1. Weight Loss in Preparation for Orthopaedic Surgery
Ashley Ritzo, RD LD
(573)

3. Topics Prevalence of Obesity
Complications of Obesity in Orthopaedic Surgery
Recommendations for Weight Loss Before Orthopaedic Surgery
Interventions
Barriers to Success
Strategies for Overcoming Barriers

4. Obesity Trends* Among U.S. Adults BRFSS, 1990, 2000, 2010
(*BMI 30, or about 30 lbs. overweight for 5’4” person)
1990
2000
2010
No Data <10% %–14% %–19% %–24% %–29% ≥30%
Slide taken from CDC Powerpoint

5. Prevalence of Obesity

6. Prevalence of Obesity
Flegal, KM, Carroll, MD, Ogden, CL, Curtin, LR. Prevalence and Trends in Obesity Among US Adults, 1999–2008. Journal of the American Medical Association. 2010; 235–241.

7. Prevalence of Obesity
Already pandemic, the prevalence of obesity may be grossly underestimated 1
Most patients presenting for total knee replacement (TKR) are obese.4-6

8. Complications of Obesity in Orthopaedic Surgery
Increased rates of post-op DVT and wound sepsis
Obese patients may differ in 02 supply requirements
Differences in med dosing and ICU outcomes 7
Increased rates prosthetic failure, infection, hardware failure and fracture malunion7
One kilogram (2.2 lbs) of weight gain increases diabetes risk by 4.5–9.0 % and cardiovascular risk by 3.1 % 2-3

9. Recommendations for Weight Loss Before Orthopaedic Surgery
American Academy of Orthopaedic Surgeons treatment of osteoarthritis of the knee (non-arthroplasty).
Recommendation 3
The authors recommend patients with symptomatic OA of the knee, who are overweight (as defined by a body mass index [BMI] > 25), should be encouraged to lose weight (a minimum of five percent [5%] of body weight) and maintain their weight at a lower level with an appropriate program of dietary modification and exercise. (Grade A, Level I)
250 lb person – 5% = 12.5

10. Recommendations for Weight Loss Before Orthopaedic Surgery
NOAN Check list before surgery (6-8 weeks)
Diet
Eat as healthy as possible with the appropriate servings of fruits, vegetables, protein, whole grains, and low fat dairy. An adequate iron supply is important before surgery. Good sources of iron include lean red meats, fortified cereals, and leafy green vegetables such as spinach or kale.
Discuss starting a multivitamin and iron supplement with your primary care doctor. These supplements may need to be stopped 1-2 weeks before surgery, so now is the time to get some benefit from the added nutrients.
Fluids are important for helping you to have regular bowel movements. Most of that fluid should be water and juicy fruits and vegetables.
Weight Loss
Seek the assistance of a dietitian or exercise specialist if weight loss is a goal before surgery. Your primary care doctor can make a referral for you.
An ideal body weight puts the least amount of stress on your new knee. Following an exercise and walking program will promote wanted weight loss. A dietitian can make suggestions for a healthy weight loss meal plan. Talk to your surgeon about visiting a dietitian if desired.

11. Interventions
Do Meal Planning Demonstration Here

12. Interventions

13. Interventions Energy Balance is basic math Weight goes up
Weight stable
Weight goes down

14. Interventions 1 lb of body weight = ~3500 calories
(-500 calories) x 7 days = l lb weight loss/wk

15. Interventions Methods to reduce calories Food Guide Plate
Calorie Counting
Meal Replacement Program
Weight Loss Surgery
Weight Loss Medications

17. Interventions Yet 2/3 of Americans are overweight…
According to a pole done in 2005:
Americans report that they have tried to lose weight an average of seven times in their lives.
24% have tried to lose weight once or twice
28% have tried between 3 and 10 times
11% have tried more than 10 times.
Only 1/3 of Americans have never tried to lose weight.
Yet 2/3 of Americans are overweight…

18. Interventions
32.5% (1/3) of Americans consumed fruit 2 or more times per day (BRFSS 2009)
26.3% (1/4) of Americans consumed vegetables 3 or more times per day (BRFSS 2009)
Americans were eating, on average, 10 servings of grains a day in Of those 10 servings, whole grains accounted for just over 1 serving. (USDA data)

