Occupational Therapy Presentation

Description and Definitions

Obesity is a public health concern and a complex social problem. The University of Rochester Minnesota Department of Senior Health Research (URMCR) reports that of the top ten most common health issues, being overweight and obesity ranked second to physical inactivity and nutrition ( URMCR, 2015 ). A constellation of factors contribute to obesity including health behaviors, diet, physical inactivity, and genetics. Health disparities such as environment, socioeconomic status, health literacy, and access to health education may also impact obesity.

Obesity is a modifiable risk factor associated with type II diabetes, cardiovascular disease, heart disease, gallbladder and liver disease, sleep apnea, gynecological problems (fibroid disease), neurological (such as atherosclerosis, hypertension, and peripheral vascular disease), and musculoskeletal changes such as osteoarthritis (OA). Metabolic syndrome and diabesityrefer to the presence of a combination of risk factors including obesity, diabetes, hypertension, high cholesterol, elevated fasting blood sugar, high triglycerides, systemic inflammation, and a tendency to form blood clots ( Blanchard, 2012 ; Kresser, 2015).

The relationship of obesity to cancer has received less attention; however, existing evidence suggests that increased adipose tissue may increase the risk of breast, prostrate, and colon cancer. Additionally, increased body weight increases circulating insulin, which affects multiple types of cancer cells (Calle & Thung, 2004). Recent research examined a possible link between obesity and Alzheimer’s disease.  Chuang et al. (2015)  studied 142 elders with an average age of 83 when diagnosed with Alzheimer’s. Findings imply that those who were overweight by age 50 tended to develop a decline in memory earlier. Higher BMI at age 50 was related to early onset of the disease and at autopsy demonstrated increased brain tangles. The Centers for Disease Control and Prevention ( CDC, 2015a ) advise that obesity is associated with poorer mental health outcomes and reduced quality of life.  Figure 28.1  represents a summary of associated complications and the impact of obesity on client factors and body structure.

Figure 28.1 Complications of obesity. (From Braun, C. A., & Anderson, C M. 2011. Pathophysiology: A clinical approach. Philadelphia, PA: Wolters Kluwer.)

The terms overweight, obesity, and morbid (or extremity obesity) refer to excess body weight (Foti, 2005). Currently, the CDC,  World Health Organization ([WHO], 2015) , and the  American College of Sports Medicine ([ACSM], 2012)  define obesity by using the body mass index (BMI) measure. The BMI was developed by the Nutrition/Metabolism Laboratory, Cancer Research Institute in Boston ( Blackburn & Kanders, 1987 ). The BMI is an international standard used to determine degree of obesity relative to height and is calculated by multiplying weight in (pounds) × 703 and then dividing by the height in inches squared. A BMI < 24.9 kg/m2 is considered normal, while a BMI in excess of 25 is considered overweight with increased risk for disease ( ASCM 2000 ,  2014 ). BMI may also be calculated electronically using the National Heart Lung and Blood Institute (NHLBI) Guidelines (NIH Web site or with smart phone apps; graphs are available for tracking BMI ( NHLBI, 2015 ).

Along with waist circumference, BMI is used to describe the degree of obesity and predict the level of disease risk. Waist size indicates the amount of fat distribution in the abdominal area. An accumulation of body fat in this area results in an apple shape body and is associated with increased risk of heart disease and diabetes ( ACSM, 2014 ). Specifically, a waist size > 35 in. or 88 cm for women and 40 in. for men is associated with higher risk for high blood pressure, high cholesterol, and heart disease ( ACSM, 2014 ;  CDC, 2015a ). More recently, the CDC suggest that a waist size > 35 for women and 37 for men is associated with increased for disease ( CDC, 2015b ).  Jacobs (2010)  found that a waist size of 47 in. or larger for men and 42 in. for women increased risk for death compared to those with a waist size of 35 and 30 respectively. An adult with a BMI between 25 and 29.9 kg/m2 is considered overweight, and an adult with a BMI higher than 30 kg/m2 is considered obese ( Table 28.1 ). A BMI between 39 and 40 is considered morbidly obese with extremely high risk for disease. BMI > 50 may be classified as super obesity or super morbid obesity ( Dallas Center for Obesity Surgery, 2013 ). The term morbid obesity refers to patients who are 50% to 100% or 100 lb above their ideal body weight (Kolata, 2015).

TABLE 28.1 Body Mass Index, Waist Size, and Disease Risk

aClassification of disease risk based on waist circumference: <88 to >88 cm.

Adapted from American College of Sports Medicine. (2014). Classification of disease risk based on BMI and waist circumference. ACSM’s resources for the personal trainer (4th ed., p. 311). China: Lippincott Williams & Wilkins.

The term bariatrics is often associated with persons who are morbidly obese. Current literature defines this condition as the medical study of the causes, evaluation, and intervention for individuals who are obese (Foti, 2005; Purnell, 2011;  Stedman’s Medical Dictionary, 2006 ). Medical and surgical management of bariatrics will be discussed later in the chapter.

