Public Health and Physical Activity
- 1 INTRODUCTION
- 2 OBESITY
- 3 BARRIERS TO RECOVERY
- 4 2. Barriers to effective treatment for the Physiotherapist,Health Care Provider’s views:
- 5 Motivational Interviewing:
- 6 Emerging Role of Physiotherapists in Obesity
- 7 CURRENT ROLE OF PHYSIOTHERAPISTS IN THE MANAGEMENT OF OBESITY
- 8 Physiotherapy Treatment Pathway options
- 9 PHYSIOTHERAPY REMIT
- 10 SELF-MANAGEMENT OF OBESITY
- 11 CONTINUED PROFESSIONAL DEVELOPMENT
- 12 CONCLUSION
- 13 REFERENCES
The prevalence of obesity has rocketed since the early 1980’s, leaving 312 million adults worldwide classified as clinically obese. Factors creating an obesogenic environment are 
Increasing energy intake
↑ Portion sizes
↑ Snacking and loss of regular meals
↑ Energy dense food
Decreasing energy expenditure
↑ Car ownership; ↓ Walking to school/work
↑ Automation; ↓ manual labour
↓ Sports in schools
↑ Time spent playing video games and watching TV
↑ Central heating
The categorisation of obesity as a health condition is now widely acknowledged and publisised. Not only is it the focus of intense scientific scrutinisation and debate, the term ‘obesity’ returning over 200,000 articles in ScienceDirect, it is the basis for films, such as Morgan Spurlock’s award winning documentary Supersize Me, and a key factor underlying the array of government strategies designed to promote healthy living and tackle weight gain. However, despite awareness of the condition being at an all time high, the prevalence of obesity in Scotland is second only to levels seen in the US, and this prevalence is rising (SOAR, 2007). Perhaps most concerning of all, this trend set to continue (Scottish Government, 2010). The direct cost of obesity to NHS Scotland in 2007/8 exceeded £175 million, and is predicted to have almost doubled by 2030 (Scottish Government, 2010). The total cost to society was estimated to be £457 million through increased sick leave, adverse effects on employment and mental well-being.
Obesity is the presence of excess fat, in the form of adipose tissue, which is stored subcutaneously and viscerally. Clinically this is most often measured using the body mass index (BMI), where BMI = weight (Kg) / height (m2). Adult weight can then be categorised as detailed in Table 1. BMI is also used to classify childhood weight status, however childhood BMI score must be compared to age- and gender-specific centiles (SOAR, 2007).
Under-weight Healthy Over-weight Obese Morbidly obese
BMI (Kg/m2) <18.5 18.5 – 24.9 25 – 29.9 30 – 39.9 >40
Quite simply, weight gain occurs when we are in a state of positive energy balance, i.e. when our energy intake exceeds our energy expenditure.A myriad of factors, both intrinsic and extrinsic, influence our propensity for weight gain, from our genetic profiles to our socio-economic status. The idea of a “thrifty genotype” has circulated ever since its proposal in the 1960’s, by J.V. Neel. The idea being that evolution through natural selection has provided us with a genetic predisposition to store energy in the form of adipose tissue; a survival mechanism in times of food shortage. Although no single genetic cause underlies common diet-induced obesity, allelic variants in certain genes, such as FTO, have been shown to correlate with increased BMI and risk of obesity (Frayling et al , 2007). A predisposing genotype together with our increasingly obesogenic environment may therefore promote weight gain and obesity in susceptible individuals.
Socio-economic status, relating to levels of income, education and level of deprivation, is strongly associated with obesity (Keenen et al , 2011). There is however a disparity between the genders regarding the strength of association in many areas, and this should be taken into account when considering the pathogenesis of obesity on a patient-specific level.
