Weighing In: Help Your Patients Fight Obesity and Win!

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By Miki Fairley

Everywhere we turn, we are urged to exercise and get fit. Never before has there been so much readily available information about healthful, delicious food, how to prepare it, and what good nutrition is all about, including online recipes, nutrition and diet advice, books, DVDs, and television cooking shows.

Despite this cornucopia of self-help options, however, the number of overweight and obese Americans continues to climb. According to the Centers for Disease Control and Prevention (CDC), 34 percent of adults aged 20 years and older are overweight (defined by the CDC as a body mass index [BMI] between 25 and 29.9); the percent of obese adults (defined by a BMI of 30 or higher) also is 34 percent, for a total of 68 percent.

And the news gets worse: according to a study by the Organization for Economic Cooperation and Development (OECD), an international organization comprising 33 leading economies, three out of four Americans will be overweight or obese by 2020. The problem isn't unique to the United States, however. Citizens of the world's richest countries are getting fatter, the OECD report notes. Unless governments, individuals, and industries cooperate on a comprehensive strategy to combat the epidemic, disease rates and healthcare spending will balloon, the report predicts. (Author's note: The OECD report is summarized by AP writer Greg Kelly in the article, "Number of Fat People in US to Grow, Report Says," September 23, 2010: abcnews.go.com/Health/wireStory?id=11708959)

Toxic Cocktail

As people gain weight and reach overweight and obese levels, the risks for a toxic cocktail of diseases and conditions increase, including coronary heart disease, type 2 diabetes, high cholesterol and triglycerides, stroke, liver and gallbladder disease, and osteoarthritis. Being overweight or obese can also exacerbate these conditions after they develop.

Simply urging people to eat less and move more oversimplifies the factors that contribute to weight gain, however. Other barriers to weight loss include the inaccessibility of healthful foods and the cost of healthier food choices versus "junk" food in tough economic times-and yes, research has shown that fast food addiction is a real condition. Concerns about crime and safety can keep more vulnerable older and disabled persons indoors. Lack of nutrition education and years of poor nutrition and exercise choices also play a role.

Your Patients: Part of the Picture

Amputees and orthosis users form part of this picture; O&P patients who are obese and overweight face additional, significant challenges. Fortunately, the outlook for this patient population need not be bleak. There are solutions that can help O&P practitioners reach out to these patients. Although this article focuses primarily on older prosthetics patients, much of this information can be helpful to orthosis wearers and younger O&P patients as well.

Getting Their Attention

"If an amputee brings it up, opens the door to a discussion, we're going to go for it," says M. Jason Highsmith, DPT, CP, FAAOP, assistant professor at the School of Therapy, University of South Florida (USF), Tampa. "Sometimes you really have to paint a gloomy picture to get their attention."

However, Highsmith also brings up the enhanced quality of life that is possible with good weight control, such as a wider selection of quality prosthetic components, which can lower costs and increase the amount patients are able to enjoy participating in physical activities-not to mention the psychological lift of looking and feeling better.

There are a number of negative consequences of being overweight or obese, besides the cardiovascular and musculoskeletal issues, according to Highsmith:

  • Limited and more expensive component options.
  • Problems with socket fit and comfort, which can lead to pain and skin breakdown.
  • Limited choices in socket design and suspension.
  • Increased difficulty in physical activity, exacerbating weight gain and deconditioning.

Regarding increased osteoarthritis and joint replacement risk, Highsmith says, "Imagine you're a transtibial amputee and now you need a knee replacement in your amputated leg."

"For every pound of body weight you gain, your knees gain three pounds of added stress; for hips, each pound translates into six times the pressure on the joints," an article on the Arthritis Today website (www.arthritistoday.org) concurs. After many years of carrying extra pounds, the cartilage that cushions the joints tends to break down more quickly than usual, the article adds. "Conversely, losing weight can reduce additional stress on joints that can cause cartilage to wear away. Easing the pressure on joints by shedding extra pounds can also reduce pain in osteoarthritis-affected joints, which will help you feel and move much better."

Robert S. "Bob" Gailey Jr., PhD, PT, associate professor, Department of Physical Therapy, University of Miami Miller School of Medicine, Florida, and a researcher at the Miami Department of Veterans Affairs (VA) Health Care System, Florida, explains, "When we teach people how to maintain equal weight bearing between lower limbs, we know they will place between one and one half total body weight on the prosthesis when the foot strikes ground." For overweight and obese amputees, that much pressure and weight on their residual limb can be especially uncomfortable, so they tend to rely on their sound limb more. "About 20 percent of the general geriatric population will develop osteoarthritis of the knee," Gailey continues. "If they are transtibial amputees, that percentage rises to about 30 percent, and for transfemoral amputees, it climbs to about 60-80 percent. You now have a double whammy with increased weight bearing being borne on both the prosthesis and the sound limb."