Childhood Obesity

Obesity among children and adolescents continues to be a health concern. Obesity is defined in children and adolescents aged 2 to 19 years of age as a BMI at or above the 95th percentile according to gender, age, and growth chart ( CDC, 2011 ). The lack of a diagnosis of obesity and an immediate plan for intervention during annual medical examinations exposes children to the same health conditions and comorbidities experienced by adults. Children may develop hypertension, systemic inflammation, dyslipidemia, type II diabetes, sleep apnea, and increased rate of obesity.  Shah et al. (2015)  examined adolescent and young adults with obesity and found increased cardiovascular risk factors (e.g. C-reactive protein, increased blood pressure, type 2 diabetes, and arterial wall thickness).  Bout-Tabaku et al. (2015)  assessed musculoskeletal pain among 233 teens average age 17 with a median BMI of 50.4. Seventy-six percent of the teens reported musculoskeletal pain, low back pain (63%), hip pain (31%), knee pain (49%), and ankle and foot pain (53%). Results suggest that adolescents with morbid obesity experience musculoskeletal pain that limits physical function and quality of life.

The American Academy of Pediatrics (APA) recommends annual monitoring of BMI to prevent childhood and adolescent obesity ( Flower, Perrin, Viadro, & Ammerman, 2007 ).

Flower et al. (2007)  interviewed pediatricians and parents and found lack of assessment, identification, reporting, and discussion about children’s obesity. Themes from focus groups also suggest that there are several barriers to using BMI screening with children, including lack of access to accurate BMI charts and accurate height and weight measurements, outdated growth charts, and lack of time to calculate BMI. BMI results may also stigmatize children as being obese and cause issues with self-esteem. This creates added psychosocial stress and pressure to be thin (Schvey, et al., 2015), which may be further perpetuated by the media, peers, friends, and family members. Dissatisfaction with body image, depression, and failed attempts to achieve weight loss through dieting may result in weight gain, altered metabolic function (insulin sensitivity), and secretion of cortisol. Combined stressors, obesity, and psychosocial challenges may lower school performance and reduce quality of life (Tonetti, Fabri, Filardi, Martoni, & Natale, 2015). Today, the requirement of electronic medical records automatically calculates BMI, tracks risk factors, and compares measurements over time ( Flower et al., 2007 ). BMI results may be used to raise parent and child awareness and discuss and set goals for lifestyle change and weight management.

Elder Obesity

Obesity among elders may result from a decline in physical activity and a change in independent living ( Blanchard & Mosley, 2010 ). As elders transition from independent living to long-term care facilities and a more sedentary lifestyle, they are often positioned in and confined to wheelchairs. Weight gain may be associated with chronic conditions, immobility, and altered eating habits. This immobility limits range of motion and strength and hinders energy expenditure necessary to maintain a healthy weight. Elders who were active and lived independently are now exposed to an increase in social eating, which also increases BMI. Limited participation in occupations, deconditioning, and loss of muscle mass (sarcopenia) influences physical function and metabolic rate. Obesity among elders can negatively impact pulmonary, cardiovascular, cognitive status (vascular dementia), cholesterol, and joint pain associated with OA (Sperling, Laviolette, O’Keefe, et al., 2009). Long-term care facilities are now monitoring elder BMI through the Minimum Data Set (MDS). This Centers for Medicare and Medicaid (CMS) resident assessment tool requires a reassessment of BMI every 30 days. Section K of the MDS monitors BMI ( CMS, 2010 ).

Obesity as Disease

Recently, the American Medical Association (AMA) approved the classification of obesity as a disease. The organization defines disease as: “(1) an impairment of the normal functioning of some aspect of the body; (2) characteristic signs and symptoms; and (3) causes harm or morbidity” ( Sales-Martinez, 2013 , paragraph 2, p. 1). The AMA and  Jones (2015)  of the Rudd Center for Health Policy and Obesity further propose advantages and disadvantages to classifying obesity as disease. Classifying obesity as a disease raises awareness, increases insurance coverage and reimbursement for treatment, and expands federal and private funding for research, which may lead to new public policies regarding obesity intervention and prevention ( Smith, 2013 ).

Proponents of the new classification support early diagnosis through primary screening and argue that chronic obesity may be prevented through follow-up care, weight loss, and reducing associated stigma. Obesity may also be viewed as an addiction. The new classification suggests that persons will take the initiative to seek intervention. However, motivation for compliance with diet, increased physical activity, or other lifestyle changes is uncertain ( Sales-Martinez, 2013 ).

Opponents of the AMA decision argue that obesity is a risk factor for other chronic diseases, that BMI does not measure fat mass, and that patients diagnosed as overweight or obese may still be healthy. Padro, Gonzales, Heymsfield, et al. (2015)agree that BMI does not differentiate between the contributions of lean body mass opposed to adipose tissue. This lack of well-defined overall body composition confounds the documented health consequences for morbidity and mortality associated with obesity across populations (Sales-Martinez, 2013). Therefore, it is felt that the disease classification is not warranted. Perceived lack of control over weight results in taking less responsibility for weight management. For example, individuals may seek a “quick fix” through pharmacological intervention or surgery ( Sales-Martinez, 2013 ). Classification of obesity as a disease has the potential to reduce stereotypes and place the responsibility on the individual; however, the classification still must consider environmental, social, cultural, and psychological issues that may impact this complex health issue ( Sales-Martinez, 2013 ;  Smith, 2013 ).

