Published 5/1/2015
Alan S. Hilibrand, MD

Taking on Heavy Discussions

New position statement provides a blueprint

What do you say to a patient who is obviously overweight or obese? Do you leave the discussion to your nurse practitioner or physician assistant? Or do you, as the orthopaedic surgeon, attempt to address the issue?

The new AAOS position statement, The Impact of Obesity on Bone and Joint Health, approved by the Academy’s Board of Directors at the 2015 Annual Meeting, outlines the effects of obesity on patient pain, function, surgical outcomes, and overall musculoskeletal health. It also calls on orthopaedic surgeons to proactively address the issue as part of patient treatment and care. It should provide a good starting point for discussing the risks of obesity with patients contemplating orthopaedic procedures.

Obesity affects nearly every organ in the body and frequently contributes to soft-tissue damage and osteoarthritis. More than two-thirds of adults in the United States are overweight, and one in three is obese. The percentage of adults with obesity has more than doubled over the past 30 years—from 15 percent in 1980 to 35 percent in 2010. At that rate, an estimated 44 percent of American adults will be diagnosed with the disease by 2030.

“With the spread of the obesity epidemic through most of the United States, it is imperative that we as orthopaedic surgeons recognize its impact on our ability to care for patients, said Michael L. Parks, MD, chair of the Academy’s Workgroup on Obesity. “This AAOS position statement highlights the detrimental effect of obesity on both bone and joint health and subsequent surgical outcomes.

“At the physician level, a broad approach is needed to address the preoperative medical issues, intraoperative technical difficulties, and additional postoperative resources needed for patients with obesity,” said Dr. Parks. “At the patient level, education about weight management and its implications on risk and surgical outcomes is important. Together these strategies require a broad organizational approach.”

“When I meet a patient with obesity, I ask: ‘Has your weight changed significantly over the past few years?’” said Claudette M. Lajam, MD, a workgroup member. “I am not sure if this is the best way to start this conversation, but at least it’s a nonjudgmental approach that encourages patients to tell me their story. Then, after an initial discussion, the follow-up is: ‘You know your weight makes a difference in how your joints function and feel. How can I help you make your weight better for your joints?’”

If the discussion is about a pending or potential surgery, Dr. Lajam explains that studies have shown that individuals with obesity have a higher risk of complications after a joint replacement—three to five times higher than those without obesity. “Fortunately,” she continued, “weight is a risk factor that we can work to change. Overall, I try to keep the discussion fact-based and clinical, but I also try to make sure that the communication highlights that the patient is in control and that I am there to help.”

Elizabeth G. Matzkin, MD, is routinely “up front” with patients on the link between weight and musculoskeletal health.

“I tell patients that there is one thing we know that will make them feel better—especially if they have knee osteoarthritis—and that is weight loss,” said Dr. Matzkin. “For every 1 pound they lose, their knee will feel like it lost 5 pounds. So, a 5-pound weight loss is like a 25-pound weight loss to the knee. This is significant!”

In addition to encouraging proactive discussions with patients on the role of obesity in musculoskeletal health, the position statement recommends that, before undergoing elective orthopaedic surgery, patients with morbid obesity (a body mass index of 40 or greater) and their orthopaedic surgeons discuss the following:

  • the impact of their weight on possible complications and results after surgery
  • resources available to help them lose weight before surgery
  • the possibility of delaying certain surgeries (if this is in the patient’s best interest), such as joint replacement, where losing weight could improve the outcome of treatment, to provide time to take interventions for obesity; a delay in surgery is not a judgmental statement, but rather a risk reduction tool to avoid potentially serious and life-changing complications
  • the possibility of participating in a weight-loss program before undergoing total joint arthroplasty
  • a plan to manage comorbidities
  • nutritional status and deficiencies; patients with obesity have a high incidence of altered nutritional status, and poor nutrition may contribute to comorbidities such as diabetes, in which blood sugar should be brought to reasonable levels to reduce risk
  • rehabilitation protocols, including patients’ ability to follow them, and the necessary commitment required for recovery
  • the possibility of a patient commitment letter in which the patient agrees to lose weight, exercise, and eat better to demonstrate responsibility for personal health; even after surgery, patients must make an ongoing commitment to keep weight down for their overall health and for issues such as the longevity of total knee arthroplasty

“Our goal is to promote an open dialogue between physicians and patients to ensure the best possible outcomes for the patients to whom we provide care,” said Dr. Parks.

The full statement is available at http://www.aaos.org/about/papers/position.asp

Alan S. Hilibrand, MD, chairs the AAOS Communications Cabinet.