports that the prevalence of adult obesity ranges from 18 percent (Colorado) to 34.4 percent (Mississippi) with minority populations having significantly higher obesity rates than Caucasian populations-and these rates are climbing.
Causes of Obesity
The physiologic cause of obesity is simple: it is an imbalance of calories/energy; specifically, excessive calories/energy into the body and too few calories being expended by the body. However, the influences and factors affecting weight and obesity are complex. These include metabolism, emotional status, socioeconomic factors, genetic predisposition, environment, culture, behavior, medications and other health issues.
All of these factors need to be considered for effective and maximal weight management. Ultimately, when caloric intake exceeds caloric expenditure, weight gain occurs. When weight exceeds norms and a person becomes obese, it becomes a detriment to health.
The negative health consequences of obesity are significant and numerous. These consequences include: cardiovascular disease, type II diabetes, metabolic syndrome, certain types of cancer, hypertension, dyslipidemia, stroke, liver and gallbladder disease, sleep apnea, osteoarthritis, gastroesophageal reflux (GERD) and gynecological problems.
The negative economic consequences are also significant and many. These include missed time from work, reduced productivity, medical interventions associated with prevention, diagnosis and treatment of obesity related comorbidities and premature death. In 2008 alone, it is estimated that obesity-related medical costs in the United States amounted to approximately $147 billion.
As health care providers, our responsibility is to make every effort to help our patients embrace positive health choices and weight management is one important aspect of good health. Some of the ways we can encourage and facilitate better weight management in our patients include recommendations such as watching less TV, taking the stairs, eating slowly, eating healthier foods, keeping a dietary and an activity/exercise journal, walking more and exercising regularly.
Ideally, an average adult should partake in at least 30 minutes of moderate exercise daily. A general rule of thumb to judge aerobic intensity of exercise is the "talk test," which means that during moderate intensity exercise a person should be able to talk but not sing. If doing vigorous activity, a person should be able to speak a few words but not carry on a conversation.
The National Institutes of Health: National Heart, Lung, and Blood Institute's Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults reports that exercise is important in the management of weight; however, calorie reduction has the greatest impact on weight loss. This report also indicates that exercise for the obese person should progress slowly, starting with light exercise such as walking for 30 minutes three days per week. They then should progress to more intense walking or exercise five days per week, ultimately working to a goal of at least 30 minutes of moderate intensity activity daily.
Considering Surgery
When diet, exercise, behavioral modification and medications fail to result in effective weight management, surgical intervention is a possible alternative. Currently, the four most common weight-loss surgeries performed in the United States are adjustable gastric band (AGB), Roux-en-Y gastric bypass (RYGB), biliopancreatic diversion with a duodenal switch (BPD-DS), and vertical sleeve gastrectomy (VSG); however, a variety of other procedures and devices are being developed and used. The prevalence and increasing number of patients who have had a bariatric surgery of some type necessitates that providers of physical therapy be aware of the related consequences and considerations.
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Some of the possible negative postsurgical consequences and considerations of bariatric surgery include dehydration; anemia; nutritional deficiencies in V-B12, iron, folate, V-D, zinc, protein, thiamine/B1 and calcium; increased incidence of gallstone formation; behavioral failure and surgical failure. Surgical failure, with regard especially to lap-band procedures, has become increasingly concerning, with 10-year postoperative failure rates ranging from 32 to 57 percent.
Some of the possible ways that laparoscopic banding can fail include band slippage, tissue erosion/ulceration, esophageal and gastric pouch dilation, port/tubing problems, small bowel obstruction and postoperative thromboembolism. Again, because there is an ever-increasing chance that we will encounter these patients in PT, we need to be aware of symptoms associated with bariatric surgical failure. Symptoms of surgical failure commonly are insidious in nature and may include: intolerance to solids, heartburn, dysphagia, vomiting, coughing, wheezing, severe abdominal pain or sepsis due to necrosis.
