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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!