Physiotherapy communication approaches in management of obesity and overweight

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Introduction

Aims

To provide final year physiotherapy students and newly qualified physiotherapy graduates with an online learning resource which aims to develop their knowledge and understanding of physiotherapy management approaches for people with overweight and obesity.

Learning Outcomes

By the end of this activity you will be able to:

1. Explain and describe some of the key contributing factors to overweight and obesity and critically evaluate how these factors impact physiotherapy practice.

2.  Appraise the relevant evidence to identify and summarise the role of physiotherapy in management and treatment of obese or overweight patients.

3. Critically evaluate the theories and evidence base for communication approaches to facilitate behaviour change in people with overweight and obesity.
 

Audience

Although this resource is aimed at final year physiotherapy students and newly qualified physiotherapy graduates, other health care students and professionals may find it useful, as well as anyone else interested in the subject.

Understanding Obesity

Obesity Quiz: How much do you know?

https://www.onlineexambuilder.com/obesity-quiz-how-much-do-you-know/exam-42680

Definition of Obesity

Obesity is where an individual is carrying excess body fat which can increase the chances of developing secondary diseases. This causes huge problems worldwide as health care demands increase and people are becoming more sedentary and unhealthy. Physiotherapists will come across obesity in all areas of physiotherapy and can cause unwanted secondary problems (NHS 2014a).

Obesity can be seen in a musculoskeletal clinic where, for example knee pain could be exacerbated or in a medical ward where diabetes may be poorly managed. There are many interventions and guidelines to assist in tackling obesity; however, obesity is still a huge on going issue. The management and approach to obesity is of huge importance to because of the huge complications and health issues it can cause. Communication is a huge part of tackling obesity, however, junior physiotherapists and newly graduates may find this a challenging subject to approach. Therefore, education on contributing factors, behavioural change and motivational interviewing will be discussed.

Obesity can be measured by Body Mass Index (BMI) as shown:

BMI 25-29.9 – overweight
BMI 30-39.9 – obese
BMI 40+ - severely obese

However, to measure obesity more reliably waist circumference can also be measured where females as classed as obese is measuring over 80cm and males over 94cm. Fat percentages can also be calculated to give a truer measurement of obesity (NOO 2011).

Implications of Obesity

There are many implications of obesity worldwide. Obesity increases the risk of many long-term health conditions such as type 2 diabetes, heart disease, arthritis, hypertension, cancer, stroke, liver problems, respiratory problems, sleep issues, mental health disorders and overall may cause a reduced quality of life (Keenan et al. 2011). People with obesity also have an increased risk of falls (Fjelstad et al. 2008).
 
With the rising obesity epidemic and reduced staff, funding and resources within the NHS the demand on the health service is huge. This could ultimately lead to reduced quantity and quality of care. Obesity also contributes to wider financial problems such as more benefit outgoings and loss of output within the economy (Public Health England 2015).  In addition, obese patients have an increased recovery time which leads to an increased length of hospital stay which further adds more pressure on the health service due the increased demand for hospital beds. Therefore, there is an increased demand for bariatric equipment which with the reduced funding and resources within the NHS currently results in difficulty (CSP 2015b).

Obesity in Scotland

Obesity is a large cause of many deaths and illnesses which could have been prevented throughout the world. Prevalence of obese people is more than 50% since 1980. Worldwide, obesity is the 5th indicating mortality factor.

In the developed countries Scotland is one of the leading obese countries. Adult obesity has increased by 17% in adults 16-64 in 1995 to 27% in 2010 where 65% of adults of age 16 or over were either overweight or obese.

The Scottish Public Health Observatory predicted different health conditions that are associated with obesity such as:

47% of type 2 diabetes
36% of hypertension
18% of myocardial infarction
15% of angina
12% of osteoarthritis

In 2007-2008 the predicted cost was £175 million to the NHS in Scotland alone due to obesity and associated diseases (Keenan et al. 2011).

Factors Contributing to Obesity

There are many different contributing factors to obesity.

Can you list 5 main risk factors to obesity?

Answers:
⦁ Age
⦁ Pregnancy
⦁ Socio-economic status
⦁ Genetics
⦁ Lifestyle
⦁ Exercise levels
⦁ Medical conditions
⦁ Medications
⦁ Diet
⦁ Lack of sleep
⦁ Quitting smoking
⦁ Mental health

There are many issues regarding obesity throughout the literature and the current economic climate, three factors that are prevalent within physiotherapy practice causing an increased demand for physiotherapy intervention are socio-economic status, mental health and genetics. These three factors need to be taken into consideration when physiotherapy assessments, problem lists and treatment plans are being formulated.

Socio-Economic Status

Socio-economic status is a large factor influencing obesity. Levels of high obesity were around 1.7 times greater in deprived children and teenagers in a group of 12,000 children than children in a non-deprived area aged 2 to 19 years (Food Research and Action Center 2015).

There are many areas within this topic that effect people in various different ways such as:

Occupation
Smoking
Cost of food
Deprived living conditions
Technology
Income
Education
Sedentary lifestyles
(Baum and Chou 2011).

Socioeconomic status refers to a person’s position compared to other people’s personalities, this has contributed to putting people into certain categories allowing evaluation of discrimination between these public categories (National Obesity Observatory 2010).

(National Obesity Observatory 2010; Baum and Chou 2011; Crawford and Ball 2011; Markwick et al. 2013). The accessibilities of food shops and the number of services that allow physical activity influence the levels of obesity.

Akil and Ahmad in 2011 show the highest obesity levels are mostly found within the people who:
-Earn the least
-Are not taught to a high level about obesity and health aspects
-Are not educated to a high level in general.
-They also illustrate that unhealthier foods are less expensive and more instantly available within deprived areas. 

