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Managing Obesity in Adults: a Role for Occupational Therapy Camille Dieterle, OTD, OTR/L Mrs

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Managing Obesity in Adults: a Role for Occupational Therapy Camille Dieterle, OTD, OTR/L Mrs Continuing Education Article Earn .1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See page CE-7 for details. Earn .1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See page CE-7 for details. Managing Obesity in Adults: A Role for Occupational Therapy Camille Dieterle, OTD, OTR/L Mrs. T.H. Chan Division of Occupational Science and Occupational Therapy trol and Prevention [CDC], 2017b). Black and Hispanic adults University of Southern California, Los Angeles, CA have a higher rate of obesity than white or Asian adults (Hales et al., 2017). Overweight and obesity are defined by body mass index This CE Article was developed in collaboration with AOTA’s Rehabilitation (BMI), which is the ratio of weight to height. BMI is calculated & Disability Special Interest Section.. in a clinical setting by measuring overall weight and height and then using a chart or online calculator to calculate BMI. A BMI ABSTRACT of 25 to 30 is considered overweight. A BMI 30 or higher is Occupational therapy practitioners commonly encounter clients considered obese (Centers for Disease Control and Prevention diagnosed with or who are at risk for obesity across all popu- [CDC], 2016). Obesity is divided into further categories: class 1 lations and settings. Because obesity can affect participation (BMI 30–35), class 2 (35–40), and class 3 (40 or higher). BMI in occupation, occupational therapy practitioners can treat is a useful screening tool, but it has limitations. For example, it obesity as the primary condition or reason for referral, as well does not indicate how much body fat a person has, and people as in conjunction with various conditions and disabilities. This with high muscle mass and low fat mass may have a high BMI. article focuses on the effects of obesity on occupational perfor- Waist circumference is another measure used. In adults, a waist mance and participation and discusses occupational therapy circumference greater than 35 inches for females and 40 inches lifestyle interventions for treating obesity with adults who are for males indicates a higher risk for obesity-related conditions or who are at risk for obesity, including primary, secondary, and (Jensen et al., 2013). tertiary prevention and bariatric surgery. The article focuses Not all people with high BMI experience poor health, but on intervention in the context of outpatient lifestyle modifica- people who are obese are at an increased risk for all causes tion, although much of the material discussed is useful in most of death (mortality); hypertension; high LDL and low HDL settings. cholesterol; high levels of triglycerides (dyslipidemia); Type 2 diabetes; metabolic syndrome; coronary heart disease; stroke; LEARNING OBJECTIVES gallbladder disease; osteoarthritis (especially both knees); sleep After reading this article, you should be able to: apnea and breathing problems; some cancers (endometrial, 1. Identify the various client factors, performance patterns, con- breast, colon, kidney, gallbladder, and liver); breast cancer texts, and environments that contribute to obesity relapse; fatty liver disease; kidney disease; pregnancy problems; 2. Describe the effects of obesity on occupation and participation low quality of life; mental illness, such as clinical depression, 3. Articulate occupational therapy’s role in treating obesity anxiety, and other mental disorders; body pain; and difficulty 4. Describe evidence-based occupational therapy lifestyle mod- with physical functioning (CDC, 2017a; Dieli-Conwright et al., ification interventions for reducing weight and preventing 2018; National Institute of Diabetes and Digestive and Kidney weight gain Diseases, 2015). Additionally, social stigma and discrimination based on weight can affect mental health, especially in the INTRODUCTION form of mood disorders and decreased quality of life (Barclay More than 70% of American adults are either overweight or & Forwell, 2018). Stigma and discrimination from within the obese. Adult obesity rates have been rising steadily since the health care system and from society at large can contribute 1970s. In 2015 and 2016, 39.8% of adults in the United States to decreased engagement in self-care and decreased access to were categorized as obese (Hales et al., 2017). Another 32.8% of health care, which can lead to additional health problems (Tylka adults were categorized as overweight (Centers for Disease Con- et al., 2014). ARTICLE CODE CEA1118 | NOVEMBER 2018 ARTICLE CODE CEA1118 | NOVEMBER 2018 CE-1CE-1 CE Article, exam, and certificate are also available ONLINE. Continuing Education Article Register at http://www.aota.org/cea or Earn .1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See page CE-7 for details. call toll-free 877-404-AOTA (2682). Etiology 30% of American adults aged 30 to 64 years get fewer than 6 The most common causes of weight gain, which leads to obesity, hours of sleep per night (Bahrami-Nejad et al., 2018). With include genetics, environmental influences, medical conditions, regard to food, most nutrition research indicates that excessive disabilities, medications, food choices, meal timing, chronic consumption of sugar and refined carbohydrates contribute sleep deprivation, long-term stress (elevated cortisol), and to the most weight gain (Astley et al., 2018). In a long-term aging. Some of these causes are modifiable and some are not. study of more than 120,000 American adults, potato chips, A tendency for obesity can be passed down through genetics French fries, sugar-sweetened beverages, and processed meats (Tylka et al., 2014). Environmental causes for weight gain can were the foods found to be most associated with weight gain start in utero with maternal nutrition (Parlee & MacDougald, (Bahrami-Nejad et al., 2018). The timing of eating is another 2014), and physical and social environments can have signifi- factor that can affect weight gain. Nightime eating is associ- cant effects on weight gain throughout the life span. Elements ated with weight gain and maintaining higher weight (Allison of an “obesogenic” environment include unhealthy food choices/ & Goelb, 2018). Increased intake of high-calorie foods and energy intake, poverty, sleep deprivation, sedentary lifestyle, and decreased physical activity are considered the two main causes inactive work (Bellisari, 2013; Kuo et al., 2013). Lack of access of obesity worldwide, and a growing body of evidence also to healthy food, opportunities for physical activities, and access indicates that a history of childhood trauma, especially sexual to green spaces are also identified causes, as is an increase in abuse, may increase the risk for severe obesity in adulthood sedentary leisure activities (González et al., 2017; Kuo et al., (Bhurosy & Jeewon, 2014; Richardson et al., 2013). There 2013). Drieling and colleagues (2014) found that community is also evidence that the social environment can also affect resources that provide health education are associated with weight. For example, in a recent study of military families who more physical activity and better diet, which can be an asset for relocate, families who moved to communities with a higher obesity-reduction strategies. However, there is a need for better average weight gained weight themselves (Datar & Nicosia, resource promotion, given the low utilization of these afford- 2018). Poverty and lower education levels are also associated able educational community resources (Drieling et al., 2014). with higher weight (Saliman Reingold & Jordan, 2013). Weight Exposure to obesogenic chemicals, such as nicotine, flame gain is usually caused by a combination of multiple factors. retardants, bisphenol A, some pesticides, and polychlorinated Most often the combination includes reduced physical activity, biphenyls may increase the risk for weight gain and are thought unhealthy diet, decreased physical function, mental distress, to be most hazardous in utero and in early childhood, when the social isolation, the presence of obesity-associated diseases, body’s weight control mechanisms are being formed (Kelishadi and perceived physical and psychological barriers (Nossum et al., 2013). et al., 2018). As body mass increases, the degree of disability Medical conditions that commonly cause weight gain include increases. The risk for occupational performance problems underactive thyroid; polycystic ovarian syndrome; Cushing’s increases significantly with moderate and severe obesity syndrome; and mental illnesses, such as depression, anxiety, (Nossum et al., 2018). Clients seeking occupational therapy posttraumatic stress disorder, binge eating disorder, and night may be more likely to be obese than the general public because eating syndrome (Assari, 2014; National Health System, 2017). of decreased mobility, additional conditions, medications, and Conditions that limit mobility and engagement in occupation other contextual factors. Obesity is considered a chronic con- can also increase the likelihood of weight gain, including phys- dition and losing weight often requires lifelong maintenance. ical disabilities and mental illness (Saliman Reingold & Jordan, Obesity is often preventable. 2013). Menopause, perimenopause, and aging can cause weight gain as well (Porter, 2016). Medications that commonly cause Effect on Occupation weight gain include steroid therapies; diabetes medications Obesity increases the risk for decreased physical function, (e.g., insulin, thiazolidinediones, sulfonylureas); psychiatric/ reduced ability to perform everyday activities, social isolation,
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