Obesity has a clear and profound impact on the health of our society and our economy, and with increasing prevalence it is a highly relevant and topical area. As Physiotherapists, the treatment of obesity according to the biomedical model of health would elicit a reductionist approach, focusing on the treatment of the physical problem of excess body fat, by addressing energy balance. However, as our understanding of obesity grows and develops, so must our practice. The psychosocial dimensions of this complex disorder must be considered when designing a patient-specific therapeutic plan, and the thus the biopsychosocial model of health may be of benefit in this endeavor. A multifaceted approach to the treatment of obesity is essential, and will not only require the application of our current skills as Physiotherapists, for example in the area of exercise therapy, but also the development and extension of skills in the cognitive behavioural sciences, where our emerging roles lie.
BARRIERS TO RECOVERY
Barriers to recovery for the patients:
• Social and Emotional Factors children bullying negative self worth and increased motivation to “fit in” (Murtagh et al, 2006)
• Economic low income .
• Environmental location inconvenience, seasonal influences (French et al, 1998)
• Gender French et al (1998) found that women reported lack of time, family duties, and conflict with work schedule as barriers.
• Family Support (Murtagh et al, 2006)
• Education or lack of rather Women with low levels of education are less likely to use helpful approaches to weight loss, such as combined physical activity and energy restriction than women of high (Levy et al, 1993)
• Psychosocial factors Attitudes, beliefs, self-efficacy, coping strategies (Murtagh et al, 2006; Van Gerwen et al, 2008;
• Genetic predisposition
• Previous Negative Experiences with weight loss and management (Murtagh et al, 2006)
• Behavioural Sacrifice (Murtagh et al, 2006)
• Delayed parental recognition (in children) (Murtagh et al, 2006)
• Lack of willpower and time constraints as barriers (Johnson et al, 1990)
• Lack of access to nutritional education or weight loss programs (French et al, 1998)
Physical and psychological levers and barriers to weight loss in children (Murtagh et al, 2006):
Barriers to action for Children (Murtagh et al, 2006):Some children found their parents answerable for their delay in action. A failure to distinguish the problem meant that these children were not engaged until the problem had grown to a greater issue than it need have been.The decision to take action, although imperative, was hardly ever the most difficult aspect of the behavioural-change process. The real difficulty remained in taking action and continuing it. The children acknowledged the need for continual support as being central in raising their self-efficacy and keeping motivated, without this they felt success would be doubtful.
2. Barriers to effective treatment for the Physiotherapist,Health Care Provider’s views:
In order to target interventions appropriately, healthcare professionals need to consider the willingness of a patient to undertake the necessary behaviour change required for effective weight management. The use of behavioural modification techniques (such as goal setting, use of rewards and self monitoring) as part of a multi-component intervention have been shown to be effective. (NICE 43, 2006)
Physicians held negative views regarding their ability to manage weight in primary care as well as stereotypical views toward obese patients in general patients were lazy or lacked self-control (Price et al, 1987).
Counseling is futile and counseling patients would take too much time (American Medical Association, 2003)
Primary care professionals expressed that low self-efficacy in the treatment and experienced a negative feeling regarding obesity management as barriers to treatment (Van Gerwen et al, 2008).
Van Gerwen et al (2008) reported three key themes related to knowledge deficits, in particular low reported use of guidelines, low levels of self perceived competency to treat childhood obesity, inconsistent use of standard measures such as BMI and lack of clinical consensus around treatment.
Walker et al (2007) also surveyed GP’s and nurses and found that they felt unable to cope with the scale of the problem and doubted the effectiveness of giving advice about diet and exercise. The HCP’s also report concerns about the sensitive nature of the subject and the negative effect that bringing attention to a child’s weight might have on their relationship with the parent.
The lack of shared understanding about how to manage infants at risk and the communication barriers between HCPs particularly in relation to records about infants’ diet, growth and weight is of concern as team working is crucial to successful prevention programmes (Walker et al, 2007).
Lifestyle interventions compared to standard care or self help can produce a significant and clinically meaningful reduction in overweight and obesity in children and adolescents (Oude et al, 2009).
The only published UK study of an individualised behavioural intervention for childhood obesity was performed in Scotland and showed modest benefits of family centred counselling and behavioural strategies (eight sessions over six months) on physical activity and sedentary behaviour (Hughes et al, 2008).
