Obesity

Disease/Disorder

Definition

Obesity is a condition defined as excessive accumulation and storage of fat in the body with multiple organ-specific consequences. The medical definition of obesity is traditionally measured as ranges of body mass index (BMI). BMI, which is calculated as body weight in kilograms divided by square of height in meters, is the typical method used to estimate body fat, and may be sufficient in non-disease or non-disability states. However, review studies have shown that the commonly used BMI cutoff values have a low sensitivity to detect adipose tissue,^1,2 and may have significant accuracy issues in disease and disability states. BMI does not take into consideration the differences in body composition, especially the percentage of body fat (%BF), which defines obesity. BMI also does not take into consideration the sites of fat accumulation, whether subcutaneous or visceral. Visceral fat, which encases organs such as the liver, heart, and bowel, is strongly associated with the organ specific consequences characteristic of obesity

Measuring Obesity

The accepted standard of measurement for obesity is BMI, although this is only a proxy for %BF (body fat). Clinicians should be mindful of difficulties in using BMI as the sole measure of healthy weight, especially in individuals with disease and disability. Table 1 below compares different methods that measure obesity and/or % BF according to advantages and disadvantages.

Table 1. Measuring body fat

Weight Categories based on BMI

• Adults
  • Underweight: BMI < 18.5 kg/m²
  • Normal weight: BMI 18.5–24.9 kg/m²
  • Overweight: BMI 25.0–29.9 kg/m²
  • Obesity: BMI ≥ 30.0 kg/m²
  • Class 1 (Mild obesity): BMI 30.0–34.9 kg/m²
  • Class 2 (Moderate obesity): BMI 35.0–39.9 kg/m²
  • Class 3 (Severe obesity): BMI ≥ 40.0 kg/m²
• Children (2-19 years)
  • Healthy weight: BMI between the 5^th and <85^th percentiles
  • Overweight: BMI between the 85^th and <95^th percentiles
  • Obesity: BMI ≥ 95^th percentile ³

Etiology

There are many causes for obesity, and an absolute etiology is unknown. A strong contributor is increased caloric intake related to activity level, in combination with genetic or other predisposing causes. Caloric balance is required to maintain a normal body weight. When calories consumed exceed calories expended, weight gain will result. The physiologic equivalent of 1 pound is 3500 calories. Reduced energy expenditure may be more important than increased food intake in causing obesity. Limited activity is a common occurrence in people with many causes for disability. Any alteration to the hypothalamus and arcuate nuclei can affect appetite, satiety, and metabolic rate. Possible genetic risk factors include melanocortin 4 receptor (MC4R) mutation, fat mass and obesity association gene (FTO), and insulin induced gene 2 (INSIG2).

While many physiological and lifestyle factors are shown to play role, there is also a component of genetic heritability found at an individual level. Twin, family, and adoption studies have demonstrated the rate heritability of obesity between 40-70%.⁴ Further research is needed in this area. Leptin and ghrelin are two hormones that have been recognized to have a major influence on energy balance. Leptin is a mediator of long-term regulation of energy balance, suppressing food intake and thereby inducing weight loss. Ghrelin on the other hand is a fast-acting hormone, playing a role in meal initiation. Ghrelin stimulates appetite and induces a positive energy balance that can lead to weight gain. Serum Ghrelin levels increase during fasting and surge shortly before meals.⁵ Leptin levels increase with overeating, reflecting adipose tissue proportion, whereas ghrelin levels rise during fasting and before meals.⁵

Another important factor to consider is the distribution of fat, specifically visceral vs. subcutaneous. Obese patients with visceral fat distribution show a higher abnormality of glucose and lipid metabolism than those with a subcutaneous fat distribution.⁵ Hence, there is a higher prevalence of insulin resistance, diabetes mellitus type 2, hypertension, and coronary artery disease in people with visceral adiposity. This pattern frequently exists in certain disability populations (e.g., spinal cord injury, spina bifida, cerebral palsy). Therefore, insulin resistant diabetes should be recognized in these populations.