Obesity and Stigma

Existing evidence supports that persons who are obese may be shunned by others. Stunkard and Sorensen (1993) refers to “obesity as the last socially acceptable form of prejudice” (p. 1037). Stigma associated with obesity is seen across population groups, among health care professionals, and across the lifespan. Persons who are obese may experience verbal abuse and verbal and physical bullying and be more vulnerable to depression, reduced self-esteem, and poor self-concept (Puhl & Latner, 2007). Unfortunately, health care professionals such as nurses, physicians and students perpetuate negative attitudes towards persons who are obese. Many fear the doctor’s response that is often stated as “I can’t help you if you don’t lose weight” ( Bailey, 2016 , p. 8).

As the BMI increases, health providers are less tolerant and attentive, do not address health concerns in a timely manner, and view the person with obesity as a “waste of time,” which results in negative psychosocial health and quality of life (Teachman & Brownell, 2001;  Wang, Brownell, &Wadden, 2004 ). Blodorn, Major, Hunger, and Miller (2015) found that over time, constant rejection associated with higher BMI threatened social identity and increased the expectation of a negative response.  Allison and Lee (2015)  compared attitudes toward 185 overweight female university students. Results from participants read one of six vignettes to describe a female student with varying weights indicated that overweight targets were viewed more negatively than average weight or underweight targets.

Persons who are obese may be perceived as dishonest, sloppy, lacking self-control, lazy, unattractive, intellectually impaired, gluttonous, and socially impaired ( Crandall, 1994 ;  Flint, 2015 ). Persons who are obese report discrimination in the workplace, doctor’s office, school, or other social or public settings. Rejection, stereotyping, and disrespect results in social isolation, overeating, and an increased potential for self-harm ( Bailey, 2016 ;  Faith, Matz, & Jorge, 2002 ; Puhl & Brownell, 2006). Choice of terms such as overweight or unhealthy weight is preferred to thick, chubby, or morbidly obese ( Dutton, Tan, Perri, et al., 2010 ;  Tailor & Ogden, 2009 ). Children who are obese may experience similar adult comorbidities and stigmatizations that perpetuate health disparities across the lifespan ( Flint, 2015 ).

Obesity and Depression

Obesity is considered to be a medical but not a mental health diagnosis. The relationship between emotional state, behavior, excessive food intake, and low energy expenditure may reflect a significant mental health or psychosocial issue. The Diagnostic and Statistical Manual of Mental Disease Version-5 (DSM-5) does not include overeating but focuses on binge eating (Grever, 2013;  Walsh, 2010 ). The American Psychiatric Association included bulimia (purging syndrome) and night eating syndrome in the most recent edition of the DSM-5, but failed to include obesity secondary to lack of acceptance of the diagnosis as a mental health disorder ( Devlin, 2007 ; Grever, 2013;  Walsh, 2010 ). Depression is one of the most prevalent psychiatric disorders and a major contributor to the United States (US) burden of disease.  Bailey (2016)  suggests that up to 80% of persons who are obese have some level of depression. Onset of depression and obesity may be related to geographical location and seasonal affective disorder (SAD) ( Atkinson, 2005 ).  Faith et al.’s (2002)  meta-analysis implies an association between obesity and depression in childhood, during midlife, and among elders.

The relationship between obesity and depression may also differ by gender and race. Several studies support a biological and psychological basis for overeating and weight gain.  Xiang and Ruopeng (2014)  correlated the BMI of 6,514 adults born between 1931 and 1941 with the Center for Epidemiology Studies Depression Scale (CESDS). The CESDS defines symptoms of clinical depression over a 2-week period. Results indicated that unhealthy body weight was associated with future onset of depression.  Blanchard (2009)  examined the relationship of BMI and Depression among 378 African American women. Eighty-six percent of the sample had an average BMI of 32.78 with a high risk for disease. CESDS scores ranged from some to severe symptoms of depression with 73 (23.5%) reporting mild symptoms of depression, 79 (25.4%) moderate, and 29 (9.4%) severe symptoms. Women also reported overeating when stressed.  Dixon, Dixon, and Obrien (2003)  reported that weight loss following bariatric surgery was associated with a decline in depression scores 1 to 4 years postsurgery. Other researchers report that psychological well-being following bariatric surgery depends on presurgery eating patterns, social support, self-esteem, body image, coping strategies, and the amount of weight loss after surgery ( Ortega, Fernandez-Canet, Alvarez-Valseita, Cassinello, & Baguena-Puigcerver, 2012 ).

Biological contributions to obesity include an increase in the stress hormone cortisol, which is a steroid hormone that is activated in response to stress and hypoglycemia and is believed to trigger depressive symptoms. In addition, medications used to treat depression may result in weight gain.

