Greater Attentional Cost of Standing With Obesity
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… Read More »
Supersizing Health Care
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
Bariatric Rehabilitation: Call to Action
In the past years, the Canadian Obesity Network has hosted two think tanks on the importance of rehabilitation expertise in the prevention and management of severe obesity. The proceeding of the first bariatric rehabilitation workshop held in Edmonton, Alberta in 2008 was now published in the latest edition of Disability and Rehabilitation. Participants at this think tank consisted of around 50 health professionals, administrators, researchers and even EMS professionals. The main goal of this workshop was to identify gaps in research and professional training that need to be addressed in light of the burgeoning number of individuals with severe and extreme obesity in Canada. According to this paper: “Gaps in knowledge and research included the need for better understanding of the biopsychosocial causes and consequences of obesity and the role for novel and existing rehabilitation interventions to prevent and treat obesity. Research is needed to explore how existing rehabilitation interventions and technology impacts the patients with obesity, who also have physical and psychological impairments typically treated by rehabilitation practitioners. Although the need for rehabilitation for persons with obesity is documented in the literature, the capacity in terms of human resources, funding for research and technology and the development of bariatric friendly, accessible environments is limited. Participants of this meeting reinforced the need to develop training programmes in the form of continuing education and the inclusion of topics in bariatrics in discipline specific training programmes. Additionally, in order for patients, their families and healthcare professionals to have access to obesity prevention and treatment services, models of care and education that reach out to rural and marginalised communities must be used. These currently exist through forms of telehealth, webinars and online courses.” Clearly a bariatric rehabilitation is a topic that deserves far more emphasis in the training of health professionals and an area where there is an urgent need for rehabilitation research regarding best practices in dealing with this rapidly growing vulnerable population. A full report on the Canadian Obesity Network’s First Bariatric Rehabilitation Think Tank can be downloaded here. AMS Edmonton, Alberta Hat tip to Mary Forhan, first author of this paper, and congratulations on the recent successful defense of her PhD thesis.
When Apple is a Bad Word
This weekend I experienced my first trip to the Yukon, where I attended the 2008 Conference of the Canadian Association of Occupational Therapists (CAOT) in Whitehorse. CAOT is a partner of the Canadian Obesity Network and I believe that this was the first time that a CAOT conference featured a professional issue forum on Obesity and Healthy Occupation. Speakers in this session, chaired by Mary Forhan (McMaster), included Kim Raine (U Alberta), Gaye Hanson (Hanson & Associates) and myself. While Kim talked about how obesity has to be seen in the context of societal changes and pressures and I presented the medical perspective on obesity as a chronic disease, Mary talked about the role and opportunities for occupational therapists in obesity prevention, treatment and in allowing patients with obesity to live complete and dignified lives (no matter how good our prevention or treatments, there will always be obese individuals in our society). Gaye, a former Midwife and ex-Deputy Minister of Health and Social Services in the Yukon, herself of Cree Ancestry, presented a most enlightening view of the challenges of addressing obesity in Aboriginal populations. But for me the most moving insights came from the closing remarks by Madeleine Dion Stout (picture), who was also the keynote speaker at the conference. Born and raised on the Kehewin First Nation in Alberta and nursing graduate from the Edmonton General Hospital, Madeleine worked for many years in the Medical Services Branch of Health Canada and has been a member of dozens of First Nations health committees and task forces aimed at improving the health of First Nations, Inuit and Metis. The one sentence that I found particularly enlightening was (in the context of obesity – “apple and pears”) “don’t ever refer to an Indian as an apple!”. For an Indian, an apple implies being “red” on the outside but “white” on the inside – not a very polite thing to say! All goes to show how cultural context can fully change the meaning of even the most seemingly innocuous words. Most interestingly, Madeleine, herself a “victim” of residential schools made the same connection between the pain, suffering, broken spirit and shame inflicted by residential schools and the increased risk for obesity that I had made in my blog posting a day earlier. Imagine my surprise, as Madeleine of course was unaware of my take on the “apology”. Overall a most insightful weekend… Read More »
Rehabilitation Research in Severe Obesity
Severe obesity, an increasingly common condition, is posing an important challenge not just for patients with this disease but also for health professionals attempting to provide the best possible care for this population. From doors not wide enough for oversized wheelchairs to limited weight capacity of diagnostic equipment, patients with severe obesity face a wide range of important obstacles to accessing and benefiting from urgently needed health care. We recently examined this in an article published in the Journal of Advanced Nursing, in which we reported on the need for specialized equipment and staff education to ensure adequate management of obese patients in the emergency department. Yesterday, I attended a full-day invitation-only Think Thank on Bariatric Rehabilitation co-hosted by the Canadian Obesity Network, the University of Alberta School for Rehabilitation and Capital Health held at the TELUS Centre for Professional Development, Edmonton. The meeting was attended by over 50 participants including University of Alberta researchers from a wide range of areas including occupational therapy, physiotherapy, rehabilitation medicine, nursing, biomechanical engineering, mechanical engineering, civil and environmental engineering, physical education, and other relevant areas. On the Capital Health side there were several high-level administrators responsible for acute care, long-term care and community care services as well as front line health professionals from various regional hospitals and health regions. Other stakeholders included the Canadian Association of Occupational Therapists, Emergency Medical Services as well as suppliers for bariatric equipment. It was clear to all that there is a wide knowledge gap regarding providing the proper medical care and rehabilitative services to patients with severe obesity and that the range of challenges to the healthcare system and particularly to front-line health professionals are largely unrecognized and unstudied. There was a consensus that bariatric rehabilitation should be high on the research agenda of various faculties within the University of Alberta and could build on many strengths in rehabilitation services that already exist within the Capital Health Region and Alberta. I learnt a lot and look forward to working with all attendees to develop a detailed research agenda to better understand the needs and find solutions to this important but largely invisible problem. AMSEdmonton, Alberta
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