Epidemiology including risk factors

• The global prevalence of obesity has risen sharply over recent decades. Between 1990 and 2021, obesity rates increased by 155.1% among males and 104.9% among females worldwide. This upward trend is projected to continue; by 2050, the number of adults classified as overweight or obese is expected to reach 3.8 billion—accounting for more than half of the global adult population.⁶
• Obesity is a global public health concern; however, its prevalence is particularly pronounced in the United States. In 2018, 42.8% of U.S. adults—approximately 76 million individuals—were classified as obese. By contrast, in 2015, Vietnam reported the lowest national obesity prevalence at just 1.6%, underscoring stark international disparities in obesity rates.^7,8
• There are several challenges that people with disability face in trying to prevent obesity. These include difficulty accessing healthy foods, side effects of certain pain medications, reduced ability to exercise, decreased energy, lack of accessible environments and resources.⁹
• Obesity, defined as a body mass index (BMI) ≥ 30, is associated with increased all-cause mortality. Epidemiological data indicate a hazard ratio (HR) of 1.18 for obese individuals compared to their non-obese counterparts, signifying an 18% higher risk of mortality ¹⁰

Patho-anatomy/physiology

Obesity is a complex, multifactorial condition influenced by social, behavioral, physiologic, metabolic, cellular, and molecular interactions.

Risk factors in adults

• Genetic predisposition
• Diabetes mellitus
• Seasonal affective disorder
• Childhood physical abuse
• Shorter sleep duration (<5 hrs. in adults <60 years old)
• Excess pregnancy weight gain with failure to lose weight by 6 months post-partum
• Obesity in social network
• Pre-existing disability that limits mobility (e.g., spinal cord injury), including progressive disabilities (e.g., multiple sclerosis)
• Subacute medical conditions that cause limited mobility, that may not be permanent (e.g., post trauma with multiple fractures)
• Lower socioeconomic status

Risks for childhood and adolescent obesity

• Obesity in older siblings
• Increased birth weight
• Infants with higher BMI or rapid growth rates in infancy
• Television more than 8 hours per week at 3 years of age
• Parental obesity, especially maternal
• Lower parental educational attainment
• Lower self esteem
• Pre-existing disability or conditions that limits mobility (e.g., spina bifida, cerebral palsy), progressive conditions (e.g., muscular dystrophy), and other conditions associated with weight gain (e.g., Prader-Willi, Down Syndrome)
• Lower socioeconomic status

Medical issues

• Neuroendocrine disorders (metabolic syndrome, hypothyroidism, Cushing’s syndrome, hypothalamic obesity, polycystic ovary syndrome, growth hormone deficiency, hypogonadism)
• Medication-induced weight gain (corticosteroids, antidepressants, antipsychotics, antiepileptics, diabetic medications)
• Obesity in and of itself (and associated conditions) can be a cause for increasing disability

Lifestyle issues

• Fast food consumption
• Sedentary behaviors
• Excessive alcohol consumption

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

There are critical periods in development (for children achieving typical milestones) when environmental and nutritional influences can be predispositions to obesity and metabolic disease.¹¹ This “metabolic programming” may account for intergenerational transmission of obesity.¹¹ High maternal BMI and excessive gestational weight gain are risk factors for childhood obesity. The period between the ages of 3 and 10 years is important in terms of predicting future overweight status. Moreover, the risk of being overweight in adulthood is at least twice as great for overweight children as for non-overweight children. This risk is 3 to 10 times higher if the child’s weight is above the 95^th percentile for his or her age. Parental overweight also plays a strong role in this group. Nearly 75% of overweight children age 3 to 10 years remained overweight in early adulthood if they had one or more overweight parent, compared with 25% to 50% if neither parent was overweight.

Obesity in middle age is associated with increased risk of hospitalization and mortality after age 65. These hospitalizations and deaths are from coronary artery disease, cardiovascular disease and/or diabetes.

For people with disability, increasing weight is often associated with decreasing activity as a factor of growth and maturation (for childhood-onset disability types), directly related to the new onset of disability (temporary or permanent), or with decreasing activity over the course of chronic disability.

