Physiotherapy communication approaches in management of obesity and overweight

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Introduction

Aims

To provide final year physiotherapy students and newly qualified physiotherapy graduates with an online learning resource which aims to develop their knowledge and understanding of physiotherapy management approaches for people with overweight and obesity.

Learning Outcomes

By the end of this activity you will be able to:

1. Explain and describe some of the key contributing factors to overweight and obesity and critically evaluate how these factors impact physiotherapy practice.

2.  Appraise the relevant evidence to identify and summarise the role of physiotherapy in management and treatment of obese or overweight patients.

3. Critically evaluate the theories and evidence base for communication approaches to facilitate behaviour change in people with overweight and obesity.
 

Audience

Although this resource is aimed at final year physiotherapy students and newly qualified physiotherapy graduates, other health care students and professionals may find it useful, as well as anyone else interested in the subject.

Understanding Obesity

Obesity Quiz: How much do you know?

Please follow this link: https://www.onlineexambuilder.com/obesity-quiz-how-much-do-you-know/exam-42680

Definition of Obesity

Obesity is where an individual is carrying excess body fat which can increase the chances of developing secondary diseases.

Obesity can be measured by Body Mass Index (BMI) as shown:

BMI 25-29.9 – overweight
BMI 30-39.9 – obese
BMI 40+ - severely obese

However, to measure obesity more reliably waist circumference can also be measured where females as classed as obese is measuring over 80cm and males over 94cm. Fat percentages can also be calculated to give a truer measurement of obesity (NOO 2011; NHS 2014a).

Implications of Obesity

There are many implications of obesity worldwide. Obesity increases the risk of many long-term health conditions such as type 2 diabetes, heart disease, arthritis, hypertension, cancer, stroke, liver problems, respiratory problems, sleep issues, mental health disorders and overall may cause a reduced quality of life (Keenan et al. 2011). People with obesity also have an increased risk of falls (Fjelstad et al. 2008).
 
With the rising obesity epidemic and reduced staff, funding and resources within the NHS the demand on the health service is huge. This could ultimately lead to reduced quantity and quality of care. Obesity also contributes to wider financial problems such as more benefit outgoings and loss of output within the economy (Public Health England 2015).  In addition, obese patients have an increased recovery time which leads to an increased length of hospital stay which further adds more pressure on the health service due the increased demand for hospital beds. Therefore, there is an increased demand for bariatric equipment which with the reduced funding and resources within the NHS currently results in difficulty (CSP 2015b).

Obesity in Scotland

Obesity is a large cause of many deaths and illnesses which could have been prevented throughout the world. Prevalence of obese people is more than 50% since 1980. Worldwide, obesity is the 5th indicating mortality factor.

In the developed countries Scotland is one of the leading obese countries. Adult obesity has increased by 17% in adults 16-64 in 1995 to 27% in 2010 where 65% of adults of age 16 or over were either overweight or obese.

The Scottish Public Health Observatory predicted different health conditions that are associated with obesity such as:

47% of type 2 diabetes
36% of hypertension
18% of myocardial infarction
15% of angina
12% of osteoarthritis

In 2007-2008 the predicted cost was £175 million to the NHS in Scotland alone due to obesity and associated diseases (Keenan et al. 2011).

Factors Contributing to Obesity

There are many different contributing factors to obesity.

Can you list 5 main risk factors to obesity?

Answers:
⦁ Age
⦁ Pregnancy
⦁ Socio-economic status
⦁ Genetics
⦁ Lifestyle
⦁ Exercise levels
⦁ Medical conditions
⦁ Medications
⦁ Diet
⦁ Lack of sleep
⦁ Quitting smoking
⦁ Mental health

There are many issues regarding obesity throughout the literature and the current economic climate, three factors that are prevalent within physiotherapy practice causing an increased demand for physiotherapy intervention are socio-economic status, mental health and genetics. These three factors need to be taken into consideration when physiotherapy assessments, problem lists and treatment plans are being formulated.

Socio-Economic Status

Socio-economic status is a large factor influencing obesity. Levels of high obesity were around 1.7 times greater in deprived children and teenagers in a group of 12,000 children than children in a non-deprived area aged 2 to 19 years (Food Research and Action Center 2015).

There are many areas within this topic that effect people in various different ways such as:

Occupation
Smoking
Cost of food
Deprived living conditions
Technology
Income
Education
Sedentary lifestyles
(Baum and Chou 2011).

Socioeconomic status refers to a person’s position compared to other people’s personalities, this has contributed to putting people into certain categories allowing evaluation of discrimination between these public categories (National Obesity Observatory 2010).

