The Emerging Role of the Physiotherapist in the Current Obesity Epidemic

Introduction

                     “Global terrorism is a real threat, but poses far less risk than obesity”
          				         (Gostin, 2008)

Obesity is a leading preventable cause of death and disease worldwide (Finucane et al. 2011). Since 1980, the prevalence of obesity worldwide has more than doubled (Finucane et al. 2011). The rapid increase in the number of obese people in the UK is a major challenge, as over half of the UK adult population could be obese by 2050 (Tackling Obesities – Future Choice, 2007). Research estimates that without a major shift in society’s attitude towards food and exercise and a change in individuals’ lifestyles, overweight and obesity costs in the NHS are projected to double to £10 billion per year by 2050. Substantial costs to society and business are also alarming being estimated to reach £49.9 billion per year (Government Office for Science, 2007).

Obesity co-morbidities such as stroke, diabetes and heart disease are major public health issues within the UK. Figure 1 demonstrates health risks associated with obesity. The current problem includes the implications that obese patients have on secondary care for example, surgery and postoperative recovery. In addition, health and safety issues in the acute care of obese patients and the need for bariatric equipment, impact on the increasing costs in the NHS.

Figure 1: The Scottish Public Health Observatory (Grant et al. 2007)

The enormity of the problem has been recognized by the government with research and guidelines emerging in an attempt to help tackle this threatening epidemic. The National Institute for Health and Clinical Excellence guidelines (NICE, 2006) on obesity advocated a multidisciplinary team (MDT) approach. The guidelines recommend that interventions are made up of different components, including strategies to increase physical activity and promote healthier eating. A more up-to-date publication of the Scottish Intercollegiate Guidelines Network (SIGN, 2010) support this with the recommendation that health professionals undertake dietary and physical interventions, including behavioural, pharmacological and bariatric surgery for managing obesity.

However, how do you think this type of holistic patient-centred care can best be delivered?

Should you as a physiotherapist undertake the responsibility to provide dietary and behavioural interventions?

Or should all members of the MDT focus exclusively on their own fields of expertise?

The Chartered Society of Physiotherapy (CSP) recognises that the prevention and management of obesity requires an aggressive and comprehensive approach that addresses the complex and multifaceted issues. However, to date there is confusion of the current role of the physiotherapist within the prevention and management of obesity, and physiotherapists have had a low profile in managing this condition as it is traditionally seen in terms of overeating. There is a great need for emphasis on the importance of exercise, activity and lifestyle as it is often not the focus in dietician led weight management programs. The Health Survey for England (2007) identified that 68-69% of adults either underestimated the amount of physical activity required to derive health benefits or were unaware of the recommendations. This area of expertise falls within the physiotherapist domain and it is crucial for physiotherapists to be at the centre of not only the management of obesity but in prevention and maintaining weight loss.

Current and Emerging Role of the Physiotherapist 

The SIGN (2010) and NICE (2006) guidelines are produced in order to provide evidence based recommendations that can best guide practice in health care. Both organisations have produced guidelines outlining their recommendations for obesity management and prevention in adults and children. While both sets of guidelines outline the strategies that should implemented in order to tackle obesity, they fail to outline which professions are best placed to deliver these interventions.

The CSP states that physiotherapists ‘help people affected by injury, illness or disability through movement and exercise, manual therapy, education and advice.’ The CSP also state that physiotherapy provides a ‘whole person approach to health and wellbeing, which includes the patient’s general lifestyle’. Consequently, it can be concluded that physiotherapists can play a major role in obesity management. Physiotherapist’s have the skills to contribute directly to the recommendations for obesity management, including general diet and lifestyle intervention, prevention of weight gain, pre and post bariatric surgery care.

The CSP report on the Obesity Steering Group (Academy of Royal Medical Colleges, 2012) outlined recommendations including ‘a call for increased recognition of the health promoting role of physiotherapy, along with improved signposting and the referral of overweight or obese individuals to physiotherapy services’. The report emphasises the need for increased support for the field of bariatric physiotherapy and recommends that physiotherapists who specialise in this area be routinely included in weight management teams. There are a number of NHS weight management services dotted around the UK in which physiotherapists play a pivotal role. The limited research investigating these ongoing schemes makes it difficult to determine the precise contribution that physiotherapists’ are making in the fight to combat the obesity epidemic.