Consequences and complications

People who are obese compared to those with a healthy weight show an increased risk for¹²

• All-causes of death
• Hypertension
• Dyslipidemia
• Diabetes mellitus type 2
• Coronary heart disease
• Stroke
• Gallbladder disease
• Osteoarthritis
• Sleep apnea and breathing problems
• Some cancers (endometrial, breast, colon kidney, gallbladder, liver)
• Low quality of life
• Mental illness such as clinical depression, anxiety, and other mental disorders
• Body pain and difficulty with physical functioning

There may be an association with

• Slipped capital femoral epiphysis in pediatric obesity
• Lateral femoral cutaneous neuropathy
• Carpal tunnel syndrome

With rapid weight loss, there may be increased risk of

• Peroneal neuropathy Superior mesenteric artery syndrome

Essentials of Assessment

History

Primary care physicians have been identified as taking primary responsibility for weight management. However, all physicians have been called into action to take some responsibility. Physiatrists may take a joint or primary role in management. Weight status may be a component of the referral for mobility issues or pain management, and many physiatrists take a primary role in health management for people with disability. General recommendations for weight management are for screening and evaluation first and foremost.

Screening

• All adults without chronic disability and disease states: determine overweight/obesity using BMI (≥ 25 kg/m²) calculated from actual measures, and/or WC following standards (≥ 35 in/88 cm for women; ≥ 40 in/104 cm for men).
• Children and adolescents without longstanding disability and disease states: routine measured height/weight should be plotted, BMI calculated.
• People with disability: BMI/WC may be used with recognition of limitations; recognize possible sarcopenic component; use of other measures based on disability type (see Table above).

Assessment

• History of present illness: discuss the factors contributing to and associated with obesity–weight gain over time, age/gender (increasing age, hormonal changes), dyspnea, joint pain
• Medication history: steroids, anti-epileptics, antidepressants, antipsychotics²¹
• Sleep history: daytime sleepiness, sleep apnea
• Past medical history: diabetes, thyroid conditions, childhood obesity, level of disability
• Mood disorders: depression/anxiety, eating disorders (binging, bulimia, night-eating);
• Family history: obesity, diabetes, family lifestyle (e.g., eating habits, activity)
• Lifestyle and social history: lifestyle events related to weight changes (e.g., change in marital status, new job, smoking cessation, level of physical activity, family lifestyle, socio-economic status participation in weight management programs,
• Inquire whether the patient has individuals in their social or academic circle—such as peers, classmates, or colleagues—who struggle with managing their weight, and explore how these relationships may have influenced the patient’s own perceptions or behaviors regarding weight management¹³
• Nutritional history: diet diary, fast food intake, soda intake
• Activity pattern: participation in exercise outside of daily routines, change in mobility status, pain or fatigue limiting activity
• Risk assessment: assess likelihood of obesity becoming a chronic problem and thus an important contributor to other medical problems (e.g., hypertension, dyslipidemia, hypertriglyceridemia, diabetes and coronary artery disease); the latter two along with sleep apnea place patients in a very high-risk category for subsequent mortality and must be managed independent of weight loss efforts.
• Functional status: As percentage of body fat (%BF) increases, assessment of most recent functional status is essential for development of a treatment plan and needed modifications.

Physical examination

• The most appropriate direct measure or proxy for %BF should be used. BMI is standardized only for those without disease or long-standing disability and requires accurate on-site measurement of height and weight. Waist circumference or waist-to-height ratio may be used to measure central or abdominal obesity,¹⁴ and may have more utility in people with long-standing disability. One standard measurement should be used to follow trends.
• Examination needed when determining most appropriate intervention:
  • Cardiac, pulmonary, and abdominal exam
  • Musculoskeletal exam, especially when there are complaints of joint pain
  • Balance assessment, 6-minute walk test, Get Up and Go test, and endurance testing