All contemporary RCTs of lifestyle interventions used programmes which targeted the family and involved at least one parent/carer and the child. Some programmes utilised parents-only group sessions to target family lifestyle and parenting skills (Goley et al, 2007; Golan et al , 2006).
NICE 43 (2006) guidelines noted that for a programme to be considered a behavioural intervention for children it must incorporate the following aspects:
• stimulus control
• self monitoring
• goal setting
• rewards for reaching goals 
• problem solving
Although not strictly defined as behavioural techniques, giving praise and encouraging parents to role model desired behaviours are also recommended (NICE 43, 2006).
Motivational interviewing (MI) was first developed in 1983 by William R. Miller and was used with problem drinkers; however it has since become an established method of communication used with a range of substance use disorders (Motivational Interviewing 2011).
MI is defined as “a collaborative, person-centred form of guiding to elicit and strengthen motivation for change” (Motivational Interviewing 2011). It has also been explained as “a patient-centred counseling method for addressing the common problem of ambivalence about change” (Motivational Interviewing 2011).
Traditionally, HPs have seen themselves at “experts” and believed the reason people do not change behaviour is due to a lack of knowledge/insight/skill/concern, and therefore once they enlighten them, change will occur (Motivational Interviewing 2011). This persuasive approach is not beneficial in promoting a change in behaviour, firstly because information is only exchanged in one direction (from HP to the individual) and secondly, the ambivalence, worries and motivations of the individual have not been explored. Imagine how an obese individual would appreciate being told “…you need to lose weight… the health problems associated with obesity are…just start exercising… ” by a fit and healthy physiotherapist? This approach is not likely to promote a change in behaviour as the individual may feel judged, criticised and unsupported. In contrast, MI focuses on building a collaborative therapeutic relationship between the HP and individual, it utilises the individual’s motivations and skills to promote the change, as commitment to change is most powerful when it comes from within, and it empowers the individual to be responsible for their actions (Motivational Interviewing 2011).
The following has been adapted from Motivational Interviewing (2011) and Miller and Rollnick (2002).
1. Express Empathy
• Skillful reflective listening is fundamental to expressing empathy.
• HP sees world from the individual’s perspective.
• Acceptance from HP facilitates change in the individual.
• Remember ambivalence from the individual is normal.
2. Develop Discrepancy
• Discrepancy between present behaviour and the individual’s goals.
• Reasons for change should be generated by the individual.
• HP intentionally directs towards the resolution of ambivalence/towards “positive” behaviour change.
3. Roll with Resistance
• Resistance presents as overt hostility, blaming others, changing account, making excuses, side tracking, rejecting HPs conception of the problem, “yes, but…” statements and pessimism about change.
• Resistance is influenced by the HP misjudging the individual’s stage of change, using a confrontational style or failing to make the individual understood. Therefore, resistance is a signal that the HP must change their responses.
• Once identified, avoid increasing resistance and use it constructively.
• Avoid arguing for change, because as the individual defends their standpoint they become more committed to it.
• Remember, the individual is a primary resource in finding answers and solutions, not the HP.
4. Support Self-Efficacy
• The individual’s belief change is possible is a key motivator.
• HP focuses the attention of the individual’s strengths, skills and past successes.
• The individual is responsible for choosing and carrying out change.
• The HP’s belief the individual is capable of changing becomes a self-fulfilling prophecy.
• HP may validate frustrations, yet remain optimistic about the prospect of change.
As previously mentioned, MI is successful for promoting behaviour change in substance use disorders (Smedslund et al. 2011). The meta-analysis performed by Rubak et al. (2005) observed MI to have a significant effect on body mass index, total blood cholesterol, systolic blood pressure and blood alcohol concentration. Studies by West et al. (2007) and Carels et al. (2007), observed the addition of MI to weight loss programmes resulted in greater weight loss and adherence in obese individuals. Limbers et al. (2008) state that although results seem favourable, more research it required to establish the effectiveness of motivational interviewing in obesity.
