Management of Obesity



The prevalence of obesity has rocketed since the early 1980’s, leaving 312 million adults worldwide classified as clinically obese[1], and Western society labelled obesogenic[2] (Figure 1).

Figure 1: Factors creating an obesogenic environment. Adapted from Davidson’s Principles & Practice of Medicine[2]
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

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 govenment 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[3]. Perhaps most concerning of all, this trend set to continue[4]. The direct cost of obesity to NHS Scotland in 2007/8 exceeded £175 million, and is predicted to have almost doubled by 2030[4]. The total cost to society was estimated to be £457 million through increased sick leave, adverse effects on employment and mental well-being.

What is Obesity?

Obesity is the prescence 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[3].

Table 1: BMI classification
 Cateogory  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[5]:

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[6]. 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[7]. 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 risked of disease development in obese adults[8]
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 the thus 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

Barriers to Recovery For The Patients

  • Social and Emotional Factors --> children bullying --> negative self worth and increased motivation to “fit in”[9]
  • Economic --> low income[10] a number of studies reported program cost, childcare responsibilities as barriers.
  • Environmental --> location inconvenience, seasonal influences[10]
  • Gender --> French et al found that women reported lack of time, family duties, and conflict with work schedule as barriers[10].
  • Family Support[9]
  • 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[11]
  • Psychocosial factors --> Attitudes, beliefs, self-efficacy, coping strategies[9][12]
  • Genetic --> predisposition
  • Previous Negative Experiences with weight loss and management[9]
  • Behavioural Sacrifice[9]
  • Delayed parental recognition (in children)[9]
  • Lack of willpower and time constraints as barriers (Johnson et al, 1990)
  • Lack of access --> to nutritional education or weight loss programs[10]

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[13]. 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[14].

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[9]. 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[9].

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 For The Physiotherapist

According to the NICE 43 guidelines[15] "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 have been shown to be effective." 

Health Care Provider’s Views

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[12].

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[12].

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[12]. 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[16]. 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[16].

In Relation to Physiotherapy Practice

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[17].

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[18].

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[19][20].

NICE [15]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[15].

Emerging Role of Physiotherapists

In general, nobody appreciates being bossed around and told what to do, whether this be from parents, teachers or health professions (HPs). 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 HPs go about encouraging this change in behaviour? How should a physiotherapist successfully promote physical activity in obese individuals? The answer may partly be answered by adopting an appropriate method of communication, such as motivational interviewing.

Motivational Interviewing: The Approach

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[21].

MI is defined as “a collaborative, person-centred form of guiding to elicit and strengthen motivation for change”[21]. It has also been explained as “a patient-centred counselling method for addressing the common problem of ambivalence about change”[21].

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[21]. 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[21].

Motivational Interviewing: The Principles

The following has been adapted from Motivational Interviewing[21]and Miller and Rollnick[22].

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[21] and Miller and Rollnick[22]. Change talk is composed of statements from the individual that signal they are considering, motivated or committed to change[21]. 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[23]. 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[24]. Studies by West et al[25] and Carels et al observed the addition of MI to weight loss programmes resulted in greater weight loss and adherence in obese individuals[26]. Limbers et al state that although results seem favourable, more research it required to establish the effectiveness of motivational interviewing in obesity[27].

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

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[28].
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[28].

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 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[29] and NICE guidelines[15] 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. Although NICE clinical guidelines provide some further information on how health professionals working in a community setting or with children may further prevent obesity, these recommendations in general are very unspecific and clearly do not emphasise which health professionals should be administrating this preventative advice to the target groups.

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 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. Questions could be asked whether this is the most appropriate way to assess and treat people who are overweight, surely an individualised approach with management strategies which best suit each person should be advocated for use rather than this one size fits all care pathway, therefore this could be illustrated as a weakness of both the SIGN and NICE guidelines.

