Tinjauan Pustaka

The Management for Grade I Obesity as the

Underlying Disease of Osteoarthritis

Tirza Z Tamin,* Fiastuti Witjaksono,** M.Antoinette C. Winokan,** Ferius Soewito*

*Physical Medicine and Rehabilitation Department, Faculty of Medicine University of Indonesia
**Department of Nutrition, Faculty of Medicine University of Indonesia

Abstract: Obesity is a serious and growing health problem. It is very rare for a patient to seek
medical assistance only for the obesity alone. More often, the complications are the patients
chief complains. Osteoarthritis is a frequent complication of obesity. This is a case report of 60
years old female who came with knee complains. The diagnoses are osteoarthritis and obesity
grade I as the underlying disease. The obesity program was conducted as soon as the knee
problem treated. Though no significance changes of her nutritional status, the knee complains
had subsided. Physicians should always evaluate the probability of obesity causing diseases
that patients have as their main complaints. The patient should understand that these therapies
should be sustained for long-term period.
Keywords: Obesity, osteoarthritis, case report, rehabilitation, nutrition, department

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The Management for Grade I Obesity as the Underlying Disease of Osteoarthritis

Manajemen Obesitas Grade I Sebagai Penyebab Osteoartritis

Tirza Z Tamin,* Fiastuti Witjaksono,** M.Antoinette C. Winokan,**
Ferius Soewito*
*Physical Medicine and Rehabilitation department, Faculty of Medicine University of Indonesia
**Department of Nutrition, Faculty of Medicine University of Indones

Abstrak: Obesitas merupakan masalah kesehatan yang serius. Walaupun demikian pasien jarang
datang berobat hanya untuk masalah obesitas. Komplikasi dari obesitas lebih sering merupakan
keluhan utama pasien. Osteoartritis merupakan komplikasi tersering dari obesitas. Ini adalah
sebuah laporan kasus mengenai seorang wanita berusia 60 tahun yang datang dengan keluhan
nyeri lutut. Diagnosis yang ditegakkan adalah osteoarthritis genu dan obesitas. Program obesitas
segera dilakukan setelah keluhan lutut tertangani. Walaupun penurunan berat badan belum
bermakna, keluhan lutut berkurang. Dokter disarankan untuk selalu mempertimbangkan
kemungkinan obesitas sebagai penyebab keluhan utama pasien. Pasien harus diedukasi bahwa
terapi obesitas adalah terapi jangka panjang.
Kata kunci: obesitas, osteoartritis, laporan kasus, rehabilitasi, nutrisi, departemen

Introduction
Obesity is a serious and growing health problem. In
1999 to 2000, 33% of men and 39% of women 65 to 74 years
old were obese.1 Obesity has grown by almost 400% in the
last 25 years.2
It is very rare for a patient to seek medical assistance
only for the obesity alone. More often, the complications
are the patients chief complains. Osteoarthritis is a frequent
complication of obesity. It is suggested for physicians to
always evaluate nutrition status of patient with osteoarthritis.
Case Illustration
A 60 years old female patient came to Obesity Clinic
Physical Medicine and Rehabilitation (PM&R) Department,
Cipto Mangunkusumo National Hospital to reduce her
weight.
She started noticing that her weight had increased in
comparison to 30 years ago. At that time, she did not suffer
from any disease. She was not consuming any drugs for
long period. She did not do any routine exercise. She did
not control her eating habit. Her husband and son were also
overweight. Her husband had heart disease and have had
catheterization. The patient did not notice any overweight
in her siblings. According to the patient there was no history of hypertension nor diabetes mellitus in her family. For
her weight, she did not seek any medical assistance.

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Since 3 years ago, she felt pain in left knee, she could
not elevate her knee. Her knee was swelling. Every morning,
she felt stiffness in her knee for about 30 minutes. Pain was
felt when walking. She came to Rheumatology Clinic Internal
Medicine Department, Cipto Mangunkusumo National Hospital and was referred to Musculoskeletal clinic, PM&R department. At that time, she was detected of having weight
problem. After being treated for 2 years, the pain had decreased, and then she was enrolled for the first time for weight
reduction program at Obesity outpatient clinic in PM&R department and was referred to Seruni Nutrition Clinic in Department of Nutrition Faculty of Medicine University of Indonesia. From history of past illness there were no hypertension, diabetes mellitus, heart disease. Until now she never
felt any chest pain.
After one year, the knee pain has subsided, the patients
vital signs were within normal limit. Her weight was 69 kg,
height was 153 cm, BMI was 29.5, waist circumference was
99 cm. Waist-hip ratio was 0.9. There were crepitations at
both knees. Other physical examination findings were not
remarkable. From body fat analysis, the result was as follow:
body weight 67.7 kg, with Body Mass Index of 28.9, fat percentage 46.1%, fat mass 31.2 kg, free fat mass (FFM) 36.5 kg,
total body water (TBW) 26.7 kg, and fat to lose for 17.7 kg.
Dietary assessment was performed and patients dietary intake was calculated as more than 1,500 kcal per day. The
diagnosis was obesity grade I with knee osteoarthritis.

