The White Elephant in the Clinic

The metaphorical idiom ‘the white elephant in the room’ has never been truer than when working with the obese patient who has a number of medical and orthopedic problems. When it comes to the underlying causes of problems that patients encounter, obesity is a major contributor… yet we’re afraid to address this issue with our patients. Why is this the norm rather than the exception?

We know that many research articles written on obesity and osteoarthritis of the weight bearing joints demonstrate the significant increase in correlation with osteoarthritis (OA) in those that have a higher body mass index (BMI) compared with those with a lower BMI. Research on OA of the hip, knee and even the hands has shown a significant correlation with obesity and the BMI.

We also know that interventions incorporating both exercise and diet in a population with OA of the knees demonstrate weight loss of as little as 5% of a person’s initial body weight is more effective than exercise alone. Subjects in this study showed significant increase in function and reduction in pain.

Additionally we know that the amount of reduction in body weight of those that have knee OA is directly correlated with decreased cartilage degeneration over a 4 year period from previous published research.

However these orthopedic issues pale in comparison with some of the other medical problems related to obesity including hypertension, diabetes, and cancer, to name a few. The very real improvement in these diseases as well as other diseases not mentioned through modest weight loss would lead us all to believe addressing obesity with your patient should be a priority. The American College of Rheumatology recommends weight loss for adults with hip or knee osteoarthritis and overweight or obesity, which can improve function and mobility while reducing pain and disability

Your response to this article might be that “as a physical therapist that’s not my area” or “that’s really not something I know about”. My rebuttal would be “why not us?” as a physical therapy profession in which our association (APTA) now clearly has placed this as a priority by providing a nutrition webpage and has stated nutrition is part of the professional scope of practice of physical therapists. The APTA Nutrition webpage has also offered several excellent websites as resources for the physical therapist, including www.nutritionfacts.org and www.eatright.org .

Offering information to your patient on how an elevated BMI is correlated to osteoarthritis of the weight bearing joints and then helping them set some realistic weight loss goals of 5-10% of their current body weight should be a part of the initial evaluation process. Physical therapists should encourage their patients to eat more fruits and vegetables and avoid inflammatory refined carbohydrates by directing them to governmental websites such as www.health.gov to obtain 2015-2020 guidelines on food choices. There is a toolkit for professionals on the site that therapists can use to guide their patients.

With all the available tools that we have as professionals which is ‘public knowledge’, making lame statements like ‘this is not my area’ or I don’t know anything about that area’, becomes part of a sad commentary for our lack of effort as professional healthcare clinicians in addressing this most important problem with our patients. The ‘White Elephant in the Clinic’ needs to be addressed not avoided.

This article was contributed by:

Jeff Gilliam, PT, PhD, OCS

Jeff Gilliam PT PhD, OCS: is a weight loss specialist, who has studied extensively in the areas of health behavior, exercise physiology and nutritional biochemistry at the University of Florida. Jeff has taught a course at the University of Florida called ’Research Applications to Obesity and Weight Loss’. He has also taught courses for the DPT program at UF in Health Promotion and Wellness’ and ‘Evidence Based Practice III’. He has presented on a national level on topics related to diseases related to obesity and changing behavior to facilitate a healthy lifestyle. His PhD research was in the area of effective behavioral interventions for obesity and its associated diseases. He is founder of Physicians’ Choice for Weight Loss, a successful lifestyle/weight loss program, which can be found in over 50 clinics in the eastern US. He currently is clinical director of ReQuest Physical Therapy (Gainesville, Florida) and incorporates his lifestyle/weight loss program into his patients’ physical therapy to help them achieve their healthiest body weight. Jeff Gilliam is an Orthopedic Certified Specialist through the American Board of Physical Therapy Specialties.

For more of his articles here on PhysicalTherapist.com, please visit click on the link [HERE!].