Obesity and Physical Therapy

I don't talk a lot about diet with my physical therapy patients.

I probably should because Body Mass Index - your weight in kilograms divided by your height in meters, squared - is an important predictor of future disablement and death.

However, I don't talk much about diet for one simple reason - I am not qualified to give anyone advice on their food consumption.

Oh, it's not that I don't have the knowledge or experience. Its just that I have no discipline.

I never met a cookie that I didn't like.

Which, I think, is most American's problem - especially those who struggle with obesity.

In The Mathematics of Obesity, MIT-trained physicist Carson C. Chow dishes out his theory of why Americans began gaining weight in the 1970's and have only recently began to cut back.

"Beginning in the 1970s, there was a change in national agricultural policy.  

Instead of the government paying farmers not to engage in full production, as was the practice, they were encouraged to grow as much food as they could.  

At the same time, technological changes and the “green revolution” made our farms much more productive.  

The price of food plummeted, while the number of calories available to the average American grew by about 1,000 a day.  

Well, what do people do when there is extra food around? They eat it! 

...the model shows that increase in food more than explains the increase in weight."

I like Chow's approach to explaining obesity - he doesn't blame individuals. Its not lack of willpower, or a sweet tooth, or "big bones".

Further, Chow's analysis dispells much of the contradictory psuedo-science of WHERE your calories come from - carbs, proteins, fats - its all calories.

However, the answer to obesity will have to come from individuals. And their healthcare providers. The individuals will have to change their eating behavior. Patients will have to control their food intake.

And, physical therpists can help them.

There is an interesting BMI Simulator based on Chow's work at The National Institute of Diabetes and Digestive and Kidney Diseases that is probably too complex for most people.

Bottom line, we'll probably all need help getting our impulses under control. For me, that means fewer cookies (pause, while I brush the crumbs off of my keyboard).

As Chow explained in his New York Times interview,

"It’s so easy for someone to go out and eat 6,000 calories a day.  

There’s no magic bullet on this. You simply have to cut calories and be vigilant for the rest of your life."

Disability Rising Due to Inappropriate Primary Care for Lower Back Pain

Would you go to see an emergency room doctor for treatment of your painful back?

I wouldn't.

Busy emergency room doctors don't want us there either. They are busy saving peoples' lives.

But, this recent report from the Healthcare Cost and Utilization Project at the Agency for Healthcare Research and Quality (AHRQ) indicates that more people are getting treatment for lower back pain in the emergency room than might be warranted.

Hospitalizations doubled from 1993 to 2008 for patients with back problems.

Hospitalized patients with back pain cost $14,338 while patients without back pain cost $9,055. This may be due to the outlier effect of increasing rates of complex, multi-level spinal fusion surgeries that cost $88,000.

"...hospitalizations for back problems in general were more expensive than all other inpatient stays..."

The aggregate costs for inpatient stays principally for back problems was over $9.5 billion in 2008, making it the 9th most expensive condition treated in U.S. hospitals.

Disability Rising

A study from North Carolina followed-up on 5,357 households to calculate the trend in disability due to lower back problems. From 1992 to 2006 chronic, impairing lower back pain rose in North Carolina from 3.9% to 10.2% of the population.

The study authors speculated the causes might be the following:

• Rising rates of Obesity: the number of obese people in North Carolina has increased from 13.4% to 26.6% of the population. Obesity is defined a Body Mass Index greater than 30.0 (weight in kilograms per height in meters squared).
• Increases in depression prevalence: rates of depression doubled from 3.3% to 7.06% through 2002. Chronic pain and depression are linked and individuals with depression are 3 times more likely to develop lower back pain.
• Medicalization of lower back pain: competing healthcare professionals, some advertising on the Internet, have increased public awareness of treatment possibilities despite the fact that many of these treatments are expensive and offer no better long-term improvement than no treatment.

The most at-risk group of North Carolinians are the age group from 45 to 54 years: they became chronically painful at the highest rate of any cohort. Their incidence increased from 15.2% to 26.7% over the time period.

Heavy, Sad and High Tech

According to a recent report in the Journal of the American College of Radiology up to 50% of diagnostic imaging tests are unnecessary and don't add to the patient's improvement.

Imaging scans cost $100 billion annually and these costs are growing 17% per year.

Physician could improve their targeted care of emergent conditions and better serve patient in need by reducing unnecessary imaging for lower back pain.

The following guideline from the American College of Radiology shows a clinical summary of imaging advice.

Further, physicians could reduce the medicalization of common, age-related physical impairments associated with lower back pain by encouraging their patients to exercise and take care of themselves before problems arise.