Obesity and Stress

Stress and anxiety may also interfere with one’s ability to lose and manage weight. Various types of stress may contribute to obesity including emotional stress. Stress results in the secretion of cortisol, which has been shown to increase central adipose tissue and secondary risk factors for disease such as metabolic syndrome. Women may be more predisposed to stress than men due to increased central fat. Studies are beginning to focus on secretion of cortisol in women. Epel et al. (2015) exposed 59 women (30 with high hip to waist ratio, and 29 with a low hip to waist ratio) to three stressful sessions and one rest session. Women with the high hip to waist ratio secreted significantly more cortisol and reported greater challenges when stressed than did the low hip to ratio group. Another study examined the relationship between chronic stress, food cravings, and BMI for a community-based sample of adults (N = 619). Chronic stress had a significant effect on food cravings, and food cravings had a significant effect on BMI. Findings are consistent with research that chronic stress is related to motivation for reward-seeking behaviors and indicate that high food cravings may contribute to stress-related weight gain (Chaol, Grilo, White, & Sinha, 2015). Repeated stress associated with altered sleep habits and routines such as rotating work shifts are examples of environmental factors that may also increase weight.

Obesity and Vitamin D Deficiency

Vitamin D deficiency is common among children, adults, and elders. Research findings support that most tissues and cells of the body have a vitamin D receptor. Current research aims to discern the role of vitamin D in the prevention of chronic diseases such as cancer, cardiovascular, depression, and obesity (Holick, 2007). Vitamin D deficiency is defined as a 25-hydroxy vitamin D level of <20 ng/mL; 30 is considered sufficient, and toxicity may occur at 150 ng/mL. Wortsman, Matsuoka, Chen, Lu, and Holick (2000) found low levels of vitamin D in a sample of persons who were obese and that oral vitamin D corrected the deficiency. They further postulate that because of low physical activity levels, persons who are obese spend less time exposed to the sun and thus have lower vitamin D levels. Solar radiation is required for synthesis of vitamin D. It is also thought that vitamin D deficiency is linked to osteoporosis and muscle weakness that may be associated with observed immobility in persons who are obese (Holic, 2007). Seppa (2013) reported that persons with low Vitamin D levels were not prone to obesity and that losing weight could reverse vitamin D deficiency. Vitamin D supplements may not be effective as a weight loss regime. While vitamin D is stored in fat tissue, the mechanism for the role of vitamin D in weight loss requires additional research.

Etiology

A variety of factors influence obesity. The consequence of physical inactivity and its relationship to obesity is well documented in the public health literature. An imbalance between calories consumed and energy expenditure during occupational performance create a positive energy balance resulting in weight gain and obesity. Even a modest energy imbalance over a sustained period of time may increase BMI. Research has shown that losing 5% to 10% of excess weight may prevent disease ( Diabetes Care, 2011 ). Location of grocery stores, food choices, and availability account for some obesity. Previously, lack of available food resulted in storing fat to prevent starvation. Now the type of food (such as fast, convenient, or refined) and high availability result in increased stored fat and the prevalence of obesity (Mance, Veach, & Veach, 2013).

Genetic Factors

Genetic factors combined with lifestyle choices increase the risk or predisposition for familial obesity. Patterns of childhood obesity are similar in appearance to adult obesity. Family, and adoption studies attribute obesity to a phenotype or observed characteristics of a group (e.g., family members who resemble each other in appearance) ( MOSBY’s Medical Dictionary, 1994 , p. 1208). Studies examining the relationship of genetics to obesity report that 40% to 70% of the variance in body mass is related to social environment (type of food consumed, factors related to heredity, and physical inactivity).  Clement, Boutin, and Froguel (2002)  used genome scans to identify the location of 68 obesity genes on several chromosomes that aid in the regulation of appetite and satiety. A more recent study of genetics and obesity in 249,796 European participants identified 32 loci or markers associated with BMI. These markers, however, explained only 1.5% of the variance in BMI (Volkow, Wang, & Baler, 2011). Available research on genotyping and obesity has yielded small, uncertain, and limited explanation of the contribution of genetic markers to obesity. Inconsistent effects make it difficult to generalize results across populations.

Obesity Hypothalamus and Hypothyroidism

The inability of the hypothalamus to recognize satiety along with thyroid dysfunction may also result in obesity. The thyroid gland secretes the hormone thyroxin into the blood stream that is essential to the regulation of normal body growth and metabolism (processing food into energy). Thyroid cells absorb and use iodine. The pituitary gland and hypothalamus both control the thyroid. When thyroid hormone levels drop too low, the hypothalamus secretes TSH releasing hormone (TRH), which alerts the pituitary to produce thyroid stimulating hormone (TSH) (Sargis, 2015). Hypothyroidism occurs when cells of the thyroid gland are damaged by inflammation resulting from an associated autoimmune response or secondary medical interventions. The most common cause of thyroid gland failure is called autoimmune thyroiditis (Hashimoto’s thyroiditis), a form of thyroid inflammation caused by the patient’s own immune system (Sargis, 2015).