Overall, deprived areas to live in are a huge factor contributing to obesity, especially in women.

The MRC National Survey of Health and Development showed that BMI was directly connected with educational success in both sexes. This most increased obesity levels were found in the people with the least academic achievements. 11% of men with O-grade level achievements had a BMI above 30, whereas, only 5% of men’s BMI were over 30 when they were at degree level of attainment. The same result showed within females as well correspondingly 15% and 4% (Fehily 1999).

Through looking at the evidence and guidelines this is a large contributing factor to obesity. By a physiotherapist recognising this problem at the beginning of physiotherapy interventions they will be able to adapt their approaches to become more relevant to the individual’s circumstances. Physiotherapists can also assist in giving the individual advice or guidance if certain SES factors are contributing to obesity.

Mental Health

Mental health includes our social and psychological well-being. It affects and can determine how we react to events, how we handle stress, and how we feel and relate to others. Early signs of mental health are:
Eating too much
No interest in social activities
Having low energy (MentalHealth.gov 2015).

There is a lack of research in establishing a definite cause and effect relationship between obesity and mental health disorders such as depression and anxiety (Puhl 2009). However it has been observed that a link could exist between these variables and these individuals making them more vulnerable to mental health issues and obesity (Bogart 2013). 
The Obesity Action Coalition (2015) states that it is thought that the two could be strongly linked or that they at least co-exist, however it has not been established which one comes first- for example whether obesity increases onset of developing depression or having depression increases the chances of developing obesity.
 
What do you think from clinical experience?
 
Depression, in most cases, can be quite debilitating, therefore decreasing an individual’s motivation to partake in exercise or other physical or social activities, they might tend to not follow such a healthy well balanced diet as well as believing they should not be taking care of themselves as much, leading to an increase chances of developing obesity (Obesity Action Coalition 2015).
 
A systematic review and meta-analysis on longitudinal relationship between depression and overweight and obese patients was conducted by Luppino (2010). It was observed that obesity did increase the onset of depression. Another study by Bogart (2013) showed that studies conducted in America found that women with a BMI over 30 linked to 50% of women developing depression over a lifetime however with men seemed to have resulted more complicated. This might be due to higher sensitivity levels that women have and the stigma the media conveys about small sizes and beauty. This picture shows a child’s toy of Barbie as she is sold and realistically what she should look like. This gives the impression of typically skinny body the media portrays from a young age. (Bell 2015).

 Puhl (2009) paper states that there has been further research done around the stigma of obesity and depression. Several studies suggest that childhood experiences have a strong link in the development of obesity and depression too (Puhl 2009; Obesity Action Coalition 2015).
 
Studies showed that the onset of either obesity or depression (or both) is strongly linked to childhood experiences. Either for being mocked about their weight which might lead to depression or for having experienced unresolved life events like bereavement that might develop into obesity in later stages of life (Stunkard et al 2003 and Puhl 2009).
 
However it is good to consider that a person with underlying mental issues and increased body weight might also be due to the type of medications they are receiving (Obesity Action Coalition 2015). A study supported a strong link between schizophrenia and depression and obesity, were results showed that metabolic risk factors can almost be double in those suffering from schizophrenia (Allison et al. 2009).

Genetics

It is not commonly thought that there is any correlation but genetics is found to be highly related to obesity. A rare genetic condition, Prader-Willi syndrome (PWS), where these children will tend to overeat. Due to their decreased metabolism and lack of muscle tone, they will have an increased risk of being obese. This rare genetic condition occurs when there is a defect in chromosome number 15, and the prevalence is no more than 1 in 15,000 children (NHS 2014b). Apart from this genetic defect that leads to obesity, hereditary factors from mothers to new-born’s are found to also contribute to obesity.
It is found that Body Mass Index (BMI) and waist circumference are highly heritable, estimated to be ranging from 40% - 70% in chance (Tenesa et al., 2009).

Childhood obesity can be predicted before a child is born from factors such as:
The relationship of the mother’s BMI before pregnancy
Mother smoking when pregnant
Inter-uterine effects on appetite
Metabolism and level of activity
(Hawkins and Law 2006; Oken et al., 2008; Smith et al., 2007; Oken, 2009).
 

(The Scottish Government, 2012)
 
Exemplary behaviours from parents will aid in the modelling of healthy actions of the child. Different types of parenting will then explain the child’s weight, diet and exercise practices. Accommodating parents are unable to help to their children to become disciplined in the activities of healthy living. Divergent or highly conflicted families are found to have problems in carrying out healthy parenting practices like family meals and outings (Sleddens et al., 2011).

Parental negligence of their children getting overweight, especially the mothers, are found to be unmotivated to try to manage their children by getting them to take up a healthy diet and regular exercising. Thus reduced parental concern on the child’s healthy weight may lead to the child not actively adopting in healthy diet and physical activity levels (The Scottish Government, 2012). Therefore, family constraints can play a huge part in the influencing the weight of the children.
In conclusion, genetics and family influences are highly correlated to obesity in children. Mind-sets of parents need to change and thus education to parents and children will play a huge part in reducing the prevalence of obesity in childhood and adulthood.

Overall, by a physiotherapist recognizing and becoming aware of these contributing factors, physiotherapy approaches can be adapted to benefit the individual in their personal circumstances. Having physiotherapy management that is sensitive to these contributing factors can improve outcomes as physiotherapy interventions will be specific to the individual and relevant to their current personal situation. These complex issues need thorough and in depth physiotherapy intervention. The role of the physiotherapist includes behavioural change which may be from motivational interviewing as well as other forms of advice and guidance.

What's Needed for Healthy Weight Loss?

