The Correlation between Physical Activity with Body Mass Index

in Obesity Patient with Knee Osteoarthritis

Ricky Fakhrazi

and Tirza Z. Tamin

Department of Physical Medicine and Rehabilitation Department, University of Indonesia, Jakarta, Indonesia.

Department of Physical Medicine and Rehabilitation Dr.Cipto Mangunkusumo National Hospital, Jakarta, Indonesia.

Keywords: Body Mass Index, Obesity, Osteoarthritis, Physical Activity.

Abstract: Obesity in Indonesia has significantly increased every year. Obesity occurs due to an imbalance of input and

output of energy, causing the accumulation of body fat. Weight gain causes stress to knee joints and prone

to osteoarthritis that will lead to pain during walking. Decreasing the level of physical activity (PAL) in

obese patients with osteoarthritis will risk them to deconditioning syndrome which will aggravate obesity.

The purpose of this study is to correlate the level of physical activity in obese patients with osteoarthritis of

the knee who was treated at the obesity clinic at Cipto Mangunkusumo Hospital. A cross-sectional method

with thirty-eight consecutive samples. Inclusion criteria are: early elderly patients, male and female, who

were diagnosed with obesity with knee osteoarthritis, can walk independently without assistance, can

communicate well. Anamnesis is conducted for one full day activity for three days a week, and the average

energy expenditure is calculated. The basal metabolic rate is calculated by the Harris-Benedict equation and

then the level of physical activity of the patient is determined. The results of this study are that there is a

weak positive correlation between PAL and body mass index (BMI) in obese patients with knee

osteoarthritis.

1 INTRODUCTION

Obesity is a disease caused by an imbalance of

energy produced due to excessive energy intake and

reduced-calorie use. However, the pathogenesis of

obesity is very complex and not yet fully understood

(Australian Government, 2013). Control of one's

appetite and sensitivity is regulated by neural and

neurohumoral mechanisms that are influenced by

genetic, nutritional, environmental, and

psychological. This mechanism is stimulated by a

metabolic response that is centered on the

hypothalamus. The neurohumoral mechanism is

divided into three components: regulation of

hormone secretion, the rate of energy expenditure,

and control of hunger and satiety.

Obesity is caused by many factors, 40-70% of

the most important factor is genetic in determining a

person's weight. Besides lifestyle, environment, and

socioeconomic status of a person can be a cause of

obesity. In general, obesity appears at age > 30 years

in men, whereas in women originating from

childhood (Sugondo, 2006).

In people with obesity, more calories are

consumed than is used and the appetite is not

reduced to compensate for the increase in body

energy stores. The amount of adipose tissue is

tightly regulated through the transmission of

humoral and neural signals to the brain. Failure of

fat cells to transmit adequate signals or errors from

the brain is responding to incoming signals that

cause obesity (Berthoud, 2002). An effective system

of regulation of energy balance, requiring sensors of

energy storage in adipose tissue, a mechanism for

delivering information to central control

(hypothalamus) for further integration, which in turn

will determine food intake and energy expenditure

(Berthoud and Morrison, 2008).

The brain gets a signal about the amount of fat

stored and secreted mainly by adipose, supplied by a

peptide hormone called Leptin. Leptin mRNA is

specifically expressed in fat cells. Leptin

concentrations in circulation, proportional to fat

reserves and BMI in normal subjects, and pulsatile

secretions are inversely related to hydrocortisone

levels. Glucocorticoids, estrogens and insulin and

are reduced by β-adrenergic agonists, triggering

316

Fakhrazi, R. and Tamin, T.

The Correlation between Physical Activity with Body Mass Index in Obesity Patient with Knee Osteoarthritis.

DOI: 10.5220/0009090103160320

In Proceedings of the 11th National Congress and the 18th Annual Scientiﬁc Meeting of Indonesian Physical Medicine and Rehabilitation Association (KONAS XI and PIT XVIII PERDOSRI

2019), pages 316-320

ISBN: 978-989-758-409-1

leptin formation. Leptin reaches the brain and enters

saturated transportation in the hypothalamus from

fat storage (Diamond and Eichler, 2002). When

hungry adipose tissue secretes leptin, CNS

stimulation, cold exposure, and exercise. Obesity,

glucocorticoids, glucose, and insulin can inhibit the

secretion of leptin from adipose tissue. When leptin

reaches the hypothalamus, NPY secretion is

inhibited, which normally reduces energy

expenditure, stimulates synthesis, stores fat, and

increases appetite. Adiponectin sensitizes tissues for

the effects of insulin. Obesity and insulin resistance

negatively regulate adiponectin secretion from

adipose tissue, where weight loss increases secretion

(Diamond and Eichler, 2002).

