Weighing Your Options

Evaluation and Treatment of the Bariatric Client

Susan Priem, PTApril 15, 2011

Bariatric

Unique Patient PopulationUnique InterventionsU que e e o sUnique Equipment Needs

CHALLENGES ARE THE SAMECHALLENGES ARE THE SAME, SOLUTIONS ARE DIFFERENT

Guide To Physical Therapy Practice

MusculoskeletalNeuromuscular

CardiopulmonaryIntegumentary

Things Learned the Hard Way

Weight Bearing Status– What Does 50% body weight mean– What Does PWB mean– How much weight can fixation, arthroplasty, lower

leg prosthesis sustainleg prosthesis sustain Prejuidice

What is Obesity?

Excessive accumulation of adipose tissue to an extent that health is impairedBMI > 30 kg/m2Imbalance between caloric input and energy

t tout put

Body Mass Index

Weight (lbs) divided by height (in) squared lti li d b 704 5multiplied by 704.5

Undernourished < 18Normal 18-24Overweight 25-29Obese 30-39Severe Obesity > 40

Body Mass Index

BMI is reliable indicator of total body fat but h li it tihas limitationsMay overestimate body fat in athletes and

th h h l b ildothers who have a muscular buildMay underestimate body fat in older persons and others who have lost muscle mass (1)and others who have lost muscle mass (1)

http://win.niddk.nih.gov/statistics

Waist Circumference

Women < 34 inchesMen < 35 inchesHighly correlated health risks with apple shape (Zhang 2008)

Waist/Hip Ratio

Waist Circumference divided by hip circumference

Males: high risk > .95

Females: high risk > .80 (Price 2006)

M t lit Lif H i htMetropolitan Life Height& Weight Tables for Women

Height Small Frame Medium Frame Large Frame

5' 2“ 108-121 118-132 128-1435' 4“ 114-127 124-138 134-1515 4 114 127 124 138 134 1515' 6“ 120-133 130-144 140-1595' 8“ 126-139 136-150 146-1675' 10“ 132-145 142-156 152-1736' 0“ 138 151 148 162 158 1796' 0“ 138-151 148-162 158-179

Weights at ages 25-59 based on lowest mortality. Weight in pounds according to frame (in indoor clothing weighing 3 lbs.; shoes with 1" heels) (Harrison 1985)

M t lit Lif H i ht & W i htMetropolitan Life Height & Weight Table For Men

Height Small Frame Medium Frame Large Frame

5' 6“ 136-142 139-151 146-1645' 8“ 140-148 145-157 152-1725' 10“ 144-154 151-163 158-1805 10 144 154 151 163 158 1806' 0“ 149-160 157-170 164-1886' 2“ 155-168 164-178 172-1976' 4“ 162-176 171-187 181-207

Weights at ages 25-59 based on lowest mortality. Weight in pounds according to frame (in indoor clothing weighing 5 lbs.; shoes with 1" heels) (Harrison 1985)

Scope of The Problem

BCBS of MN Report

Obesity and Future Health Care Costs:A Portrait of Two Minnesotas (4)

Scope of the Problem

Less than ¼ of Minnesota Adults will be at a healthy weight by 2020

Adult obesity related conditions could cost Mi t t l t dditi l $900 illiMinnesota at least an additional $900 million per year by 2010; 3.7 billion by 2020

BCBS (4)BCBS (4)

Scope of the Problem

In national rankings, Minnesota ranks 21st

out of all states, BUT Minnesota is becoming obese at a faster rate than the rest of the nationnation

BCBS (4)

Scope of the Problem

31% f t f 2005 2020 ill b d t31% of costs from 2005-2020 will be due to projected increases in the number of people who are overweight and obesewho are overweight and obese

In 2020, it will cost 61% more to treat an , %obese patient than a healthy weight patient (4)

Scope of the Problem

According to WHO (5), globally more than one billion people are overweight, at least one

illi bmillion are obese

O t iti d d t iti ft i tOver-nutrition and under-nutrition often co-exist side by side

Why Should We Care?

