Although metabolic benefits are often presented as one of the key benefits of bariatric surgery, in my experience, the benefits to patients in terms of less pain and mobility have always been far more impressive.
Now, a study by Wendy King and colleagues, published in JAMA, confirms these clinical observations in a large cohort of patients undergoing bariatric surgery for severe obesity.
The researchers looked at data from the Longitudinal Assessment of Bariatric Surgery, an ongoing observational cohort study at 10 US hospitals.
Based on results of 2221 participants (89% women, median BMI 46, median age 47), bariatric surgery at 1 year post surgery resulted in a clinically meaningful improvement in 60% of participants for pain, 75% for physical function, and 60% for walk time.
These improvements were largely related to significant reduction in disability related to knee and hip pain.
Nevertheless, the researchers also found that between year 1 and year 3, rates of improvement significantly decreased to 50% for pain and to 70% for physical function, although improvement rates for walk time, knee and hip pain, and knee and hip function were largely sustained.
Variables that appeared to increase the chances of post-surgical benefits included younger age, male sex, higher income, lower BMI, and fewer depressive symptoms presurgery; no diabetes and no venous edema with ulcerations postsurgery (either no history or remission); and presurgery-to-postsurgery reductions in weight and depressive symptoms.
Given that (in contrast to metabolic problems) there are few effective medical treatments for pain and mobility, these “benefits” of bariatric surgery certainly warrant greater attention as it is often these (and not the metabolic problems) that determine the often poor quality of life associated with severe obesity.
The title of this post may sound like a “no-brainer”, but the research literature on the long-term health benefits of weight loss from longitudinal intervention studies in people with severe obesity is much thinner than most people would expect.
Thus, a new study from our group, that looks at the relationship between changes in body weight and changes in health status over two years in patients with severe obesity enrolled in the Alberta Population-based Prospective Evaluation of the Quality of Life Outcomes and Economic Impact of Bariatric Surgery (APPLES) study, published in OBESITY, may well be of considerable interest.
As described previously, APPLES is a 500-patient cohort study in which consecutive, consenting adults with BMI levels > 35 kg/m2 were recruited from the Edmonton Adult Bariatric Specialty Clinic. The 500 patients enrolled were between 18 and 60 years old and were either wait-listed (n=150), beginning intensive medical treatment (n=200) or had just been approved for bariatric surgery (n=150). Complete follow-up data at 24 months was available for over 80% of participants.
At study enrollment, the proportion of patients who reported >2 and >3 chronic conditions was 95.4% and 85.8%, respectively. The most common single chronic conditions at baseline were joint pain (72.2%), anxiety or depression (65.4%), hypertension (63.4%), dyslipidemia (60.4%), diabetes mellitus (44.6%), gastrointestinal reflux disease (35.4%), and sleep apnea (33.5%).
After 2 years, just over 50% of participants had maintained a weight loss > 5%, with a mean weight change for the entire cohort of about 13 kg.
Losing > 5% weight was associated with an almost 2-fold increased likelihood of reporting a reduction in multimorbidity at 2-year follow-up, whereby outcomes varied between treatment groups: in the surgery group, the top three chronic conditions that decreased in prevalence over follow-up were sleep apnea (43% at baseline vs. 25% at 2 years,), dyslipidemia (60% vs. 47%), and anxiety or depression (59% vs. 47%); in the medically treated group anxiety or depression (69% vs. 57%) and joint pain (77% vs. 67%); and none in the wait-listed group.
As expected, any reduction in multimorbidity was associated with a clinically important improvement in overall health status.
In summary, this paper not only documents the considerable multimorbidity associated with severe obesity, it also documents the clinically important improvement in health status associated even with a rather modest 5% weight loss over 2 years in these individuals.
Osteoarthritis is one of the most common and disabling complications of obesity. Irrespective of whether or not the osteoarthritis is directly caused by excess weight, there is little doubt that the sheer mechanical forces acting on the affected joints will significantly impact mobility and quality of life.
Now the Canadian Agency for Drugs and Technologies in Health (CADTH) has released a report on the Clinical Effectiveness of Obesity Management Interventions Delivered in Primary Care for Patients with Osteoarthritis.
This systematic review of the literature leads to the following findings:
1) Dietary weight loss interventions, either alone or in combination with exercise produce greater reductions in the peak knee compressive force and plasma levels of interleukin-6 (IL-6) in knee OA patients compared with exercise-induced weight loss.
2) There is a significantly greater reduction in pain and improvements in functions in patients who received diet plus exercise interventions compared with either diet–only or exercise–only interventions.
3) Regardless of the type of weight-loss interventions, participants who lost 10% or more of baseline body weight had greater reductions in knee compressive force, systemic IL-6 concentrations, and pain, as well as gained greater improvement in function than those who lost less of their baseline weight.
4) Participants who lost the most weight also experienced greater loss of bone mass density at the femoral neck and hip, but not the spine, without a significant change of their baseline clinical classification with regards to osteoporosis or osteopenia.
Thus, in summary, weight loss, particularly when achieved through a combination of both diet and exercise can result in significant improvement in physical function, mobility, and pain scores in individuals with osteoarthritis.
Unfortunately, this is by no means easy to achieve and even harder to sustain.
Although I may sound like a broken record – we desperately need better treatments for obesity.
Reason enough to turn my readers attention to a “tip sheet” developed by members of the Alberta Health Services’ Bariatric Resource Team that explains when to refer their patients with obesity to an occupational therapist.
The preamble to this sheet notes that,
“Occupational therapists promote health and well being for people with obesity by facilitating engagement in occupations of everyday life, including addressing occupational performance issues in the areas of self-care, productivity and leisure. This can impact quality of life, including how people with obesity participate in their daily lives and in health and weight management activities.”
Occupational therapy referral may be indicated for a person with obesity presenting with challenges ranging from occupational engagement to completing simple activities of daily living.
Happy OT month!
Many people living with obesity experience significant physical limitations that can be addressed with appropriate physical therapeutic approaches.
Now, the Bariatric Resource Team of Alberta Health Services has compiled a “Tip Sheet“ that briefly highlights the role of physiotherapeutic interventions in the care of people with obesity.
The sheet includes recommendations on the following topics:
– Challenges With Movement, Pain or Daily Function
– Obesity Related Co-morbidities that Affect Daily Function
– Energy Management
– Posture and Positioning Issues
– Activity Counselling Needs
– Equipment Issues
– Access to Community Resources
This “Tip Sheet” should be helpful to anyone involved in the care of bariatric patients.