SIGN guidelines (2010) recommend: -       Produce a 600 kcal/day energy deficit -       Reduce intake of energy-dense foods (high fat foods, confectionery, sugary drinks). Select low energy-dense foods (wholegrains, cereals, fruits, vegetables, salads) -       Reduce consumption of ‘fast-foods’ -       Reduce alcohol intake -       Encourage physical activity, reduce sedentary behaviour (e.g. television watching) -       Physical activity of minimum 45 mins, thrice a week COMBINED WITH diet (600kcal/day or low-fat)   significantly greater weight loss than diet alone. -       Walking is an excellent form of physical activity for overweight and obese people. 1km of walking on flat ground burns 60-90kcal of energy.

The Role of Physiotherapy

What can physiotherapists do to help?

CSP: “Physiotherapy is an ideally placed profession to provide the physical activity component of multidisciplinary weight management services”. (2015)
 
Physiotherapists will come across patients with overweight or obesity in their careers. As mentioned above in section 2.4, a large proportion of the Scottish population are obese or overweight, and this will also include large proportion of physiotherapy patients. Obesity can mean that a person is more likely to develop physiotherapy- related issues, such as osteoarthritis (Fu and Griffin 2015 in book) and restricted movement at some joints leading to functional limitation and pain (Wearing et al. 2006).

Physiotherapists often treat clients that suffer from secondary conditions due to their being overweight. An interesting analysis was made by the Canadian Joint Replacement Registry where they found that 73% of hip replacement patients and 87% of knee replacement patients were classified as overweight or obese at the time of their surgery. Physiotherapists are well aware of the treatment for these conditions however there is little research describing the physiotherapist’s role in managing the individual’s weight as an underlying problem that is associated with their joint replacement.

Physiotherapists are well placed to manage and treat people with overweight and obesity. Specialist knowledge and skills that physiotherapists have include:

• Anatomical, physiological, and psychosocial mechanisms of health and disease
• Assessment and diagnosis
• Behaviour change
•  Biomechanics
•  Exercise prescription and therapeutic exercise
•  Management of long-term conditions

(Canadian Physiotherapy Association 2007)

Physiotherapy treatments for obese/ overweight patients may comprise of:

• Provision of personalised lifestyle advice, taking into account individual attitudes, beliefs, circumstances, cultural and social preferences, and readiness to change
•  Prescription, supervision, and progression of appropriate physical activity to increase muscle strength, flexibility, and endurance, and sustain energy output to enhance and maintain weight loss under safe and controlled conditions
• Management of associated conditions such as arthritis, back pain, and other musculoskeletal and chronic conditions, such as heart disease.
•  Co-ordination of comprehensive and sustainable programmes of management in collaboration with service users, other health and social care professionals, and community services 

(CSP 2015)

Overall, physiotherapists have a huge role in managing obese and overweight patients with exercise interventions, mobility training and cardiorespiratory programmes (You et al. 2012).
Further Reading Opportunity?
 
Alexander et al. (2012) recommended an evidence-based approach for the physiotherapy management of obesity:

1. Assessment of the individual’s medical history
2. Evaluation of current physical activity level
3. Provision of an individualised physical activity program
4. Gradual progression of a physical activity program
5. Prescription of a cardiovascular training program
6. Prescription of resistance exercises
7. Prescription of moderate-intensity physical activity, 30 min/d, 3–5 d/wk
8. Calculation of body mass index.

Note: Including education on strategies for adherence to an independent exercise program is also recommended whenever possible.

Tackling the issue- Physiotherapists’ Perceptions

Despite the fact that physiotherapists have ideal knowledge and skills to combat obesity, many do not feel that is their responsibility in including behaviour change intervention in their practice and others feel that have not the required skills to undertake this approach, or are fearful to do so for lack of confidence (Alexander et al. 2012); as also not many have received the appropriate training during the university years to have the tools to establish effective communication with patients in promoting lifestyle changes (Grave et al 2010). The lack of knowledge and training for clinicians in how to approach the subject of weight with their patients was identified as one of the barriers that can limit the proper care of obesity (Mauro et al. 2008).

However, there is an increasing amount of evidence showing that obesity is a multidisciplinary issue and should be addressed by all health care professionals (Hamdy 2015). Alexander et al. (2012) stated that it is important for health care professionals to be involved in the early stages of treatment of an obese individual. Physiotherapists may be the first contact for these clients who might present with various pains due to their increased weight. NICE guidelines (2015) support this by specifying that this type of intervention would be best supported and carried out by a health care professional.

This means that even though health professionals find that they have many time constraints in their practice (Konrad et al. 2010), tackling the issue of overweight and obesity is something that should be included if not prioritized in healthcare interventions (Monsen et al. 2014).

Tackling the issue- Patients’ Perceptions

On the other hand, patients’ perceptions of physiotherapists can also impact the effectiveness of tackling the issue. A study by Setchell et al. (2015) found that there were a number of factors that could cause a negative reaction to physiotherapists discussing weight with overweight patients (see table):

Expectations ⦁ That weight loss would be mentioned ⦁ Of a negative attitude towards increased weight	Environment (“gym-like”) ⦁ Mirrors ⦁ Use of images with thinner bodies ⦁ Lack of bariatric equipment ⦁ Displays of exercise equipment
Physiotherapist body image ⦁ Fit and healthy = makes patients more uncomfortable when the issue of weight is raised	Physiotherapist attitude ⦁ Too simplistic about causes of weight gain ⦁ Too much emphasis placed on benefits of weight loss and links between weight and presenting complaint

