DIAGNOSIS.

Physical examination should be directed at determining the presence of and distribution of body fat by measuring height, weight, body circumference (extremity and waist), and nutritional status. In addition, the presence of associated causes of obesity should be investigated.

Abdominal (visceral) fat is metabolically active. Measurement of circumference is needed to identify the distribution of body fat and to determine the risks associated with increased waist circumference. Waist circumferences that are above 40 inches for men and above 35 inches for women increase the risk for premature death and disability as a consequence of overweight or obesity. Waist circumference is the best predictor of visceral (intraabdominal) fat and total fat. The most clinically telling physical sign of serious underlying disease is increased waist circumference, which is linked to insulin resistance, hypertension, dyslipidemia, type 2 diabetes, coronary heart disease, sleep apnea, and gallbladder disease.¹⁰⁸

Waist circumference measurements have a high correlation with BMI.¹²⁹ Measurement of extremity circumference may also be useful in the adult population for the physician to rule out lipedema, a symmetrical “swelling” of both legs, extending from the hips to the ankles, caused by deposits of subcutaneous adipose tissue.

Although BMI and waist circumference measurements are the most clinically feasible methods to identify clients who are overweight or obese, additional methods may be used to measure subcutaneous fat or body composition.⁷⁰ Methods that are known for accuracy but often only used in research settings include hydrostatic weighing and dual-energy x-ray absorptiometry (DEXA).^37,144

Additional methods that require less expensive equipment include the use of skinfold measurement calipers and the measurement of bioelectrical impedance. Skinfold measurements using calipers (the pinch test) are performed in several locations on the body (e.g., midbiceps, midtriceps, and subscapular areas). Measurements greater than 1 inch are thought to indicate excessive body fat. Skinfold measurement has been questioned in relationship to accuracy because interobserver variability may be high.¹⁵⁹ Skinfold measurement should be taken into consideration along with body type and height.

Bioelectrical impedance analysis (BIA) measures the impedance or resistance to an electrical signal that is circulated through the body. A person who has more fat mass will have larger impedance because there will be more resistance to the electrical signal traveling through the body since fat mass contains less water. BIA measures have been shown to be reliable and valid; however, variability among individuals can be high, and inaccuracy can occur in situations of altered hydration status and extreme obesity in those being measured.^24,122 Additionally, BIA has not been shown superior to BMI as a predictor of overall adiposity in a general population.²⁶³

All of these examples of measures can provide a baseline measurement for relative fat mass and can be used to monitor progress of body composition as people advance through a weight loss program.

TREATMENT.

Both physical activity and nutrition are important in addressing obesity. Physical activity and nutrition are modifiable factors that respond similarly to the same interventions. To maintain a healthy weight, it is important to keep energy expenditure at or above energy intake. This can be accomplished by decreasing caloric intake, increasing exercise energy expenditure, or both.

Weight loss is regarded as a major aspect of treatment for the person who is obese. Although the amount of weight loss necessary is arguable, 10% loss in body weight is regarded as a standard that improves health.

The National Weight Control Registry (www.nwcr.ws/) reports that weight loss and maintenance of the weight loss are best accomplished if individuals participate in regular intensive exercise, attend support groups, restrict the amount and kinds of food eaten, and weigh themselves often.

A multidisciplinary approach with emphasis on weight loss maintenance should be directed toward anyone with a BMI of 30 and above and for those people with a BMI in the 25 to 29 range who have associated health problems. Such a treatment program includes moderate calorie intake, behavior modification, exercise, and social support.

Medications for obesity are widely available over the counter and by prescription. The use of pharmacologic agents to inhibit appetite, reduce fat absorption, and increase metabolic rate is highly controversial and provides at best only a short-term benefit. Drug therapy is thought to work best when it is part of an overall program aimed at lifestyle change involving dietary changes, exercise, and behavior modification.^255,260 To be effective, drug treatment for obesity should be continued indefinitely much like treatment for any chronic condition.^5,74,260 Researchers continue to look for drugs that can prevent or alter the physiology of obesity.

