PM&R
Volume 1, Issue 9 , Pages 795-797, September 2009

Action on Obesity and Fitness: The Physiatrist's Role

Mayo Clinic Sports Medicine Center; Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN†

Article Outline

 

Despite massive public education efforts on the health consequences of obesity and inactivity, the United States remains in the throes of a national epidemic and public health dilemma. The incidence and prevalence of obesity continue to grow and remain a significant problem, not only for the health of our nation, but for our health-care economy. The statistics are startling. Almost two-thirds of Americans are overweight (as defined as a body mass index, or BMI, of between 25 and 29.9) or obese (as defined by a BMI of ≥30), and more than 70% of Americans do not achieve the recommended amount of physical activity to obtain health benefit [1, 2, 3]. Recent research [4, 5] has shown that there is an association between the amount of sedentary time in an individual's life and their overall metabolic risk, independent from time spent in moderate or vigorous activity. People who stand and move around and spend less time sitting have healthier blood lipid profiles and blood glucose levels than those who meet minimum recommended activity levels but sit for prolonged periods.

This unhealthy environment is translating its devastating effects to our children; childhood obesity has tripled during the past generation and almost 20% of youths aged 12 to 19 are overweight [6]. Alarmingly, the authors of one study [7] have shown that >70% of overweight adolescents will grow up to be overweight adults. Among overweight or obese 5 to 10 year olds, approximately 60% have at least one cardiovascular disease risk factor (eg, elevated cholesterol, hyperinsulinemia, or hypertension). Seventy-four percent of school-aged children with 3 or more cardiovascular risk factors are overweight or obese [8]. Since the founding of this nation, the current generation may be the first with a shorter predicted lifespan than the previous generation.

The consequences of obesity on quality and quantity of life are significant. A BMI of >30 (obese) translates to a 200% to 300% greater rate of mortality, and a BMI of 25 to 29.9 (overweight) translates to a 20% to 40% greater rate of mortality than normal weight adults [9]. Between 1986 and 2000, the percentage of individuals with a BMI of ≥40 (ie, approximately 100 pounds overweight) quadrupled, increasing from about 1 in 200 to 1 in 50 adult Americans [10]. Hypertension is the most common health condition related to obesity and is also the number one modifiable risk factor for stroke. Obese individuals are more than twice as likely to have high blood pressure as normal-weight individuals [11]. More than 400,000 deaths since 1990 have been attributed to obesity and inactivity, second only to tobacco [12].

Obesity and inactivity combined have far-ranging consequences, including financial drain on business and other workplace consequences. The cost to business of obesity-related health-care issues totaled 15.4 billion dollars in 2002 [6]. Health insurance expenditures make up the bulk of these costs, but sick leave and life insurance and disability insurance payments account for 39% of the total. These figures do not include other significant costs, such as lost productivity and absenteeism [6]. The authors of one large study [13] found that employees who had an elevated BMI (overweight or greater) had medical costs that were on average >50% greater than normal-weight employees. Obese employees are also nearly 75% more likely to experience high rates of absenteeism than normal-weight employees [14]. Medical spending on obesity-related conditions is estimated to have reached $147 billion dollars per year in 2008, which is almost 10% of all medical spending [15]. When combined with type II diabetes—the most common sequela of obesity—the impact on our health-care economy is estimated to be an extraordinary 259 billion dollars [16]. As I have presented the aforementioned statistics throughout the country in my role as a member of the President's Council on Physical Fitness and Sports, it has been surprising to me how many people are unaware of the scope and magnitude of the obesity and inactivity epidemic. One of the most common responses that I hear when people (including health-care professionals) are presented with the data is: “I knew it was bad, but I did not realize it was this bad.”

The musculoskeletal consequences of obesity and inactivity are significant. Currently, >20 million Americans have osteoarthritis, which has been closely linked with obesity. The risk of developing arthritis increases by 9% to 13% for every 2-pound increase in weight [17]. Women who are obese have nearly 4 times the risk of developing knee osteoarthritis compared with nonobese women, and men have nearly 5 times the risk compared with nonobese men [18]. Many of the musculoskeletal sequelae of obesity involve conditions that can be improved with activity and exercise interventions that a physiatrist is uniquely suited to address. Physiatrists are trained to be experts in the application of therapeutic exercise and, historically, physiatrists prescribe therapeutic exercise to those with musculoskeletal (eg, osteoarthritis) or neurologic impairments.