Setchell et al. (2015) also identified ways that physiotherapists could attempt to make patients less uncomfortable when discussing this issue. These include:
⦁ Think about layout of treatment room (less mirrors, range of body types represented in pictures/ posters etc.)
⦁ Be sensitive about when weight is discussed, and be sensitive what is discussed when patients are undressed/ have body parts exposed
⦁ A collaborative rather than educational approach is most beneficial (Trede 2012)
⦁ More positive responses shown from patients when empathy is shown
⦁ Do not ignore OR overemphasize topic of overweight, but be non-judgemental when discussing it

Using the NHS Knowledge and Skills Framework

The Knowledge and Skills Framework (KSF) model is aimed at Band 5 physiotherapists to assist them in providing “a comprehensive physiotherapy service, which encompasses assessment, treatment and management” of patients in a wide range of settings (eKSF 2008). The KSF is a good tool which demonstrates what abilities a health professional should have. It contains a number of dimensions such as Communication and Equality & Diversity, as well as dimensions specific to physiotherapy: Assessment and Treatment Planning or Interventions and Treatments. Band 5 physiotherapists will need to fulfil these indicators as best possible with all types of patients, including those who may be obese or overweight.
 
Obese and overweight patients have specific additional risks and implications to health care (see sections 2.3 and 2.4). Some factors physiotherapists may have to consider when treating obese/ overweight patients in relation to the specific dimension ‘Assessment and Treatment Planning’ are outlined below as an example of how the KSF model can help guide physiotherapy treatments.

Level Indicators	Related Physiotherapy Management Specific to Overweight/ Obesity
a) Evaluates relevant information to plan the range and sequence of assessment requires and determines: - The specific activities to be undertaken - The risks to be managed - The urgency with which assessments are needed	Assessment tools or tests may need to be modified to people’s abilities- for example if range of movement is limited due to excess adipose tissues then the person may not be able to carry out certain movements required for a test, leading to inaccurate results. Palpation will be more difficult as surface anatomy will be under a layer of adipose tissue (Carucci 2012). Risks connected with larger weights need to be considered- will bariatric equipment be required for assessments or treatments to be carried out? Physiotherapists may need to monitor their own positioning and safety when carrying out assessments and treatments. Assistance from other therapists may be required. (Hignett and Griffiths 2007)
b) Selects appropriate assessment approaches, methods, techniques and equipment, in line with - Individual needs and characteristics - Evidence of effectiveness - The resources available	" "
c) Respects people’s dignity, wishes and beliefs; involves them in decision making; and obtains their consent	There are clear links between obese/ overweight people and increased body image problems (Schwartz and Brownell 2004) If a person has a poor body image, they may feel uncomfortable in the physiotherapy setting and physiotherapists should attempt to make every effort to make them as comfortable as possible. They can do this with reassurance, being aware of the surroundings and creating an atmosphere of non-judgement if possible (Setchell et al. 2015).
d) Prepares for, carries out and monitors assessments in line with evidence based practice, and legislation, policies and procedures and/ or established protocols/ established theories and models	Guidelines like SIGN (2010) and NICE (2006) as well as information provided by the National Obesity Observatory (2013; 2011).
e) Monitors individuals during assessments and takes the appropriate action in relation to an significant changes or possible risks	Be aware of additional risks associated with obese/ overweight patients including diabetes, increased falls risks, heart issues, respiratory issues etc. See section 2.3
f) Evaluates assessment findings/ results and take appropriate action where there are issues	" "
g) Considers and interprets all of the information available using systematic processes of reasoning to reach a justifiable assessment and explains the outcomes to those concerned	In addition to treating the person for the condition they are presenting with, explanation and education may also be required to help the person understand: - How their weight or health conditions associated with it may be contributing to their presenting problem or delaying its recovery - The health risks related to increased weight and the benefits of healthy weight loss (Alexander et al. 2012; You et al. 2012)
h) Determines and records diagnosis and treatment plans according to agreed protocols/ pathways/ models that are: - Consistent with the outcomes of the assessment - Consistent with the individual’s wishes and views - Include communications with other professions and agencies - Involve other practitioners and agencies when this is necessary to meet people’s health and wellbeing needs and risks - Are consistent with resources available - Note people’s wishes and needs that it was not possible to meet	Currently there are no set protocols for overweight/ obesity management (but there are recommendations in NICE (2006) and SIGN (2010) guidelines and NOO recommendations (2010; 2011). Use individual’s own goals and aims to shape treatment- for example help them to find a weight loss activity/ sport/ exercises that they will enjoy and will realistically be able to do and participate in. Work together with other professionals to achieve goals (Nowicki et al. 2009).
i) Monitors and reviews the implementation of treatment plans and makes changes within agreed protocols/ pathways/ models for clinical effectiveness and to meet people’s needs and views	" "
j) Identifies individuals whose needs fall outside protocols/ pathways/ models and makes referrals to the appropriate practitioners with the necessary degree of urgency	Instances where this may be required include: - GP review of medication - Psychiatry/ psychology regarding increased mental health problems with obesity/ overweight - Recommendation of bariatric surgery

Guidelines, Recommendations and Other Resources

There are a number of guidelines and recommendations available for the use of physiotherapists and other health professionals when working with people who are obese or overweight. The SIGN guidelines (2010) are a good reference for health professionals to use when planning advice and treatments (see section 2.6).

Links to some of these guidelines are outlined below:

NICE https://www.nice.org.uk/guidance/CG43 2006
SIGN http://www.sign.ac.uk/guidelines/fulltext/115/index.html 2010
National Obesity Observatory Briefing Papers http://www.noo.org.uk/pages.php5?pg=314#d1109

One technique that physiotherapists can use that is recommended in the above protocols and guidelines (NOO 2010; NOO 2011) is behaviour change.