The primary positive outcome of bariatric surgery is weight loss. Gastric banding typically results in a loss of 40 to 50 percent of excess weight, and gastric bypass typically results in a loss 60 to 70 percent of excess weight. Secondary positive and more important outcomes include improved quality of life and self-image as well as reduced rates of incidence for the following health concerns: Type II diabetes remission 76.8 percent, hypertension resolved 61.7 percent, high cholesterol reduction 70 percent, sleep apnea resolved 85.7 percent, metabolic syndrome resolved 80 percent, cancer risk reduction 76 percent, cardiovascular disease 65 percent, infectious disease 77 percent, musculoskeletal problems 59 percent, endocrine disease 65 percent, as well as a significant reduction in overall mortality and health care costs.
Weight Maintenance Concerns
Following bariatric surgery, patients must slowly resume dietary activities per their surgeon's guidelines and resume physical exertion and exercise, albeit in a judicious manner.
It is important for the postsurgical bariatric patient to begin a regular exercise routine as soon as possible after surgery to create new patterns of behavior relative to a healthy lifestyle. During the early recovery phase after surgery, it is important for the patient to avoid straining the surgical site and to not exceed limitations relative to their specific surgical procedure, so as not to risk development of a hernia.
Immediately after surgery, walking is typically the first form of activity and exercise is resumed in order to facilitate circulation and prevent deep venous thrombosis (DVT). Use of a pedometer is a good way for patients to track their number of steps and their progress over time. Ultimately, patients should progress their walking up to 10,000 steps per day.
Ideally, patients should keep an exercise log so they can develop a better understanding of how active they truly are being and determine how many calories per day they are burning. The Mayo Clinic website provides a number of examples of calorie expenditure relative to exercise as well as good guidelines for calorie and weight management.
Once cleared by the patient's surgeon, the patient should then progress to gentle stretching to improve general mobility, circulation, comfort and energy levels.
Patients should incorporate strengthening into their fitness routine. Increasing lean muscle mass results in increased calorie expenditure, promotes joint stability and improves activity tolerance. Patients should begin with very light resistance done at higher repetition progressing slowly over time from one to three times per week.
Eventually, patients should work on core strengthening and stabilization, but again this must be cleared by their surgeon. Cardiovascular exercise should also be integrated into the patient's fitness routine and this can include activities such as bicycling, swimming, elliptical machines and others.
Hydration is an important consideration for the postsurgical bariatric patient. Because bariatric surgery results in a significant reduction in gastric volume, consuming enough fluids to offset those lost can be a challenge. Patients should drink slow steady amounts of water while they are exercising, peaking at up to 64 ounces of water per day. Motivation to exercise can be a challenge, so it is important to find ways to keep it interesting and to make it fun. This can be accomplished by having a variety of exercise routines that the patient rotates through over the course of a week.
Exercising with a friend or in an exercise class can also provide motivation. Again, keeping an exercise log is important because it can provide motivation by showing patients the progress that they are making over time.
In summary, patients are trending toward ever-increasing weight and obesity, so bariatric considerations are a growing concern that health care practitioners need to be educated on. Physical therapy staff will encounter more and more overweight patients and many of them will have had bariatric surgery.
Understanding postsurgical considerations and precautions is important because we may be the health care providers working with these patients at some point after their surgery.
Because physical therapists may be the health care providers who encounter a patient experiencing surgical failure, we should be able to identify the symptoms.
Clinicians and specifically physical therapy staff need to be aware of how to rehabilitate these patients, be aware of the symptoms associated with postsurgical complications, and hopefully become a part of the solution to the obesity problem.
Resources available at www.advanceweb.com/PT or by request.
Jeffrey Heskin earned his doctorate of physical therapy from the College of St. Scholastica in December 2009. He works for Essentia Health-St. Mary's/Duluth Clinic in Superior, WI, and Duluth, MN, treating general orthopedic and neurological conditions. His experience also includes working in long-term, acute and subacute care, and he has been adjunct faculty in the PTA program at Lake Superior College in Duluth, and the PT program at the College of St. Scholastica in Duluth.