Prosthesis Issues

Highsmith points out that as amputees gain weight, their prostheses may at first become uncomfortable, then painful, skin may break down, and the device may not fit properly, requiring a replacement at a greater cost. Generally, insurance companies will not pay for a new prosthesis simply because of weight gain or loss. "However, it's easier for us to deal with weight loss than with weight gain because we can do simple, low-cost or no-cost things like pad a socket or pull a flexible, thicker interface."

Some amputees worry that they could lose so much weight that a new prosthesis would become necessary and would not be covered by insurance. "Many insurance programs only pay to replace a prosthesis every two to five years, and that's not realistic for someone on a weight-loss program," Highsmith says. "Then we bring together the physician, the therapist, and the prosthetist and write well-documented letters of medical necessity that show that losing this weight, even if a new prosthesis is needed, is in the insurance company's best interest in overall cost savings by cutting other expensive overweight/obesity risks such as heart attacks, strokes, and joint replacements, as well as benefitting the patient." This approach has produced good results for patients who lost a large amount of weight, Highsmith says.

Amputees who are obese face limited options when it comes to available prosthetic componentry, socket design, and suspension. Obtaining a comfortable fit is also difficult.

An article co-authored by Highsmith and Jason Kahle, CPO, LPO, West Coast Brace & Limb, Tampa, Florida, in the March/April 2008 issue of inMotion, published by the Amputee Coalition of America (ACA), stresses the importance of firm tissue consistency in fitting a socket that will provide good prosthetic control, gait stability, and weight bearing. When there is too much fat tissue between the muscles and the socket, the article contends, the muscles can't provide a firm foundation for the socket. The effect is somewhat like trying to build a house on mud rather than stone.

Quality Care for High-Weight Amputees

Kevin Carroll, MS, CP, FAAOP, vice president of prosthetics for Hanger Prosthetics & Orthotics, Austin, Texas, points out that many overweight/obese amputees simply aren't likely to lose weight and get fit, and perhaps don't even want to-and that prosthetists need to be prepared to give this population quality care that takes into account their unique issues.

"We do talk about nutrition and strategies to help manage their situation," Carroll says, "but some will tell you right away, 'This is just what I am,' and we say, 'Well, that's fine.'

"We as clinicians need to manage their expectations-those are the keys words: 'manage expectations,'" he adds.

Carroll comments that prosthetists are fortunate that some manufacturers are building components that can tolerate a weight load up to 500 pounds. "With the materials available today, these components can be strong, yet lightweight," he says.

Although Carroll sees adequately equipped facilities, he also sees some that are not prepared for larger patients. Clinicians need to make sure their facilities can accommodate overweight/obese patients, such as having a chair that is comfortable and will hold their weight and an examination table that is strong enough to accommodate them, he says. "Doors have to be wide enough for them to go through, whether in a wheelchair or walking.

"As clinicians, we will continue to see this very important population come into our clinics across America," Carroll observes. "Again, it's our responsibility to be prepared to care for them and figure out how to manage them."

Fast Food versus Healthy Food: It Really Is All in Your Head

Would you be surprised to see a Harvard-trained doctor, lawyer, medical school dean, and former commissioner of the U.S. Food and Drug Administration (FDA) dumpster diving in the dead of night?

This is what former FDA Commissioner David A. Kessler, MD, JD, did as he compiled research for his book, The End of Overeating, published in 2009.

Kessler was a man on a mission. He wanted to understand a problem that had vexed him since childhood: why he couldn't resist certain foods, according to an article in The Washington Post ("Crave Man: David Kessler Knew That Some Foods Are Hard to Resist; Now He Knows Why," Lyndsey Layton, April 27, 2009). "His resulting theory...is startling," Layton's article states. "Foods high in fat, salt, and sugar alter the brain's chemistry in ways that compel people to overeat."

For instance, Kessler's dumpster diving revealed that one chain restaurant's egg roll appetizers topped out at 910 calories, 57 fat grams, and 1,960 milligrams of sodium. Instead of satisfying hunger, the salt-fat-sugar combination will stimulate a diner's brain to crave more, according to Kessler. The food industry manipulates this neurological response, designing foods to induce people to eat more than they should or even want, Kessler found, a revelation that takes into account not only fast-food chains but regular restaurant chains. "His theory, borne out in a growing body of scientific research, has implications not just for the increasing number of Americans struggling with obesity but for health providers and policymakers," Layton says.

And if the potential for addiction isn't bad enough, fast food is just that-fast and convenient. Various research studies show that fast food also is generally cheaper than healthier alternatives, thus more appealing in difficult economic times. Fresh fruits and vegetables are often difficult to access in lower-income neighborhoods, adding to the problem.

Highsmith says that he is seeing this scenario play out in South Florida. "If you are part of a lower-income family, soda is cheaper than [bottled] water, and if you're already stressed over being overworked and underpaid like everybody else, you're likely going to buy the soda. So there are a lot of factors that go into what families are deciding to put in their grocery carts."