The National Obesity Observatory (2010) recommends behavioural change should address dietary requirements and physical activity, assist the individual to change their attitude and behaviour in regards to these aspects, and improve eating behaviours as well as decreasing energy intake and improve the quality of their diet.
Key aspects of behaviour change are detailed below:

Self-monitoring	Encouraging patients to keep a diary and monitor calories and food intake as well as the amount of exercise achieved each week is important part of therapy. Studies showed that the use of a diary for the first six months is predictive of success in losing weight.
Environment	Altering the environment that might activate/ tempt the patient to over eat and modify food consumption by encouraging to exclude high dense foods and introduce and increase intake of fruit and vegetable as well as helping them decrease their portion size.
Pacing	Encourage the individual to eat slower. This is so to help signal for fullness come into play as well as encouraging taking small breaks and encourage the individual to drink more water.
Behaviour	Reinforce the successful outcomes in continuing with the programme and therapy. Some studies suggest that use of rewards as incentive have been found helpful and observed a reduction in weight between the two groups.
Education	Important to educate the patient in relations to their diet and physical activity. Might be beneficial to have an “eat well plate” cut out to assist you with this. It is a useful tool in achieving a balanced and healthy diet and guiding patients to what they should be reducing and increasing as part of their diet.
Physical activity	Encourage the individual to increase their activity as well as educate them on the benefits of increasing their physical activity i.e. The psychological benefits it has too. Ask them to monitor their level of activity in their diary and possibly set this as a goal too. This will help them to keep motivated and on track.
Social support	Ensure that the individual has good and stable social support. Suggest the involvement of spouses, partners, family and friends. Studies have shown that individual that has this support in place where able to lose weight more than the control groups. This support also makes these changes more sustainable in the long term.

Some of these techniques will be discussed in more detail in the following section (see section 4), along with practical advice to carry out behaviour change techniques in physiotherapy practice.

What's available for weight loss in your practice area?

Follow-up of weight loss interventions has been shown to be beneficial for both physiological and psychological health (Poobalan et al. 2007), even though much more research is required to determine the intensity and how long follow-ups should extend for (NICE 2006). Finding out what is available locally can be a great resource for patients who want to lose weight (McManamon 2015).

ACTIVITY: Think about what’s available for weight loss in the community you work in. Are there any activities/ organisations you can recommend or refer your patients to?

• • • EXAMPLE: to be added***

Behaviour Change in Relation to Obesity

What is behaviour change?

Behaviour change has been defined as “anything a person does in response to an internal or external influence” (Hobbs et al 2010, Mitchie and Johnston 2012), implying that changes have to been made to the response when faced with tempting scenarios (Foster et al 2005). Interventions that include behavioural change are complex (Mitchie and Johnston 2012) and are designed to target and change a specific behavioural pattern and are put in place so to promote a healthier lifestyle.
However, it is important to highlight that this type of intervention is best effective when used for long duration and intense sessions, as well as being used alongside other interventions like medications. (REF)

An important characteristic of behavioural therapy intervention is that it adopts a non-critical and non-confrontational approach but uses a collaborative approach instead (Grave et al 2010). This means that the physiotherapist and the patient work as a team, facilitating lifestyle changes as well as equip the individual to maintain and self-manage their weight post-intervention (Mitchie and Johnston 2012).

This means that creating and developing a strong patient-therapist relationship is key in ensuring trust from the patient as well as in increase in motivation and willingness towards change and adherence in the long term (REF). The development of this relationship is is key especially for the sensitive issues that weight is and the need for encouragement and support that is required (Hamdy)

Why Behaviour Change?

Many research papers highlight that one of the main difficulties in losing weight is then maintaining the weight lost off it in the long term (REF). The research available in regards to follow ups past one year is limited, however there has been a recent study undertaken by Action for Health in Diabetes (AHEAD 2010) looking at long term effects of incorporating behaviour change as part of the intervention with patients with type 2 diabetes. The study recruited a large sample of participants from 16 different centres in the United States and participants were between 45-76 years old, presenting with a BMI of greater or equal to 25. Participants were randomly assigned, to decrease bias, to either the intensive lifestyle intervention or the diabetes support education. The intensive lifestyle group received diet modification and physical activity and behavioural strategies such as goal setting, self-monitoring and problem solving were addressed.

However in the diabetes support education group participants were not presented with any behavioural changes support but just given general focus on diet and physical activity. It was observed that there was a greater weight loss in the intensive lifestyle group compared with the other thus meaning that behavioural change interventions can be effective amongst obese and overweight individuals, especially in the long term as it equips patients with essential tools to be able to make healthier lifestyle choices and changes. The study did not specify whether patients suffered from any mental health issues or from a low income, however the results can still be applicable to such population yet keeping in mind of the difficulties in changing external factors that could contribute to obesity.

What is important? What to include and be aware about?

The main three key aspects of behavioural therapy are the following:

⦁ It is goal directed. Goals are designed in a manner that is specific to the patient and measurable (Foster et al 2010). Many studies and articles highlight the importance of physical activity and the recommendations for exercise to aid weight loss. The common fear and wrong perception by overweight individuals in regards to physical activity can sometimes prevent them from being active. Therefore it is important as professionals to address these wrong expectations, and doing so by discussing possible patient centered goals. Goal setting should be discussed with the individual and should be realistic. Findings show that overly optimistic goals might lead to failure and disappointment instead and become demotivated in regards to exercise (Grave et al 2010, Foster et al 2005). Setting goals is seen extremely important as part of this type of intervention as this can motivate and encourage the patient to be fully on board and give them visible goals to achieve to allow them to look back and reflect on. Remember the importance to set small yet achievable changes (REF).