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The Management for Grade I Obesity as the Underlying Disease of Osteoarthritis

She was programmed for endurance training using static
bicycle in obesity clinic 2-3 times a week, stress test using
symptom-limited method was conducted prior to the endurance training. The intensity was then settled according to
the stress test. She also did strengthening exercise at her
arms and legs.
As the home program, she was informed about her disease and the importance of sustaining the therapy. She was
advised to do routine morning walk everyday for about 30
minutes until her target heart rate was reached. Her target
heart rate was 96 (60 % x {220-60}). She was taught to calculate and measure her radial pulse. She was also advised to
increase her daily activity and record it in a book. The
strengthening exercise was also done at home. Calorie intake in amount of 1200 Kcal was prescribed, and the patient
was also requested to record her meals for further evaluation.
The patient came after one week. There were no significance changes on her nutritional status. After that, there
was no available data because the patient was lost of follow
up.
Discussion
Obesity is defined as excess in adipose tissue accumulation. Body weight adjusted for stature is universally used
as an alternative to the measurement of adipose tissue mass
in the evaluation of individuals or populations for obesity.
Body mass index (BMI), which is body weight in kilograms
divided by stature in square meter, is used to describe the
relationship between body weight and stature in human.
Many studies have shown that BMI is a reasonable measure
of adiposity.3
International committees establish being overweight as
BMI greater than or equal in 25 kg/m2 and obesity as BMI
greater than 30 kg/m2.4,5 However, the Asia Pacific classification establish the cut-offs for overweight is 23.0 kg/m2 and
obesity is 25.0 kg/m2 for Asian population.5 (see table 1)
Table 1. Classification of Obesity Using BMI Measurement. 5
Classification BMI (kg/m2)

Risk of co-morbidities
Waist circumference
<90 cm (men)
$90 cm (men)
<80 cm (women) $80 cm (women)

Underweight

< 18,5

Normal range
Overweight
At risk
Obese I
Obese II

18,5-22,9
>23
23- 24,9
25-29,9
>30

Low but increased Average

Risk of other clinical problem
Average
Increased
Increased
Moderate
Severe

Moderate
Severe
Very severe

This patients BMI was 29,5. Based on Asia Pacific classification this patient is diagnosed as grade I obesity.
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Etiopathophysiology
Based on the etiology, obesity can be classified as primary or secondary. Primary obesity is a result of genetic
factor.6 Secondary obesity is resulted from other diseases
such as diabetes, Cushing syndrome, etc, or lifestyle.7
In general, one can summarized the causes of obesity
as excessive energy intake, inadequate calorie used, emotional problems, modern lifestyle, and genetic factor.3,6 Above
all causes, the pathophysiologic chain of obesity is started
from increased energy intake, decreased energy expenditure,
or a combination of the two.7
As this patient does not have any histories of diseases
nor long period used of drugs, we may assume that the etiology is neither diseases nor drugs. It is confirmed from her
lifestyle and family history that the obesity may be due to
unhealthy lifestyle.
Measurements
Some measurements can be done in clinical settings. As
has been mentioned before, the most important measurement is BMI, as its used for obesity diagnoses. Other measurement commonly done is waist measurements. Waist circumference is measured by locating the iliac superior anterior spine and lower border of costal arc. A measuring tape is
placed in a horizontal plane around the abdomen at the level
of midway between the iliac superior anterior spine and lower
border of costae arc. Before reading the tape measure, make
sure the tape is secure, but not too tight and is parallel to the
floor. The reading should be taken at the end of expiration. It
is found to be associated with a substantially increased risk
of metabolic complications. The cut-off point for waist circumference is 90 cm for men and 80 cm for women.5
The ratio of waist to hip circumference (WHR) is also
used as a measure of abdominal obesity. A WHR >1.0 for
men, and WHR >0.85 for women are used to identify those
with abdominal fat accumulation, however, waist circumference is the preferred measure of abdominal obesity compared to the WHR.5
This patients waist circumference was 91 cm and her
waist-hip ratio was 0,9. According to the measurements, this
patient was definitely risked to have cardiovascular complications. Since waist circumference can dynamically change
while exercise and nutritional therapy are in process, waist
circumference should be measured routinely as frequent as
her attendance to the program.
Complications
Obesity has major adverse effects on health. Mortality
rates rise as obesity increases, particularly when obesity is
associated with increased intraabdominal fat. It is also apparent that the degree to which obesity affects particular
organ systems is influenced by susceptibility genes that vary
in the population.7
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The Management for Grade I Obesity as the Underlying Disease of Osteoarthritis

