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Helping Obese Patients by Weight Management, not Diet
By Jeff Fredrick, MS, CPO The same America that expects to attain viable
longevity into its 80s has tallied up an unprecedented record of
obesity. It comes as no surprise that booming obesity rates are
correlated with an ever-skyrocketing appetite for junk food--often
called "recreational consumption." Anyone with a genetic
predilection for weight gain, who pursues a sedentary lifestyle, or
is employed in a non-physical vocation, easily can become trapped
in the deadly cycle of uncontrolled weight gain. The physically
challenged patient is even more at risk.
 Sadly, healthcare providers, especially those who
have never personally dealt with excessive weight gain, are often
insensitive--even dismissive--toward the clinical presentation of
chronic obesity. Too often, "You need to lose weight" is the curt
clinical response to patients who present with an obvious inability
to manage their weight.
We live in an information-driven culture, and the general public
is well-informed about the hazards of obesity. The astute,
sensitive clinician will recognize that obesity may indicate other
equally serious issues such as depression, healthcare
non-compliance, pharmaceutical dependence, an inability or
reluctance to access medical care, or simply a failure to
discipline the appetite. The fact that someone sustains obesity in
a culture that puts such inordinate stress on physical beauty
should be a wake-up call regarding the depth of the problem. If
that's not serious enough, obesity can not only be physiologically
detrimental, it can be psychologically humiliating as well.
So, how can clinicians sensitively address excessive weight gain
and obesity in their patients regardless of their medical or
rehabilitation specialty? More specifically, how can we factor in
weight loss to increase the success of O&P functional
outcomes?
Case study: Woman, age 25, suffering
post-operative pain following a repaired fracture of a Charcot foot
set in marked valgus. Conservative estimate: 100 lb. overweight.
During my initial workup, she volunteers (more like apologizes)
that she knows her weight is not helping her foot and ankle.
I respond, "May I discuss a few weight issues with you?"
She looks surprised that I even ask permission, and says, "Why
not?"
 I tell her about another patient. He suffers from
post-polio syndrome and has gained more than 100 lb. in the 20
years I've provided unilateral KAFOs for him. One day he presents
with complaints of hip and back discomfort that have pushed him to
the threshold of his pain tolerance. He wants me to adjust his
orthosis to correct the problem. I respond with the suggestion that
he conduct an experiment:
"Drop a 25-lb. barbell plate in one of your kids' book bags and
wear it around for a few hours after work. Call and let me know how
your back and hip feel."
He calls me a few weeks later.
"I did what you said and within an hour I hurt so bad I had to
ditch the bag!"
I respectfully advise him that he is already wearing four
flesh-and-blood 25-lb. barbell plates wrapped around his midriff.
The only reason they aren't hurting four times as much is because
he gained the weight slowly. However, the extra 100 lb. is no less
a threat. The serial addition of excessive body weight to virtually
any lower-extremity orthopedic etiology easily can cause further
injury or deterioration.
Back to my patient: She was referred for an AFO. However, if I
truly wish to provide competent rehabilitation care, her weight
must be managed toward a steady decrease. But is this part of the
O&P clinical repertoire? It is--if successful use of an AFO is
the targeted functional outcome. That is, if the stability and
healing of her ankle is the prescription rationale for orthotic
intervention, and not simply to fit an AFO and have the patient
sign the delivery paperwork.
So how do you recommend a particular diet when the higher
domains of nutritional science are generally beyond our training as
O&P practitioners? There is a plethora of diet chatter
reverberating throughout the pages and airwaves of our culture. The
latest successes flash onto the fad stage and then fade away at an
alarming rate. Alarming rate, that is, if there really are any
scientific "diet" absolutes out there. Why is the crash rate of
most "miracle" diets so high? It's simple really. Most diets demand
a sudden, inflexible disconnect from a person's lifestyle and
comfort zone.
A diet, to be successful, must evoke a significant reduction in
the quantity of foods ingested, eliminate sweets, junk carbs, and
most other enjoyable, recreational foods. The typical dieter has
worked up the motivation needed to begin withdrawal, loses a
significant amount of weight to reward his/her motivation, and then
suddenly binges out of the process. Why? Because he or she has lost
a primary means of escape and enjoyment, and the resulting sense of
well-being recreational foods and their celebrated occasions
provide.
So, what are the reasonable clinical options? First, recognize a
diet per se may not be the best option for your patient, especially
if he/she has a history of failed attempts to lose and maintain
weight loss. Perhaps a more clinically reasonable strategy is a
weight management program with protracted, easily
attainable results--results that will not demand a sudden and
catastrophic change of lifestyle.
E Scale: A Practical Program
Toward meeting the challenge of weight management, especially
among my patients who present with physical dysfunction that
excessive weight clearly exacerbates, I have developed a practical
weight management program. The approach is simple and guides the
patient toward weight loss and long-term maintenance of healthy
body weight. It is a simple model that can provide realistic and
sustainable outcomes for your patients. Best of all, it does not
require any sudden dietary restrictions, special foods or cooking,
reductions in recreational foods, or calorie counters. It is a
simple management plan that enables patients to track and adjust
their eating habits via a very low impact, i.e., gradual, form of
change.