Emerging Role of Physiotherapists in Obesity
The emerging role of physiotherapists could in part involve the use of MI as a strategy to promote physical activity in obesity, as it is likely to be more beneficial in encouraging lasting lifestyle changes than simply educating individuals about the health risks of obesity and instructing them to exercise.
Cognitive Behavioural Therapy (CBT) in the Management of Obesity. CBT has frequently been used over the past 20 years and has been found to be effective in improving adherence in this population (Dalle Grave et al, 2010). These strategies have features which distinguish them from other forms of psychological treatment. By incorporating concepts of CBT into their fitness practice, physical therapists can help obese patients see the connection between their thoughts about exercise and their behavior.
CBT Strategies to initially engage in physical activity:
The first step is to educate patients about the benefit of exercising and the need to increase the level of physical activity for long-term weight control.
The next step is to create a “pros and cons to change” table. Patients should be asked to evaluate their reasons for and against adopting an active lifestyle. It is advised to begin by asking patients to list the cons of changing, considering whether sedentary life provides them with something positive that they are afraid to lose. Then patients are asked to evaluate in detail the pros of changing their lifestyle. The list of pros and cons should be put on a table and discussed in detail. Every reason for change should be reinforced. It is also important to analyze the cons of changing, helping patients reach the conclusion that the positive aspects of increasing the level of activity are attained in the long term, and are always associated with positive gains.
The final step is to help patients reach the conclusion that adopting an active lifestyle will be a positive opportunity for a new and healthy life and long-term weight control.
CURRENT ROLE OF PHYSIOTHERAPISTS IN THE MANAGEMENT OF OBESITY
SIGN guidelines (2010) and NICE guidelines (2006) were both published to identify evidence based recommendations that would help in the prevention and management of obesity in children and adults. Both the national guidelines for the management of obesity and the Scottish Intercollegiate guidelines are aimed at all health professionals working in primary, secondary and tertiary care within the NHS who are actively involved in the prevention and management of obesity in either children or adults. However a criticism of both guidelines is that they don’t specify at any point in their recommendations which health professionals may be the most suitable to administer preventative or management interventions at the various stage of childhood and adult obesity. Therefore from examining these guidelines it is difficult to understand what exactly is the current role of the physiotherapist in the prevention and management of obesity.
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 such as the eat well plate, 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. .
It is difficult to examine the precise contribution physiotherapists are making to the fight against obesity in Britain today as there is only limited research on the current practice and on-going schemes which physiotherapists are actively involved in. However a number of NHS weight management services have been identified across Britain where physiotherapists play a central role in the design of specific and individualised exercise programmes for people attending this service.
However further research is needed which examines the current role of the physiotherapist in areas such as the behavioral management of obesity and the also the degree to which the physiotherapist profession is contributing to achievement of targets set in the SIGN and NICE guidelines. Although the management of obesity is a very important and controversial topic in todays society and there is evidence which point to fact that the physiotherapist may have a crucial role in the fight against an increasing obese population the evidence base in this area is significantly lacking. Therefore it is fair to conclude that although the role of the physiotherapist in the management of obesity is currently centered around the prescription and distribution of exercise programmes there may be scope in the future for the involvement of physiotherapists in the psychological aspect of obesity management, an area which needs to be focused on in more detail.
Some additional information on The Aintree Weight Management and what they do (adapted from Aintree Weight Loss Programme)
Physiotherapy Treatment Pathway options
• Tone up and feel good programme
◦ 12 wk group exercise programme held in 3 community venues
◦ Patients attend a weekly 1 ½ hour session which are made up of 3 components:
▪ Exercise component- 20 min exercise session comprising of warm-up, 10 minute circuit 1 minute exercises, cool down.
▪ Breathing control techniques- they teach and practice a variety of breathing control and relaxation
▪ Health promotion discussion- they discuss a wide range of topics affecting weight management and barriers to activity. Inviting guest speakers from community activity schemes to promote their services.