Highsmith continues, "Fast-food chains like McDonald's go to great lengths to make sure their feature items-burgers and fries-are very affordable, to the point that it would probably be cheaper to feed your family at McDonald's than go to the grocery store and buy fresh fruits and vegetables."

He adds, "When there's a major economic downsizing like now, it makes more sense to many people to make those unhealthy decisions if they think the financial perspective outweighs the health issues."

Solutions to Better Nutrition

When junk-food addiction is the problem, clinical psychologist Douglas Lisle, PhD, director of research, TrueNorth Health Center, Rohnert Park, California, says that patients have had the most success in breaking the addiction through "therapeutic fasting."

"In essence, [they are] rebooting the 'hard drive' in their brain through a period of water-only fasting in a medically supervised setting, followed by the introduction of a diet emphasizing fresh fruits, vegetables, whole grains, beans, nuts, and seeds, according to a WebMd article (www.webmd.com/diet/features/break-your-food-addictions, reviewed December 6, 2010).

If this is too difficult, Neal Barnard, MD, author of Breaking the Food Seduction, recommends quitting the foods you crave "cold turkey," according to WebMD. Barnard says this works much better than trying to eat them in moderation. "At the end of three weeks, your tastes will have changed," he says. "You won't want the food as much anymore."

Gailey notes that the CDC and the American Diabetes Association (www.diabetes.org) provide a wealth of healthful-eating information, menu-planning tools, recipes, and other resources-all for free. The U.S. Department of Agriculture (USDA) provides helpful information as well (www.usda.gov). An informative CDC webpage can be found at www.cdc.gov/nutrition/everyone/resources/index.html

Smart shopping tips can also help. For instance, watch for weekly produce sales, stock up on sale items and freeze what you can't use right away, team up with family or friends to share bulk buys at good prices, buy frozen vegetables when fresh is too costly, use coupons, make a list and stick to it, don't shop hungry-and leave the kids at home, if possible.

To help in your personal diet planning, WebMD provides a "BMI Calculator Plus" interactive tool at www.webmd.com/diet/calc-bmi-plus#moreWTH. After the user inputs the required information, the calculator provides not only the user's BMI but also waist-to-height ratio, often considered to be the best indicator of health related to weight, along with the recommended number of calories per day for reaching the user's weight goal.

Regarding diets, weight-control programs, and exercise programs, it is recommended that patients consult their physician or other qualified healthcare professional.

Exercise

Exercise can be a challenge for older amputees. Depending on the cause and level of amputation, amputees expend between 10 and 60 percent more energy than non-amputees walking at a reduced speed, Gailey explains. For overweight/obese persons, the additional weight results in even higher energy expenditures. "It is hard to begin even the minimum threshold of exercise because they have to work harder and have to be willing to do so."

The Centers for Disease Control and Prevention (CDC) and other sources report that people from some countries average around 10,000 steps per day; the average American only takes about half as many, Gailey says. "The average amputee takes a little less than 2,000 steps, less than half as many as average Americans, who only walk about half as much as people from some other countries."

Highsmith points out that fear of crime can be a deterrent to walking or bicycling in some neighborhoods, plus the cost of fitness centers or golf courses may be prohibitive for many. "Virtual fitness" devices such as Wii Fit and other home exercise equipment can be a viable alternative, he notes.

Gailey mentions that going to a mall to walk can be a good option, especially in quiet, early-morning hours. He advises obtaining a pedometer, which not only tracks the number of steps a person takes, but can also serve as an incentive to reach goals.

Gailey encourages amputees to become involved in support groups, such as those offered through the ACA. "We know that one of the most effective ways to get amputees back into the community is through support systems. If you can connect with people and share what you're going through, you may be able to avoid the traps of depression and isolation." Finding friends to exercise and enjoy recreation with is a good motivator as well, he adds.

"I encourage people to join organizations such as the Challenged Athletes Foundation (CAF) or other groups that have activities and to set goals throughout the year such as five-mile walks, golf outings, or ski trips," Gailey says. "And nobody ever leaves my care without telling me which gym, wellness center, or community center they'll be going to."

Sunny Outlook

Highsmith sums up a sunny picture for geriatric O&P patients: "Certain chronic conditions tend to ramp up with age-cardiovascular conditions and osteoarthritis, for instance. If you start exercising, you may need a little more guidance and monitoring to get that exercise program up and running.

"But the good news is that there is plenty of data to show that even at an advanced age, you can still get cardiovascular benefits and strength gains from an exercise and conditioning program, just as you could when you were young. The gains may not be as rapid, but if you do make lifestyle changes in diet and exercise, the gains should be there for you if you stick with it."

Then, with improved quality of life and wider horizons, O&P patients can say along with Abraham Lincoln: "And in the end, it's not the years in your life that count. It's the life in your years."

Miki Fairley is a freelance writer based in southwest Colorado. She can be reached at