Evidence and recommendations on how to treat obesity in the adults have been sub-divided into dietary interventions, physical activity, behavioural interventions pharmacological treatment and bariatric surgery with physiotherapists having an active role to play in the first three categories outlined. A brief overview of the recommendations with the best evidence base in support are that weight management programmes should include physical activity, dietary change and behavioural components, dietary interventions for weight loss should be calculated to produce a 600 kcal/ day energy deficit, overweight individuals should be prescribed five sessions of 45-60 minutes moderate physical activity per week and behavioural interventions should be delivered with the support of an appropriately trained professional to include some of the following strategies; self-monitoring of behaviour and progress, stimulus control, goal setting, slowing rate of eat, ensuring social support and relapse prevention. Although just a brief overview of the recommendations issued by NICE and SIGN on how to treat obesity in adults, it is fair to say that a multi-disciplinary team approach including physiotherapists would be required in order for people in this specific population to gain access to the entire care package which, according to the available research, is required for the management of this condition.

With regard to the treatment of obesity in children findings with the strongest evidence base, B recommendation by SIGN guidelines, were that programmes should target a decrease in overall dietary energy intake, increase levels of physical activity, incorporate behaviour change components, be family based, involving at least one parent and aim to change the whole family’s lifestyle. Comparing these recommendations to those outlined for the management of obesity in adults a similar conclusion may be drawn which is that obesity can not be managed by only one treatment approach or one health professional on their own a team effort is required in order to fully manage this disorder. Both these guidelines add valuable research to and give clear instructions to all staff in the NHS on the best way to treat adults and children who are overweight, however in saying that there are also a number of downfalls to these guidelines, especially when examining them in order to fully the role of the physiotherapist in this ever expanding area. As mentioned previously there is no reference to which health professional should be implementing these recommendations and many of the guidelines are quite vague which may lead to confusion amongst both NHS and non-NHS staff on their role should be in managing people with obesity. Although these guidelines do not specifically focus on the current role of the physiotherapist the ever expanding scope of the physiotherapy profession means that physiotherapists may be appropriately trained to deal with the physical activity, dietary and behavioural components of management of obesity as part of a larger MDT team.

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.

The Aintree LOSS Expert Weight Management Service provides a comprehensive, specialist, MDT weight management service to adults living in Merseyside and surrounding areas such as Cheshire, Lancashire and North Wales. Individuals referred by their GP’S receive individualised management plans for up to two years incorporating medical support, dietetic and exercise programmes. A similar weight management service is based at Heartlands hospital in the West Midlands who are the largest providers nationally for medical weight management and bariatric surgery serving patients from 40 PCTs. An overview from both weight management services concluded that physiotherapy is a crucial part of any approach to long-term weight management. Considering the vital part physiotherapists play in these weight management services it is fair to conclude that the current role of this profession is to use the extensive skills and knowledge held in the area of exercise prescription in order to formulate individual exercise programmes for obese patients.

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)

Physiotherapists here aim to promote successful weight management and improved general health by appropriately increasing patients levels of physical activity.
Their assessments are carried out to establish the patients current activity levels and any barriers the patient has to increased activity. The Physiotherapists then offer a treatment plan aimed at tackling these barriers and promoting the optimal activity for the patient.

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:
  1.  Exercise component- 20 min exercise session comprising of warm-up, 10 minute circuit 1 minute exercises, cool down.
  2. Breathing control techniques- they teach and practice a variety of breathing control and relaxation.
  3.  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.

Physiotherapists' Views on Aintree Weight Loss 

(adapted from Love your Body CSP article)

  • Although weight loss is a recognised, quantifiable objective for patients, the focus is firmly grounded in the promotion of patient health and well-being.
  • It is a holistic approach and aimed at the patient working towards overall fitness and maintaining any current weight loss.
  • We remove a lot of the psychological pressure that our patients have as a result of the aim to lose weight. We allow them to change their focus to having objectives that are not only positive but essentially achievable.
  • It gives patients lots of different ideas. We're good listeners and non-judgemental.
  • Before Hydrotherapy was introduced : I got so fed up with people saying they couldn't do more activity because of medical problems or because people would laugh at them.
  • After Hydrotherapy was introduced: One patient recently got in a pool for the first time in 20 years.
  • We think our success lies in the strength of our programme running as phase one for 16 weeks and phase two, where patients can access a monthly group session, for up to two years.

