Dr. Sharma's Obesity Notes

At a recent talk, I happened to meet a recreational therapist, who expressed an interest in perhaps getting involved in obesity management. I must admit that I had not seriously considered the potential contribution that recreational therapists may bring to the field of bariatric care.

For readers, who are not be familiar with this profession, it may be important to point out that the field of therapeutic recreation recognizes leisure, recreation and play as an integral component of quality of life. Recreational therapists specialize in helping individuals, who have physical, mental, social, or emotional limitations which impact their ability to engage in meaningful leisure experiences.

This is something that would certainly be of relevance to many patients that I see in our bariatric program - many express loss of interest and ability to engage in leisure activity due to the very real barriers posed by their excess weight.

It turns out that recreational therapists are the professional experts in helping clients to rediscover and maximise independence in leisure, optimal health and quality of life.

Recreational therapy has been shown to reduce depression, stress, anxiety, as well as recover or maintain motor functioning, reasoning abilities and build confidence that allows clients to enjoy greater independence and quality of life.

Although, many readers may think that this is a new profession, recreational therapists have been around for a while. For e.g. the Alberta Therapeutic Recreation Association was founded in 1985, i.e. over 25 years ago and has over 400 members.

Established benefits of therapeutic recreation include maintenance of physical and pscyhosocial health, cognitive functioning, personal and life satisfaction, and prevention of complications of physical disabilities and improved self-care and adherence to treatment plans.

These services would most certainly be relevant to many of the severely obese patients that we see in our clinic, who have experienced social isolation due to their excess weight and have certainly lost much of their social network and interactions.

I am not aware of ‘bariatric’ recreational therapists, who have specialized in managing clients with severe obesity or ‘recovering’ from severe obesity following bariatric surgery.

If my reader have, I’d certainly be most interested in hearing about their experiences with recreation therapists and whether or not they found these services helpful.

I most certainly would love to hear from recreational therapists working in this field or who happen to have ideas on what they would bring to obesity management.

AMS
Edmonton, Alberta

One of the most interesting booths here at the International Federation for Surgery of Obesity and Metabolic Disorders in Hamburg is that of a small Danish exhibitor that specializes in bariatric wheelchairs, beds, mattresses and other devices.

This company, with the name XXL Rehab, has evidently put considerable research and expertise into the development of their products - and while I have seen many such devices and mobility aids before, I was particularly impressed by the considerable thought, research and testing that has gone into this particular line of products.

Indeed, the long conversation I had with the young and most enthusiastic owner Keld Jørgensen, was absolutely delightful and educational.

Although this company has yet to expand in North America (they’re still working at expanding in Europe), there is a clear need for such products - certainly not something you can find in your local mobility or medical aid stores.

Interestingly, XXL Rehab is organising a Bariatric Rehabilitation Congress (BRC 2011) in Copenhagen in November, and, from what I see on the program, this two-day meeting (Nov. 9-10, 2011) will certainly be a most interesting meeting for any European colleagues interested in topics like patient and provider safety, skin care and hygiene, exercise interventions, seating and handling and other relevant issues.

AMS
Hamburg, Germany

Osteoarthritis is one of the most disabling and painful conditions attributable (in part) to excess weight. Once established, osteoarthritis significantly reduces quality of life and mobility, often precipitating further weight gain and posing an important barrier to weight management.

A panel of experts (The Ottawa Panel) has now released a comprehensive set of evidence-based clinical practice guidelines for the management of osteoarthritis in overweight and obese patients, published in PHYSICAL THERAPY.

The recommendations are based on an extensive review of published articles with strict application of quality criteria to rate the strength of evidence (A, B, C, C+, D, D+, or D-) as well as experimental design (I for randomized controlled trials and II for nonrandomized studies).

Clinical significance was established by an improvement of ≥15% in the experimental group compared with the control group.

The panel decided on a total of 79 recommendations: 36 positive (21 grade A and 15 grade C+) - all were of clinical benefit.

Overall the data supports the recommendation that physical activity combined with (mildly restrictive) diet programs are beneficial for pain relief, functional status, strength and quality of life.

Although 5% reduction in body weight reduced pain and functional status, this degree of weight loss was insufficient to slow disease progression.

Both aquatic and land-based aerobic exercise were shown to be more effective in reducing pain than home-based strengthening exercises. On the other hand, land-based exercise performed in a gym that included strength, aerobic, stretching, and range-of-motion training was more effective in reducing pain compared with a home-based strengthening exercise program.

These benefits of exercise are independent of any changes in body weight and the authors suggest:

“The significant improvements in QoL among study participants with OA who were obese or overweight may be a reflection of mental health and social benefits associated with the participation in physical activities. Physical activity promotes psychological well-being by reducing feelings of fatigue, depression, and anxiety and improving self-esteem, confidence, concentration, and mental awareness. The social benefits of participation in physical activity include a reduction in the sense of isolation and loneliness, improved social networks and social capital, and increased community connectedness and cohesion.”

Importantly, the authors also note that:

“To the knowledge of the Ottawa Panel, there is no conclusive evidence on the most appropriate methodological scale to apply for OA and obesity research. The use of BMI, waist circumference, and body weight as valid indicators of successful weight loss in individuals with OA is debatable because these measurements do not discriminate between lean and fat body mass.”