(National Obesity Observatory 2010; Baum and Chou 2011; Crawford and Ball 2011; Markwick et al. 2013). The accessibilities of food shops and the number of services that allow physical activity influence the levels of obesity.

Akil and Ahmad in 2011 show the highest obesity levels are mostly found within the people who:
-Earn the least
-Are not taught to a high level about obesity and health aspects
-Are not educated to a high level in general.
-They also illustrate that unhealthier foods are less expensive and more instantly available within deprived areas. 

Overall, deprived areas to live in are a huge factor contributing to obesity, especially in women.

The MRC National Survey of Health and Development showed that BMI was directly connected with educational success in both sexes. This most increased obesity levels were found in the people with the least academic achievements. 11% of men with O-grade level achievements had a BMI above 30, whereas, only 5% of men’s BMI were over 30 when they were at degree level of attainment. The same result showed within females as well correspondingly 15% and 4% (Fehily 1999).

Mental Health

Mental health includes our social and psychological well-being. It affects and can determine how we react to events, how we handle stress, and how we feel and relate to others. Early signs of mental health are:
Eating too much
No interest in social activities
Having low energy (MentalHealth.gov 2015).

There is a lack of research in establishing a definite cause and effect relationship between obesity and mental health disorders such as depression and anxiety (Puhl 2009). However it has been observed that a link could exist between these variables and these individuals making them more vulnerable to mental health issues and obesity (Bogart 2013). 
The Obesity Action Coalition (2015) states that it is thought that the two could be strongly linked or that they at least co-exist, however it has not been established which one comes first- for example whether obesity increases onset of developing depression or having depression increases the chances of developing obesity.
 
What do you think from clinical experience?
 
Depression, in most cases, can be quite debilitating, therefore decreasing an individual’s motivation to partake in exercise or other physical or social activities, they might tend to not follow such a healthy well balanced diet as well as believing they should not be taking care of themselves as much, leading to an increase chances of developing obesity (Obesity Action Coalition 2015).
 
A systematic review and meta-analysis on longitudinal relationship between depression and overweight and obese patients was conducted by Luppino (2010). It was observed that obesity did increase the onset of depression. Another study by Bogart (2013) showed that studies conducted in America found that women with a BMI over 30 linked to 50% of women developing depression over a lifetime however with men seemed to have resulted more complicated. This might be due to higher sensitivity levels that women have and the stigma the media conveys about small sizes and beauty. This picture shows a child’s toy of Barbie as she is sold and realistically what she should look like. This gives the impression of typically skinny body the media portrays from a young age. (Bell 2015).

 Puhl (2009) paper states that there has been further research done around the stigma of obesity and depression. Several studies suggest that childhood experiences have a strong link in the development of obesity and depression too (Puhl 2009; Obesity Action Coalition 2015).
 
Studies showed that the onset of either obesity or depression (or both) is strongly linked to childhood experiences. Either for being mocked about their weight which might lead to depression or for having experienced unresolved life events like bereavement that might develop into obesity in later stages of life (Stunkard et al 2003 and Puhl 2009).
 
However it is good to consider that a person with underlying mental issues and increased body weight might also be due to the type of medications they are receiving (Obesity Action Coalition 2015). A study supported a strong link between schizophrenia and depression and obesity, were results showed that metabolic risk factors can almost be double in those suffering from schizophrenia (Allison et al. 2009).

Genetics

It is not commonly thought that there is any correlation but genetics is found to be highly related to obesity. A rare genetic condition, Prader-Willi syndrome (PWS), where these children will tend to overeat. Due to their decreased metabolism and lack of muscle tone, they will have an increased risk of being obese. This rare genetic condition occurs when there is a defect in chromosome number 15, and the prevalence is no more than 1 in 15,000 children (NHS 2014b). Apart from this genetic defect that leads to obesity, hereditary factors from mothers to new-born’s are found to also contribute to obesity.
It is found that Body Mass Index (BMI) and waist circumference are highly heritable, estimated to be ranging from 40% - 70% in chance (Tenesa et al., 2009).

Childhood obesity can be predicted before a child is born from factors such as:
The relationship of the mother’s BMI before pregnancy
Mother smoking when pregnant
Inter-uterine effects on appetite
Metabolism and level of activity
(Hawkins and Law 2006; Oken et al., 2008; Smith et al., 2007; Oken, 2009).
 