Body mass index, formerly called the Quetelet

index, is a measure to indicate nutritional status in

adults. BMI measured by weight in kilograms (kg)

divided by height in meters squared (kg / m2) (CDC

USA, 2009). In Asians, the limit of overweight is 

23.0 kg / m2 which is lower than WHO criteria. The

suggested classification for Asians while still needs

to be revised because of further validation and

clinical symptoms. Some research that supports this

limit comes from Chinese living in Hong Kong (ko

et al 1999) where the risk of morbidity increases

with a BMI> 23.0 kg / m2.

Osteoarthritis (OA) is a disease caused by

mechanical and biological disorders that damage the

stability of the normal series of degradation and

synthesis of joint cartilage chondrocytes,

extracellular matrix, and subchondral bone. This can

occur due to various factors including genetic,

developmental, metabolic and trauma factors. OA

involves various tissues in the arthritic joints. OA

manifestations include morphological, biochemical,

molecular and biochemical changes in both cellular

and bone matrix that cause softening, fibrillation,

ulceration, loss of joint cartilage, sclerosis and

subchondral bone eburnation, osteophytes and

subchondral cysts. Clinically the symptoms that

appear in patients with OA are joint pain and

stiffness, limited mobility, crepitation, effusion,

various signs of inflammation without accompanied

by systemic effects (Sharma L, 2007).

Obesity is a risk factor for the development of

osteoarthritis. The association of height weight with

the incidence of OA is still said to be uncertain but

may involve cartilage degeneration due to overload.

Another mechanical factor is knee alignment. In

patients with knee varus, BMI appears to be related

to the severity of OA, especially medial tibiofemoral

OA.

A very important factor in the pathomechanics of

OA genu is the high and repeated burden on the

knee joint during walking and activity. During

walking, the load that passes through the knee joint

is not transmitted equally between the medial and

lateral compartments. The load on the medial

compartment is about 2.5 times greater than the load

on the lateral compartment. This is the reason for the

high prevalence of OA genu media compartments

(75% of all cases) rather than lateral compartments

(Enohumah KO and Imarengiaye CO, 2008).

Also, there are changes in the synovial

membrane and synovial fluid. Mild to moderate

inflammatory reactions occur in the synovial

membrane that contains cartilage articular

fragments. Whereas in the synovial fluid there is a

decrease in the concentration of molecular weight

and abnormal production of hyaluronate. Impaired

hyaluronate production and increased hyaluronate

breakdown which causes a decrease in hyaluronate

concentration. Changes in the synovial fluid also

result from an increase in water content and an

increase in pathological concentrations (Enohumah

KO and Imarengiaye CO, 2008).

Physical activity is defined as body movements

produced by skeletal muscles that require energy

expenditure. The most commonly used way to be

always active is by walking, cycling, recreation, and

sports that can be done at any level of skill and

pleasure (“WHO | Physical Activity,” 2019). MET is

a unit used to estimate the energy expended from

each activity (Miles, 2007). Understanding the level

of physical activity is the total energy needed (TEE)

or used in 24 hours divided by the basal metabolic

rate (BMR) for 24 hours.

The total energy needed in 24 hours can be

calculated based on the activities carried out in one

day and calculated the amount of energy needed for

these activities, then added up. The amount of

energy used can be seen based on the compendium

of physical activity. The purpose of this study is to

find whether there is a relationship between the level

of physical activity and body mass index in obese

patients with knee osteoarthritis. We hypothesize

that a decrease in physical activity caused by an

increase in BMI in patients with obesity and

osteoarthritis of the knee who seek treatment at the

obesity clinic.

2 METHODS

This study protocol was approved by the University

of Indonesia Ethics Committee and written consent

The Correlation between Physical Activity with Body Mass Index in Obesity Patient with Knee Osteoarthritis

317

was obtained from all the participants of the study.

The design of this study was cross-sectional with

consecutive sampling. The study was conducted on

obese patients with knee OA at the Obesity

Polyclinic of the Department of Medical

Rehabilitation at the National Center General

Hospital (Cipto Mangunkusumo Hospital/

University of Indonesia). The sample obtained was

37 women and 1 man based on the criteria for

sample acceptance with a diagnosis of Overweight

/obese (table 1) and OA of the knee, age > 50 years,

never had knee surgery before, can walk

independently without assistance, can communicate

well, and are willing to fill out informed consent.

The criteria for rejection in this study were patients

with a history of knee surgery, using walking aids,

having cardiorespiratory system disorders, having

knee deformity > 15

, experiencing cognitive

impairment or mental health disorders, impaired

balance, and were unwilling to participate in the

study.

Table 1: Asia Pasific BMI Classification.

Classification BMI (kg/m

) Risk of co-morbidities

Waist circumference

Men

Women

< 90 cm

<80 cm

 90 cm

 80 cm

Underweight < 18,5 Low Average

Normal range 18,5 – 22,9 Average Increased

Overweight

 23

At risk 23 – 24,9 Increased Moderate

Obese I 25 – 29,9 Moderate Severe

Obese II

 30

Severe Very severe

Samples that meet the inclusion criteria and do

not meet the exclusion criteria are given background

information on the research, objectives, and benefits

of the study. They were asked to sign the informed

consent provided if they agree to participate in this

study. Then the researchers conducted anamnesis,

height, and weight measurements, followed by

interviews. Interview of physical activities carried

out in one full day, starting from waking up, to

going back to sleep. Retrieval of data at 3 days a

week. 2 days between Monday to Friday, and 1 day

between Saturday and Sunday.

