The United States is officially experiencing an obesity epidemic. With more than 97 million people currently overweight or obese – 400,000 of whom fall into the range of the morbidly obese – this epidemic has become a major contributor to the prevalence of chronic disease and physical disability.

The increasing consumption of more energy-dense, nutrient-poor foods with high levels of sugar and saturated fats, combined with reduced physical activity, have led obesity rates to spike drastically since the 1980s. Moreover, obesity and overweight pose a major risk for serious diet-related chronic diseases, including type 2 diabetes, obstructive sleep apnea, osteoarthritis, cardiovascular disease, hypertension, and stroke.

Today’s therapists are quickly becoming versatile foot soldiers in the struggle against obesity, dealing with individuals of all ages, whose physical conditions limit their abilities to move and perform daily tasks.
         
To see how the therapeutic field is responding to the problem of obesity in healthcare, Therapy Times hosted a “Therapy Roundtable,” bringing professionals across several specialties together to shed light on how this epidemic is changing the field.


Round Table Therapists:

• Julie Miller Jones, PhD, CNS, LN, professor of nutrition in the department of family, consumer and nutritional sciences at the College of St. Catherine in St. Paul, Minn.
• Daniel Seidler, PT, MS, executive director of the Bronx, N.Y.-based WSPT, specializing in orthopedic physical therapy, manual physical therapy, aquatic therapy, and anodyne therapy for patients with diabetes
• John Bagnulo, MPH, PhD, nutrition and fitness instructor at the Kripalu Center for Yoga and Health in Stockbridge, Mass.
• Susan Kasik-Miller, MS, RD, CD, CNSD, a registered dietitian at the Eau Claire, Wis.-based Sacred Heart Hospital
• Linda Dean, RRT, a subacute provider and clinical specialist for Irvine, Calif.-based Passy-Muir Inc., with experience in critical care and clinical education

Therapy Times: What are the common causes of obesity in your field?

Bagnulo: Insulin resistance is usually tied in with the etiology of this condition. A diet high in refined carbohydrates and/or excess animal protein seems to be the most common dietary pattern; this, in conjunction with very little activity and/or exercise.

Seidler: As we’re located in the Bronx, a large part of our population here is Hispanic and African-American. The diet of many Bronx residents consists of a lot of fried food, a lot of rice and beans – an especially large part of the Puerto Rican-American diet. So, whether these people are congenitally more susceptible to obesity or if it’s merely their diet, we don’t know. But we do see a lot of it. Obesity is pretty prevalent in our area.

Kasik-Miller: At Sacred Heart, we see poor eating habits and inactivity as some of the most common causes of obesity. Many people eat at erratic times, eat too large of portions, and eat high-calorie foods. This, coupled with lack of physical exercise, causes weight gain.

TT: What debilitating conditions do you see entering your field as a result of obesity?

Jones: People with ‘diabesity’ can go blind, need foot amputations, are impotent, and have joint and back problems, as well as skin problems. In addition, they are not comfortable in theater and airplane seats – even those who are normal weight are not – more prone to fall, and have complications as the result of the fall. These are just to name a few.

Dean: Sleep apnea, secondary to obesity, is a disease in itself. Left untreated, sleep apnea has been shown to cause congestive heart failure, high blood pressure, and stroke. Poor sleep patterns are not healthy, and make weight loss more difficult.

Bagnulo: I think that the depression associated with obesity is the most debilitating. It leads to a greater impact on the cardiovascular system than the obesity alone. It also breaks social ties, and really exacerbates any physical condition.



TT: What methods do you and other therapists use to assist or rehabilitate patients with these conditions?

Bagnulo: I try to have patients establish a better relationship with food, and shift their perspective to not see food as the enemy, but as an ally. Overall, I try to have patients follow a more Paleolithic way of eating.

Kasik-Miller: Nutrition professionals at Sacred Heart Hospital try to individualize diet changes for patients. This entails learning what diets have been tried, exploring what did not work about these diets, and examining what and why they are eating now. In short, we are doing a complete diet history with the person and developing a plan that would work for them. Effective methods range from calorie-counting; referral to programs, such as Weight Watcher’s; bariatric surgery; and, sometimes, even finding new friends.

I worked with a young woman who was in a relationship where her boyfriend was unsupportive of anything she did, and he made her feel worthless. This was very stressful so she ate her anxiety. After breaking up with the boyfriend, she lost more than 35 pounds.

Dean: From a night-shift hospital RT perspective, we are often the first ones to recognize sleep apnea. Sometimes, we implement nasal CPAP before a formal sleep study can be completed. This early intervention and first-time setup of CPAP in the hospital requires us to fit the patient with a mask, teach them about the disease and therapy, and be creative to make our machines/masks as comfortable as possible during this first night. This may make or break the patient becoming compliant with their CPAP therapy in the future.