Weight Management Programmes

An example of an existing programme is the Glasgow and Clyde weight management service (GCWMS). The service is a referral based intervention offering a multi-modal approach towards weight loss. The service utilises diet, activity, behaviour, surgery, pharamacotherapy and weight maintenance. Physiotherapists play a central role in this programme and are responsible for delivering activity classes, providing one to one physiotherapy assessments and providing access and confidence to access community based activity programmes. Physiotherapists also provide individualized home activity programmes and provide chair based classes.

The service has received recognition from the NHS Diamond Healthy Lifestyle Award and the National Obesity Forum Best Practice for excellence in weight management. In a 2011 evaluation, Morrison et al., found that the service was cost effective, clinically effective and that weight loss did not vary between patients from differing socioeconomic backgrounds. Whilst the research did not specifically evaluate the role of physiotherapists within the service, the findings suggest that the GCWMS is well designed and physiotherapists are a key component in the delivery of this service.

Another existing programme where physiotherapists’ play a key role within a MDT is the Aintree LOSS weight management service. Physiotherapists in charge of this programme argue that ‘sustainable weight management’ is the way forward for physiotherapy treatment in the management of obese patients (CSP, 2008). Physiotherapy interventions should focus more on health promotion, patient well-being and improving quality of life and less on weight loss. They suggest that weight management interventions that emphasise weight loss, such as those typically adopted by slimming clubs, place significant psychological pressure on patients to lose weight. If the focus of weight management services changes towards objectives that are achievable, and less on what the weighing scales read, then patients are more likely to have positive experiences and maintain their new activity levels and lifestyle changes.

Bariatric Patient Care

Specialist bariatric physiotherapy is an emerging area of practice, and is generating a lot of interest due to the increasing number of obese patients that require surgery. Nevertheless, a lack of training, equipment, and facilities suggest not enough is being done to cope with the additional demands of these patients (CSP, 2011). An article on the CSP website titled, ‘Bariatric patients being failed’ poses the question, should bariatric care become an integral part of physiotherapy training in all degree courses, rotations and static posts?

Case study: Bariatric patients have feelings too!

This evidence suggests that there is a strong argument for the need of specific training in bariatric care and specialist manual handling training (CSP, 2008). This should include training in the use of the necessary equipment, such as bariatric beds, hoists and walking aids, as well as carrying out the necessary risk assessments in the work place to ensure physiotherapists’ own safety. We also need to consider how to treat these patients with the appropriate sensitivity to ensure that patients’ dignity is maintained at all times. These are all new challenges that face physiotherapists and the profession, particularly in light of incidents where patient dignity has been compromised simply because of a lack of appropriate equipment and training in dealing with this type of patient.

Further research on the effectiveness of the existing weight management programmes is needed for physiotherapists and other healthcare professionals to implement best practice in relation to the prevention and management of obesity. The CSP recognises that these services are highly variable and do not yet regularly perform adequate evaluation to monitor outcomes or incorporate the level of skill required to effectively manage bariatric patients. Therefore it is suggested that frequent evaluation of programmes through patient reported outcome measures, experience and clinical measures should be undertaken (Obesity Steering Group, 2012). This will ensure these patients are provided with the standard of care and service they need.

Barriers to Practice

There are numerous challenges facing physiotherapists as the prevalence of obese patients rises. This raises several issues that must be considered if we are to fulfil our emerging role in providing an effective and efficient service in treating this condition.

The CSP identifies the need for mechanisms to be in place to ensure obesity management expands into the wider community and not just those seeking support, particularly individuals in society that are hard to reach such as low socioeconomic groups, those with mental health needs and ethnic minority groups. Therefore, an expansion of multidisciplinary weight management programmes and increased awareness of these services available in the local area amongst health care professionals is vital. It is also recommended that early intervention is recognised by local health and social care professionals. Access to clinical weight management programmes are normally through GP referral or self-referral with the majority of these individuals requesting bariatric surgery rather than non-surgical support (CSP, 2012). This emphasises the need for raised awareness in the general population that bariatric surgery is recommended as a last resort when non-surgical interventions have failed and only appropriate in certain clinical circumstances (NHS Choices, 2012).