An endocrinologist may diagnose hypothyroidism with a medical and family history, risk factors, and physical examination. A definitive diagnosis may be achieved with a blood test called a TSH; additional laboratory analyses such as thyroxine or T4, and triiodothyronine or T3 also support the diagnosis. Normally, the thyroid gland produces 80% T4 and 20% T3; T3 is the stronger of the two hormones (Sargis, 2015). Combined, T3 and T4 increase the rate of metabolism, affect body temperature, and regulate protein, fat, and carbohydrate catabolism (conversion of nutrients into energy) in the cells of the body. Without intervention, fatigue, weakness, weight gain, or increased difficulty losing weight increases. The inability to burn fat normally is often referred to as having a “fast” or “slow” metabolism ( Mosby’s Medical Dictionary, 1994 , p. 1555). It is believed that weight loss may lead to decreased systemic inflammation that may restore thyroid function (Longhi & Radetti, 2013). Pharmacologic interventions such as synthetic hormones (Synthroid, levothyroxine sodium, liothyronine sodium) may be used to regulate hormone function (Sargis, 2015). Care must be taken to avoid a rapid increase in dosage to avoid symptoms of hyperthyroidism such as nervousness, tremor, tachycardia, arrhythmia, or menstrual irregularity ( Carl, Gallo, & Johnson, 2014 ).

Hunger is associated with increased blood flow to the hypothalamus, thalamus, and frontal and temporal lobes. Destruction or trauma to the ventromedial hypothalamus, which regulates appetite and feeding behavior, may increase food intake and reduce metabolic rate resulting in obesity. Leptin is a hormone that is present in adipose tissue and signals receptors in the brain of satiety, or when one is full. Diminished leptin in the brain results in impaired signaling of satiety, thus promoting overeating. Females tend to have a higher percent of body fat or adipose tissue than do males; thus, with low levels of leptin they experience weight gain, increased hunger, and reduced metabolic rate ( Atkinson, 2005 ; Couillard et al., 2002;  Meyers, Leibel, Seeley, & Schwartz, 2010 ). For elders, low leptin levels, increased fat tissue, and loss of muscle mass are referred to as sarcopenia.

Gorden and Gavrilova (2003)  report that leptin replacement leads to reduced food intake, weight loss, and reduced percent body fat. Satiety has also been achieved in both human and mouse models, but an increased resting metabolic rate only occurred in mice, suggesting that a loss of fat mass may impact resting metabolic rate.

Obesity and Neuroscience

Available research indicates that there is inconclusive but plausible evidence linking the neurobehavioral effects of overeating, obesity, and addiction (Ziauddeen, Farooq, & Fletcher, 2012). Neuroscientists are aware of neural structures that contribute to obesity; addiction research infers that addiction to food is similar to addiction to drugs both in behavioral and neurological response (Ziauddeen et al., 2012). Food addiction literature reports that foods high in fat, salt, and sugar are enjoyed by those who are obese. Processed foods may be more addictive than foods in their natural state such as fruits and vegetables ( Benton, 2010 ). The addiction model supports the premise that obesity is related to food addiction and binge eating. Binge eating is characterized by uncontrolled, rapid consumption of large amounts of food in isolation and in the absence of hunger despite the negative impact on health, social or financial limitations. Multiple failed attempts to alter behavior results in feelings of guilt, remorse, distress, and failure ( Smith & Robbins, 2013 ). The Yale Food Addiction Scale (YFAS) used DSM-5 addiction criteria to format questions that identify those who may exhibit signs of addiction toward certain foods (such as high fat, salt, and sugar). Knowledge of which foods trigger overeating and food addiction has the potential to impact food marketing strategies across the lifespan and may impact public policy (Gearhardt, Corbin, & Brownell, 2008).

Several neural structures are thought to contribute to addictive behavior and obesity. The hypothalamus regulates satietyor the feeling of fullness. The prefrontal cortex is associated with habitual and compulsive overeating; the dorsal striatum is responsible for loss of executive control over the behavior. Impulsive eating or initiating behavior without considering the consequences may be related to lower levels of dopamine. Insufficient dopamine may increase seeking of the feelings of reward and result in overeating (Volkow et al., 2002,  2011 ).

The more food that is consumed, the more one loses control and awareness of the amount of food consumed. Results of positron emission tomography studies show that striatal dopamine receptors are reduced in persons who are obese compared to leaner counterparts and that they tend to overeat to compensate for reduced striatal sensitivity (Mahapatra, 2010). Thus, long-term overeating of pleasurable foods alters the chemical response in the brain and sensitizes the brain to “crave certain foods”; thus the motivation and drive to eat and consume certain food increases with environmental cues (Volkow & Wang, 2005; Volkow et al., 2011). Researchers are focusing on food addiction rather than diet and the possibility of prescribing pharmacological agents to artificially alter dopamine as an intervention for obesity. Proposed medications may be addictive and only recommended for those with morbid obesity and urgent health risks ( Devlin, 2015 ).

Prevalence and Incidence

The global public health epidemic of obesity is often referred to as “globesity.” Nationally obesity has doubled since 1980. The CDC, National Center for Health Statistics (NCHS) Data Brief (2015b) reports that the prevalence of obesity from 2011 to 2014 was 36% for adults and 17% for youth; for adults aged 20 to 39 and 40 to 59, the prevalence of obesity was higher among women than men; more than one-third of adults and youth in the United States were obese. If people who are classified as overweight are included, the estimate increases to 69% or two-thirds of the population (Mance et al., 2013). Harvard medical school researchers estimate that overweight, obesity, and physical inactivity were responsible for 1 in 10 deaths in the U.S. (Mance et al., 2013).

