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 projectents

Lead Editors  

Introduction

The prevalence of obesity has rocketed since the early 1980’s, leaving 312 million adults worldwide classified as clinically obese, and Western society labeled obesogenic (Figure 1). The categorisation of obesity as a health condition is now widely acknowledged and publicised.

Figure 1: Factors creating an obesogenic environment. Adapted from Davidson’s Principles & Practice of Medicine

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

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.

Table 1: BMI classification

Category	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. However, factors influencing the development of obesity can be far from simple, as demonstrated by the Foresight Report’s Obesity System Map:

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 varients in certain genes, such as FTO, have been shown to correlate with increased BMI and risk of obesity. 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. 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.

The Impact of Obesity on Health

Globally, obesity is the 5th leading cause of mortality. Furthermore, it increases the risk of many non-communicable diseases (Table 2), most notably type 2 diabetes mellitus.

Table 2: The relative increased risk of disease development in obese adults

Condition	Relative Risk in women	Relative Risk in men
Type 2 Diabetes	12.7	5.2
Hypertension	4.2	2.6
Myocardial infarction	3.2	1.5
Colon cancer	2.7	3.0
Angina	1.8	1.8
Gall bladder diseases	1.8	1.8
Ovarian cancer	1.7	-
Osteoarthritis	1.4	1.9
Stroke	1.3	1.3

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 thes the biopsychosocial model of health may be of benefit in this endeavour. 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 For The Patients

• Social and Emotional Factors --> children bullying --> negative self worth and increased motivation to “fit in”
• Economic --> low income a number of studies reported program cost, childcare responsibilities as barriers.
• Environmental --> location inconvenience, seasonal influences
• Gender --> French et al found that women reported lack of time, family duties, and conflict with work schedule as barriers.
• Family Support
• 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
• Psychocosial factors --> Attitudes, beliefs, self-efficacy, coping strategies
• Genetic --> predisposition
• Previous Negative Experiences with weight loss and management
• Behavioural Sacrifice
• Delayed parental recognition (in children)
• Lack of willpower and time constraints as barriers (Johnson et al, 1990)
• Lack of access --> to nutritional education or weight loss programs

Theories of Behaviour Change

Behavioural change may occur as a result of changes in factors that mediate intervention and these mediating factors have classically come from the theories or models used to comprehend behaviour. Behavioural or social science theories or conceptual models can offer the basis for understanding these behaviours. The mediating factor model has been proposed as a guideline both for designing interventions and for understanding how interventions work to encourage change in diet and physical activity behaviours.

Physical and Psychological Levers and Barriers to Weight Loss in Children

Humiliation of social torment and exclusion are identified by children as the key reason for wanting to lose weight, however commencement of behavioural change required the active intervention of a role model. The maintenance of action was thought unlikely without continual emotional support offered at an individual level. Behavioural sacrifice, delayed parental recognition and previous negative experiences of weight loss were identified as barriers to action. Participants acknowledged shortcomings in their own physical abilities, the extensive time needed to lose weight and uncontrollable external limitations as barriers to continual behavioural change.

As human nature dictates people will not always react in a rational and predictable manner when given information about future health risks. Simply educating a population seldom has a marked effect on behavioural change.

Barriers to Action for Children

When considering behavioural change, people must first evaluate what they will gain from an action against what they will have to give up. Children spoke liberally about the difficulties of making the sacrifices essential to achieve weight loss as well as struggling to stick to the lifestyle limitation necessary in their attempt to lose weight.

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.

Barriers to Effective Treatment

According to the NICE 43 guidelines "in order to target interventions correctly, healthcare professionals (HCPs) 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 has been shown to be effective." 

The views of members of the medical team however, can have a detrimental effect on a patient's participation and compliance. in a weight-loss programme

• 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).
• Counselling is futile and counselling 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 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.

Van Gerwen et al found that of all the studies they reviewed, physicians recommended dietary advice, exercise or referral to a dietician and they concluded that there is a need for education of primary care professionals to increase the uniformity of the assessment and to improve physicians' self-efficacy in managing childhood obesity. And that multidisciplinary treatment including general practitioners, paediatricians and specialized dieticians appears to be the way to counteract the growing obesity epidemic!