Surgical treatment, referred to as bariatric surgery, may be considered for some obese people if serious attempts to lose weight have failed, if BMI is greater than 40 kg/m² with or without comorbidities, or if there is a BMI of 35 kg/m² with significant health-related comorbidities^{5,74,194,239,260} and complications of obesity that are life-threatening. Surgical approaches rely on reconfiguring or redirecting the gastrointestinal system through gastric restriction called vertical gastric banding (VGB) or gastric bypass procedures (e.g., Roux-En-Y gastric bypass [RYGB]). Bariatric surgery has been shown to provide the greatest degree of sustained weight loss in people with morbid obesity.¹⁵⁷ Other benefits and complications of bariatric surgery are listed in Table 2-4.

Laparoscopic RYGB has been referred to as the “gold standard” operation for surgical control of obesity. It is effective in achieving weight loss, improving comorbidities and quality of life, and reducing recovery time and perioperative complications.²²⁴ This procedure is safe, effective, and decreases overall costs.¹⁹⁴

Evidence supports this shift in surgical approach for individuals having laparoscopic surgery based on studies demonstrating improved SF-36 scores,^{93,193,194,239} decreased recovery times,^193,224 earlier return to work,¹⁹³ less postoperative pain,^193,224 and comparable amounts of weight loss.^61,193

The relationship(s) between biologic and behavioral factors influencing obesity is not yet completely understood. However, regardless of the medical and surgical treatments available to treat obesity, behavioral change in the frequency and type of eating and exercise habits remains the foundation of both prevention and intervention.²⁵⁶

Behavior in both prevention and treatment is influenced by what options are available (e.g., vending machines, safe parks in which to walk), how and to whom health information is portrayed (e.g., media versus health practitioner), and what type of support is given to individuals who seek and/or need to make a change.¹³⁵

Practitioners require knowledge of what motivates change, how behavioral change occurs, what resources are needed to make change, and strategies useful for promoting change. Across the theoretic foundations guiding this knowledge, the combined merits of providing accurate information, understanding barriers preventing change, anticipating personal readiness for change, and providing structure and support over extended periods to enable sustained new behaviors have been recognized as helpful.²⁰

Although lifestyle programs have been shown to be the most successful in creating durable change, regulation of body weight (to either prevent gain or maintain loss) is still affected by a myriad of intrapersonal and environmental factors that interact to make obesity control difficult. Tailoring all interventions to the “personal environment” of each individual is critical in overcoming the intrinsic and extrinsic pressures in the American culture that affect the current epidemic of obesity.¹⁶¹

PROGNOSIS.

The management of obesity continues to be challenging, particularly because its effect on the whole person is so broad and the causes/influences are so numerous that prognosis relies on significant and sustained lifestyle changes that must last a lifetime. When therapy is confined to dietary measures alone, treatment of obesity is less likely to be successful. Because the risk of mortality and morbidity from obesity rises in proportion to the degree of obesity and the presence of complications, treatment is essential. For example, among the cardiovascular problems associated with obesity, hypertension in combination with obesity increases the risk for development of cerebrovascular disease, specifically cerebral thrombosis.

Weight loss alters conditions associated with obesity and even moderate weight loss in an obese person (i.e., 10 to 20 lbs) provides substantial changes in risk factors. Following weight loss in the obese, a decrease in blood pressure usually occurs with a regression of left ventricular hypertrophy, total and HDL cholesterol are favorably changed, and glucose tolerance improves in those people with type 2 diabetes mellitus.

The addition of exercise to a comprehensive program of caloric reduction and behavior modification can improve results. Regular exercise can maximize body composition change and increase the probability of maintaining weight loss.

Patterns of fat distribution are important in determining the risks associated with obesity. Visceral fat within the abdominal cavity is more hazardous to health than subcutaneous fat around the abdomen. Upper body obesity around the waist and flank is a greater health hazard than lower body obesity marked by fat in the thighs and buttocks.

People who are obese with high waist-to-hip ratios (greater than 1.0 in men and 0.8 in women) have a significantly greater risk of diabetes mellitus, stroke, coronary heart disease, and early death than equally obese people with lower ratios. Waist circumference alone has also been designated as an independent predictor of health risks and may replace the waist-to-hip measurement as a predictor of increased risk. For women, weight-related health risks increase when the waist measurement is 35 inches or more; for men, this figure is 40 inches or more.