Patients' View on The Programme

  • So far it's been brilliant. The main thing is you get all different types of support and it is much more intense: at slimming clubs you just worry about the scales. It sounds daft, but here it is the last thing they worry about.
  • The main thing with me is that I wasn't exercising before and they really encourage me on the programme. The aqua-fit sessions help a lot. I was really worried about putting on a cozzie, but we're all in the same boat. The group supports each other, and once I got more confident I started to go to other exercise classes.
  • Without a doubt the programme has made a difference. I have lost two stone and everyone is so nice and approachable. I can't praise it enough.

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[30]. As the prevalence of obesity increases a multidisciplinary approach must be implemented in order to manage patients in this population[31].
A study by Epstein and Ogden[32] 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[33]. 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)

However with further training a basic knowledge of these areas would be beneficial and appropriate for most of the population.
As well as knowledge of the physical manifestation of obesity and its co-morbidities physiotherapists are required to have good communication skills, tolerance, patience, reliability, honesty and trustworthiness as stated by the core NHS job description templates ( These are ideal characteristics to engage in the complex management of obese people where psychosocial issues are the main problem.
The encyclopedia of NHS Wales ( defines physiotherapy as a profession that “uses physical methods, such as massage and manipulation, to promote healing and well-being”. Based on this definition, complex management of psychological barriers does not fit into the scope of a physiotherapist, however, as obesity is becoming more prevalent as time goes on, and patients are presenting to physiotherapy with chronic conditions associated with obesity, perhaps it is not appropriate to let the job be restricted by previous definition, but rather allow the definition to change to fit the job.

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.
Self-management support can be conceptualised by dividing interventions into those that focus on building knowledge and those that focus on skill acquisistion.
Categorising such interventions is difficult; an intervention may focus one behavior change only whereas another intervention may address self-efficacy and behavior change. The Health Foundation (2011) reviewed hundreds of studies and found that proactive self-management schemes 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 effectively.

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[34] but whether such written information results in behaviour change is debatable[35].
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[36][37].

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[38]
‘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[39].
‘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[40]. 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[41] . They found that self-efficacy in greatly increased when patients succeed in solving patient identified problems.
The benefits of goal setting in self-management are well documented;
Schillinger et al trialed the effectiveness of automated telephone disease management (ATDM) among diabetic patients[42]. The ATDM was a form of self-management strategy designed to assess patient’s progress regarding set goals versus a control group attending monthly health centre visits. The results showed that the ATDM was a successful medium and was particularly popular amongst those with limited English and of limited intellect. Engagement in action planning was high in the ATDM group.

Behaviour Change

According to the Health Foundation (2011) the most promising way of supporting self-management appears to involve approaches, which empower and activate people so they feel more confident about managing their conditions and are more likely to alter their behaviours.
Techniques that aim to change behaviours include motivational interviewing (see section 3), group and individual education sessions and telephone coaching.

Individual Education

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 found a strong relationship between level of parental education and childhood obesity[43]. 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 state that ‘empowerment programmes for diabetic teenagers in early and middle adolescence should include parental involvement’[44].
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[45].

Group Education

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 found that culturally sensitive group education sessions twice a week were effective in educating a population of African Americans[46]. 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[47] state that “The ultimate aim of CPD is to improve healthcare delivery and patient care”. Bury describes CPD as “learning activities designed to facilitate professionals acquiring new competencies”[48]. 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

As well as courses designed specifically in relation to obesity, courses based on comorbidities and also healthy eating were found:

  • Human nutrition
  • Diabetes risk factors and treatments
  • Chronic heart disease therapies

According to governmental and NHS guidelines it is an employers duty to provide training and support to staff members to promote knowledge and understanding in community health issues[49] therefore, if deemed appropriate, often funding can be obtained for some of these courses.
However, courses are not the only method of CPD available to physiotherapists and there are several other ways to gain CPD that are often overlooked.