Risk for insulin resistance and type 2 diabetes mellitus,
reproductive disorders, cardiovascular disease, pulmonary
disease, gallstones, cancer, musculosceletal and cutaneous
disease, will be higher in patient with obesity.7
In this report, though the weight had not been reduced
significantly, the knee complains was subsided. It is important to treat obesity as the underlying disease of osteoarthritis.
Treatments
The management of obesity involves weight management strategies, which should include modification of diet
and physical activity, and of daily habits and thoughts5,9,
therefore the patient should begin weight reduction program since the beginning of diagnosis, in order to have the
required dietary planning.
The aim of weight reduction should be to decrease
morbidity and obese persons should be encouraged to set
reasonable short-term goals for weight loss, bearing this aim
in mind. They must recognize that any lifestyle alterations,
in the form of increased exercise or decreased caloric intake,
made to lose weight will need to be continued indefinitely if
the lower body weight is to be maintained.8
Although psychological disturbances are not often the
primary cause of obesity, behavior modification based on an
analysis of the circumstances in which a person tends to eat
and the particular meaning of eating for that person can be
helpful for weight reduction. Experts in this approach recommend that persons receive advice or counseling in a stable
group setting for a long period and that close contact with
the therapist and members of the group be maintained after
losing weight.8
Energy requirement for this patient was 25 kcal per kg
body weight per day. Ideal body weight can be estimated
using Brocas formula, (body height-100) 10%; thus, if the
patients height was 153 cm, with 69 kg of body weight,
therefore the patients ideal body weight should be approximately 48 kg, and energy requirement per day would be 1200
kcal (low-calorie diet). Carbohydrate intake would cover 5565% of the total calorie, with protein in amount of 15% of
total calorie,5 20-30% of fat, and 20-30 grams of fiber.4,5
Patients overweight would be a result of higher energy
intake than the energy expenditure. Therefore, the plan was
to have 0.5 to 1 kg per week of weight reduction, which
could be achieved by reducing calorie intake of 500 to 1,000
Kcal per day, until the target intake is achieved.4 Daily meals
would be divided into three meals with adequate size hence
snacks would not be needed between meals.5
Increased physical activity not only increases caloric
expenditure but also promotes dietary compliance. Exercise
may increase the desire for foods that are high in carbohydrates and reduce the desire for foods that are high in fat.
Thus, treatment programs for obesity that include physical
activity may be more successful than those that do not.
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Different types of exercise may affect fuel use differently. Intermittent exercise (high intensity followed by low
intensity) results in a greater reduction in weight and fat
than continuous exercise of low-to-medium intensity that
involves expending the same number of calories.8 To prevent musculoskeletal complications, high impact exercise
should be avoided for obese patients. Bicycling or exercise
in water is the treatment of choice.
This patient was programmed for adjusted endurance
exercise using stationer bicycle. The intensity is adjusted
using symptoms limited test method. The intensity was adjusted carefully using symptoms such as dyspnoe, fatigue,
blood pressure, heart rate et cetera. It is an appropriate method
especially for elderly obesity patients since it provides secure exercise regimen for these patients.
Pharmacological treatment may be needed in certain
cases, in addition to diet, exercise, and behavior modification. It should be considered as part of a long-term management strategy, to help patient achieve compliance to dietary
restriction and to achieve weight maintenance after satisfactory weight loss. Use of anti-obesity drug should be considered when hunger or overt hyperphagia are the recognized
factors contributing to weight gain, or there are associated
co-morbidities e.g. impaired glucose intolerance, dyslipidemia, and hypertension, or symptomatic complications of
obesity such as severe osteoarthritis.5 Several treatment
option for different levels of BMI in Asian populations is
summarized in table 2.
Table 2. Treatment op Tions for Different Levels of BMI and
Other Risk Factors in Asian Populations 5

BMI 23-25 kg/m2

No additional risk
Increased
DM/CHD/HT/HL
BMI 25-30 kg/m2
No additional risk
Increased
DM/CHD/HT/HL
BMI > 30 kg/m2
No additional risk
Increased
DM/CHD/HT/HL

