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, Juwayriah Dalvi, Vidya Acharya, Emma Roche, Judith Lane, Kate Oakes, Sai Kripa, 127.0.0.1, Lucy Manico, Sinead Collins, Daniel Thomas, George Prudden and Tony Lowe  

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 table 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

Impact of Hormones

Obesity can alter the Hypothalamic-pituitary hormonal axis while an altered hormonal axis may lead to obesity. The hormones that impact obesity or are impacted by it include thyroid hormone, sex hormones, insulin and growth hormones. Hence it is important to consider conditions like hypothyroidism, polycystic ovarian disease/syndrome, Cushing’s disease, hyperinsulinemia and/or diabetes while evaluating and managing obesity.

Physiotherapists must ensure that their clients/patients are undergoing required treatment and life-style modifications to address their hormonal conditions along with their weight gain.

Treatment/Management

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

• 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 energy expenditure modification (i.e., 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.

Physiotherapy

Physiotherapists can play a role in educating client regarding weight loss and assessing and planning an exercise program. The program of exercise focuses on energy expenditure modification through exercise. Utilizing exercise as a means of reducing obesity (i.e., reducing fat mass) has benefits beyond the reduction of fat mass. Fitness is associated with more desirable clinical outcomes in many instances, e.g. decreasing metabolic disease, cardiovascular disease, inflammation etc.

Patients must be cleared by their healthcare provider for any comorbid conditions by history and physical examination to maximize patient safety. Screening can be done by using certain outcome measures such as Physical Activity Readiness Questionnaire (PAR-Q) and Health/Fitness Facility Preparticipation Screening Questionnaire.

Exercise recommendations

Minimum of 150 to 300 minutes of moderate physical activity per week or 75 to 150 minutes of vigorous physical activity weekly is essential to prevent weight regain, increase weight loss and improve fitness. However, for individuals who wish to lose weight, at least 200 to 300 minutes of moderate to vigorous physical activity each week is recommended to encourage long-term weight loss.

1. The recommendation for inactive individuals is “start low and go slow” by starting with lower intensity activities and gradually increasing the frequency and duration of the activity.
2. It is a good idea to spread out aerobic activity over the week, versus all the time in one day.
3. Utilize appropriate gear and sports equipment and chose safe environments.
4. Adjust exercises as necessary to decrease orthopedic risk or is non-ambulatory (if applicable). This can include cycling or hydrotherapy instead of running if an individual has arthritis. If individuals are not ambulatory or may have to modify exercise due to special circumstances, the exercise guidelines still apply. However, the patient can get creative to find ways to achieve them, such as utilizing limbs that are more ambulatory than others (e.g., moving arms faster in order to get the heart rate up if legs are not able to be used, upper body ergometer, etc.)
5. Anaerobic training can be implemented and may even increase muscle mass. Anaerobic exercise has not been shown to be effective in altering energy expenditure or absolute weight loss. However, if the goal of the patient is to increase muscle mass, then anaerobic exercise is highly encouraged. Furthermore, in order to increase muscle mass, each muscle group should be exercised at a minimum of 10 sets per week, with one set consisting of 8 to 10 reps. Also, ensure proper form to avoid injuries. Individuals who are not ambulatory or may have limited movement are still able to participate in an anaerobic exercise. Individuals must ensure proper form but can modify exercises as needed, such as upper body only exercises, lower body only exercises, using a neutral grip, keeping stable movements, etc.)
6. It is important to understand that when it comes to weight-loss, the one size fits all approach cannot be opted. Physiotherapists must ensure that they assess the outcomes and the responses of individuals towards various types of exercise and modify the treatment accordingly.

Our Unique Skills

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 may have large contact time with obese people, therefore they can potentially make a big impact.
• 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 behavioral change interventions at the other. Self-management support can be conceptualized 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.
  Electronic information sources - Audiovisual technology, computers, Internet and the mass media can also be utilised in the delivery of self-management information.
• Electronic health (eHealth) interventions- While less convincing results over a longer period of time (> 1 year) and in younger persons, electronic health (eHealth) interventions, such as wearable activity monitors and smartphone apps, social networking sites (SNS), short messaging service (SMS) and exergaming can enhance PA and are associated with moderate weight loss in middle-aged and older individuals.

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.