Sutton and Dalley describe reflection as “an effective method of providing evidence of professional development, learning and continued competence”[50]. Reflection is a fantastic tool for re-examination and consolidation of learning achieved through any activity. Reflecting upon a single case study can allow for evaluation of specific treatments and is essential for evidence based practice, but case studies are not the only thing that can be reflected upon. Any experience, such as discussions with other members of the MDT, seminars, meetings and workshops can all be reflected on.

Journal Articles and Journal Clubs

Obesity is such a prevalent condition that there are a wealth of articles written about its management. Reading journal articles helps gain understanding and can suggest or provide research into treatment strategies. Journal clubs exist which study obesity in certain areas, however these are not common place. Journal clubs regarding the latest issues in management of obesity, behavioral treatment and biological issues are a fantastic way for peers to generate discussion and actively engage in CPD ( As opposed to traditional journal clubs where one article is focused on it might be more useful to focus on several publications with the common theme of obesity. As with all other forms of professional development these journal clubs can also be used as a topic for reflection.


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.


  1. Haslam D.W. and James W.P.T. 2005. Obesity. Lancet 366: 1197–209.
  2. 2.0 2.1 Boon 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.
  3. 3.0 3.1 SOAR (Scottish Obesity Action Resource). 2007. Available at: [Accessed November 4 2011].
  4. 4.0 4.1 Scottish Government. 2010. Preventing Overweight and Obesity in Scotland: A Route Map Towards Healthy Weight. [Online] Available at: [Accessed November 3 2011].
  5. Foresight Report. 2007. Tackling Obesity: Future Choices. Full obesity system map. [Online] Available at: [Accessed November 3 2011].
  6. 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.
  7. Keenan, K., Grant, I. and Ramsey, J. 2011. Topic report on Obesity from the Scottish Health Survey series. [Online] Available at: [Accessed November 3 2011].
  8. National Audit Office. 2001. Tackling Obesity in England. Report by the Comptroller and Auditor General. London: The Stationery Office. [Online] Available at: [Accessed November 4 2011].
  9. 9.0 9.1 9.2 9.3 9.4 9.5 9.6 9.7 Murtagh, J., Dixey, R. & Rudolf, M. 2006. A qualitative investigation into the levers and barriers to weight loss in children: the opinions of obese children. Arch Dis Child; 91:920–923
  10. 10.0 10.1 10.2 10.3 French, S., Jeffery, R., Story, M., & Neumark-Sztainer, D. 1998. Perceived barriers to and incentives for participation in a weight-loss program among low-income women. Journal of American Dietetic Association, 98(1), 79-81.
  11. Levy, A. S. & Heaton, A. W. 1993. Weight control practices of US adults trying to lose weight. Ann In tern Med; 119:661-666.
  12. 12.0 12.1 12.2 12.3 Van Gerwen, M., Franc, C., Rosman, S., Le Vaillant, M. & Pelletier-Fleury, N. 2009. Primary care physicians' knowledge, attitudes, beliefs and practices regarding childhood obesity: a systematic review. Obesity Reviews, 10(2):227-36.
  13. 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
  14. Baranowski, T., Lin, L. S., Wetter, D. W., Resnicow, K. & Hearn, M. D. 1997. Theory as mediating variables: why aren’t community interventions working as desired? Ann Epidemiol.;7: S89–95.
  15. 15.0 15.1 15.2 15.3 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:
  16. 16.0 16.1 Walker, O., Strong, M., Atchinson, R., Saunders, J. & Abbott, J. 2007. A qualitative study of primary care clinicians’ views of treating childhood obesity. BMC Family Practice, 8:50.
  17. Oude Luttikhuis, H., Baur, L., Jansen, H., Shrewsbury, V. A., O’Malley, C., Stolk, R. P. 2009. Interventions for treating obesity in children (Cochrane Review). In: The Cochrane Library, Issue 1, London: Wiley.
  18. Hughes, A. R., Stewart, L., Chapple. J, McColl, J. H., Donaldson, M. D. & Kelnar, C. J. 2008. Randomized, controlled trial of a best-practice individualized behavioral program for treatment of childhood overweight: Scottish Childhood Overweight Treatment Trial (SCOTT). Pediatrics; 121(3):e539-46.