• Joint Physiotherapy/Dietetics/Psychotherapy Group Programmes
◦ 12 wk group programme held at 1 community venue
◦ Weekly 2 hour session for patients
◦ Group discussion led by any one of the 3 health professionals (physio, dietician or psychotherapist) depending on topic
◦ 20 min exercise component each week
• Hydrotherapy Group Sessions
◦ 8 week programme
◦ 2 sessions of group Hydrotherapy each week in the Aintree Uni Hospital Physio Dept.
◦ Patients attend a 30 minute water based group exercise session which includes:
▪ 10 min circuit of exercise stations
▪ 5 min cool down
▪ optional 10 min free swim at the end
• One to one Physiotherapy Sessions
◦ Up to 4 one to one 40 min follow up sessions can be provided at the community venue of the patients choice.
◦ These are used to tackle specific barriers the patient has to activity.
• Pedometer Loan
◦ 3 month loan of an accurate pedometer.
◦ With regular follow session throughout this 3 month period to have step targets to have step targets reviewed and progressed.
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 (Perri et al 1997). As the prevalence of obesity increases a multidisciplinary approach must be implemented in order to manage patients in this population (Dalle Grave et al. 2011).
A study by Epstein and Ogden (2005) 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 (Cade et al. 1991). 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.
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. Figure 1 (taken from the Health Foundation, 2011) illustrates these divisions and types of self-management support along a continuum.
Categorising such interventions is difficult; an intervention may focus one behavior change only whereas another intervention may address self-efficacy and behavior change. Although only an illustrative figure it can be useful for Health Professionals to conceptualise interventions within such a continuum. The Health Foundation (2011) reviewed hundreds of studies and found that proactive self-management schemes located in the top right area of figure 1 are associated with increased change or more consistent levels of behavioural and clinical benefits. We will now introduce some of the self-management approaches and the relevant evidence. As a physiotherapist, an understanding of the efficacy of each approach will help the practitioner to advise patients how to self-manage most effective
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:
o Body Mass Index calculation 
o Assessment of cardiovascular disease risk factors
o Determination of need for treatment
o Individualized weight-loss goals
o Individualized treatment recommendations (lifestyle therapy, pharmacotherapy,
o and surgery options)
o Follow-up and maintenance recommendations
o Evidence-based supporting information available throughout
Many studies have investigated the impact of one-on-one education on chronic disease elf-management. Perhaps the earliest and most critical one-on-one education an individual should experience is from parents. Lamerz et al (2005) found a strong relationship between level of parental education and childhood obesity. Children from lower socioeconomic backgrounds were exposed to less parental education regarding healthy living, as a result they were more than 3 times more likely to develop childhood obesity. The modern health practitioner should have an awareness of this early family dynamic and consider whether it is the child or the under-educated parent who is the route of the problem. Viklund et al (2007) state that ‘empowerment programmes for diabetic teenagers in early and middle adolescence should include parental involvement’.
Studies suggest that while individual education may enhance individual’s knowledge, it is unlikely to have significant impacts on behaviour change and outcomes unless it is targeted, specific, and long term (Duke et al, 2009).
In the health care setting there are numerous examples of group education programmes that cater for different demographics and target many different diseases. Funnell et al (2005) found that culturally sensitive group education sessions twice a week were effective in educating a population of African Americans. Research generally suggests that group education can improve patient’s self-efficacy, clinical outcomes and health service use. Group sessions range from those focused on technical information such as how to administer insulin and healthy eating, to more proactive education seeking to change people’s attitudes towards self-management and initiate behaviour change.
CONTINUED PROFESSIONAL DEVELOPMENT
CPD is becoming increasingly important in current physiotherapy practice and in mandatory in many countries, French and Dowds (2008) state that “The ultimate aim of CPD is to improve healthcare delivery and patient care”. Bury (2010) describes CPD as “learning activities designed to facilitate professionals acquiring new competencies”. In order to progress in the management of obesity health professionals such as physiotherapists must develop their knowledge skills and understanding of both obesity and its associated co-morbidities.