Regarding race, higher rates were noted with women who are African American at 56.9%, women who are Hispanic at 45.7%, men who are Hispanic at 39.9%, and 37.5% for men who are African American. People who are Asian tended to have lower rates of obesity at 11.9%. The average weight for men in the U.S. in 2011 was 88.3 kg (about 195 lb), and for women it was 74.7 kg (or 165 lb). Depending on BMI, this represents a significant increase (Mance et al., 2013). Recent findings by  Ogden, Carroll, Kit, and Flegal (2014)  reveal no significant reduction in obesity, and prevalence remains high.

Table 28.2  summarizes the prevalence of obesity across the lifespan.

TABLE 28.2 Obesity Prevalence

Adapted from the Center for Disease Control and Prevention National Center for Health Statistics Data Brief. (2015). Prevalence of obesity among adults and youth: United States, 2011–2014. Retrieved from  http://www.cdc.gov.nchs/data/databriefs/db219.htm

Certain states and areas of the country have a high incidence of obesity No state had a prevalence of obesity <20%; 5 states and the District of Columbia had a prevalence of obesity between 20% and <25%; 23 states, Guam, and Puerto Rico had a prevalence of obesity between 25% and <30%; 19 states had a prevalence of obesity between 30% and <35%; 3 states (Arkansas, Mississippi, and West Virginia) had a prevalence of obesity of 35% or greater; and the Midwest had the highest prevalence of obesity (30.7%), followed by the South (30.6%), the Northeast (27.3%), and the West (25.7%) ( CDC, 2014 ).

Signs and Symptoms

Classic signs and symptoms of obesity include pannus and abdominal fat, lymphedema, and OA. Obesity may also be described by the location and distribution of adipose or fat tissue, or pannus and its characteristic anthropometric shape.  Dionne (2006)  identified six body types: apple ascites, apple pannus, pear abducted, pear adducted, gluteal shelf, and posterior adipose. Each body type may be predisposed to challenges with activities of daily living, functional mobility, gait, and activity tolerance. These body types are described in  Table 28.3 .

TABLE 28.3Body Type & Pannus Distribution

Adapted with permission from  Dionne’s (2006)  Six Body Types Images and Lisle E. Veach, PTcourses.com, 2013.

Obesity and Lymphedema

Persons with obesity may experience compromised skin integrity secondary to skin on skin contact and impaired lymph drainage. Diabetes may further complicate wound healing and increase the risk of infection. For clients who are immobile, the Braden Scale may be used to predict risks for pressure sores (15 to 16 = low risk, 13 to 14 = moderate risk, 12 or less = high risk) ( Braden, 2014 ).

A BMI > 50 often results in bilateral lower extremity edema associated with lymphatic dysfunction. Adipose tissue is composed of adipocytes or fat cells that produce hormones referred to as adipokines. These hormones cause a chemical reaction that impedes the function of the lymph system causing lymphatic leakage or lymphedema (swelling) ( Greene, 2015 ). Obesity combined with decreased muscle pumping action further limits lymphatic function. The number of patent lymphatic vessels cannot keep up with the demand of new and proliferative adipose tissue; thus, the extra weight increases resistance to the distal and proximal flow of lymph (Bertsch, 2015;  Greene, 2015 ). Impaired lymph node regeneration and abnormal swelling associated with cycles of weight loss and gain is known as primary lymphedema and may develop early in infancy, childhood, or adolescence and continue into adulthood ( Greene, 2015 ). A diagnosis of lymphedema is made using lymphoscintigraphy, which verifies backflow or blocked lymphatics ( Greene, 2015 ).

Abdominal obesity such as that observed in the apple ascites or apple pannus body type may compress the lymphatics in the abdominal and groin area and add to lower extremity edema. Weight loss may improve lymphatic function but may not reverse the condition (Bertsch, 2015). Decongestive therapy, dietary intervention, and weight loss are recommended as primary interventions.

Obesity and Osteoarthritis

Osteoarthritis is also known as degenerative joint disease (DJD) or a “wear and tear” disease. Clients 75 and older with obesity report higher knee pain and are more likely to be disabled ( Jordan et al., 1996 ). Oviatt (2009) reports that 65% of adults with DJD are overweight or obese; 44% of those with DJD report limited physical activity. Persons 85 years of age and older, who are obese, account for 57% of annual hip and knee replacements. CDC Behavioral Risk Surveillance System data from 2009 revealed that 53% of adults with DJD had no leisure time activity, limited access to a fitness center for appropriate exercise, and lack of fitness instructors who are knowledgeable about DJD ( Morbidity and Mortality Weekly Report 2011 ). BMI levels of ≥30 kg/m2 increases joint loading and causes misaligned joints and failure of weakened quadriceps to contract adequately and absorb forces needed to transition from sit to stand ( Sowers & Karvonen-Gutierrez, 2010 ).  Coggon et al. (2001)  suggest that those with obesity were nearly three times more likely than were those of normal weight to develop severe knee pain over a 3-year period. Of those who are overweight and obese, a reduction of weight by 5 kg, and achieving a BMI within the recommended normal range, would result in an estimated 24% reduction in knee surgeries associated with OA. Strong support for public health initiatives aimed at reducing the burden of knee OA by controlling obesity is needed.

