Obesity And How We Can Help

This blog was transcribed from our 3rd episode of our Spine & Rehab Specialists podcast series featuring Harry Koster, PT, Cert. MDT and Andrea Goche, PT, DPT. Scan this QR code or click the button on the right side of this page if you are interested in listening to this, or any of our other episodes!
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Obesity is not an easy subject to talk about, but well worth having this discussion. When you look at the numbers, they are staggering. According to the Centers for Disease Control, 74 % of people in the United States are overweight. That is three quarters of the population. And according to the CDC, from 1999 to 2018 the rate of obesity had increased from 30.5 % to 42.4 % with 9.2 % considered severely obese. So not only is this a big problem in this country, but it also seems to be getting worse and worse. Obesity is a complex health issue resulting from a combination of causes and individual factors such as behavior and genetics. Behaviors can include physical activity, inactivity, dietary patterns, medication use, and other exposures. Additional contributing factors include the food and physical activity environment, education and skills, and food marketing and promotion.
 
I think that everybody will probably know that being obese isn’t a good thing, that it isn’t healthy. Obesity is serious because it is associated with poorer mental health outcomes and reduced quality of life. Obesity is also associated with the leading causes of death in the United States and worldwide, including diabetes, heart disease, stroke, and some types of cancer. I think a lot of people are probably aware that obesity contributes to things like heart disease, strokes and diseases like that. But there is another area that people may not realize that obesity can contribute to problems and that is with soft tissue damage and osteoarthritis. Osteoarthritis is a highly prevalent joint disorder estimated to affect more than 37% of adults over the age of 60; it is a leading cause of pain and disability. Osteoarthritis is associated with considerable loss in productivity and healthcare expenditures, accounting for 97% of the total knee replacements and 83% of the total hip replacements in 2004.]
 
Every step you take, all that weight goes through your hip, knee and ankle, and every pound of body weight places four to six pounds of pressure on each knee joint. So if someone is 50 pounds overweight… that means 200-300 pounds of extra pressure on the knee joint. I don’t think I even want to do the math for someone who is 200 pounds of more overweight. That is why the impact of obesity is especially felt in osteoarthritis of the hip and knee joints. Individuals with obesity are 20 times more likely to need a knee replacement than those who are not overweight.
 
So that is a lot of wear and tear on the joints! We used to think that knee osteoarthritis was mostly a  ‘wear-and-tear’ condition, but that is not even true… it gets worse. It is now recognized that knee osteoarthritis exists in the highly metabolic and inflammatory environments of adiposity. Cytokines associated with adipose tissue, including leptin, adiponectin, and resistin, may influence osteoarthritis though direct joint degradation or control of local inflammatory processes. Further, pound-for-pound, not all obesity is equivalent for the development of knee osteoarthritis; development appears to be strongly related to the co-existence of disordered glucose and lipid metabolism.
That’s a lot of official and difficult words, but to summarize it, we now know that certain chemicals, substances associated with fat tissue also contribute to arthritis, on top of the ‘wear and tear’ from the extra weight.

I guess we need to invest in the companies that manufacture the parts for total knees! From 2002 to 2009, the number of total knee arthroplasty (TKA) procedures performed on patients with obesity doubled. The detrimental effects of obesity on surgical outcome results and complication rates are well documented in medical literature. These effects include higher rates of infection and prosthesis failure/loosening of the implant when compared to patients of normal weight. In addition to contributing to arthritis and other musculoskeletal health issues, obesity also is linked to diabetes, heart disease, sleep apnea, liver disease, pancreatitis, certain tumors and cancers, and psychiatric disorders.
This really creates a bigger problem all together. Obesity contributes to knee arthritis, and causes us to have more knee replacement surgeries, but then at the same time, that obesity causes other health conditions that give us worse outcomes on those surgeries. Obesity, in the absence of these conditions, does not appear to significantly increase the risk of orthopedic pre- and postoperative complications. However, in combination with any of these conditions, obesity can adversely affect orthopedic surgical outcomes. Pre- and postoperative complications may include wound healing, infections, blood clots, blood loss, and dislocation of the replacement joint, especially in the hip.

The decision to have a total knee replacement should not be taken lightly but look at all the factors and not just the fact that your knee hurts because you are overweight. Now, how can we, as Physical Therapists, help with this problem? Obviously, we can do the rehab on your knee after the knee replacement, but we can help patients BEFORE getting surgery with patient education, physical exercise, and weight loss (for overweight or obese individuals) should be the first-line knee OA treatment approach. And of course, we know that one of the pillars of weight loss, is exercise (combined with healthy eating – which is a whole different subject that we are not going to be able to talk about today). One of the simplest forms of exercise is walking, right? But how do we tell someone whose knee hurts a lot, to start walking? Great idea, but they literally not going to go very far… but thankfully we have other options for patients that just can’t walk far enough to make a dent in their weight.
 
One of the options would be aquatic therapy… exercises in the water. I read this study, performed in 2010, where the researchers were comparing the effects of aquatic based therapy and land-based therapy in patients with obesity experiencing knee pain from knee OA. The study showed that body fat proportion in the AQE group decreased significantly after intervention and it showed significant improvements in pain, disability, and quality of life. Notably, the change in pain interference with activity in the AQE group was greater than that of the LBE group. So that shows us that there are some good advantages for overweight patients with knee pain to do exercises in an aquatic therapy setting.  So, how would a person that is interested in losing weight, and start aquatics, go about that? We have a therapy pool in the clinic at Physicians Drive that is specifically designed for this. It’s a Hydroworx 500 Pool, with different water depths, we can use different equipment in the water and the best feature I think is the underwater treadmill. Patients can walk at different speeds, forward/ backwards/sideways, it is awesome. And we even have cameras that can help them correct how they walk.

​Now, not everybody has to go in to the water. Some people may not want to get wet, are afraid of water, or just dislike water.  The pool is not for everyone, and we have lots of different ways to help patients without going in to the water. We have the AlterG antigravity treadmill, where we can also unload the joints and provide a more painfree way of moving, exercising and walking. We also have all sorts of other exercises that will help both with weight loss and with painful knees and hips.
 
So we can come to the conclusion that for obese and overweight patients there are lots of reasons to start exercising and start working on that weight, for your heart health, to lower your blood pressure, improve your diabetes, but also help reduce some of these inflammatory substances that exist due to obesity and that may set you up for a poor outcome on knee surgery.  And we have lots of ways to help people get started and help them along the way.

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