Although the connection between obesity (BMI greater than 30) and coronary heart disease is well established, it remains unknown whether a similar link exists for those who are mildly overweight. Research has shown that people whose BMI at midlife (30 to 55 years of age) was between 23 and 24.9 had a 50% higher risk of heart attack compared with those whose BMI was under 20. Women whose BMI was greater than 29 had a 3.6 times greater risk of heart attack compared with the leanest group.²⁶⁴ Moderately higher adiposity at younger ages (18 years) is associated with increased premature death in younger and middle-aged women.²⁵²

Smoking and Tobacco Use

Smoking and the use of tobacco products are associated with a number of chronic diseases, including chronic pulmonary diseases and cardiovascular conditions, as well as many types of cancers. Smoking also decreases the health of individuals who smoke. Some of the significant links between smoking and disease are reported in the Surgeon General’s report.²²⁰

Beside the obvious health risks associated with tobacco use as a lifestyle choice, it can become a psychologic problem because of the addictive qualities of this substance. For this reason, we have chosen to include tobacco use as part of a discussion of Substance Abuse in Chapter 3.

Alcohol and Other Drugs

Whether to consider substance use/abuse a behavioral condition or a psychologic problem remains uncertain. Many psychologists and addiction counselors say it is a condition, illness, or problem with multiple factors, including physical, psychologic, social, economic, and spiritual. Others place it on a continuum from behavior to disorder, depending on the individual’s relationship to the substance(s) and how that individual’s friends, family, colleagues, or coworkers are affected. Substance use is considered by some a “choice,” whereas addictions may be diagnosed as a disorder and then categorized as a pathologic psychologic disorder.

Addiction specialists and drug educators want to make it clear that alcohol is a drug. The commonly used phrase today when discussing substance use and abuse is “alcohol and other drugs.”

Culturally and socially, we live in a world that advertises and encourages the use of alcohol and other drugs as part of the American lifestyle. Addictions may be considered unique disorders that have their start in personal or lifestyle behaviors and choices but later become addictions with diagnosable pathology. Someone who drinks or uses drugs recreationally may not be an alcoholic or addicted, but when the use of substances has consequences in other areas of their life, then a problem is identified. There can be a fine line between lifestyle choices and behaviors and addictions and psychologic disorders. For now, we have chosen to place alcohol and other drug use in Chapter 3 but mention it here as a possible lifestyle, behavior, or choice that can impact the health of the individual and/or family members.

Domestic Violence

Domestic violence (DV) can be classified under categories of child abuse, intimate partner violence (IPV), and elder abuse. Because of the wide variety of practice settings in which they work, physical therapists are likely to encounter individuals of all ages who have been victims or survivors of DV.

DV is the physical, emotional/psychological, or sexual abuse; financial exploitation; neglect; or stalking of an individual by a person with whom they have a marital, familial, social, or dependency relationship. DV occurs in all socioeconomic and racial/ethnic groups. In all forms of DV, the incidence of abuse of individuals with disabilities is greater than in the nondisabled population.^{211,240,251,279}

Physical abuse involves nonaccidental physical injury, which can range from superficial bruises and welts to broken bones, burns, serious internal injuries, and death. Emotional and psychologic abuse can result from acts or omissions that cause or could cause serious behavioral, cognitive, emotional, or mental disorders as a result of actions such as confinement or the constant use of verbally abusive language and criticism.

Sexual abuse ranges from nontouching offenses, such as exhibitionism, to fondling, rape, molestation, or the forced use of a child or an adult in the production of pornographic materials.

Neglect can involve the withholding of or failure to provide adequate food, shelter, clothing, hygiene, medical care, and/or supervision needed for optimal health and well-being. Neglect also includes refusal or delay in seeking health care, abandonment, inadequate supervision, and expulsion from home. Emotional neglect in children includes allowing a child to witness chronic or extreme spousal abuse or permitting truancy or drug/alcohol use. Stalking, another form of DV, is defined by the National Criminal Justice Association as “a course of conduct directed at a specific person that involves repeated visual or physical proximity, nonconsensual communication, or verbal, written or implied threats, or a combination thereof, that would cause a reasonable person fear.”¹⁸⁹

Stress, Coping, and Self-Efficacy

People react to a stressful event using coping mechanisms, also called relief behaviors. Behavioral or cognitive coping mechanisms are used to resolve, reduce, or replace the level of stress, depression, and anxiety. When the stress is resolved, accepted, or changed, adaptation occurs, implying that a sense of equilibrium is restored to the person disordered by stress.