⦁ Behavioural intervention address in depth the question “but how?”. This type of intervention does not just address what to change but more importantly help those individuals identify how to change (Foster et al 2005). This means that the physiotherapist can act as a facilitator in the process – once a goal is agreed, the patient should be encouraged to examine what factors might either facilitate or hinder achieving the agreed goals (Foster et al 2005). New strategies, responses and skills are discussed and taught in order to overcome any barriers that might be faced during the patient’s weight loss journey. Foster et al (2005) states that is not a matter of will power that will lead to success but it is “skill power”.

⦁ Another important aspect to discuss are patients expectations. Behaviour changes should be small rather than large. This is also to avoid failure or disappointment (Foster et al 2005, Grave et al 2012). It is important to ensure that incremental steps are made and that the patient fully understands of the slowness of the process and of the benefits of setting small changes to which they can build on instead of attempting drastic changes that might only be short lived. This process is important to ensure that patients are equipped to maintain a healthy lifestyle and manage their own weight in a healthy manner. (REF) It is important to also establish what the individual is capable to sustain in the long term so to prevent their relapse and regain weight.

How can this intervention be used with obese and overweight patients?

Information and advice on healthy eating and a healthier lifestyle have gradually increased and are now widely accessible (BNF 2013). So, why do people struggle to put this in to practice despite being aware of the benefits of increasing physical activity and improve their diet? Interestingly enough, a study showed that being aware of these required changes did not automatically translate or bring the individuals to take any measure of change in their behaviour, allowing us to raise the issues as to whether people have become so overloaded with such health information that might be in “danger” of switching off (Watson & Wyness 2013).

However, many professionals still think that the primary and most effective tool is providing the patient with advice and education (Foster et al 2005). Although educating the patient can be very useful, most overweight patients are often already aware of what they should or should not eat or the benefits of physical activity. In those cases, being willing and taking time instead to explore the barriers to weight loss might be more effective rather than wanting to ‘fix’ the problem (Foster et al 2005). This will allow the therapist to explore the reasons behind the person’s behaviour and lifestyle choices, trying to skillfully identify any activities or circumstances that encourage or stimulate unhealthy habits/balance (Hamdy 2015).

In this wiki we have looked at the three most relevant barriers. As you have previously read, mental health issues are growing in the current population and they can be a real hindrance and struggle for people (REF) and there is evidence supporting that mental health and obesity could be linked (REF).
In the US Diabetes Prevention Program, greater readiness for change in physical activity level, higher exercise self-efficacy, and lower perceived stress, depression, and anxiety scores were linked with higher levels of baseline activity and maintenance of activity levels at 1 year and at end of study. These findings show that the individual’s initial psychological well-being might play a crucial part in predicting whether the individual will adhere to changes or not, and it is unlikely that someone with poor psychological well-being will have the ability as well as the energy available to take those steps toward behaviour change (Grave et al 2005). Poor psychological well-being might also impact and decrease the individual’s confidence and self- efficacy (Grave et al 2005). Therefore it comes with no surprise that such changes are difficult and require time as well as support (BNF, 2013) and it is important to keep in mind when delivering this type of intervention and undertake a brief assessment of the readiness levels of the patient as it might help the therapist determine which patients are most likely to increase physical activity levels in lifestyle intervention programs

Moreover, the difficulty in undertaking those behavioural changes could also be explained by the COM-b model (Watson & Wyness 2013).
This theory model explores three aspects that are key for any behaviour change to take place, those are: capability, opportunity and motivation (Mitchie et al 2011). Image?

Mind map type?

Capability: Having the physical and psychological capability (Atkins and Mitchie 2004) to understand and have the skills to act upon it (Mitchie et al 2004).

Motivation: it is not driven purely on goal setting but by brain processes that direct and energize the behaviour of the individual (Mitchie et al 2004).

Opportunity: External factors that might either facilitate or prompt to develop the behaviour (Mitchie 2004).

Therefore it is said that for certain behaviour to occur the individual must have knowledge as well as the physical and mental capability to act upon it, be motivated to do so and be clear how to achieve the change (Atkins and Mitchie 2004). It is useful to be aware of this model when trying to design an intervention or when initiating the difficult conversation so to be able to explore and engage the level of readiness that the individuals is at and to assist you to create an intervention that can target one or more of these processes and be patient centered.

Dealing with Ambivalence

Most individuals have either been told by a GP or by their family and friends about their weight and some of the will have express a desire in regards to change or at least thought about it, demonstrating one of the COM-b model process, which is capability. They see the benefits of decreasing their weight, but also the barriers stopping them. Being ambivalent, is both wanting and not wanting to change at the same time, and it is a common place to be stuck. A common pattern is to start to think of change, then start to think of a reason not to do it and then just stop thinking about it. The way out of this is to go with one path and stick to it.

This is something to be aware of when communication with patients as it is easy to present only the benefits losing weight and try to fix the patient, also called “the righting reflex”. What might happened is that the person start to voice the other side of the argument and justify why they have not done the change yet and responds with denial and oppositional-like behavior. Exactly the opposite of what we are looking for!

Try this thought experiment, or do it with a friend
⦁ Find something you want to change in your life, something that you are ambivalent about and then let the friend tell you how to do it, a list of reasons why, assure you are able to do the change, encourages you to do it.

⦁ How are you likely to respond?

Angry, defensive, annoyed, uncomfortable, not heard, eager to leave, ashamed and powerless was the some of the most common responses described in the population who did this

Now, do this thought experiment, or do it with a friend.
⦁ Again, discussing something you want to change in your life, something you are ambivalent about. However, this time the friend is not going to argue why you should change, but instead ask a series of questions and listen to what you have to say.
⦁ Why would you want to make this change?
⦁ What do you need to do in order to succeed?
⦁ What are your top three reasons to do it?
⦁ How important is it for you to make this change, why?

