Management of Obesity

Original Editors - Ben Carter, Maire Nic Amhlaoibh, Niamh McCormack, Emma Roche, Sinead Collins, Lucy Manico and Daniel Thomas as part of Queen Margaret University's Current and Emerging Roles in Physiotherapy Practice Project

Top Contributors - Admin, Kim Jackson, Lucinda hampton, Niamh McCormack, Maire Nic Amhlaoibh, Ben Carter, Vidya Acharya, Judith Lane, Emma Roche, 127.0.0.1, Sai Kripa, Kate Oakes, George Prudden, Tony Lowe, Lucy Manico, Sinead Collins and Daniel Thomas  

Introduction

According to the WHO in 2016 1.9 billion people were overweight, 600 million of these were obese and alarmingly 41 million children under the age of 5 were overweight or obese (childhood obesity)

The figure below shows environmental factors that create a role in causing obesity.

Increasing energy intake	Decreasing energy expenditure
↑ Portion sizes ↑ Snacking and loss of regular meals ↑ Energy dense food ↑ Affluence	↑ Car ownership; ↓ Walking to school/work ↑ Automation; ↓ manual labour ↓ Sports in schools ↑ Time spent playing video games and watching TV ↑ Central heating

Evaluation

A standard screening tool for obesity is the measurement of body mass index (BMI). See here

Waist to hip ratio should be measured, in men more than 1:1 and women more than 0:8 is considered significant. See here

Further evaluation studies like skinfold thickness, bioelectric impedance analysis, CT, MRI, DEXA, water displacement, and air densitometry studies can be done. See here

Treatment/Management

Obesity causes multiple comorbid and chronic medical conditions, and physicians should have a multiprong approach in the management of obesity. Practitioners should individualize treatment, treat underlying secondary causes of obesity, and focus on managing or controlling associated comorbid conditions. Management should include dietary modification, behavioural interventions eg exercise, medications, and surgical intervention if needed.

The dietary modification should be individualized with close monitoring of regular weight loss. Low-calorie diets are recommended. Low calorie could be carbohydrate or fat restricted. A low-carbohydrate diet can produce greater weight loss in the first months compared to a low-fat diet. The patient's adherence to their diet should frequently be emphasized.

Behaviour Interventions: Obese patients to be referred for intensive behaviour interventions. Several psychotherapeutic interventions are available which includes motivational interviewing, cognitive behaviour therapy, and interpersonal psychotherapy. Behaviour interventions are more effective when they are combined with diet and exercise.

Medications: Antiobesity medications can be used for BMI greater than or equal to 30 or BMI greater than or

Surgery: Indications for surgery are a BMI greater or equal to 40 or a BMI of 35 or greater with severe comorbid conditions. The patient should be compliant with post-surgery lifestyle changes, office visits, and exercise programs. Patients should have an extensive preoperative evaluation of surgical risks.

CBT to Increase Adherence

Assessing Patients’ Activity Levels

An initial assessment is needed to determine the patient’s current activity levels. Physiotherapists should ask patients how they judge their actual level of physical activity, and if they believe that it is adequate to lose or maintaining body weight.

Tailoring Activity Goals to Individual Patients

Find out which type of activity is physically possible for patients, and the barriers that can prevent a successful increase in activity.
Physical activity should start at a low level and gradually increase. Compliance to exercise can be enhanced by increasing lifestyle activities (e.g., climbing stairs, gardening, and walking the dog), developing an appropriate home-based exercise program, and considering short bouts rather than long bouts of activity for patients who “can’t find the time to exercise”.

Self-Monitoring

Self-monitoring is the cornerstone of the behavioural treatment of obesity. Monitoring raises patients' awareness of their exercise habits and helps them identify ways to maximise their energy deficit.

Stimulus Control

The main focus is to modify the external environment to make it more conducive to making choices that support exercising. Patients should be instructed not only to remove triggers of inactivity, but also to increase positive cues for healthy activity (e.g., lay out exercise clothes before going to bed).

Involving Significant Others

Social support is a key ingredient for behavioural change. Significant others may play an important role in encouraging patients and should be educated about obesity, weight management, and physical activity.