Laboratory studies

• Genetic testing may be pursued for research purposes (mutations noted above)
• For ongoing or primary care evaluation:
  • Endocrine concerns: Thyroid-stimulating hormone (TSH), free T4; 24-hour urine for free-cortisol
  • Lipid profile: asses for comorbid cardiovascular disease risk
  • Diabetes management: Glycosylated hemoglobin or oral glucose tolerance test
• If specific measure of body fat is indicated: skinfold thickness, DEXA, BIA, CT/MRI; will need standardized results by disability for comparison

Imaging

People with obesity and/or disability may require modifications for imaging techniques. MRI and CT have been used to identify visceral adipose and body fat but is not routinely used in the assessment of obesity. Weight bearing hip and/or knee radiographs, if there are symptoms or signs, may allow follow-up over time as needed, but is not standard.

Social and environmental factors

There is an important association between low socioeconomic status (SES) and overweight/obesity. Neighborhoods influence food availability (e.g., cost, distance, healthy and non-super-sized options), access to physical activity (e.g., accessible sidewalks, parks, transportation), and sense of safety (e.g., crime rate, traffic, adequate lighting) in pursuing a healthy weight. Discretionary income often plays a part in access to gyms and health clubs, and services and equipment must be accessible. In addition, parental and family support of unhealthy food choices and a sedentary lifestyle influence the patterns of these in a child and can thus heavily contribute to the development of obesity. Additionally, obesity has been shown to be influenced by social network dynamics. Nicholas Christakis conducted a longitudinal study spanning 32 years and involving over 12,000 individuals to examine the social dynamics of obesity. The findings indicate that obesity is not merely an individual health issue but one that is significantly influenced by social networks. The risk of becoming obese increased by 40% if a sibling was obese, 57% if a friend was obese, and 37% if a spouse was obese. Notably, these associations extended up to three degrees of separation, suggesting that an individual’s obesity could influence even distant social connections, such as a friend of a friend’s friend. This study highlights the potential for social contagion in health behaviors and implies that medical or behavioral interventions targeting a single individual may yield broader effects across their social network.¹³

Rehabilitation Management and Treatments

Available or current treatment guidelines

Guidelines have been developed regarding screening, assessment, and management of obesity in the general population. Common features include emphasis on complications rather than BMI alone, use of multicomponent interventions (e.g., nutrition, physical activity, counseling, behavioral approaches), and highlighting the importance of adherence. The goals of treatment for obesity differ with age and presence of chronic conditions. In younger patients the goal is to decrease mortality and co-morbidities, whereas in the elderly, the focus is to improve quality of life and increase survival without limiting function.¹⁵ It is also important to mention neurogenic obesity seen in patients living with spinal cord injury. This patient population undergoes a significant reduction of anabolic hormones, obligatory sarcopenia, loss of bone mineral content and an increase in fat mass, all in the setting of reduced movement secondary to their injury. This dramatic metabolic change in conjunction with decreased energy expenditure allows for the development of obesity.¹⁶ There are no guidelines, nor suggested modifications to existing guidelines, for the assessment and management of obesity in people with disability. But the goal of treatment in that population may be a combination of the two noted above, i.e., to decrease or modify co-morbidities and to improve mobility and quality of life.  A negative energy balance through modification of food and physical activity behaviors is required to achieve weight loss in most conditions.¹⁷

PM&R practices may require obesity management for patients with acute/subacute disorders that limit mobility (e.g., musculoskeletal pain, post multiple fractures), those with chronic disability (e.g., stroke, cerebral palsy, orthopedic disorders, pain disorders), and those seen within inpatient programs (e.g., inpatient rehabilitation facilities [IRF] or skilled nursing facility rehabilitation programs) following planned or emergency hospitalizations. Morbid obesity is not an IRF qualifying impairment group in its own right, however it is an important factor to take into account when it is present in patients admitted to an IRF. Morbidly obese patients require specialized hospital and durable medical equipment including space to accommodate this and use of overhead lifts to prevent hospital worker injuries. Such patients often require a longer stay to achieve functional independence measure (FIM) gains comparable to those who are not morbidly obese.¹⁸