19. Barriers to Success
Approaches to weight loss via diet, exercise, and behavior modification with or without pharmacologic support are sometimes successful in the short term, available data indicate that they do not last beyond 6 months to 1 year. 11

20. Barriers to Success
Loss of weight in obese patients awaiting surgery is difficult, partly because the symptoms limit their ability to exercise, and they often believe that joint replacement is crucial for weight loss. It has been suggested that this may not occur after TKR. 8-9

21. Barriers to Success
One study that used a 5% change from the pre-operative weight as the cut-off point found at 12 months after surgery:
14% of participants lost weight
65% remained unchanged
21% gained weight
Only 12.6% of the patients classified as obese and morbidly obese lost weight at 12 months. 10

22. DIETS DO NOT WORK!!!!

23. Overcoming Barriers to Success
“Get rid of the diet mentality”
Desire to be Thin
Dieting
Intense Cravings/Over-hungry
Over-eat
Regain of lost weight

24. Overcoming Barriers to Success
Change approach to eating
Eat in response to physiological cues, not societal or emotional rules or triggers

25. Overcoming Barriers to Success
Strategies:
Food Log
Studies indicate individuals who use a food logs are more likely to achieve weight loss success
Increase awareness
Thought provoking – Am I hungry? What does being hungry feel like? If I’m not hungry, why do I want to eat?

26. Overcoming Barriers to Success
“Use nutrition as a tool, not a weapon.” (Eat what you love, love what you eat with diabetes)
Choose healthy foods vs. unhealthy because of how they make you feel physically; not because you have to
Choose foods that will fill you up, while eating foods you like at the same time
Make foods appealing to all senses

27. Overcoming Barriers to Success

29. Overcoming Barriers to Success
Eliminate Guilt and rules
Not good or bad based on what foods are eaten
Habituation (M-W.COM) decrease in responsiveness upon repeated exposure to stimulus

30. Overcoming Barriers to Success
Have a plan
Brains are geared for survival, path of least resistance, and immediate results
We have to be able to anticipate what is going to occur in our lives and change our environment to be more conducive to long term goal

31. Summary

32. Sources
Swinburn BA. Commentary: closing the disparity gaps in obesity. Int J Epidemiol. 2009;38(2):509–11
Mokdad AH, Ford ES, Bowman BA, et al. Diabetes trends in the U.S.: 1990–1998. Diabetes Care. 2000;23:1278–83.
Willett WC, Manson JE, Stampfer MJ, et al. Weight, weight change and coronary heart disease in women. JAMA. 1995;273:461–5.
Fehring TK, Odum SM, Griffin WL, Mason JB, McCoy TH. The obesity epidemic: its effect on total joint arthroplasty. J Arthroplasty 2007;22(Suppl 2):71-6.
De Guia N, Zhu N, Keresteci M, Shi JE. Obesity and joint replacement surgery in Canada: findings from the Canadian Joint Replacement Registry (CJRR). Health Policy 2006;1:36-43.
Liu B, Balkwill A, Banks E, et al. Relationship of height, weight and body mass index to the risk of hip and knee replacements in middle-aged women. Rheumatology (Oxford) 2007;46:861-7
Guss, D., and T. Bhattacharyya. "Perioperative Management of the Obese Orthopaedic Patient." Journal of American Academy of Orthopaedic Surgery 14.7 (2006): PubMed. Web. 15 Aug <
Heisel C, Silva M, dela Rosa MA, Schmalzried TP. The effects of lower-extremity total joint replacement for arthritis on obesity. Orthopedics 2005;28:157-9.
Donovan J, Dingwall I, McChesney S. Weight change 1 year following total knee or hip arthroplasty. ANZ J Surg 2006;76:222-5.
The impact of pre-operative obesity on weight change and outcome in total knee replacement: A PROSPECTIVE STUDY OF 529 CONSECUTIVE PATIENTS
A Review of Unmet Needs in Obesity Management. N. Nguyen & J. K. Champion & J. Ponce & B. Quebbemann & E. Patterson & B. Pham &W. Raum & J. N. Buchwald & G. Segato & F. Favretti