(The Scottish Government, 2012)
 
Exemplary behaviours from parents will aid in the modelling of healthy actions of the child. Different types of parenting will then explain the child’s weight, diet and exercise practices. Accommodating parents are unable to help to their children to become disciplined in the activities of healthy living. Divergent or highly conflicted families are found to have problems in carrying out healthy parenting practices like family meals and outings (Sleddens et al., 2011).

Parental negligence of their children getting overweight, especially the mothers, are found to be unmotivated to try to manage their children by getting them to take up a healthy diet and regular exercising. Thus reduced parental concern on the child’s healthy weight may lead to the child not actively adopting in healthy diet and physical activity levels (The Scottish Government, 2012). Therefore, family constraints can play a huge part in the influencing the weight of the children.
In conclusion, genetics and family influences are highly correlated to obesity in children. Mind-sets of parents need to change and thus education to parents and children will play a huge part in reducing the prevalence of obesity in childhood and adulthood.

These three factors all contribute to obesity which is a huge problem found within physiotherapy practice. These complex issues need thorough and in depth physiotherapy intervention. The role of the physiotherapist includes behavioural change which may be from motivational interviewing as well as other forms of advice and guidance.

The Role of Physiotherapy

What can physiotherapists do to help?

CSP: “Physiotherapy is an ideally placed profession to provide the physical activity component of multidisciplinary weight management services”. (2015)
 
Physiotherapists will come across patients with overweight or obesity in their careers. As mentioned above in section 2.4, a large proportion of the Scottish population are obese or overweight, and this will also include large proportion of physiotherapy patients. Obesity can mean that a person is more likely to develop physiotherapy- related issues, such as osteoarthritis (Fu and Griffin 2015 in book) and restricted movement at some joints leading to functional limitation and pain (Wearing et al. 2006).

Physiotherapists often treat clients that suffer from secondary conditions due to their being overweight. An interesting analysis was made by the Canadian Joint Replacement Registry where they found that 73% of hip replacement patients and 87% of knee replacement patients were classified as overweight or obese at the time of their surgery. Physiotherapists are well aware of the treatment for these conditions however there is little research describing the physiotherapist’s role in managing the individual’s weight as an underlying problem that is associated with their joint replacement.

Physiotherapists are well placed to manage and treat people with overweight and obesity. Specialist knowledge and skills that physiotherapists have include:

• Anatomical, physiological, and psychosocial mechanisms of health and disease
  * Assessment and diagnosis
  * Behaviour change
  * Biomechanics
  * Exercise prescription and therapeutic exercise
  * Management of long-term conditions

(Canadian Physiotherapy Association 2007)

Physiotherapy treatments for obese/ overweight patients may comprise of:
* Provision of personalised lifestyle advice, taking into account individual attitudes, beliefs, circumstances, cultural and social preferences, and readiness to change
* Prescription, supervision, and progression of appropriate physical activity to increase muscle strength, flexibility, and endurance, and sustain energy output to enhance and maintain weight loss under safe and controlled conditions
* Management of associated conditions such as arthritis, back pain, and other musculoskeletal and chronic conditions, such as heart disease
* Co-ordination of comprehensive and sustainable programmes of management in collaboration with service users, other health and social care professionals, and community services 

(CSP 2015)

Overall, physiotherapists have a huge role in managing obese and overweight patients with exercise interventions, mobility training and cardiorespiratory programmes (You et al. 2012).
Further Reading Opportunity?
 
Alexander et al. (2012) recommended an evidence-based approach for the physiotherapy management of obesity:

1. Assessment of the individual’s medical history
2. Evaluation of current physical activity level
3. Provision of an individualised physical activity program
4. Gradual progression of a physical activity program
5. Prescription of a cardiovascular training program
6. Prescription of resistance exercises
7. Prescription of moderate-intensity physical activity, 30 min/d, 3–5 d/wk
8. Calculation of body mass index.

Note: Including education on strategies for adherence to an independent exercise program is also recommended whenever possible.

Using the NHS Knowledge and Skills Framework

The Knowledge and Skills Framework (KSF) model is aimed at Band 5 physiotherapists to assist them in providing “a comprehensive physiotherapy service, which encompasses assessment, treatment and management” of patients in a wide range of settings (eKSF 2008). The KSF is a good tool which demonstrates what abilities a health professional should have. It contains a number of dimensions such as Communication and Equality & Diversity, as well as dimensions specific to physiotherapy: Assessment and Treatment Planning or Interventions and Treatments. Band 5 physiotherapists will need to fulfil these indicators as best possible with all types of patients, including those who may be obese or overweight.
 