  19. 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.
  20. Golan, M., Kaufman, V. & Shahar, D. R. 2006. Childhood obesity treatment: targeting parents exclusively v. parents and children. Br J Nutr; 95(5):1008-15.
  21. 21.0 21.1 21.2 21.3 21.4 21.5 21.6 21.7 Motivational Interviewing. 2011. An overview of motivational interviewing. [online] Available at [Accessed October 28 2011].
  22. 22.0 22.1 Miller, W. and Rollnick, S. 2002. Motivational interviewing: Preparing People for Change. 2nd ed. New York: Guilford Press.
  23. Smedslund, G., Berg, R., Hammerstrøm, K,, Steiro, A., Leiknes, K., Dahl, H. and Karlsen, K. 2011. Motivational interviewing for substance abuse. Cochrane Database of Systematic Reviews, 5, pp.1-65
  24. Rubak, S., Sandboek, A., Lauritzen, T. and Christensen, B. 2005. Motivational interviewing: a systematic review and meta-analysis. British Journal of General Practice, 55, pp.305-312.
  25. West, D., Dilillo, V., Bursac, Z., Gore, A. and Greene, P. 2007. Motivational interviewing improves weight loss in women with type 2 diabetes. Diabetes Care, 30(5), pp.1081-1087.
  26. 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.
  27. Limbers, A., Turner, E. and Varni, J. 2008. Promoting healthy lifestyles: behaviour modification and motivational interviewing in the treatment of childhood obesity. Journal of Clinical Lipidology, 2, pp.169-178.
  28. 28.0 28.1 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
  29. SIGN. 2010. SIGN 115- Management of Obesity - A national clinical guideline. Scottish Intercollegiate Guidelines Network. Available from url:
  30. 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
  31. 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
  32. Epstein, L. & Ogden, J. 2005. A qualitative study of GP’s views of treating obesity. British Journal of General Practice. 55 pp.750-754
  33. Cade, 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
  34. 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).
  35. 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.
  36. Lafata, J. E., Baker, A. M., Divine, G. W., McCarthy, B. D. & Xi, H. 2002. The Use of Computerized Birthday Greeting Reminders in the Management of Diabetes. Journal of General Internal Medicine. 17 (7), pp. 521-530.
  37. Enwald, H. P. & Huotari, M. L. 2010. Preventing the Obesity Epidemic by Second Generation Tailored Health Communication: An Interdisciplinary Review. Journal of Medical Internet Research. 12 (2), e24.
  38. 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.
  39. 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.
  40. Clark, 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.
  41. 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.
  42. Schillinger , D., Hammer, H., Wang, F., Palacios, J., McLean, I., Tang, A., Youmans, S. & Handley, M. 2008. Seeing in 3-D: Examining the Reach of Diabetes Self-Management Support Strategies in a Public Health Care System. Health Education and Behaviour. 35, pp. 665-683.
  43. 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.
  44. Viklund, G., Ortgvist, E. & Wikblad, K. 2007. Assessment of an Empowerment Education Programme. A Randomised Study in Teenagers with Diabetes. Diabetes Medicine. 24 (5), 550-556.
  45. Duke, S. A. S.,Colagiuri, S. & Colagiuri, R. 2009. Individual patient education for people with type 2 diabetes mellitus. Cochrane Database of Systematic Reviews. 1, Art. No.: CD005268.
  46. 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.
  47. French, H.P. Dowds, J. 2008. An overview of continuing professional development in physiotherapy. Physiotherapy. 94 pp.190-197
  48. Bury, S. 2010. Continuing professional development and irish libraries: Report of key survey findings. [online] Available at: [Accessed 09/11/11]
  49. Department of Health/NHS. 2004. Choosing health, making healthy choices easier. executive Summary. Department of Health/NHS [online] Available at: [Accessed 09/11/11]
  50. Sutton, L. Dalley, J. 2008. Reflection in an intermediate care team. Physiotherapy. 94 pp.63-70