Affects all ages, social and economic groups

Obesity is a major contributor to global burden of chronic disease and disability

WHO (5)

Medical Complications

Type 2 DiabetesCoronary Heart DiseaseHypertensionOsteoarthritisBirth DefectsCarpal Tunnel SyndromeChronic Renal Insufficiencyy

Medical Complications

CancersWomen: gallbladder, uterine, may be

breastMen: prostate, rectalBoth: Colon

Daytime sleepinessEndstage renal disease

Medical Complications

Deep Vein ThrombosisGallbladder diseaseGoutHeat DisordersImpaired Immune responseImpaired Respiratory FunctionInfections Following Woundsg

Medical Complications

InfertilityLiver DiseaseLow Back PainObstetric and Gynecologic ComplicationsPainPancreatitisSleep Apneap p

Medical Complications

StrokeSurgical ComplicationsStress IncontinenceOtherSee www.obesity.org (6)Fast FactsHealth Effects of Obesityy

M t b li S dMetabolic SyndromeAmerican Heart Association

Characterized by a group of metabolic risk factors in one personfactors in one person

– Abdominal obesity– Atherogenic dyslipidemia (high triglycerides, low HDL, high

LDLLDL– Elevated blood pressure– Insulin resistence or glucose intolerance

P th bti t t (hi h fib i l i ti t– Prothorombtic state (high fibriogen or plaminogen activator inhibitor – 1 in blood)

– Proinflammatory state (elevated C-reactive protein)

M t b li S dMetabolic SyndromeAmerican Heart Association

Metabolic syndrome causes high risk for:– Coronary heart disease– Stroke– Peripheral artery disease

Type 2 diabetes– Type 2 diabetes

M t b li S dMetabolic SyndromeAmerican Heart Association

Other associated conditions:– Physical inactivity– Aging– Hormonal imbalance

Genetic predispositioin– Genetic predispositioin

M t b li S dMetabolic SyndromeAmerican Heart Associaiton

Generally accepted criteria:– Elevated waist cirumferenceElevated waist cirumference

Men equal to or greater than 40 inchesWomen equal to or greater than 35 inches

– Elevated triglycerides G /Greater than or equal to 150 mg/dL

– Reduced HDLMen less than 40 mg/dLWomen less than 50 mg/dLWomen less than 50 mg/dL

Elevated blood pressure– Elevated fasting glucose

Equal to or greater than 100 mg/dL

M t b li S dMetabolic SyndromeAmerican Heart Association

Recommended clinical management– Reduce risk factors for cardiovascular disease

and type 2 diabetesStop smokingStop smokingReduce LDL cholesterol, blood pressure and glucose levels to recommended levels

M t b li S dMetabolic SyndromeAmerican Heart Association

Recommended lifestyle interventions– Weight loss to achieve a desirable weight

BMI less than 25 kg/m2

Increased physical activity– Increased physical activityAt least 30 minutes moderate-intensity activity most days of the week

– Healthy eating habitsReduced intake of saturated fat, trans fat and cholesterol

Preventable Factors Leading to Death

#1 cause of preventable death currently is ki (435 000/ )smoking (435,000/year)

#2 cause of preventable death is obesity (400 000/ )(400,000/year)If obesity trend continues obesity soon to overtake smoking as the nation’s leadingovertake smoking as the nation s leading cause of death – Former US Surgeon General David SatcherGeneral David Satcher

Rehab Complications

Obese Patients Stay in Hospital Longer– Increased $$$– Hip and Knee Surgery Extremely overweight 1/3

longer, costs 30% more– Moderate obesity lengths of stay and cost similar– Moderate obesity, lengths of stay and cost similar

to normal weight individuals (Am J Health 1987)

Causes of Weight Gain

Medical Causes– Diseases– Medications

G tiGeneticEnvironmental

Ch i Di t– Change in Diet– Change in Physical Activity

Medical Causes of Weight Gain

Congenital Heart DiseaseCushing’s SyndromeHypothyroidismKidney FailurePolycystic Ovary SyndromePregnancyg y