Obese and overweight patients have specific additional risks and implications to health care (see sections 2.3 and 2.4). Some factors physiotherapists may have to consider when treating obese/ overweight patients in relation to the specific dimension ‘Assessment and Treatment Planning’ are outlined below as an example of how the KSF model can help guide physiotherapy treatments.

�Level Indicators Related Physiotherapy Management Specific to Overweight/ Obesity
a)    Evaluates relevant information to plan the range and sequence of assessment requires and determines:
-       The specific activities to be undertaken
-       The risks to be managed
-       The urgency with which assessments are needed Assessment tools or tests may need to be modified to people’s abilities- for example if range of movement is limited due to excess adipose tissues then the person may not be able to carry out certain movements required for a test, leading to inaccurate results. Palpation will be more difficult as surface anatomy will be under a layer of adipose tissue (Carucci 2012).
Risks connected with larger weights need to be considered- will bariatric equipment be required for assessments or treatments to be carried out?
 
Physiotherapists may need to monitor their own positioning and safety when carrying out assessments and treatments. Assistance from other therapists may be required. (Hignett and Griffiths 2007)
b)    Selects appropriate assessment approaches, methods, techniques and equipment, in line with
-       Individual needs and characteristics
-       Evidence of effectiveness
-       The resources available

c)    Respects people’s dignity, wishes and beliefs; involves them in decision making; and obtains their consent There are clear links between obese/ overweight people and increased body image problems (Schwartz and Brownell 2004) If a person has a poor body image, they may feel uncomfortable in the physiotherapy setting and physiotherapists should attempt to make every effort to make them as comfortable as possible. They can do this with reassurance, being aware of the surroundings and creating an atmosphere of non-judgement if possible (Setchell et al. 2015).
d)    Prepares for, carries out and monitors assessments in line with evidence based practice, and legislation, policies and procedures and/ or established protocols/ established theories and models Guidelines like SIGN (2010) and NICE (2006) as well as information provided by the National Obesity Observatory (2013; 2011).
e)    Monitors individuals during assessments and takes the appropriate action in relation to an significant changes or possible risks Be aware of additional risks associated with obese/ overweight patients including diabetes, increased falls risks, heart issues, respiratory issues etc.
See section 2.3
f)     Evaluates assessment findings/ results and take appropriate action where there are issues  
g)    Considers and interprets all of the information available using systematic processes of reasoning to reach a justifiable assessment and explains the outcomes to those concerned In addition to treating the person for the condition they are presenting with, explanation and education may also be required to help the person understand:
-       How their weight or health conditions associated with it may be contributing to their presenting problem or delaying its recovery
-       The health risks related to increased weight and the benefits of healthy weight loss
(Alexander et al. 2012; You et al. 2012)
h)   Determines and records diagnosis and treatment plans according to agreed protocols/ pathways/ models that are:
-       Consistent with the outcomes of the assessment
-       Consistent with the individual’s wishes and views
-       Include communications with other professions and agencies
-       Involve other practitioners and agencies when this is necessary to meet people’s health and wellbeing needs and risks
-       Are consistent with resources available
-       Note people’s wishes and needs that it was not possible to meet Currently there are no set protocols for overweight/ obesity management (but there are recommendations in NICE (2006) and SIGN (2010) guidelines and NOO recommendations (2010; 2011).
?examples of area-specific protocols
 
Use individual’s own goals and aims to shape treatment- for example help them to find a weight loss activity/ sport/ exercises that they will enjoy and will realistically be able to do and participate in.

Work together with other professionals to achieve goals (Nowicki et al. 2009)
i)     Monitors and reviews the implementation of treatment plans and makes changes within agreed protocols/ pathways/ models for clinical effectiveness and to meet people’s needs and views
j)      Identifies individuals whose needs fall outside protocols/ pathways/ models and makes referrals to the appropriate practitioners with the necessary degree of urgency Instances where this may be required include:
-       GP review of medication
-       Psychiatry/ psychology regarding increased mental health problems with obesity/ overweight
-       Recommendation of bariatric surgery

How can communication be used to facilitate behaviour change?

Motivational interviewing

Introduction 

Motivational interviewing (MI) is described as “a collaborative conversation style for strengthening a person’s own motivation and commitment to change” (Miller and Rollnick p. 12 2013)

Four processes in Motivational interviewing

1. Engaging
2. Focusing
3. Evoking
4. Planning

O.A.R.S Strategy

Open-ended questions
Affirmations
Reflective listening
Summaries

Example of use of O.A.R.S. Strategy

(Recording) Are you able to identify all parts of the strategy?

References

References will automatically be added here, see adding references tutorial.