Efficacy of weight loss programs
Obesity management is difficult because it entails actively changing patterns of behavior not only in an individual but many times also in his/her family. Family or friends making a group effort to support health management strategies may result in more success. Losing weight and maintaining a healthy weight requires lifestyle modifications to decrease calorie consumption (diet) and increase caloric expenditure (exercise) on a daily basis. For people who are obese, that usually means major, life-long lifestyle modifications. Behavior modification involves counseling about or self-management of behaviors that contribute to weight gain, and the factors that may lead to recurrence of those behaviors.¹⁵ Self-management is complex and should include goal setting, monitoring, self-efficacy, problem solving, accountability, social support, relapse prevention, and positive reinforcement/feedback. An element of regular support from health professionals or some routine check-in has proven to be helpful for some. Some studies have shown success in the general population using electronic assistance (e.g., smartphone applications, web-based systems, wearable technology) to provide feedback and reinforcement for lifestyle changes. ¹⁹

In the general population, weight loss peaks at 6 months with interventions (advice/counseling, diet, exercise).¹⁵ Interventions including diet modifications have the most significant effect on weight loss. Effect differences between diets (e.g., Atkins, Ornish, DASH) are of low clinical significance. Physical activity alone rarely results in significant weight loss. However beyond 6 months, significantly greater weight loss is seen in programs that include both diet and physical activity vs either alone.^15,19 In general, adherence to weight management programs is often poor with high attrition rates.²⁰ Higher levels of physical activity (expenditure of 2500 kcals/week) lead to significantly greater long-term weight loss (at 12 and 18 months) as compared with an expenditure of 1000 kcals/week.²¹ The National Weight Control Registry examined the characteristics of individuals who were successful at long-term weight reduction and found that these individuals reported purposeful physical activity resulting in an average expenditure of 2,600 kcal/week.²² The combination of routine diet and exercise can result in greater weight loss (measured as kg lost over time) at 6 months and again at 1 year, compared to diet alone.²¹

Medications
Medications for weight loss are now FDA-approved. Many over the counter (OTC) medications are not effective for weight loss, and some OTC and prescription medications can have serious side effects. A few of the more commonly prescribed are listed below.

Orlistat – Decreases the absorption of dietary fats by inhibiting gastric and pancreatic lipases. Side-effects range from GI discomfort, vitamin malabsorption, steatorrhea, fecal incontinence, to rare post-marketing reports of hepatocellular necrosis and acute hepatic failure, with some cases resulting in death. 

Phentermine – A CNS stimulant that increases the release of norepinephrine in the hypothalamus resulting appetite suppression. It can have very serious side effects including heart valve disorder, primary pulmonary hypertension and severe drug interactions. There is also concern for the development of tolerance, dependance and abuse potential. The FDA classifies this as a schedule IV controlled substance due to these risks.

Phentermine/Topiramate – The CONQUER trial demonstrated that at 56 weeks, patients on a combination therapy of phentermine 15mg and topiramate 92mg lost an average of 10.2 kg, significantly more than the control group.²³ Topiramate is an anticonvulsant that enhances appetite suppression, however the exact pathways are not understood. Side effects of this combination therapy include dry mouth, constipation, insomnia, and dizziness. There is also concern regarding teratogenicity, requiring reliable contraception for women of childbearing potential. 

GLP-1 receptor agonists – Primarily used in the management of Type 2 Diabetes mellitus and expanded its use to individuals with obesity. This family of medications also have the effect of delaying gastric emptying and suppressing appetite, thereby assisting with weight loss. Side effects range from pain at the injection site (in subcutaneous formulations), nausea/vomiting, to acute pancreatitis. Association with rare thyroid C-cell tumors has been seen in rodent models but has not been established nor ruled out in humans. The outcome of weight loss was significant with GLP-1 receptor agonists. However, the health plan’s coverage is highly variable; Medicare currently not covering this medication, commercial insurance coverage depending on the plans and strict requirements (e.g., ongoing participation in a weight management program, failed attempts at lifestyle modification, and other BMI criteria).