Obesity Hypoventilation Syndrome

Sleep apnea is referred to as obesity hypoventilation syndrome (OHS) or pickwickian syndrome. OHS results from excess weight compressing on the chest, preventing breathing, and increasing the amount of carbon dioxide in the blood; lack of oxygen contributes to poor sleep quality and hypoxia (Mance et al., 2013). As weight increases around the neck, trunk, and abdomen, temporary lapses in breathing compromise respiratory function. Clients with obesity may benefit from using a larger electric hospital bed with the head of the bed elevated between 45 degrees to 90 degrees known as the Fowler position or elevating the head of the bed to 90 degrees and placing the arms over a bed table in a orthopneic position. Continuous positive airway pressure (CPAP) may also be used to achieve positive flow of air into the nasal passages in order to keep the airway open.

Course and Prognosis

Failure to achieve a sustained healthy weight with nonsurgical procedures, pharmacological intervention, dietary changes, and some physical activity will lead to more invasive procedures such as bariatric surgery. Outcome data focus on the total amount of weight lost, reduction in chronic health conditions, and number of prescribed pharmacological interventions used to treat comorbidities. Following bariatric surgery a weight loss of 50% to 70% is expected ( Health Grades, 2013 ). There is a significant decrease or reversal of chronic conditions including type II diabetes and high cholesterol; improvements in blood glucose levels may appear within days following bariatric surgery ( Health Grades, 2013 ). For clients with a BMI of 35 or with comorbidities, bariatric surgery resolves migraines (57%), hypertension (52% to 92%), cardiovascular disease (82%), dyslipidemia (63%), metabolic syndrome (80%), type II diabetes (83%), obstructive sleep apnea (74%), fatty liver (90%), gastroesophageal reflux disease (72% to 98%), urinary stress incontinence (44%), gout (72%), DJD (41% to 76%), polycystic ovarian syndrome (79%), depression (55%), reduced quality of life (95%), and mortality (89%) (Brethauer, Chand, & Schauer, 2006). Long-term health benefits also include lower risk of cardiovascular and cerebrovascular events with improved quality of life ( Health Grades, 2013 ).

Quality of life following bariatric surgery depends on type of surgery and procedure, residual intestinal and digestive problems, discomfort and pain, and presence of excess skin folds. Clients requiring body contouring to reduce loose skin a year following surgery reported improved quality of life (Lier, Aastrom, & Rortveit, 2015). Occupational therapy faculty and student researchers surveyed 11 clients post bariatric surgery using an activity and functional health and well-being assessment. Average weight loss was 105.1 with highest loss of 189 lb. Although this was a small sample size, several themes emerged from the study. Post– bariatric surgery participants reported a significant increase in participation in instrumental activities of daily living (IADLs) that require physical movement, leisure pursuits, social interaction, and health maintenance. Even though participants achieved weight loss, some clients transferred food addiction to alcohol or other drug use. Additionally, clients experienced relationship changes and divorce and often reverted to previous unhealthy eating patterns and habits ( Mata, Mikkola, Loveland, & Hallowell, 2015 ).  Ortega et al. (2012)  surveyed 60 morbidly obese clients (46 women and 14 men) 1 year post–bariatric surgery. Findings indicate that negative preoperative body image improved after surgery but self-esteem did not change. Overall findings suggest that psychological intervention is needed to prepare clients for realistic expectations following surgery and to improve postsurgical outcomes.

Medical and Surgical Management

Diet and exercise may be recommended at various levels of intervention. Clients at risk for a diagnosis of obesity (BMI 25) may receive primary health screenings to increase awareness about the health risk factors associated with obesity. Secondary intervention aims to prevent the progression of obesity (BMI >25 to 30) from becoming a chronic health issue and tertiary intervention (BMI > 30) attempts to maintain quality of life with chronic obesity ( Garvey, Mechanick, & Einhorn, 2014 ).

Following a comprehensive review of systems, modifiable risk factors, and laboratory evaluations of blood work, clients may be prescribed pharmacological intervention or psychiatric consultation. More often, immediate interventions for weight loss, such as pharmacological interventions, are used to increase motivation and promote weight loss. It is important to recognize that side effects of some medications increase hunger, promote overeating, and result in weight gain or obesity. Glucocorticoids produce an increase in truncal adipose tissue and insulin and oral hypoglycemic drugs increase fat in tissues of persons with diabetics. Antipsychotics such as phenothiazine and antidepressants (selective serotonin reuptake inhibitors) also produce weight gain. Adrenergic antagonists such as propranolol reduce sympathetic nervous system acidity and lead to weight gain ( Atkinson, 2005 ). Some of the Food and Drug Administration (FDA)–approved medications for the treatment of obesity may cause serious side effects and must be monitored. Currently, orlistat (Xenical) is used to absorb fats, decrease side effects including oily and frequent bowel movements, and increase absorption of fat-soluble vitamins (A, D, E, and K), so a multivitamin may be prescribed. Alli is a similar, less potent over-the-counter (OTC) version of orlistat. Qsymia, previously known as Qnexa, reduces appetite, contributes to satiety, and alters the taste of food. Belviq alters serotonin levels in the brain and may lead to addiction (Mance et al., 2013). Cortisol blockers are not yet FDA approved for weight management but may be used in the future to reduce the formation of central adipose tissue (Zeratsky, 2015).