Walker et al 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.

Emerging Role of Physiotherapists

A significant and clinically meaningful decrease in overweight and obesity in children and adolescents can be produced with lifestyle interventions as opposed to standard care or self-help self help.

An individualised behavioural intervention for childhood obesity was performed in Scotland, and was the only study of its kind in the UK, which resulted in moderate benefits of family centred counselling and behavioural strategies (eight sessions in six months) on physical activity and sedentary behaviour.

All modern RCTs of lifestyle interventions utilised programmes which were aimed at the family and included at least one parent/carer and the child. Some programmes made use of parents-only group sessions to pinpoint family lifestyle and parenting skills.

NICE guidelines detailed that for a programme to be deemed a behavioural intervention for children it must include the following factorts:

• Stimulus control
• Self monitoring
• Goal setting
• Rewards for reaching goals
• Problem solving

Although not strictly defined as behavioural techniques, appraisal and encouraging parents to demonstrate desired behaviours are also suggested.There are instances when it is vital for people to make drastic lifestyle changes in relation to smoking, alcoholism or obesity for example, however how should physiotherapists encourage this change in behaviour and successfully promote physical activity in obese individuals? One approach could be adopting an appropriate method of communication, such as motivational interviewing.

Motivational Interviewing

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.

MI is defined as “a collaborative, person-centred form of guiding to elicit and strengthen motivation for change”. It has also been explained as “a patient-centred counselling method for addressing the common problem of ambivalence about change”.

Motivational Interviewing: The Principles

The following has been adapted from Motivational Interviewingand Miller and Rollnick.

1. Express Empathy

• Skilful 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.

Motivational Interviewing: The Strategies “O.A.R.S”

The following strategies, aimed at promoting change talk, have been adapted from and Miller and Rollnick. Change talk is composed of statements from the individual that signal they are considering, motivated or committed to change. This can for example include the individual listing advantages of change, disadvantages of the current situation or optimism about changing.

1. Open Ended Questions

• Require more than yes/no responses, therefore facilitate dialogue.
• Gather broad descriptive information.
• Encourage elaboration and oblige the individual to think deeply about the subject.
• Confirm the HP is truly interested in what the individual has to say.

2. Affirmations

• Must be done sincerely.
• Affirmations are statements from the HP that acknowledge the individual’s strengths and past successes.
• Involves reframing behaviours/worries into more positive light.
• Supports and promotes self-efficacy.
• Prevents discouragement.

3. Reflective Listening

• Expresses empathy, as the HP attempts to truly understand the individual’s feelings.
• Enables the HP to clarify what the individual means.
• Guides the individual towards resolving ambivalence and the intention to change.

4. Summaries

• Reinforce that the HP is interested in the individual.
• Draw attention to important points of the conversation.
• Prepare the individual to “move on”.
• Acknowledge the individual’s ambivalence, yet highlight the discrepancies identified.

Motivational Interviewing: The Evidence

As previously mentioned, MI is successful for promoting behaviour change in substance use disorders. The meta-analysis performed by Rubak et al 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 and Carels et al observed the addition of MI to weight loss programmes resulted in greater weight loss and adherence in obese individuals. Limbers et al state that although results seem favourable, more research it required to establish the effectiveness of motivational interviewing in obesity.

Cognitive Behavioural Therapy (CBT) in the Management of Obesity

Cognitive behavioural therapy (CBT) has frequently been used over the past 20 years and has been found to be effective in improving adherence in this population.
These strategies have features which distinguish them from other forms of psychological treatment.
Herning et al (2005) state that CBT posits that thoughts or cognitions (interpretations) mediate behavior.
The 3 fundamental propositions of CBT are:

1. Cognitions affect behaviour (self-regulation)
2. Cognitions (interpretations) may be monitored and altered
3. Behaviour change may be produced through cognitive change (self-regulation).

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.
In a review of CBT strategies to increase adherence in patients with obesity Dalle Grave et al provide a guide with steps to follow.

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.

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.

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.