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.3
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 obesity4
Of special interest is the development of sarcopenic obesity and its consequences for people with certain disability or medical conditions and in elderly adults. This condition is characterized by the co-existence of decreased lean muscle mass (sarcopenia) and increased or replacement fat mass.5
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.2,6
Table 1. Measuring body fat
|BMI (Body mass index)||Easy to measure Inexpensive In general population, high BMI is associated with higher risk of chronic disease and early death.||Initially developed to define activity level: low BMI is related to higher activity; proxy for %BF More accurate in predicting body fat in younger and middle-aged adults than in older adults or people with disability Does not distinguish between body fat and lean body mass; may overestimate body fat in those who are overweight and muscular Underestimates body fat in the elderly and disability states due to muscle loss (sarcopenia) and relatively increased adipose tissue Does not account for limb loss (underestimation of body fat in patients with limb amputation)|
|Waist circumference||Easy to measure Inexpensive Strong correlation with body fat, especially visceral fat, in adults Predicts adverse metabolic or cardiovascular outcomes independent of BMI||Proxy for central body fat Not standardized in disability No good reference data in children Difficult to measure and less accurate if BMI≥35|
|Waist-to-Hip Ratio||Inexpensive Good correlation with body fat Predicts development of disease and death in adults||Proxy for body fat More prone to measurement error More complex to interpret than waist circumference Difficult to measure if BMI≥35|
|Waist-to Height Ratio||Inexpensive More accurate than BMI at predicting percentage body fat7 Differentiates between whole body obesity and abdominal obesity||Proxy for body fat More prone to measurement error Difficult to measure if BMI ≥35|
|Skinfold thickness||Convenient Safe Inexpensive – requires calipers Portable Fast and easy||Not as accurate or reproducible Requires training Very hard to measure if BMI≥35 Need comparison for age and to disability standards|
|Bioelectric impedance analysis (BIA)||Convenient Safe Relatively inexpensive – device available to purchase Portable Fast and easy||Hard to calibrate Decreased accuracy during illness, dehydration, weight loss (ratio body water/fat may change), asymmetries Not standardized for disability|
|Underwater weighing (densitometry)||Accurate||Time consuming Special equipment, not easily available Requires water submersion Difficult for some children, older adults, those with BMI≥40, some people with disability|
|Air-displacement plethysmography||Accurate Safe Relatively quick and comfortable Good option for children, older adults, pregnant women, BMI≥40||Expensive Special equipment, not easily available Not standardized in disability|
|Dilution method (hydrometry)||Accurate Safe Relatively low cost Can be used in children, pregnant women, BMI≥40||Expensive Special equipment, not easily available Decreased accuracy during illness, dehydration, weight loss (ratio body water/fat may change)|
|Dual Energy X-ray Absorptiometry (DEXA)||Accurate Available at medical centers||Expensive Cannot distinguish between different types of fat Not used in pregnant women and BMI ≥35|
|MRI||Measures visceral fat Available at medical centers No radiation exposure Greater discrimination of adipose and lean tissues to improve estimates of ectopic8||Expensive Long scan duration|
|CT||Measures visceral fat Available at medical centers Incapable of detecting ectopic fat.8||Expensive Radiation exposure Finite diameter may limit size of patients that can be scanned|
Weight Categories based on BMI:
- Underweight: BMI <18.5 kg/m2
- Normal weight: BMI 18.5 to 24.9 kg/m2
- Overweight: BMI 25-29.9 kg/m2
- Obesity: BMI ≥30 kg/m2
- Severe Obesity: BMI >40 kg/m2
These BMI cutoffs apply to Caucasian, Hispanic, African American individuals, and some Asian populations. Certain Asian populations define overweight as 23-24. 9 kg/m2 and obesity as >25 kg/m2.
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%.9 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.10 Leptin levels, which reflect the proportion of adipose tissue, increase with overeating by nearly 40 percent within 12 hours.11Ghrelin levels decrease after eating. It is unclear how these genetic risk factors and hormones affect the body fat accumulation of people with disability.
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.12 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 and primary prevention
- Obesity is a chronic disease with an increasing prevalence in the United States as well as worldwide.
- More than one-third (34.9% or 78.6 million) of the adults in the United States are obese.13
- The estimated annual medical cost of obesity in the US was $147 billion in 2008 US dollars; the medical cost for people who are obese was $ 1.429 higher than those of normal weight.13
- People with disability have a higher prevalence of obesity than people without disability.14
- There are several challenges that people with disability face in trying to prevent obesity. These include difficulty accessing healthy foods, side effects of certain medications, poorly monitored enteral feeding,15 pain, reduced ability to exercise, decreased energy, lack of accessible environments and resources.14
- Low socioeconomic status plays a large role in the development of obesity for a variety of reasons. Obesity prevalence among preschoolers was the highest for families in which the household income was at or below the poverty threshold.16
- Prevention: Obesity is a complex health issue and there is not a simple strategy to help prevent it. There are state and local programs available as well as community efforts that try to prevent obesity by promoting healthy living behaviors.17
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
- 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
- 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.18 This “metabolic programming” may account for intergenerational transmission of obesity. 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 95th 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 for:19
- All-causes of death
- Diabetes mellitus type 2
- Coronary heart disease
- Gallbladder disease
- 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:
- Femoral nerve amyotrophy
- Superior mesenteric artery syndrome
Essentials of Assessment
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.
- 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).
- History of present illness: discuss the factors contributing to and associated with obesity–weight gain over time, age/gender (increasing age, hormonal changes)20, 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/anxiety22, eating disorders (binging, bulimia, night-eating); depression is a known comorbidity, so screening with Beck Depression Scale or similar instrument may be warranted
- 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 cessation22, level of physical activity, family lifestyle, socio-economic status (low income associated with higher risks for obesity20), participation in weight management programs
- 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 %BF increases, assessment of most recent functional status is essential for development of a treatment plan and needed modifications.