Allowing the person to say what change they want to address, what needs to be done, why they want to do it and how they are going to succeed. Then ask the final question:
⦁ So, what do you think you will do?

How do you feel after this approach?

In both scenarios, the subject of the conversation is the same, but the approach is different. From the second approach people reported to be: engaged, understood, empowered and respected which is more likely to help the patient towards the change they wanting to make (Miller and Rollnick 2013)

How can communication be used to facilitate behaviour change?

Motivational interviewing

Introduction 

Communication has been recognised as a significant factor to improve, maintain and treat health problems (Lindhardt et al. 2015). MI started off as a therapeutic approach to treat addicts (Armstrong et al. 2012), but has now been successfully been applied to a range of health problems as an evidence-based counselling approach for health care professionals (Lindhardt et al. 2015) and is therefore included in this wiki.

“Motivational interviewing is a person-centred counselling style for addressing the common problem of ambivalence about change” (Miller and Rollnick 2013 p.29)

The goal of MI is to create an environment where the patient, rather than the interviewer, becomes the main advocate for change. The approach is aiming to enhance intrinsic motivation by exploring and resolving the person’s ambivalence in regards to their problem (Gourland et al. 2013).

Four processes in Motivational interviewing

Engaging

As previously mentioned, engaging is the process where a mutually trusting and functional working relationship is established.
Even before patients are coming in for an appointment, they will have wondered about how they will be treated and what the practitioner will be like. First impressions do leave a significant mark; on the other hand, it is not unchangeable. During the first visit the patient decide how much they like and trust the practitioner and if they are coming back (Miller and Rollnick 2013)

The importance of a good dialog between practitioner and patient cannot be stressed enough as it has major impact on the patients attitudes in relation to manage own weight (Campos 2014). A study from 2014 found that patients who felt judged about their weight by their primary care providers reported lower trust in their health practitioner compared to the rest (Kimberly et al. 2014). With this in mind, it is suggested that first addressing the reason the patient is coming in for is good practice, in order to build a relation and enhance patient-centred practice (Campos 2014).

It is the important to address the patient with an empathetic and non-judgemental approach, trying to separate the weight problem from the person (Wong and Cheng 2013). The person might be vulnerable and frustrated from previous attempts to reduce their weight and be quite sensitive to discuss their problems (Campos 2014), however this should not be a reason for the practitioner to shy away from the problem and bring up the implications of overweight (Chadwick et al. 2008).
It can be easy to start in the wrong direction, even with the best of intentions. There are different “traps” that should be avoided not to disengage the patient. E.g. taking control and asking a set of questions puts the patient in a passive position and also implies “I’m in control here, just do as I tell you and you will be fine”. An important part of MI is knowing that you need the collaboration of the patient to succeed (Miller and Rollnick 2013).

Several factors can promote engagement, and the table below suggest how patients should be managed to maximise their engagement:

	Factors	Practitioners should:
Desires/goals	Patients’ expectations before coming What they want to get out of the appointment?	Find out why this patient is coming to see you and what their goals are
Importance	How important it is for the patient to archive this? How much they are willing to put into it?	Find out how important it is for the patient to achieve this goal Scale 0-10 can be useful
Positivity	At what level the patient felt valued, listened to, and treated in a friendly manner	Be friendly and welcoming and be genuinely interested in what the patient tells you. Look for things you can appreciate and comment positively about.
Expectations	Did the appointment live up to the patients expectations they had before coming	Map out patient expectations and explain what to expect from the appointment
Hope	If the patient believe that this will help them getting any better Explain what you do and how it may help. Present an honest and positive picture of what the patient can expect	Explain what you do and how it may help. Present an honest and positive picture of what the patient can expect

(Miller and Rollnick 2013)

Focusing

To know where you are going with your MI intervention there must be a focus; what did the person come to talk about? However, the practitioner might also have an agenda that is linked to the original problem. E.g., the patient you are treating might be complaining of low back pain or a bad knee, in addition the same person has a BMI of 30. The practitioner should address the patient complaint but should also consider bringing up the possible contributing factor to this problem. By doing so the practitioner get a better picture of the patients knowledge, self-awareness and readiness to change (Miller and Rollnick 2013).

Miller and Rollnick (2013) identify three main sources, which will influence the focus and direction of the problem or concern.

The client …is normally the main source to the focus of the problem. If the practitioner is confident and competent to help the client with the concern they are presenting the focus is set.
The setting …itself can direct the focus. If the setting is a weight management clinic, this will influence the focus of the conversation. What to be aware of is that this can limit the context as the setting predetermines it and make it harder to raise other issues that may arise.
Clinical expertise Often, patient will arrive an appointment with one goal in mind, while the clinician perceives that another kind of interaction is needed. The clinician need to investigate the patients’ willingness and readiness to discuss this other issue. Maybe it relates to their initial goal and may help them achieve that?

Example:
- An obese person turns up to his physiotherapy appointment because he got low-back pain. The physiotherapist wants to discuss his weight with him.

The patient may or may not recognize the relationship between the two. The hope of the practitioner is that the patient is going to recognise the relationship between the two which will increase their motivation to make a change.

There are three different communication styles that the practitioner can use to find the focus

1. Directing

The practitioner takes the position: “I am the professional here and I know what we should focus on here”. Try to come with suggestions and check the patients’ response to them. If the patient is not on-board with your proposal, suggest something else. Practitioners feeling responsible to come up with the direction and solution might use this approach; this could be because they feel the problem is so serious that a change is required urgently. In some scenarios this approach might be appropriate, however for enhancing patient motivation and change its use is limited (Miller and Rollnick 2013).

