The AAOS is getting the word out, but a villain—just like the Joker in the Batman movies—is standing in the way, maybe even gaining and winning. That villain is none other than obesity, and what a villain it is!
The statistics in this country are profound:
- From 1960 to 2000, the number of obese individuals in the United States more than doubled.
- By 2010, more than 78 million U.S. adults met the criteria for obesity (BMI ≥ 30), and no state had an obesity rate of less than 20 percent.
- By 2030, 40 percent of the U.S. population will meet the criteria for obesity.
- The expense of medical treatment of obese patients is much higher: an additional $215 billion in medical expenditures will occur each year, with healthcare costs attributable to overweight predicted to account for nearly 20 percent of the total U.S. healthcare costs.
Americans seem to have accepted this lifestyle, despite futile attempts such as that by the mayor of New York City who tried to limit the volume of sugary drinks sold and consumed.
What’s it to me?
So, why am I particularly upset? Well, I was a fat kid. I ran all over the “skinny” kids on the playground, but because I was fat, they teased and made fun of me: “Hey, Fatso, throw me the ball” and “Hey, Fatso, you’re so fat you split your pants.”
Also, my father played football at Notre Dame, but later made a fatal mistake by not exercising and letting his muscle turn to flab. He died young—but morbidly obese—at age 44 of coronary artery disease. I was just 17 when I lost my father, my best friend, and coach. I vowed never to be obese, so I engaged in aerobic sports, listened to the likes of Ken Cooper, and followed his aerobic advice.
After medical school and residency, I ran, ran, and ran some more—just like Forrest Gump. Too late I realized that joints are like tires: they have treads and can wear out. I now have two total hip replacements, but no fat! A “little atrial fib” but no coronary artery disease, no stents, no bypasses. I have a familial risk factor, but have outlived my father by 30 years. “Get out and get moving” worked for me, and it can work for others.
I am writing this on an airplane, sitting next to a guy who needs two seat belts. I am using his thigh as the “tray table.” Fortunately, he is on my right and I am left-handed. I can tell that he is embarrassed and he doesn’t want to be obese. He would be as thin as Jack Spratt if he could. My emotion at the moment is empathy for him.
I used to be contemptuous of anyone who was obese, but I now realize that that reaction is out of order. People don’t want to be fat. They have been told to lose weight a thousand times. So, in my mind, there is something more to it than just being obese, and more to it than losing weight with proper exercise and diet, and more to it than bariatric surgery, and more to it than being denied orthopaedic surgery because the complication rate is too high in obese patients.
Obesity, orthopaedics, and outcomes
So what is obesity all about? The answer was made crystal clear at the O3 (Obesity, Orthopaedics, and Outcomes ) forum sponsored by AAOS Now in March. Thirty-three experts on obesity and its effects on orthopaedic patients attended this by-invitation-only forum. Among the issues they discussed were the following:
- Is there bias toward or even “profiling” of obese patients by the medical profession?
According to the literature presented at the AAOS Now forum, medical professionals, including orthopaedists, and individuals in all other walks of life have a bias about overweight and obese individuals. Efforts need to be made to stop “prejudging” obese patients and treat each patient’s unique problems individually.
- Should obese patients be denied reconstructive orthopaedic surgery because of the increased complication rates in obese patients?
Philosophically, this argument has two sides. Some surgeons believe that the increased complication rate and the elective nature of the surgery justify delaying joint reconstruction until the patient achieves a weight-loss goal. This would lower the complication rate (infection, pulmonary embolism, etc.) and reduce the cost of revision surgery. On the other hand, the patient may need the surgery to improve his or her quality of life and mobility. If the patient is made aware of the risks and complications, then, ethically, he or she should not be denied the surgery.
- Are some elective orthopaedic procedures in obese patients fraught with more complications than others? If so, which procedures are they?
Major joint reconstruction seems to be more prone to complications than spine surgery, but foot and ankle procedures, treatment of pediatric conditions, open reduction and internal fixation for trauma, and shoulder procedures have been reported to have greater, almost unacceptable complication rates. Anesthesia risks are also greater in obese patients.
- Is it realistic to ask a patient to lose a large amount of weight before an elective orthopaedic procedure? What percentage of patients actually do lose the weight and have the procedure?