Nevertheless, the panel recommends:

“…reducing weight prior to the implementation of weight-bearing exercise to maintain joint integrity and to avoid joint disease and dysfunction.”

How this weight loss is best achieved (and maintained) of course remains open to debate.

Importantly perhaps, the readers should also note that the review did not look at surgical studies, where patients generally experience substantially greater weight loss than with ‘diet and exercise’ alone.

I would certainly love to hear my readers’ experience of the impact of diet and exercise and/or weight loss on their osteoarthritis symptoms. What worked? What didn’t?

AMS
Edmonton, Alberta

p.s. the issue of osteoarthritis and obesity will be an important topic at the upcoming 2nd National Obesity Summit in Montreal next week.

Brosseau L, Wells GA, Tugwell P, Egan M, Dubouloz CJ, Casimiro L, Bugnariu N, Welch VA, De Angelis G, Francoeur L, Milne S, Loew L, McEwan J, Messier SP, Doucet E, Kenny GP, Prud’homme D, Lineker S, Bell M, Poitras S, Li JX, Finestone HM, Laferrière L, Haines-Wangda A, Russell-Doreleyers M, Lambert K, Marshall AD, Cartizzone M, & Teav A (2011). Ottawa Panel Evidence-Based Clinical Practice Guidelines for the Management of Osteoarthritis in Adults Who Are Obese or Overweight. Physical therapy PMID: 21493746

Regular readers may recall previous posts on the finding that obese individuals tend to spend less time on their feet than lean people - a trait that is apparently not corrected by weight loss.

In a study from the Laboratoire TIMC-IMAG in La Tronche, France, just published in PLoS, Jean-Baptiste Mignardot and colleagues show that obese individuals need more attentional resources to control postural stability while standing than non-obese indivdiuals.

These results were based on observations in 10 non-obese (BMI = 22 age = 42) and 10 obese (BMI=35, age=46) adults, who were asked to maintain postural stability on a force platform in while seated or while standing on one leg.

While there were no differences in postural stability while seated, obese participants showed far greater postural instability (measured as centre of foot pressure oscillations) standing on one leg than their lean counterparts.

Additionally, when challenged with an acoustic reaction time test, there were no differences between the groups while seated but, when standing on one leg, obese individuals had substantially slower reaction times, suggesting that they were exerting far more attentional resources on maintaining their stance than the lean participants.

Thus, it appears that to reduce the risk of falling over, obese individuals must dedicate a substantial part of their attentional resources to postural control, to the detriment of non-postural events.

This may well be one reason why obese individuals would prefer to sit down while performing tasks that require their full attention. Thus, standing may not only be physically exhausting for obese individuals (from holding up that extra weight) but also mentally exhausting from the increased mental demand required to maintain their balance.

What the study does not tell us is whether or not this increased attention cost of standing in obese individuals is simply due to lack of training or perhaps a reflection of some innate neurological problem with balance control.

Indeed, the authors propose that the greater problem with balance experienced by obese individuals may be related to changes in their body schema resulting from altered inputs from cutaneous and proprioceptive receptors to their somato-sensory cortical area responsible for balance and coordination.

The study certainly helps me better understand the almost pathological fear of falling expressed by so many of my overweight and obese patients.

Let us not forget that balance and coordination can be made even worse by some medications (e.g. antidepressants) as well as complications of obesity such as arthritis or diabetic neuropathy.

This is certainly a problem that clinicians should be aware of to help prevent falls and injuries in their obese clients.

AMS
Berlin, Germany

Mignardot JB, Olivier I, Promayon E, & Nougier V (2010). Obesity impact on the attentional cost for controlling posture. PloS one, 5 (12) PMID: 21187914

As readers will recall, I am currently co-hosting a national workshop to develop a research agenda for bariatric care in Canada.

Following a most touching and thoughtful kick-off presentation, by two remarkable individuals who shared their personal experiences and battles with severe obesity, most of yesterday was spent reviewing and discussing knowledge gaps in the care and treatment of adults and children with severe obesity.

This condition now affects millions of Canadians and it is clear that there will be no simple solutions in the foreseeable future.

Not only does this mean that we have to be more serious about providing obesity treatments but it also means that we will be seeing an ever increasing number of individuals with severe obesity in our health care system.

This has a wider range of important implications for health authorities, including the challenge of providing safe and appropriate physical environments in clinical facilities.

As outlined by Lili Liu, Professor and Chair Department of Occupational Therapy, University of Alberta, healthcare organizations across the nation will need to adapt their care practices to address the increasing needs of this bariatric population.

As the healthcare industry now works on developing equipment that addresses the requirements for bariatrics, architects and designers must consider the sizes and ratings of exam tables, surgical tables, stretchers, patient beds, imaging equipment, bariatric furniture, floor scales, commodes, wheelchairs, recliners, floor-mounted toilets, lifts, and repositioning devices.

Some of these challenges are nicely outlined in the Planning and Design Guidelines for Bariatric Healthcare Facilities published by the American Institute of Architecture.

Thus, not only is more research required into new treatments, health services delivery and other aspects of patient care, but also into the design and structure of health care facilities.

I would certainly love to hear from individuals with severe obesity, who have encountered problems with accessing health care due to design and physical limitations of health care facilities.

AMS
Montreal, Quebec