2. Following

This is the exact opposite of the “Directing” approach. This time the approach is: “What do you want to talk about today? What concerns do you have?” The essence is to understand the patients’ problems and explore them. This can awake engagement within the patient, which can have a therapeutic intervention on its own (Miller and Rollnick 2013).

3. Guiding

This approach finds the middle ground from the two approaches mentioned. This incorporates both the patients’ agenda and the practitioners’ expertise negotiating a common focus. This can be a good way to explore the concerns and from here, go into either a more directing or following approach depending on how the patient presents (Miller and Rollnick 2013).

Evoking

This process is the tipping point. The patient starts to realise that the pros outweigh the cons which again is the core of MI, resolving the persons’ ambivalence and make them commit to change. This stage emphasise the importance of the interviewer to promote this “change talk” in the patient.

Example of change talk:
- I really want to get fitter
- I am not happy with my current weight and want to change is
- I miss being able to go for a run without being out of breath after the first hill

By reflecting and exploring these responses, you reinforce the person statements and enhance the patients, motivation for change. There are four response techniques used to enhance change talk.

O.A.R.S.

o O: remember to use Open-ended questions instead of close ended as they will help you to explore more in depth the patient’s feelings and views regarding their weight.
o A: importance of affirmations and pointing them to the need for change
o R: reflective listening
o S: summarize to the individual what they have explained to you so to assist in reinforcing goals and ideas
(Miller and Rollnick 2013)

For a more detailed introduction to this concept see: 

Core Clinician Skills: Introducing O.A.R.S

Planning

When do you know that the patient is ready to take the final step and go from “I want to do it” to “how am I going to do it?” It is a judgement call, but things to look for are:
- More change talk: “I want to do this”
- Question about change: “What would this exercise group involve?”
- Taking steps: “I’ve been out walking the dog for 30 minutes three days in a row”

D.A.R.N. C.A.T

The acronym D.A.R.N. C.A.T can be helpful to help you identify the patients’ readiness for change. The D.A.R.N is preparatory, while the C.A.T is required for moving from general intention of wanting the change to actually do something about it.

Desirability of change
Ability to change
Reasons to change
Needing to change.
Commitment to change
Activation that include talk about being willing to change
Taking Steps toward change.


When designing a plan it is important to include the patient to have the patient on-board and avoid them falling back to being ambivalent. The planning process builds on the same principles as the previous stages; collaborative spirit, O.A.R.S strategy and a clear direction towards change.

Evidence base for Motivational interviewing in managing overweight and obesity 

MI was found to reduce BMI and weight in overweight and obese adults (Armstrong et al. 2012). Previous evidence also indicates that that MI has a small positive effect on weight management (Lundahl et al. 2010) and significant effect on BMI, total blood cholesterol and systolic blood pressure (Rubak et al. 2005). In addition, MI might support long-term weight loss maintenance and was found to be a feasible intervention (Simpson et al. 2015) and appropriate for older adults with long-term conditions (Cummings et al. 2009).

However, it is possible that MI is not as effective in some ethnic minority groups. In a study by Befort et al. (2008), Obese African-American woman failed to improve outcomes after MI interventions. Armstrong et al. (2012) also raises the issue that the small data size makes it difficult to draw a conclusion, as only 11 studies was applicable for their meta-analysis, reducing the statistical power of the findings. Thus, more big size studies are required to draw a clear conclusion of the effectiveness of MI. In addition, more long-term studies are required to confirm the long-term effects of MI.

Futher reading

Part VI: Motivational Interviewing in everyday practice in Miller and Rollnick., Motivational interviewing: Helping people change (reference)

http://learning.bmj.com/learning/module-intro/.html?moduleId=10051582

What words to use when addressing excess weight with patients?

As obesity is an increasingly bigger problem physiotherapists needs to be able to address this topic in a sensitive and effective way, as there is a lot of stigma in relation to this topic (Campos 2014). To avoid misinterpretation, practitioner’s needs to be aware of terminology used to reduce the chances of damaging their relationship with the patient (Chadwick et al. 2008; Campos 2014).

What words would you have used/avoided?

Find your top and bottom 3 before continue reading.

Large size	Excess fat	Excess Weight	Obesity	Weight	Unhealthy BMI
Unhealthy weight	Overweight status	Fatness	BMI	Weight Problem	Heaviness

Click here for answers

Linked to:
Preferred terms:
Weight, BMI, Weight problem, Unhealthy weight, Unhealthy BMI, Excess weight

Undesirable terms:
Overweight status, Heaviness, Obesity, Large size, Excess fat, Fatness

(Dutton et al. 2010; Volger et al. 2012; Campos 2014)

In the studies available, there is a consistency that the terms “weight” and “BMI” are the most desirable terms when raising the question about patients’ excess weight (Wadden and Didie 2003; Dutton et al. 2010; Volger et al. 2012; Swift et al. 2014; Campos 2014). While the terms “excess fat”, “obesity”, “fatness”, “large size” and “heaviness” was found to be undesirable terms by participants (Wadden and Didie 2003; Dutton et al. 2010; Volger et al. 2012; Swift et al. 2014; Campos 2014).

However, a study looking at patients’ reactions when their GP used the term “obesity” compared with euphemisms e.g., “Your weight might be damaging your health” found, interestingly, that the obese patients reacted more to the euphemisms than to the term “obesity”, while it was the opposite for non-obese patients (Tailor and Ogden 2009).

Guidelines on terminology and communication styles would be beneficial to inform training for health care students (Swift et al. 2013). Research suggests that some words are better to use than others are when communicating with patients regarding their excess weight. Having in mind there is a huge variation of terms that people find reasonable and asking the patient what terms they use might be helpful in order to avoid misinterpretation (Chadwick et al. 2008).

Case Study

To be added***

References

References will automatically be added here, see adding references tutorial.