The body also has physiologic coping mechanisms, referred to as the generalized adaptation response, to stressors with multiple physiologic events (see Fig. 2-4). The human stress response has been characterized, both physiologically and behaviorally, as the “fight, flight, or freeze” response. The autonomic nervous system activates the body’s involuntary responses such as hormone secretions, metabolism, and fluid regulation.

Once the body recognizes a continued threat, physiologic forces are mobilized to maintain an increased resistance to stressors and return to a state of homeostasis. Chronic resistance eventually causes damage to the involved systems as the body enters a stage of exhaustion, possibly resulting in diseases of adaptation or stress-related responses or conditions.

A landmark UCLA study suggests that women may physiologically respond to stress with a cascade of chemicals that causes them to make and maintain friendships with other women. This response is referred to as “tend-and-befriend.” When the hormone oxytocin is released as part of the stress response in a woman, it buffers the fight-or-flight response. She is more likely to tend to children and gather with other women instead.²⁴⁴ When the woman engages in tending or befriending, more oxytocin is released along with endogenous opioids, which further counters stress and produces a calming effect. This calming response does not occur in men because testosterone, which is produced in high levels when the male is under stress, reduces the effects of oxytocin.¹⁸¹

The fact that women respond differently to stress than men has significant implications for their health. It may take time for new studies to reveal all the ways oxytocin helps women manage stress physiologically.²⁴⁴ The concept of tend-and-befriend may also help explain sex-based differences in behavioral manifestations of some psychiatric illnesses.¹³⁹

The idea that stress can cause premature aging and death is not new. For example, chronic depression has been linked with heart disease and immune system dysfunction. Heightened levels of stress hormones (i.e., glucocorticoids) and the increased activity of the sympathetic nervous system also increase the rate of oxidative damage, formation of free radicals, and shortening of telomeres. The end-result is acceleration in the aging of leukocytes.⁷²

Life stressors do not necessarily cause shortened chromosomes. Some research suggests it could be the other way around: people with intact telomeres are better able to resist psychologic and emotional stress.²²² Researchers are now focused on individual genetic differences in the vulnerability of telomeres to stress.

The process of coping with chronic pain, trauma, or illness is ongoing. Each change in the downward course of the illness requires new and painful acceptance of the disease and its limitations. Behavioral or cognitive coping may be adaptive (e.g., talking or reading about the problem, prayer, or seeking God) or maladaptive (e.g., denial and distancing or the use of alcohol or other drugs). When a person is unable to mobilize the necessary resources to manage stress, death from disease may result or suicide may be the final step to conflict resolution.

Social Support, Networks, and Roles That Influence the Effects of Illness

There are several key terms that describe the role of social relationships and the effect it has on health. Social network refers to the web of social relationships that encompass an individual.¹¹² They are the linkages between people. Network analysis focuses on the characteristic patterns of social ties between individuals.

Previous work has demonstrated the strength of weak ties (acquaintances) between people are as important if not more as the strength of strong ties (close friends).⁹⁸ Unfortunately, these weak ties have been measured indirectly, such as membership in religious or voluntary civic organizations. Social networks are not always positive influences. For instance, cigarette smoking by peers is among the best predictors of smoking for adolescents.¹⁴⁸ Social support is the functional content of relationships, the aid and assistance exchanged through interpersonal relationships. Social support is always intended to be helpful and is consciously provided by the sender.¹¹²

There is a two-way directional pathway between social networks and social support and health outcomes or disease. A person’s health status is affected by social support, whereas the ability to maintain a social network is in turn affected by the person’s health status.

Data collected over the last 20 years connect social support and social networks to physical and mental health, including studies that looked at all-cause mortality²⁸; cardiovascular disease^147,199; stroke^26,137; infectious disease,¹⁷⁹ including the common cold⁵⁶; and HIV/AIDS.¹⁵¹

Berkman and Glass²⁷ describe the impact on health by social networks as being along a continuum of factors (e.g., cultural, socioeconomic, political, religious, geographic, psychologic). More specifically, poverty, discrimination, and conflict are social-structural conditions that can exert a negative influence on health, whereas factors such as access to resources and material goods, close family ties, and help-seeking behaviors provide positive social support.

This comprehensive model addresses the social structural conditions at all levels and helps connect the psychosocial and behavioral pathways to the concept of social networks to health, bridging the work of social scientists and social epidemiologists to the health psychology models described earlier.⁶⁷

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