There are many diets that claim to result in various levels of weight loss. Popular diets used for weight loss include Atkins, Human chorionic growth hormone (HCG) South Beach, Weight Watchers, the Zone, and Body for Life. The Atkins diet is a low-carbohydrate, high-protein diet that burns fat for fuel. Side effects may include reduced brain glucose and increased blood lipid levels. HCG is extracted from the urine of pregnant women and injected, while prescribing a restriction of calories to 500 per day. There is minimal evidence to support the efficacy of HCG, and it is not FDA approved. The South Beach diet is supported by research; balances carbohydrates, protein, and fat; and does not limit fruits and vegetables, which is a disadvantage for maintaining a restricted pattern of eating. The Zone diet requires 30% each of fats, protein, and carbohydrates and focuses on healthy grains and fiber. Body for Life program encourages six small meals per day to maintain stable blood sugar. Weight Watchers is well researched and uses a point system, a balanced meal plan, and a support group or online participation. Although there are many diets from which to select, a 69% obesity rate continues in the U.S.

Bariatric Surgery

Bariatric surgery is often recommended for persons with super or morbid obesity or for a BMI ≥ 40; a BMI of 35 with accompanying metabolic syndrome or sleep apnea may also benefit from surgical intervention. The goal of bariatric surgery is to lose 50% of body weight or achieve a healthy target weight. An interprofessional bariatric health care team may include a bariatric physician or surgeon, nurse, psychiatrist, dietician or nutritionist, physical therapist, and occupational therapist.

Bariatric surgery produces a quick reduction in weight; when combined with a healthy diet and consistent physical activity, weight loss can be sustained over a period of time. There are two general surgical strategies: stapling and banding. Within these two categories, there are several surgical procedures available. Each may be associated with complications such as diarrhea, bleeding, infection, malabsorption and lower extremity blood clots  (Table 28.4 ;  Figure 28.2 ).

TABLE 28.4 Advantages and Disadvantages of Different Types of Bariatric Surgery

Figure 28.2 Two surgical procedures for morbid obesity. A. Gastric bypass with Roux-en-Y. A horizontal row of staples creates a pouch with a capacity of 50 mL or less. The proximal jejunum is transected and the distal end anastomosed to the new pouch. The proximal segment is anastomosed to the jejunum. B. Laparoscopic gastric banding. The silicone adjustable band component of the lap band is placed around the upper part of the stomach, forming a small gastric pouch (15 mL) to limit intake and slow gastric emptying. Size is adjusted by injection of saline into a subcutaneous reservoir that is connected to the lap band. (From Farrell, M., & Dempsey, J. (2010). Smeltzer and Bare’s textbook of medical–surgical nursing (2nd ed.). Philadelphia, PA: Wolters Kluwer.)

Impact on Occupational Performance

Obesity is a modifiable risk factor that impacts multiple client factors and performance skills, patterns, and occupational engagement. Persons with obesity may experience changes in mental functions (mood) associated with altered levels of serotonin. Medications used to treat depression may result in weight gain but aid in appetite control. Excess weight aggravates symptoms of OA resulting in loss of joint structures, destruction of cartilage, and spinal and peripheral nerve compression. Joint pain, malalignment, reduced range of motion, and disuse atrophy limit mobility and activity tolerance.

Diminished skin integrity is another challenge for persons with obesity. Loose skin may cause friction and reduced skin integrity between the thighs during ambulation. Excess skin may need to be camouflaged by wearing larger rather than fitted clothing. Because of multiple skin folds associated with pannus under the breasts, around the abdomen, and perineal area, it is difficult to maintain hygiene following urination or bowel movement. Clients may become embarrassed to have a family member or caregiver perform this task. Skin may have poor vascularization secondary to atherosclerosis and lymphedema. Prolonged sitting in one position or changing position may result in skin shearing, abrasions, or other pressure sores. Clients may be dependent for pressure relief including lateral weight shifts and raises.

Performance of occupations (such as activities of daily living) that are usually performed in the bathroom (bathing and toileting) and self-feeding a meal in the kitchen or dining room are now performed in the same location, which is often in bed. These clients may experience shame and loss of self-esteem and prefer social isolation. Loss of intimacy and lack of human touch may also hinder self-concept. Lack of mobility and tolerance to supine and prone positions in bed may interfere with breathing. Positioning in a wheelchair or chair may be ill tolerated secondary to neuropathy, peripheral vascular disease, or pressure sores related to type II diabetes. Clients may perform at a slower pace and require a wheelchair or other mobility aide to access the community. The increased cost for larger assistive technology such as a wheelchair and accessible van may not be reimbursed by the insurance provider. The inability to fit into a standard-size chair, car seat, or restaurant booth restricts driving, social participation, educational pursuits and work.

The lack of awareness of clearly defined occupations that promote planned energy expenditure versus energy conservation may impede progressive and graded physical activity needed to achieve a steady reduction in weight over time. Altered roles, habits and previously performed routines must be modified to achieve maximum participation in occupations.