According to O3, it is reasonable to ask a patient to lose weight preoperatively, but very few (an estimated 18 percent) actually do so.
- What percentage of patients actually lose weight after surgery due to their ability to be more mobile and in an exercise program?
It depends on the procedure, but only a small percentage of patients lose weight after surgery. In fact, a recent study on lower extremity reconstruction (total hip and total knee arthroplasty) revealed negligible weight loss at 1 year after the joint replacement.
In my practice
To prepare for O3, I decided to canvass my patients. I saw 517 adult, older children, and athletic patients (excluding young children and competitive athletes) from Jan. 2 through March 2, 2013.
Using my “modified folk” obesity scale, I determined obesity and morbid obesity. Based on this scale, if a food stain was situated on the shirt, tie, or blouse at the abdominal level (before the food hit the floor), the patient was obese; if the patient couldn’t see the tips of his or her shoes while standing, they were morbidly obese. As a screening device, this scale was OK, but it wasn’t very objective, and several patients wondered why I was “staring” at their ties or the tips of their shoes.
So I switched to the BMI scale, which was available thanks to the help of my nurse Jenny (often called “Nurse Yes”). Under the Obama healthcare reform, you have to obtain the height and weight of patients and the electronic medical record computes the BMI (see, all of Obamacare isn’t bad). Try it in your office and see what your percentages are.
In my office, 84 patients or 16 percent were obese (BMI > 30), and 25 percent of these patients were morbidly obese (BMI > 40). This is amazing because most of the patients were older children, adolescents, or “recreational” athletes.
I then asked these patients about obesity. I started the conversion with, “In my estimation, I feel that you may be struggling with your obesity. How does that fit with what you are thinking?”
I’m sure there’s a better way to start, but that was my first attempt. Although I thought it was pretty empathetic, I’m still ducking. At the forum, I learned that “obese” is nearly as bad a term as “fat,” so it is not to be used. “Weight” is the appropriate, more palatable term that should be used.
From what I learned at the forum, the opening, nonembarrassing question should be something like, “Can I discuss your weight situation with you?” It seems that no matter how you ask, it is still an embarrassing question.
A third of patients were defensive (I have tried everything), a third were indifferent (you’re not the first to tell me that), and a third were willing to listen and seek advice and recommendations.
It’s our responsibility
Regardless of how embarrassing the question, I believe that, as orthopaedists, we cannot ignore the problem of obesity or “excessive weight” or whatever it’s called. I believe we should have a two-pronged attack against the “fat man” villain.
First, our obese patients need to be confronted and counseled in the office. I believe all orthopaedists need a “spiel” on the adverse effects of obesity at their fingertips and a referral source in their community for a multidisciplinary weight-loss program, even if it means delaying or denying surgery to get the patient’s attention. It won’t be the first time orthopaedists have not recommended surgery.
What I heard as a child—“Hey, Fat Kid, you need to lose some weight”—just won’t work anymore. Weight is much more complex than that; we, as orthopaedic surgeons, in addition to counseling our patients into an appropriate weight-loss program, need to take the lead and get out and get moving on this issue.
Second, because obesity is more than a simple weight-gain problem and has many facets—including psychological, social, and advocacy issues—attendees at the AAOS Now forum pushed for a more active role by orthopaedists and the AAOS itself. Among the ideas proposed were the following:
- a symposium or instructional course lecture at the 2014 AAOS Annual Meeting
- articles in the Journal of the AAOS and AAOS Now on obesity and orthopaedic patients
- a possible work group or task force to make recommendations about what AAOS and other orthopaedic organizations can do to fight obesity
As Lynda H. Powell, PhD, chair of the department of preventive medicine at Rush University Medical Center, noted, “Orthopaedists—unlike most medical specialtists—have a chance to counsel patients about the need for surgery and challenge them to lose weight and change their lifestyles.” She defines this as a life-defining, life-changing moment, a moment that could ultimately prolong the patient’s life, as well as greatly improve his or her quality of life.
Let’s do this. Let’s go to war against this villainous epidemic.
S. Terry Canale, MD, is editor-in-chief of AAOS Now. He can be reached at firstname.lastname@example.org