- 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,7,23 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
- 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
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. In a study done by Dr. Singh of Stanford University, the meaning of food was also seen to differ based on families’ socioeconomic status.24 In 96% of high-income families reported regularly denying their children requests for junk food compared to only 13% of low-income families. Low-income families were noted to cite food as a sign of emotional support. Furthermore, family members and other close friends who are obese pose a risk for personal obesity. Alcohol use and high levels of stress may also contribute to obesity by increasing caloric intake.
Rehabilitation Management and Treatments
Available or current treatment guidelines
Guidelines have been developed regarding screening, assessment, and management of obesity in the general population.25-28 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.29 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.
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.30
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.31 Self-management is complex and should include: goal setting, monitoring, self-efficacy, problem solving, accountability, social support, relapse prevention, and positive reinforcement/feedback.31 An element of regular support from health professionals or some routine check-in has proven to be helpful for some.32 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.33On the other hand, multiple studies have found activity trackers ineffective in increasing physical activity.34-36
In the general population, weight loss peaks at 6 months with interventions (advice/counseling, diet, exercise).
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.31,37,38 In general, adherence to weight management programs is often poor with high attrition rates.39Higher 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.33The 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.31 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.40
Although medications for weight loss exist, many are not FDA regulated. 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:
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 in increased serum leptin levels and thus suppresses appetite. 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.
GLP-1 receptor agonists. Primarily used in the management of Type 2 Diabetes mellitus, this family of medications also have the effect of delaying gastric emptying and suppressing appetite, thereby assisting with weight loss.41 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.
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.
Indications for bariatric surgery for adults without disability:
- BMI > 40 kg/m2
- BMI > 35 kg/ m2and a serious obesity-related comorbidity (i.e., DM, CAD, sleep apnea)
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 children42but very few directly address people with disabilities. The pediatric guidelines of the American Society for Metabolic and Bariatric Surgery include one sentence recommending against denying treatment to adolescents with cognitive disabilities.43
Types of bariatric surgical procedures:
- Gastric banding
- Roux-en-Y gastric bypass
- Sleeve gastrectomy
- Biliary pancreatic diversion
- 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 measures25-27
- Longer duration of maintaining healthier weight in adults25-27
- 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-op25-27
At different stages
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.
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.
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,44 as well as limit opportunities for physical activity.45,46 There can also be additional condition-specific mechanisms that increase risk of developing obesity, eg. In spinal cord injuries.47. 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, especially when participants have chronic conditions and/or disability. 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 a poorly utilized CPT-code for physical activity counseling (ICD-9: V49.89 and ICD-10: Z78.9). 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.33 The low rates are attributed to limited physician education in undergraduate and graduate medical education about the topic, time restraints in clinical practice, and difficulties broaching the subject.22,48
- 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.22Patients 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
|Transtheoretical Model49||Stages of or readiness to change behaviors:|
– Pre-contemplative (no thought about change)
– Contemplative (thoughts about change)
– Preparation (taking steps to change)
– Action (initiating changes or activities)
– Maintenance (sustaining activities of change) Processes or strategies used to change: consciousness raising, goal setting, social support, role modeling, self-efficacy, decisional balance, self-rewards
|Social Cognitive Theory50||Interrelationships of social environment, personal cognitive capabilities, present behaviors that may affect future behaviors, with a focus on education Behavior influences and is influenced by the person and the environment Behavior changes explanations: self-efficacy, self-regulation, outcome expectancy values, observational learning, reinforcement|
|Ecological Models of Health Behavior51||Influence of behaviors by intra- and interpersonal factors, sociocultural groups, policy and physical-environmental factors Comprehensive approaches (multi-factorial program) more effective than a single approach|
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, and a few of interest are people with SCI should be considered obese with BMI >22 kg/m2;52 amputation and limb loss limit use of BMI, and a “BMI calculator” has been developed to accommodate for this weight discrepancy;53 people with intellectual disability more closely follow the general public on BMI usage.54
- 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.55-57 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.58
- 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.59-61 Few surgical complications were noted, however typical post-surgical issues may have implications for long-term care, such as difficulties managing dumping syndrome.62
- 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.63 The use of auricular acupuncture may have more promise, not used alone, but in combination with diet and exercise.64
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 foods. Implications for systems and policy changes should be further discussed and researched.65 It is paramount to involve the community (family and neighborhoods) in intervention planning and respond to real-time barriers as participants engage in change,66 with culturally appropriate and accessible programming.67
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, as per Walter et al. 2020:
- 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.68
Betts et al studied the adaptation of “Diabetes Prevention Program” with a 20-week modification of the DPP Group Lifestyle Balance™ (DPP GLB) program, demonstrating a feasible, usable, and potentially effective intervention for promoting weight loss among person with impaired mobility. The plan included self-monitoring and problem-solving monitored with conference calls.69
Also, active video games have shown a potential to increase physical activity participation in youth with disabilities, giving another accessible and engaging option.70
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.71
Sarcopenic obesity in disability: There has be 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. However, there is no information about how this sarcopenia (and resulting replacement with fat) can be mitigated. Supplementation with enteral feeding is a challenge, especially with late introduction in children with lifelong disability.12 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.
- Fox MH, Witten MH, Lullo, C. Reducing obesity among people with disabilities. J Disabil Policy Stud. 2014; 25(3):175-185.
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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
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Zeus Castro, MD
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Nicole Ortiz, MD
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Cecilia Cordova-Vallejos, MD
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