Building the Mindset of an Active Lifestyle

Encourage patients to make a list of personal reasons to adopt an active lifestyle.
Set short-term goals. Goal setting has been shown to be effective in focusing the attention of participants toward behaviour change.

Address Obstacles With Problem Solving - Responding to Non-adherence

Congratulate the patients for every small success they achieve, and never criticise failures. Criticism may produce guilt and loss of self-confidence, leading to non-adherence. An unconditional acceptance of the patients’ behaviour and a problem-solving approach to address barriers will preserve the clinician-patient relationship. This approach will also help patients understand that the long-term success in weight management is related to a set of skills rather than simply to willpower.

Current Role of Physiotherapists in the Management of Obesity 

SIGN guidelines and NICE guidelines were both published to identify evidence-based recommendations that would help in the prevention and management of obesity in children and adults. Both guidelines overlap considerably in that they aim to address the primary prevention of obesity, treatment of obesity through diet and lifestyle intervention, pharmacological therapy and bariatric surgery and the prevention of weight regain following treatment in both adults and children. Taking into account the Curriculum Framework for Physiotherapy (2002) definition of physiotherapy practice; a health care profession concerned with human function and movement and maximising potential. It uses physical approaches to promote, maintain and restore physical, psychological and social well-being, taking account of variations in health status, it could be concluded that physiotherapists may have a valuable role to play in the primary prevention, treatment through diet and lifestyle modification and prevention of weight gain following treatment in people with obesity.

General clinical recommendations, drawn from both guidelines, for health professionals involved in the prevention of obesity in adults or children include:

• Offering specific individual information on how to reduce the intake of energy-dense foods, alcohol and fast foods through the use of health promotion initiatives
• Encourage increased physical activity by focusing on exercise such as walking that can easily fit into a person’s life and provide continuing support and encouragement to people concerned with weight management through the use of telephone/ internet follow-ups.

A cross-sectional study performed in 115 children in Japan assessing the factors associated with excess weight in children suggest that decreasing children's sedentary behavior in addition to more physical activity is essential for the prevention of overweight status and obesity in high-risk children with lifestyle diseases.

Although guidelines for the treatment of obesity in both adults and children are much more evidence based and specific to the population in question there is still a significant gap in this literature on both how and who should be administering these treatments. Both guidelines make use of primary care pathways for both adults and children which includes criteria for the assessment, classification, and management of people who are overweight/obese. After assessing the individual’s willingness to change, lifestyle, co-morbidities and deciding upon which obesity group they fall into depending on BMI a level of general or specific management is chosen according to the pathway instructions.

Evidence and recommendations on how to treat obesity in the adults have been sub-divided into:

• Dietary interventions
• Physical activity
• Behavioural interventions
• Pharmacological treatment
• Bariatric surgery
  

Due to the breadth of knowledge and expertise of physiotherapists they are excellently placed to treat obesity. Negative body image and confidence issues can lead to patients being intimidated by the large numbers attending exercise classes, therefore it is often a good starting point to introduce a home exercise program. As the prevalence of obesity increases a multidisciplinary approach must be implemented in order to manage patients in this population.
A study by Epstein and Ogden found that general practitioners do not feel that obesity is part of their domain because of a lack of effective medical intervention such as drug therapy, however only 3% refer obese patients to cognitive behavioral therapy which would tackle the root cause. As a result many will develop musculoskeletal problems that result in patients requiring physiotherapy. Physiotherapists may therefore be ideally placed to identify these patients and treat them appropriately.
Some of the skills possessed by physiotherapists that make them qualified to deal with the growing obese population are:

• Anatomy (important to know about strengthening exercises to allow the musculoskeletal system to cope with the extra demands placed on them by overweight individuals)
• Physiology (important to know about changes to heart rate, blood pressure, etc.) and Exercise Physiology (important to create and implement exercise programs)
• Cardiovascular/Cardiopulmonary systems (important to know about changes to breathing patterns, apneas, cardiovascular disease.)
• Biopsychosocial Model (important to know about environmental factors, cultural factors, social factors, etc., that lead to the development of this condition)
• Physiotherapists have got a large amount of contact time with obese people in the NSH, therefore they can potentially make a bigger impact than other health professionals
• Physiotherapists also have good knowledge of secondary complication such as – hypertension, diabetes, osteoarthritis and complex profound physiological changes.