TT: As many overweight patients already receive recurring admonishments from health professionals, what are some fresh methods of breeching the topic of their weight and general health in relation to the therapy at hand?

Kasik-Miller: Asking if patients are interested in losing weight is a method for addressing the topic. Many people are frustrated by lack of knowledge on how to do it or lack of support from significant people. Exploring obstacles identified by the patient provides an individualized plan and allows the patient to feel in control of the situation from the start.

Bagnulo: Hope is the focus of our message. I often have patients ask themselves questions, such as “What will it be like to feel better?” or “What would it be like to be able to do things you want to do?”

Jones: Many people who are overweight also have pre-diabetes or diabetes, elevated blood lipids or high blood pressure. A talk about the problems and expenses that results from these conditions motivates some – especially in these tough economic times.

            

Seidler: For us, it’s really just about making it clear to the patient what being overweight means on multiple levels. For instance, it can affect their cardiovascular condition, and for many of the patients that we treat, it’s a major cause of arthritis or joint pain.

The real challenge for us is that what we want the patient to do most is lose weight. The patient’s doctor may say, “You need to get on a better, low fat diet and cut down on the sugars,” and give them a general guide to better health. The problem is that this means almost nothing to most people. It has no relevance, and the patient questions, “So what do I do? Do I join a gym? Do I start walking?” The patient doesn’t know where to start, how much to do, or what sort of parameters for exercise they should be following safely.

TT: What are some of the challenges in initiating therapy?

Jones: Sometimes, spouses or other family members do not want the spouse to lose weight  – possibly due to jealousy. Also, friends and family may try to sabotage any strict diet/exercise regimens. Another problem is that the patient simply does not understand that effective weight loss should be no more than a 1 or 2 pounds per week, and as people reach their goal weight, perhaps even 1 pound per month. Many people want the weight lost immediately – however, the slower the weight loss, the more likely it is to stay off.

Dean: I was diagnosed with mixed sleep apnea eight years ago, and I have been a model for compliance with my CPAP – the reason being that I know the increased health risks if I am not compliant. However, even I had some problems getting my equipment. Initially, it took me almost two months after my initial diagnosis to get my first CPAP machine. Also, I recently had to replace my original CPAP machine, and that took two months to accomplish as well. 

Getting new masks and tubing every six months is next to impossible. And once my equipment was installed, I found that there was no follow-up from my home care company. Perhaps this was because I am an RRT, but what if there is no follow-up for the layperson? After all, we all know if the patient is not educated and followed-up with, their chances for compliance decrease greatly. 

TT: Are there external barriers to access of care for obese patients?

Kasik-Miller: The first barrier that comes to mind for caring for obese patients is access to healthcare in general. Many obese people are uninsured and/or underemployed. Having access to providers that counsel people on weight loss is an area that limits care for obese patients. Another barrier is that doctors don’t always address the issue with the patient or, if they do, they don’t relate it to improving their health, which makes patients feel that they have failed again.


TT: How is equipment being specialized to better accommodate obese patients?

Kasik-Miller: At Sacred Heart Hospital, special equipment – including large-sized beds, chairs, wheelchairs, commodes, lifts, and scales that accommodate wheelchairs – are used for obese patients. The patient is more comfortable when the equipment fits. This is a benefit because it decreases their embarrassment when a chair, bed or table is too small and they do not fit. Also with proper equipment, our staff is able to more easily move the patient. This benefits their physical condition and decreases chances of injuries by staff when providing care.

Seidler: This is a new facility, so when we designed this office, we tried to be sensitive to people who are obese. Although we don’t see many morbidly obese people, we do have several overweight patients, and its important to have proper seating, and exam tables that can handle them.

For example, all of our exercise equipment is scaled to 450 pounds. We also have some wide chairs. Most chair manufacturers – which I didn’t really know until I got into it – make wide chairs as well as the standard narrow chairs. So we do have a few of the wider chairs to accommodate obese people, and we even have a few chairs around the office that don’t have arms, because we have had patients who couldn’t fit in between the armrests.

Dean: I do believe as the nation has become more aware of sleep apnea, there have been many improvements in the home-care products. CPAP machines are smaller, quieter, more portable, and smarter – with ramps that ease the breaths to begin sleep easier – without all of the pressure pushing into a patient’s nose, disrupting their sleep. Sleep-apnea testing has evolved into a profession unto itself. Equipment, as well as professional credentialing, continues to evolve for the better.


— Bob Stott