Diet

Activity

Drug

a
a
a

a
a
a

a
a
a

a
a
a

a
a
a

a (consider)
a (consider)
a

a
a
a

a
a
a

a (consider)
a
a

Drugs available for obesity treatment are sibutramine,

orlistat, phentermine, diethylpropion, fluoxetine, and
bupropion. According to meta-analysis, the pooled amounts
of weight lost with these drugs were 4.45 kg at 12 months for
sibutramine, 2.89 kg at 12 months for orlistat, 3.6 kg at 6
months for phentermine, 3.0 kg at 6 months for diethylpropion,
3.15 kg at 12 months with fluoxetine, and 2.8 kg at 6 to 12
months with bupropion.10,11
American College of Physicians recommend pharmacologic therapy for whom have failed to achieve their weight
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The Management for Grade I Obesity as the Underlying Disease of Osteoarthritis

loss goals through diet and exercise alone.11 In this case, the
patient had not be considered to use pharmacologic therapy.
The goal of bariatric surgery is to improve health in
morbidity obese patients by achieving long-term, durable
weight loss. It is done by reducing caloric intake and/or
absorption of calories from food, and may modify eating
behaviour by promoting slow ingestion of small boluses of
food.12 Surgery is considered for BMI more than 30 kg/m2
with or without co-morbidities if diet, exercise and drugs
therapy failed to achieve benefit.5
The problem of every weight reduction program
lies in the compliance. It is impossible to expect any significant results in a short time. This; an extensive cooperation
between patients and doctors plays a great role. Patients
motivation should be build as the first step of every obesity
program.
Conclusion
Obesity is a serious and epidemical disease which physicians should aware of. It is very prevalent that the patients
themselves have not been aware of their obesity. Frequently,
patients seek medical assistance for the complications of
obesity. Physicians should always evaluate the probability
of obesity causing diseases that patients have as their main
complaints.
Obesity management would include behavioral therapy,
nutrition therapy, and physical exercise. Education for patient and family members would be beneficial to achieve goals
of these therapies for long-term period. The patient should
understand that these therapies should be sustained for longterm period. Treating obesity will also treat the complications in this case, musculoskeletal problem.

3.

Hoffman DJ, Gallagher D. Obesity and Weight Control. In:

Gonzales EG, Myers SJ, Edelstein JE, Lieberman JS, Downey JA,
eds. Downey and Darlings Physiological Basis of Rehabilitation
Medicine. 3rd edition. USA: Butterworth-Heinemann; 2001.p.485502.
4. North American Association for the Study of Obesity. National
Institutes of Health, National Heart, Lung, and Blood Institute.
The practical guide, identification, evaluation, and treatment of
overweight and obesity in adults. NIH Publication Number 004084, October 2000
5. International Diabetes Institute, a World Health Organization
Collaborating Centre for the Epidemiology of Diabetes Mellitus
and Health Promotion for Noncommunicable Diseases. The AsiaPacific perspective: Redefining obesity and its treatment. Western Pacific (WPRO), World Health Organization, the International Association for the Study of Obesity and the International
Obesity Task Force. 2000.
6. Tamin T. Dosis Olah Raga yang Tepat pada Obesitas. Pelatihan
Rehabilitasi Medik Sport.
7. Flier JS, Flier EM. Obesity. In: Kasper DL, Fauci AS, Longo DL,
Braunwald E, Hauser SL, Jameson JL, eds. Harrisons Principles
of Internal Medicine. 16th edition. USA:McGraw-Hill;
2005.p.422-9.
8. Roseenbaum M, Leibel RL, Hirsch J. Obesity. N Engl J
Med,1997;337:397-407
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Adults: Executive Summary. Am J Clin Nutr 1998;68:899917
10. Li Z, Maglione M, Tu W, Mojica W, Arterburn D, Shugarman LR,
et al Meta-Analysis: Pharmacologic Treatment of Obesity. Ann
Intern Med, 2005;142:532-46.
11. Snow V, Barry P, Fitterman N, Qaseem A, Weiss K. Pharmacologic and Surgical Management of Obesity in Primary Care: A
Clinical Practice Guideline from the American College of Physicians for the Clinical Efficacy Assessment Subcommittee of the
American College of Physicians. Ann Intern Med, 2005;142:52531.
12. Schauer PR, Schirmer BD. The surgical management of obesity.
In: Brunicardi FC, Andersen DK, Billiar TR, Dunn DL, Hunter JG,
Pollock RE, eds. Schwartzs principles of surgery. 8th edition.
USA:McGraw-Hill; 2005.p.997-1016

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