The development of additional skills may focus on secondary conditions related to obesity (cardiovascular disease, hypertension, osteoarthritis, etc.), but also to psychological barriers and/or cognitive strategies whose implementation will increase the likelihood of permanent habitual change.
It is common practice these days for physiotherapists to attend courses aimed at furthering their knowledge in certain areas. Course, in-service training and clinical training and supervision have been shown to be the most effective forms of gaining CPD (French, 2006). There are many courses relating to obesity in areas such as:
• Obesity management
• Childhood obesity
• Obesity education
The emerging role of physiotherapists in public health and physical activity in relation to obesity could include the use of motivational interviewing to support obese individuals making lasting lifestyle changes.
- Carels, R., Darby, L., Cacciapaglia, H., Konrad, K., Coit, C., Harper, J., Kaplar, M., Young, K., Baylen, C. and Versland, A. 2007. Using motivational interviewing as a supplement to obesity treatment: a stepped-care approach. Health Pyschology, 26 (3), pp.369-374.
- Bodenheimer, T., Lorig, K., Holman, H. & Grumbach, K. 2002. Patient Self-management of Chronic Disease in Primary Care. Journal of the American Medical Association. 288 (19), pp. 2469-2475.fckLRBoon N.A., Colledge N.R., Walker B.R. and Hunter J.A.A. 2006. Davidson’s Principles and Practices of Medicine, Chapter 5. 20th Edition. Elsevier publishing.fckLRBury, S. 2010. Continuing professional development and irish libraries: Report of key survey findings. [online] Available at: http://pi.library.yorku.ca/dspace/bitstream/handle/10315/4164/cpdreportexecsummary.pdf?sequence=1 [Accessed 09/11/11]fckLRCade, J. & O’Connell, S. 1991. Management of weight problems and obesity: knowledge, attitudes and current practice of general practitioners. Br J Gen Pract. 41. pp.147–150
- Baranowski T., Cullen, K. W., Nicklas, T., Thompson, D. & Baranowski, J. 2003. Are current health behavioural change models helpful in guiding prevention of weight gain efforts? Obes. Res. 11:23–43S
- lark, M. & Hampsen, S. E. 2001. Implementing a psychological intervention to improve lifestyle self-management in patients with Type 2 diabetes. Patient Education and Counseling. 42 (3), pp. 247-256.fckLRThe Chartered Society of Physiotherapy. 2002. Curriculum framework for qualifying programmes in physiotherapy. London: The Chartered Society of Physiotherapy.
- Nice clinical guideline 43. 2006. Obesity-guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children
- Dalle Grave, R. Calugi, S. Centis, E. El Ghoch, M. Marchesini, G. 2011. Cognitive-behavioral strategies to increase the adherence to exercise in the management of obesity. Journal of Obesity. 2011. pp.1-11
- Coulson, N., Goldstein, S. & Ntuli, A. Promoting health in South Africa. 1998. London: Heinemann.
- Department of Health/NHS. 2004. Choosing health, making healthy choices easier. executive Summary. Department of Health/NHS [online] Available at: http://news.bbc.co.uk/nol/shared/bsp/hi/pdfs/16_11_04_executive_summary.pdf [Accessed 09/11/11]
- Little, P., Dorward, M., Warner, G., Moore, M., Stephens, K., Senior, J. & Kendrick, T. 2004. Randomised Control Trial of the Effect of Leaflets to Empower Patients in Consultations in Primary Care. British Medical Journal. 328, pp. 441-4.
- Golley, R. K., Magarey, A. M., Baur, L. A., Steinbeck, K. S. & Daniels, L. A. 2007. Twelve-month effectiveness of a parent-led, family-focused weightmanagement program for prepubertal children: A randomized, controlled trial. Pediatrics; 119(3):517-25.
- National Audit Office. 2001. Tackling Obesity in England. Report by the Comptroller and Auditor General. London: The Stationery Office. [Online] Available at: http://www.nao.org.uk/publications/0001/tackling_obesity_in_england.aspx [Accessed November 4 2011].