Physiotherapists are recognized as able to prescribe exercise programs targeted at an individual’s specific problems, however, the precise boundaries of a physiotherapists remit when dealing with obesity can be hard to define. Therefore physiotherapists should be aware of significant problems that will require referral to the relevant professionals such as:

• Psychology/cognitive-behavioral approaches (psychologist)
• Nutrition/caloric management (nutritionist)

Self Management of Obesity

Many approaches have been assessed to support self-management, ranging from passive approaches such as information sharing at one end of the spectrum to active behavioural change interventions at the other. Self-management support can be conceptualised by dividing interventions into those that focus on building knowledge and skills (such as healthy eating habits) versus those that target self-efficacy.

Providing Information

Written information - Written information materials to support self-management are common and include guidebooks and printed educational materials. Written motivational leaflets or letters help people feel more willing to raise concerns and discuss their symptoms but whether such written information results in behaviour change is debatable.
There is evidence to suggest that the most effective form of written information targets an individual and is personalisedand will result in greater behaviour change than standardised information.

Electronic information sources - Audiovisual technology, computers, Internet and the mass media can also be utilised in the delivery of self-management information.
Samoocha et al found that there is evidence for TV/DVD, audio and computer-based education being as effective as personally delivered materials and education, measured using 3 scales including the Diabetes Empowerment Scale
‘The internet offers the possibility of reducing inequalities in health—through low-cost dissemination of consumer and professional information’ (Powell et al 2003). It is suggested by Powel et al that health care promotion over the Internet allows development of communities— explicit in chat room format, but also implicit communities of individuals linking with each other through hypertext or e-mail connections.

Another way to encourage self-management among an obese population involves helping people to re-think their attitudes. This could be done in several ways; care planning, decision support tools, or patient held medical records. In addition to providing information, support interventions encourage change through the provision of incentives, the learning of new skill and practical strategies to help an individual to self-manage.

Decision Support Tools 

Protheroe et al found that the implementation of decision support tools encourages consideration of problems and priorities from a patient perspective and thereby encourage participation in making decisions about their management. ‘Such tools may encourage service users and their carers to take more responsibility for their care, help people with long term conditions feel more in control, encourage health professionals to follow recommended care protocols, and have some impacts on quality of life’, Health Foundation, (2011). Hayward (2004) suggests that health professionals include electronic texts, drug information and practice guideline data- bases in their definition of CDS (clinical decision support tools), while others restrict the term to rules-based guidance systems that direct clinicians about exactly what to do for specific clinical problems. In order for decision support tools to be effective it is essential that the knowledge that underpins their development translate into practical clinical events that have a positive impact on a patient’s ability to self-manage their obesity. This point is summarised succinctly by Hayward; ‘information alone does not change practice; good decisions about information change practice’.

The National Heart Lung and Blood Institute (2005) in the USA implemented its Obesity Education Initiative using smart phones or desktop computers as a medium for delivery. The programme generated an individualised and evidence based assessment and treatment options for all patients included in the initiative. The features of the programme are as follows:

• Body Mass Index calculation
• Assessment of cardiovascular disease risk factors
• Determination of need for treatment
• Individualized weight-loss goals
• Individualized treatment recommendations (lifestyle therapy, pharmacotherapy, and surgery options)
• Follow-up and maintenance recommendations
• Evidence-based supporting information available throughout

Planning and Goal Setting

Planning and goal setting often take the form of care plans; these are a written document designed by service users and healthcare professionals, which address issues, treatments/interventions, review schedules and targets.
Care plans often include both goal setting and development plans with the aim of achieving the set goals. Clark & Hampsen found that mutually agreed goals between the practitioner and patient were successful in the self-management and empowerment of individuals with type-2 diabetes. Bodenheimer et al claim that a central concept in self-management is self-efficacy—confidence to carry out a behavior necessary to reach a desired goal. They found that self-efficacy in greatly increased when patients succeed in solving patient identified problems.

Resources

National Institute for Health and Clinical Excellence (NICE). 2006. Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children. London: NICE.