M di ti C t ib ti tMedications Contributing to Weight Gain

AntidepressantsAnticonvulsantsDiabetes MedicationOral ContraceptivesCorticosteroidsHigh Blood Pressure MedicationsAntihistamines

Genetic Causes of Weight Gain

If one or more parents are obese (Whitaker 2000)2000)Genetics vs shared lifestyleGenetics affect hormones involved in fatGenetics affect hormones involved in fat regulationLeptin Deficiency (Farooqi 2007)p y ( q )Race (affects onset and rapidity of weight gain) (Vahratian A 2008)

E i t l CEnvironmental Causesof Weight Gain

WHO (5)

– The key causes are increased consumption of d f d hi h i t t d f t denergy-dense foods high in saturated fats and

sugars, and reduced physical activity.

Psychological Factors

BoredomSadnessSadnessStressAngerAnger

M di l T t tMedical Treatment of Obesity

Bariatric SurgeriesPost-Bariatric Plastic SurgeryMedicationsLifestyle Modification

B i t i S iBariatric SurgeriesRoux-en-Y (11)

Bariatric SurgeriesG t i B diGastric Banding(11)

B i t i S iBariatric SurgeriesVertical Banding (11)

B i t i S iBariatric SurgeriesBiliopancreatic Diversion(11)

M di l C diti I dMedical Conditions Improvedby Bariatric Surgery (11)

Type 2 diabetesHypertension

DyslipidemiasCADHypertension

OSAObesity hypoventilation

CADCardiac dysfunctionVenous stasis diseasey yp

GERDDepressionDJD

Polycystic ovary syndromeInfertilityDJD

Quality of lifeInfertilityCancers

Conventional Treatment

Diet– Outside our scope of practice, but information

from other healthcare providers can be reinforced and tools providedand tools provided

Exercise– This is our expertise!p

One size

Eat This, Not That

Eat This, Not That!

BaconOr

Sausage?Sausage?

Eat This, Not That!

B SBacon– 42 calories– 3 g protein

Sausage– 82 calories– 4 g proteing p

– 0 carbs– 1 g fat

0 fiber

g p– 0 carbs– 7 g fat

2 6 saturated– 0 fiber 2.6 saturated– 0 fiber

Eat This, Not That!

Glazed DonutOrOr

Cake Donut?

Eat This, Not That

Gl d D t C k D tGlazed Donut– 180 calories– 3 g protein

Cake Donut– 300 calories– 4 g proteing p

– 25 g carbs– 8 g fat

1 5 g saturated fat

g p– 28 g carbs– 19 g fat

5 g saturated fat1.5 g saturated fat– 1.5 g fiber

5 g saturated fat– 6 g fiber

Eat This, Not That

McDonald’s Quarter Pounder with CheeseOr

Burger King Whopper with Cheese?

Eat This, Not That

McD’s 1/4er pounder with cheese

BK Whopper with cheesewith cheese

– 510 calories– 29 g protein

cheese– 800 calories– 35 g protein

– 43 g carbs– 25 g fat

12 g saturated

– 53 g carbs– 49 g fat– 4 g fiberg

– 3 g fiber– 1150 mcg sodium

4 g fiber18 g saturated

– 1450 mcg sodium

B t I h ft hild ll dBut I chase after my children all day long! My job is really physical!

Info on next slides are for 30 minutes of activity for a person weighing 150 lb (13)

But . . . I’m active!

House work, 135 calories

Shopping for groceries, 90 caloriescalories

Ironing, 75 caloriesMopping 111 calories

90 caloriesSnow shoveling, 292 caloriesMopping, 111 calories

Mowing, 202 caloriesRaking, 112

Vacumming, 112 calories

Common Exercise Activities

Biking, 10 mph, 188 calories

Jogging12 i il 278calories

Biking, 13 mph, 300 calories

– 12 min mile, 278– 10 min mile 345

RunningGardening, 135 caloriesWalking

g– 7.5 minute mile, 458– 6.7 minute mile, 495

– 30 minute mile, 90– 20 minute mile, 120– 15 minute mile, 150

– Treatment Goals!

,

Lets Assess Ourselves!