For the most part, medications are usually meant to be a part of a larger program of diet, physical activity, and behavior changes. In general, only those physicians with knowledge, skill, and plans for routine follow-up should prescribe medications.

Surgical management
Indications for bariatric surgery for adults without disability

• BMI > 40 kg/m²
• BMI 35-39.9 kg/m² and a serious obesity-related comorbidity (i.e., DM, CAD, sleep apnea)
• BMI 30-34.9 kg/m² with inadequately controlled type 2 diabetes or metabolic syndrome despite optimal medical treatment²⁴

One of the above AND both of the following

• Have failed less invasive weight loss methods
• Are highly motivated to improve their quality of life

Separate guidelines exist for bariatric surgery in adolescents and children but very few directly address people with disabilities. The pediatric guidelines of the American Society for Metabolic and Bariatric Surgery emphasize the importance of evaluating the ability of the patient and family to adhere to recommended perioperative care.²⁵

Types of bariatric surgical procedures

• Gastric banding
• Roux-en-Y gastric bypass
• Sleeve gastrectomy
• Biliary pancreatic diversion

Long-term Effects

• Potential nutrient deficiencies including vitamin B12, folate, vitamin D, and iron
• Greater weight loss (20-35% of initial weight at 2-3 years post-op) than conservative measures²⁶
• Longer duration of maintaining healthier weight in adults
• Favorable effect on obesity-related comorbidities:
  • Reductions in fasting glucose and insulin levels
  • Decreased incidence of type 2 diabetes
  • Greater likelihood of remission of diabetes
• Improvement in most measures of health-related quality of life at 2 and 10 years post-op²⁶

At different stages

Childhood onset
Childhood and adolescent obesity should be addressed as soon as possible. A combined approach including decreased caloric intake and increased caloric expenditure is optimal. Children should always be in a medically supervised intervention program.

Adult identification
Lifestyle modification in combination with a weight-loss program should be initiated. Unless one is in a medically supervised intervention program, the lowest daily caloric intake recommended is 1,200 calories for women and 1,500 for men. Medical comorbidities should be discussed and reviewed.¹⁵

Identification with disability and prevention
The risk of developing obesity is also an important health concern in individuals with disability. A significant predisposing factor is impaired mobility, as it can be a barrier to accessing healthy food options, as well as limit opportunities for physical activity. There can also be additional condition-specific mechanisms that increase risk of developing obesity, e.g. spinal cord injuries.²⁷ There must be anticipatory guidance to monitor nutritional intake early on and to implement an adapted exercise regimen.

Coordination of care

Most dedicated weight loss programs involve multidisciplinary teams, including exercise physiologists, athletic trainers, dieticians/nutritionists, and psychologists, with involvement of physicians. People with disability can engage in and benefit from weight management strategies, but may require cognitive, motor, or environmental modifications and different supports from those typically offered. Self-management programs, while individually driven, require frequent clinical assessment and outside monitoring.

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

Obesity is a prevalent health problem. Physiatrists care for a large variety of patients with obesity as a cause for disability, or in association with disability. Typical office practices can be organized to include routine measures of healthy weight status (e.g., on-site weight/height measurement, determination of BMI, waist circumference measurement, or other accepted measurement), discussion of and guidance for physical activity, guidance for caloric intake or referral for individual discussion, and sources for dedicated weight loss programs, health clubs and gyms (especially those offering modified programs), or self-management strategies.

Please note that there is no specific CPT code for physical activity counseling, however health care providers may use CPT 97110. Observing trends of mobility associated with weight changes in individual patients or patients grouped by disability type can offer insights into rehabilitation interventions. Documentation of even some of the above can demonstrate participation in quality measures and can support appropriate ICD and CPT coding.

Counseling rates for obesity and weight management are low among healthcare professionals, likely due to limited physician education in undergraduate and graduate medical education about the topic, time restraints in clinical practice, and difficulties broaching the subject.