Despite this dark cloud of obesity and inactivity related influences on morbidity, mortality, and quality of life, the silver lining is that the effects of obesity and inactivity are reversible. As the American College of Sports Medicine's “Exercise Is Medicine” campaign points out, exercise offers a myriad of therapeutic benefits associated with its consistent application. Physically active people have shorter hospital stays, fewer physician visits, and less medication use [17]. But exercise is also like a medicine in that it has an appropriate dosage, indication, contraindication, and side effect profile. For example, osteolysis of the distal clavicle can be precipitated by suboptimal technique with bench press exercise, certain yoga poses can place excessive load on the lumbar spine and also the wrist and shoulder joints, and certain hamstring stretches can be problematic for individuals with a history of knee or back problems. The importance of proper technique in strength training and flexibility exercise, appropriate guidance in aerobic activity progression, and the role of kinetic chain and movement pattern analysis are all essential to accurate exercise prescription as well as injury prevention.

These areas also are areas of expertise in the physiatric domain. In the cardiovascular realm, there is a need for accurate prescription of aerobic activity to treat and help prevent obesity as well as to provide health benefits and cardiovascular protection. The aerobic exercise prescription will vary depending on an individual's risk assessment and goals, and the amount of aerobic activity required as a minimum for cardiovascular health is different from the amount of aerobic activity required for weight loss.

There is a great need, however, for accurate prescription of exercise for those who may not have a current impairment but may be starting (or needing to start) a program of physical activity for weight control and to optimize cardiovascular and musculoskeletal fitness. In our current health-care environment, exercise application for “healthy” people is unlikely to be prescribed by physicians. Physical therapists, athletic trainers, personal trainers, coaches, physical education teachers, and other fitness specialists make up the bulk of those prescribing activity. However, the physiatrist has the unique qualifications and fund of knowledge to provide accurate, research-based exercise prescriptions. There is still a fair amount of tradition in many current exercise recommendations, but tradition is not always accurate. The physiatrist possesses the knowledge and skill to prescribe for the healthy adult/fitness enthusiast, as well as for the obese individual with associated joint complications or the inactive individual who needs to begin an activity program.

The reversal of the harmful effects of obesity and inactivity, however, should not be based on a single approach or assigned to a specific specialty or group. A multifaceted plan that includes health-care providers as well as all stakeholders, including business, government, education, insurance, and individuals and their families, is necessary. The physiatrist is uniquely suited to be effective in this environment, using his or her skills of program management and program development. The effective coordination of multiple members of the health-care team will be just as integral in the treatment of obesity and inactivity as it is in the multidisciplinary management of a stroke patient. Coordination of care and team leadership are unique skills of the physiatrist that also have the potential to be used in the battle against obesity and inactivity.

In summary, the specialty of physiatry is entering into an unprecedented period with a unique opportunity; few other medical specialties are as well qualified to address the problems of obesity and inactivity. For many physiatrists, however, the prescription of exercise for both healthy and obese individuals will be venturing into a different realm of practice, beyond their ordinary experience and possibly beyond their comfort zone. Some may feel the need to reinforce and further develop their skills in specific areas of exercise application for these populations. Physiatry in general will benefit from widespread education and research efforts in the areas of obesity and inactivity. It is a task well worth undertaking, for the benefit of our nation's health as well as for the benefit for our patients. Even now, opportunities exist for physiatrists to take action against obesity and inactivity at many levels—national, community, family, and individual. Are we up for the challenge?

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References 

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  • † Disclosure: nothing to disclose

 Disclosure Key can be found on the Table of Contents and at www.pmrjournal.org

PII: S1934-1482(09)01234-9

doi:10.1016/j.pmrj.2009.08.448

PM&R
Volume 1, Issue 9 , Pages 795-797, September 2009

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