About this Research Topic
The concept of “circular health” is gaining momentum, in which an interdisciplinary approach is a key to identifying and treating the multifactorial determinants of ill health in a cost-saving and resource-efficient way. Health is a system of communicating vessels and this is particularly true when alterations in the body’s capacity to achieve and maintain energy balance occur. Metabolic syndrome is defined as a cluster of conditions that occur together and determine a higher risk for cardiovascular heart diseases, and type 2 diabetes, such as increased blood pressure and blood glycemic levels, excess body fat around the waist, and abnormal cholesterol or triglyceride levels. Low physical activity level syndrome is identified as a cluster of co-existing conditions such as osteoporosis, sarcopenia, obesity, as well as other risk factors, that ultimately determine a higher risk for falls and fractures in affected subjects, consequently increasing the related mortality rate. However, the common denominator in both syndromes is higher individual fragility and impaired energy balance, either in terms of its generation or dissipation/transformation.
Research over the past two decades has demonstrated that our skeleton plays an important role in energy metabolism through “local” hormonal connection, such as leptin and insulin/insulin-like growth factor 1, osteocalcin/undercarboxylated osteocalcin pathways, with other organs involved in the metabolic control. Moreover, such hormonal-molecular pathways have been suggested to be fundamental in maintaining energy homeostasis by controlling and coordinating both fuel uptake and energy expenditure in all the organs of the body, probably co-adjuvating speciﬁc central nervous system neurons in sensing energy needs and facilitating the communication with peripheral energy centers. The common cellular origin of osteoblasts, myocytes, and adipocytes makes the hypothesis that the skeleton has a role in energy metabolism unsurprising. However, it is currently unclear how, at a pathophysiological level, human bone cells contribute to global energy, glucose, utilization, and homeostasis. In fact, general systemic metabolic impairments are associated with diabetes mellitus and the aging process and both substantially contribute to skeletal fragility and/or osteoporotic fractures, as suggested by animal models and in vivo human studies in diabetic patients revealing the close interaction between whole-body metabolism and skeletal health. Osteoporosis, diabetes, and obesity, caused by genetic or environmental disturbances in endocrine control mechanisms, represent metabolic diseases with common metabolic pathways. Despite osteoporosis being widely diagnosed, the majority of fragility fractures occur in people with BMD T-scores greater than -2.5 standard deviations, simply because they sustain falls and/or the quality of their bones deteriorates. Sarcopenia, also linked to adverse health consequences and substantial fracture and fall risk, remains largely undiagnosed in clinical care.
The impact of obesity and diabetes on rehabilitative outcomes is often underestimated. Instead of focusing on single components, it seems likely that the combination of low bone and muscle mass, poor skeletal quality, low muscle function, and relatively high-fat mass among other factors could better identify the risk of falls, fractures, and disability. Recognition of complex, unifying osteoporosis, sarcopenia, obesity, and diabetes, brings the focus back where it belongs: on the patient as a whole, not simply on his/her bones or fat and lean mass. In a circular health model, findings from the endocrinologist, the bone specialist, and the internal medicine colleague should become “food” for the Physical and Rehabilitation Medicine specialist to address bone, muscle, and fat mass and function simultaneously and more effectively. A circular approach to healthcare could provide us with a larger and more effective therapeutic armoire for minimizing impaired mobility and disability. Composite scores considering osteoporosis, low lean mass, history of falls within the past year, slow gait speed, low grip strength, and high-fat mass to stratify patients’ risks could be developed to boost the effectiveness of rehabilitation programs, other than the known fracture risk calculators. A comprehensive approach to decrease the risk of adverse outcomes such as falls, fractures, disability, and mortality focusing on the whole patient rather than on single components can be implemented by learning from the osteoporosis and metabolic fields. Promoting synergic actions with other specialties may increase the overall effectiveness of rehabilitation programs from a cost-benefit perspective.
Keywords: Rehabilitation, Obesity, Diabetes, Metabolic, Syndromes, Low Physical Activity
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