• As the prevalence of obesity continues to rise in the population at large, as well as in those with disability, it is imperative that this issue not be overlooked. Population medicine and public health have been promoted in undergraduate medical education and include information about obesity and strategies to engage patients. Graduate medical education must also include obesity prevention and management within each specialty area. Understanding the theories and constructs of behavior change is a key element of health promotion strategies (Table 2).
• As health/medical homes and quality measures become more mainstream, documentation of obesity and interventions may be required.
• Training physicians in motivational interviewing would make it easier to start conversations with obese patients about their weight and the importance of noting this health issue. A life-style events vs. body weight graph (that tracks life events with associated weight gain) may allow physicians to begin conversations about the path to weight management. Patients must be aware that behavior modification is significant in long-term success for losing weight and subsequent weight management.

Table 2. Theories of behavior change and health promotion

Cutting Edge/Emerging and Unique Concepts and Practice

Recognition and management of unhealthy weight for people with disability

Although this document presents recognition and management of obesity in people with and without disability, it is not common for practitioners in general to consider weight management for people with disability. Routinely following weights or assessing %BF is an important component of follow-up for the health and function of people with disability, because both over- and underweight conditions can develop. Anticipatory guidance and preventing significant obesity in people with disability may be up to the physiatrist, who has the knowledge and skills to develop an exercise program with needed modifications.

• Measurement of obesity: BMI has been shown to not effectively measure obesity for people with disability in general, because disability and disease can affect the measurement of accurate height/weight and correct practices are not often done; %BF is actually the value of interest. There have been a number of studies about a variety of disability types showing this inaccuracy. People with SCI should be considered obese with BMI >22 kg/m².²⁹ People with amputation and limb loss should limit use of BMI, and instead, a “BMI calculator” has been developed to accommodate for this weight discrepancy.³⁰ People with intellectual disability, however, more closely follow the general public on BMI usage.
• Heath promotion programs: Weight management has been successfully achieved for people with disability through organized health promotion programs providing guidance about physical activity, nutrition, stress management, health responsibility and self-management, and behavior change. Curricula have been based on existing programs, with physical and cognitive modifications plus routine personal support and feedback. Many of the same adherence issues are seen for people with as without disability.
• Telemedicine: Littman et al tried a telephone-delivered physical activity and weight management intervention for individuals with lower extremity amputation. The intervention arm received self-monitoring tools (e.g., pedometer, scale) and written materials, a single exercise counseling home visit by a physical therapist, and up to 11 telephone calls from a health coach over 20 weeks that involved motivational interviewing to set specific, attainable, and measurable goals, with better response when being followed up by phone calls.³¹
• Bariatric surgery: There are increasing numbers of case reports and series documenting success with bariatric surgery managing obesity for people with disability, primarily those with spinal cord dysfunction and intellectual and developmental disabilities. Subjects were determined to be obese with BMI typically >40kg/m² with comorbidities (e.g., DM, sleep apnea) and failed conservative measures. Most subjects noted weight loss and decreased obesity-related comorbidities. Few surgical complications were noted, however typical post-surgical issues may have implications for long-term care, such as difficulties managing dumping syndrome.^24,26
• Acupuncture: Popular marketing promotes acupuncture as a successful management option for obesity. Studies exist touting the benefits, but systematic search/review articles note there are design flaws and limited rigor. The use of auricular acupuncture may have more promise, not used alone, but in combination with diet and exercise.³²

Gaps in the Evidence-Based Knowledge

Barriers to a healthy lifestyle: Children, adolescents, and adults with disabilities lack access to opportunities for engaging in physical activity as well as access to affordable healthy food.³³ Implications for systems and policy changes should be further discussed and researched. It is paramount to involve the community (family and neighborhoods) in intervention planning and respond to real-time barriers as participants engage in change, with culturally appropriate and accessible programming. Living in unsafe neighborhoods can further encourage sedentary behavior rather than motivate individuals to participate in activities. Health literacy is another important consideration. Individuals need to be educated in obesity prevention and management so they can make healthy choices. Additionally, cost is an important factor to consider. The cost of semaglutide is about $892 monthly without insurance. Given already increased healthcare costs in patients with disabilities, weight loss through pharmacologic therapies may not be affordable.³⁴ Of note, while many GLP-1 receptor agonists are brand name, there is an increase of generic versions that have become available. This works to offer more affordable options to patients.³⁴ The use of generic version, however, is depending on the shortage of the medication and subsequent policy regarding this.