- Samoocha, D., Bruinvels, D. J., Elbers, N. A., Anema, J. R. & Van Der Beek, A. J. 2010. Effectiveness of web-based interventions on patient empowerment: a systematic review and meta-analysis. Journal of Medical Internet Research. 12 (2), e23.
- NHS Direct Wales/Encyclopaedia. 2011. Physiotherapy. NHS Wales. [online] Available at: http://www.nhsdirect.wales.nhs.uk/encyclopaedia/p/article/physiotherapy. [Accessed at 09/11/1
- HS Direct Wales/Encyclopaedia. 2011. Physiotherapy. NHS Wales. [online] Available at: http://www.nhsdirect.wales.nhs.uk/encyclopaedia/p/article/physiotherapy. [Accessed at 09/11/1
- Perri, M. G. Martin, A. D. Leermakers, E. A. Sears, S. F. Notelovitz, M. 1997. Effects of group-versus home-based exercise in the treatment of obesity. Journal of Consulting and Clinical Psychology. 65 pp.278–285
- Protheroe, J., Blakeman, T., Bower, P., Chew-Graham, C. & Kennedy , A. 2010. An intervention to promote patient participation and self-management in long term conditions: development and feasibility testing. BMC Health Services Research. 10, pp. 206-220.fckLRRegis, D. 1998. Conformity, consistency and control. Educ Health;6:4–9
- Funnell, M. M., Nwanko, R., Gillard, M.L., Anderson, R. M. & Tang, T. S. 2005. Implementing an Empowerment-based Diabetes Self-management Education Program. Diabetes Education. 31 (1), pp. 55-61.
- Glasgow, N. J., Ponsonby, A.L., Yates, R., Beilby, J. & Dugdale, P. 2003. Proactive Asthma Care in Childhood: General Practice Based Randomised Control Trial. British Medical Journal. 327 (659).
- Foresight Report. 2007. Tackling Obesity: Future Choices. Full obesity system map. [Online] Available at: http://www.bis.gov.uk/assets/bispartners/foresight/docs/obesity/obesity_final_part5.pdf [Accessed November 3 2011]. Frayling, T.M., Timpson, N.J., Weedon, M.N., Zeggini, E., Freathy, R.M., Lindgren, C.M., Perry, J.R., Elliott, K.S., Lango, H., Rayner, N.W., Shields, B., Harries, L.W., Barrett, J.C., Ellard, S., Groves, C.J., Knight, B., Patch, A.M., Ness, A.R., Ebrahim, S., Lawlor, D.A., Ring, S.M., Ben-Shlomo, Y., Jarvelin, M.R., Sovio, U., Bennett, A.J., Melzer, D., Ferrucci, L., Loos, R.J., Barroso, I., Wareham, N.J., Karpe, F., Owen, K.R., Cardon, L.R., Walker, M., Hitman, G.A., Palmer, C.N., Doney, A.S., Morris, A.D., Smith, G.D., Hattersley, A.T. and McCarthy, M.I. 2007. A common variant in the FTO gene is associated with body mass index and predisposes to childhood and adult obesity. Science 316 (5826): 889–94.
- eenan, K., Grant, I. and Ramsey, J. 2011. Topic report on Obesity from the Scottish Health Survey series. [Online] Available at: http://scotland.gov.uk/Publications/2011/10/25091711/0 [Accessed November 3 2011]. Kopelman, P.G, Grace, C. 2004. New thoughts on managing obesity. Gut. 53 pp.1044-1054.
- Lamerz, A., Kuepper-Nybelen,., Wehle, C., Bruning, N., Trost-Brinkhues,. Brenner, H., Hebebrand, J. & Herpertz-Dahlmann, B. 2005. Social class, parental education, and obesity prevalence in a study of six-year-old children in Germany. International journal of Obesity. 29, pp. 373-380
- r General. London: The Stationery Office. [Online] Available at: http://www.nao.org.uk/publications/0001/tackling_obesity_in_england.aspx [Accessed November 4 2011]. 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. Available from url: http://guidance.nice.org.uk/CG43