Table 2: PAL Classification.

Category PAL value

Sedentary or light activity lifestyle 1,40-1,69

Active or moderately active lifestyle 1,70-1,99

Vigorous or vigorously active lifestyle 2,00-2,40

All data in the 3 days were carried out with the

Compendium physical activity, then totaled and

divided by 3, then obtained the energy expended in

one day. Furthermore, energy expenditure is

calculated in one day by multiplication between the

energy expended by weight. Each sample is

calculated BMR with the Harris-Benedict formula.

Then calculate the level of physical activity (table 2)

with the division between energy expenditure (EE) /

BMR.

3 RESULT

In this study, a total sample of 38 people was

obtained. The largest sample in this study were

women. Education levels in both bachelor and non-

bachelor are in somewhat balanced proportion. This

study reveals that most of the subjects received a

rehabilitation program for more than one year.

Table 3: Subjects Characteristic.

Age

64.13  5.34

Sex

Male

Female

1 (2.6%)

37 (97.4%)

Height (cm)

152.55  6.68

Weight (kg) 64.00 (63.78-69.53)

BMI

28.61  3.05

Formal Education

Bachelor

Non-bachelor

17 (44.7%)

21 (55.3%)

Information, Education, and

Communication (IEC)

< 6 Months

6 Mo – 1 Yr

> 1 Yr

6 (15.8%)

3 (7.9%)

29 (76.3%)

PAL 1.52 (1.52-1.62)

KONAS XI and PIT XVIII PERDOSRI 2019 - The 11th National Congress and The 18th Annual Scientiﬁc Meeting of Indonesian Physical

Medicine and Rehabilitation Association

318

In this study, we want to find the correlation

between PAL and BMI. On the normality test we

found that the PAL variable is not normally

distributed (Table 3), a non-parametric correlation

test (spearman's) was used. In the Spearman test,

there was a significant relationship (p = 0.016)

between the PAL group and the BMI with a positive

weak correlation (r = 0.390)(Figure 1).

Table 4: Correlation test.

PAL (r)

BMI 0.390 0.016

Spearman’s

Figure 1: Scatterplots of the correlations BMI and PAL.

4 DISCUSSION

The largest sample in this study was women with the

length of therapy in rehabilitation clinics for more

than one year. 44.7%(17) of grade 1 obese samples

had undergone rehabilitation for more than one year.

It is a positive value of a patient's compliance with

treatment.

Rehabilitation treatment is most important for

the return of function in obese patients with OA

(Lau et al., 2011), is to provide education and

emotional approaches, so that patients have high

motivation to carry out rehabilitation not only during

treatment but also during daily activities. Some

patients with obesity have active physical activity

even very active, this proves that education to

always do activities, applied by patients in daily life.

In one study, an extra minute in the encounter

discussing these issues was associated with a 2.5-

fold increase inpatient recall. (Carroll et al., 2008)

With comprehensive education, patient compliance

will also increase In addition to increasing daily

activities, food intake and calories must also be

closely monitored.

Diet is an important factor if there are limitations

in daily activities (Oenema and Brug, 2003). the

sample we examined had an average age of 64 years,

most of them only spending time at home and

hospital. The differences in the associations between

BMI and PA in obese vs non-obese people indicate

that obesity may act as a barrier to PA (Hemmingsson

and Ekelund, 2007). A recent longitudinal cohort

study indeed suggested that obesity preceded low

levels of PA, but not the commonly held notion that

low levels of PA predicted the development of obesity

(Petersen et al., 2004).

In this study, a significant relationship was seen

between PAL and BMI. Our results show that one of

the grade 2 obese patients with osteoarthritis of the

knee has PAL which is very active. This shows that

people with high BMI do not necessarily have low

activity. This can be because the sample is an obese

patient with knee OA who is undergoing treatment

in an obesity clinic and get a lot of education. This

result shows that people with higher BMI who have

been visiting Obese Clinic routinely can have a high

activity level. Highlighting the importance and

effectiveness of proper rehabilitation treatment for

obese patients.

More than 75% of patients have undergone

rehabilitation for more than 1 year, where the

duration of this treatment has an impact on

increasing physical activity from the sample, making

it difficult to get a strong correlation value. Our

study has the advantage of researching health

facilities which are referral centers from various

regions. The rehabilitation program that is

implemented already has measurable targets for

patient achievement.

5 CONCLUSIONS

There is a significant relationship between physical

activity level and body mass index of someone

suffering from obesity with knee osteoarthritis with

a weak correlation.

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