Technology and Rehab for weight loss: There are few programs of weight loss that address people with disabilities. Although there is not enough robust research, current knowledge provides some directions into components that should be considered when designing future interventions.

Implications for Rehabilitation

• Clinicians should be aware of the high prevalence of overweight and obesity and the resultant consequences in children with disabilities.
• The use of inter/multidisciplinary teams, technology, and family engagement all appear to be promising approaches to creating successful weight management programs:
  • Weight-management programs should utilize inter/multidisciplinary teams to consider physical, social and psychological aspects of weight and health, to allow treatment plans to encompass a wider range of suggestions and recommendations.
  • Health care providers should consider using technology as a platform to deliver weight-management programs and services and/or to directly track progress.
  • Families are powerful agents of change and should be consulted and involved in the delivery of weight-management programs. ³⁵

Also, active video games have shown a potential to increase physical activity participation in youth with disabilities, giving another accessible and engaging option. A systematic review published in Disability and Rehabilitation found that exergaming can provide moderate-intensity physical activity and even meet the recommendations set forth by the American College of Sports Medicine for individuals with neurologic disabilities.³⁶

Adherence to weight management: Many people can achieve significant weight loss with our current interventions. However, long-term studies note that maintaining this weight loss seems to be elusive. Lifestyle modifications likely need incentives to help keep weight under control. The key components of a weight loss program where weight can be stabilized and maintained has not yet been determined.

One component that has been notorious is family and community involvement, showing a better weight loss when parents are also willing to change their own dietary behaviors, being the physical activity level more difficult to modified in the family.

Sarcopenic obesity in disability:  There has been recognition that loss of muscle mass (as seen in many types of disability) and replacement with or addition of body fat can be a part of the weight management challenge in people with disability. Resistance exercise, in conjunction with nutritional intervention, has been shown to improve muscle mass and function in individuals with sarcopenic obesity.³⁷ Supplementation with enteral feeding is a challenge, especially with late introduction in children with lifelong disability. Exercise is promoted for people with disability, but its effect on this feature of disability has not been elucidated.

Guidelines for measurement and management of increased body fat in disability: As noted, there is no consensus on the best way to measure increased body fat in disability, and BMI has been shown to be inaccurate for people with many types of disability. While there are management guidelines for the general population (see section C. Management and Treatment), these guidelines have not been evaluated in disability, and there are no suggested modifications to these. The lack of guidelines for measuring healthy weight in this population is a great barrier to patient care since without adequate tools to assess a problem, management becomes all the more difficult.

References

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2. Kim JE, Choi J, Kim M, Won CW. Assessment of existing anthropometric indices for screening sarcopenic obesity in older adults. Br J Nutr. 2023;129(5):875-887. doi:10.1017/S0007114522001817
3. Cornier MA, Després JP, Davis N, et al. Assessing adiposity: a scientific statement from the American Heart Association. Circulation. 2011;124(18):1996-2019. doi:10.1161/CIR.0B013E318233BC6A
4. Mahmoud R, Kimonis V, Butler MG. Genetics of Obesity in Humans: A Clinical Review. Int J Mol Sci. 2022;23(19). doi:10.3390/IJMS231911005
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Original Version of the Topic

Devon Shuchman, MD, Brian Kelly, DO. Obesity. 2/23/2012.

Previous Revision(s) of the Topic

Maria Martinez, MD, Andreea Nitu-Marquise, MD, Margaret Turk MD. Obesity. 9/13/2016.

Julio Vazquez-Galliano, MD, Zeus Castro, MD, Nicole Ortiz, MD, Cecilia Cordova-Vallejos, MD. Obesity. 1/13/2022

Author Disclosure

Mooyeon Oh-Park, MD
Nothing to Disclose

Anju Sanchala, DO
Nothing to Disclose

Michael Thornton, MD
Nothing to Disclose