Let's pursue my patient as an example. What is my response when
she volunteers that she is 100 lb. overweight?
"Well, you're planning on being alive two years from now,
right?" I ask, mitigating the import of the question with a teasing
smile.
"I'm planning to be," she smiles back, but with a question in
her eyes.
"Then you could lose one pound a week for the next 24
months--since you plan to be around that long anyway, right?"
"Only one pound a week?' she laughs, "I've lost that much in the
first morning of at least a dozen diets!"
"Yep, just one pound a week. Why not settle for an easy-to-lose
one pound a week for the next 100 weeks? Best of all, you'll lose
it slowly, naturally, just like you gained it, not starving down
and then binging back up again."
"Tell me more," she asks, taking the first step toward a
healthier, more disease- and stress-resistant body.
Figure 1 is a chart we provide for patients
interested in adding a reasonable and potentially successful weight
management program to their rehabilitation regime. I call it the
Emily or E Scale after my
daughter who has successfully used it to manage her
fashion-critical five-lb. weight fluctuation. The E Scale is never
suggested without mention that we are not dieticians. It
presupposes there are no medical conditions that might be
aggravated, and we include a recommendation that patients ask their
physician for permission before they begin.
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Figure 1 |
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How It Works
In Figure 1, the X axis is incremented in weeks, and the Y axis
weight in pounds. My patient has charted her present weight of 275
lb., and her ideal or target weight of 175 lb., 100 weeks later. A
patient could settle for a half-pound per week target or even less
to minimize culinary trauma, but I feel any long-term increase over
a single pound per week negates the psychology of the concept.
The two weights are connected with a Weight Management Line
(WML). On the same day of every week, the patient records his/her
weight. A successful E Scale reduction actually mimics a descending
stock market graph. A dinner with Aunt Martha leaves us a pound
heavy as recorded on week three, so two lb. are required over the
next week or two to achieve correlation to the WML. Obviously any
fluctuation can be spread over time to soften recovery and ease
trauma--but only by small, easily manageable increments to plan
ahead or recover. Staying on top of management is the critical
issue.
The E Scale does not impose a rigorous regime of deprivation in
place of favorite foods or the meaningful social occasions when
they are enjoyed. Rather, it substitutes low-impact management for
forced caloric reductions, and consequently preserves the
psychologically uplifting moods and comforting social life that are
inarguably associated with food in our culture.
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Figure 2 |
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E SCALE ALERT : Our patient's two
sisters (also chronically overweight) are coming to town to
celebrate a good, old-fashioned family Thanksgiving. Our patient
usually gains ten lb. before her sisters pack up the leftovers and
head out of town. But this time she is prepared. Since she has been
using the E Scale for 20 weeks for a sum loss of 20 lb., her
lifestyle and caloric intake/dependence already has begun to
diminish. (And yes, the argument can be made that for some,
food--its effect--is an addictive drug!) Planning ahead for her
yearly Thanksgiving food fest (or, should I say, managing ahead),
she opts to lose an extra half-pound per week over the ten weeks
preceding the holiday. Figure 2 illustrates that
Thanksgiving arrives and she is five lb. under scale going into the
weekend. This is an example of successful weight management.
The following Monday (her regular chart day) she records only a
five-lb. spike above the WML which she will manage over another
ten-week period in the same manner she prepared for the
much-anticipated gain. This ability to retain the recreational
component of eating while effectively managing weight toward health
is the heart of the E Scale philosophy. This represents its
advantage over traditionally harsh modes of dieting.
What about eating the wrong foods, the need for a
well-balanced meal, and the danger of too many carbs? The fact that
weight gain has become a problem for some is not a function of
their ignorance of nutrition, but the lack of a successful strategy
to address the problem. The E Scale is managerial, not nutritional,
in its approach. It bases success on a low-impact reduction in
portions and frequency of intake, not the termination of any
particular food type or understanding of correct nutritional
balance. Most obese Americans understand which foods cause
excessive gain, and which are healthier. Comprehension is not the
issue, but rather the need for a realistic strategy to gain control
over unmanaged excess in overall caloric intake.
Lifelong Maintenance for Health
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Figure 3 |
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The success of any weight management program
should be based on maintenance of the loss--not short-term,
diet-driven or artificial reductions. This is, perhaps, the key to
effective, long-term weight management. Once our patient achieves
her 175-lb. target ( Figure 3 ), the Weight
Management Line becomes a Weight Maintenance Line tracking a
horizontal course for the rest of her life. She will continue to
chart her weight weekly, planning for fluctuations.
The E Scale represents a strategy that allows patients to slowly
and consistently reduce body weight without unnecessary social,
psychological, or physical trauma. Teaching a patient how to
effectively lose weight and keep it off is as important as weight
loss itself--if maintenance of that loss is the ultimate goal.
Participating in effective weight loss as a clinical modality can
contribute significantly to the success of virtually any form of
orthotic or prosthetic intervention. Jeff Fredrick, MS, CPO, is director of Hanger's Rehabilitation for Development (Hanger RFD) and branch manager at Hanger Prosthetics & Orthotics, Tallahassee, Florida. He can be contacted at 850.878.1108 
Table Of Contents - April 2006
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