Clinicians' Commentary on You et al.

You and colleagues¹ are to be applauded for their insightful survey study examining the role of physiotherapists in the management of obesity. The prevalence of obesity has reached epidemic proportions in Canada: as You and colleagues note,¹ 59% of adult Canadians are overweight or obese (defined as a body mass index of 25–29.9 and >30 kg/m², respectively). Obesity is increasingly prevalent,² and, unsurprisingly, many segments of the population are affected by this trend. Immigrants to Canada become increasingly overweight as their length of stay in Canada increases.² Children are also affected, showing a fivefold increase in prevalence of obesity over the 15-year period from 1981 to 1996.² Without question, more Canadians are becoming overweight and/or obese, and this dramatic trend shows no sign of slowing.

As You and colleagues point out,¹ obesity is a major risk factor for several progressive diseases that have potentially life-threatening consequences. A recent systematic review found that obesity increased the relative risk (RR) of type II diabetes, several different types of cancer, cardiovascular disease, asthma, osteoarthritis, and chronic back pain.³ For example, the RR of coronary artery disease increased 1.5- to threefold, depending on sex and degree of obesity; the RR of diabetes was 3.9, and the RR of joint replacement 4.2, among people with obesity.³ A 2004 review article estimated the health care costs related to obesity at CAD$4.3 billion,⁴ and this condition also has negative repercussions for the workforce: older men and women (aged 55–64) with obesity were more likely to reduce their work activity because of a long-term health problem.⁵ The detrimental consequences of the obesity epidemic show no signs of waning, and the increasing health burden and workforce implications require immediate strategies to ameliorate this problem.

Osteoarthritis (OA) is a prime example of a condition associated with obesity that is commonly treated by physiotherapists. People with OA often present with musculoskeletal disorders that can be followed up by physiotherapy interventions such as exercise,^4,5,6 electrophysical agents,^7,8 prescription of braces and insoles,⁹ and manual therapy.¹⁰ Patients are referred for hip or knee replacement as the disease progresses, even as their being overweight, a major contributing factor, remains unaddressed. You and colleagues state that 80–90% of these patients are overweight.¹ Relative to the estimated $18,000 cost of a total knee replacement, the resources allocated to promoting and maintaining weight loss are paltry. Why does the health care system so fully support knee-replacement surgery when one of the major underlying causes of knee problems—obesity—remains virtually untreated? Why, when physiotherapists play a major role in treating the musculoskeletal disorders associated with obesity, including rehabilitation for joint replacement, are we reluctant to embrace the opportunity to treat a major epidemic affecting so many Canadians?

You and colleagues note¹ that physiotherapists are often the first point of contact for a person with obesity reporting pain or limited function. As front-line health care providers, physiotherapists are ideally positioned to provide evidence-based interventions that lead to effective weight loss. Including weight-reduction interventions is essential—indeed, the recent guidelines issued by the OA Research Society International (OARSI) specifically recommend weight reduction among the first-line interventions for management of knee OA.¹¹ However, physiotherapists report a key barrier to inclusion of this area of practice: lack of knowledge about assessment of body fat and management of weight loss.¹ This knowledge gap is likely the most straightforward challenge to overcome. The greater chasm to be crossed is to change behaviour: improving the health of those affected by obesity requires not only changing activity and eating behaviours of those with obesity but also changing the daily practice of physiotherapists.

Fortunately, resources exist to facilitate both the change in lifestyle behaviour of the client and the change in practice behaviour of the physiotherapist. With respect to facilitating client behaviour change, an excellent starting place is the “3-Minute Empowerment” approach.¹² This approach gives clinicians strategies and tools to positively engage the client and quickly assess the client's readiness for change, as well as practical techniques to both increase motivation and successfully address the barriers to change. Designed to be universally applicable to any behavioural change and to fit into the reality of brief clinical visits, it is logical, concise, and appealing to physiotherapists who feel they require direction in supporting clients for weight reduction. The foundations of this approach are described in more detail by Rollnick and colleagues.¹³

With respect to facilitating behaviour change in the daily practice of physiotherapists, the knowledge-translation literature is replete with helpful resources. A recent publication by Michie and colleagues¹⁴ provides a compelling framework for addressing change in practice. After reviewing 26 frameworks for behaviour change, the authors developed a new framework, the Behavior Change Wheel (BCW; see Figure 1), that specifically addresses the limitations evident in the others. At the centre of the wheel are the three essential components: capability, opportunity, and motivation. The next layer consists of nine interventions (including education, persuasion, and environmental restructuring) that can address deficits in the central components. In the outer layer are seven categories of interventions (e.g., regulation, service provision, fiscal measures) that would enable those interventions to occur. The authors also give examples of appropriate interventions and policies. The BCW could be used by physiotherapy practice leaders to identify and implement strategies to support individual practitioners incorporating measurement of body fat and interventions to facilitate weight reduction for clients with obesity.

Figure 1.

The Behavior Change Wheel, an integrated framework addressing change in practice (from centre: behavioural constructs; interventions to address deficits or barriers; policy and overarching strategies to supplement change).

Reproduced from Michie and colleagues (2011)¹⁴ by permission of BioMed Central.

In addition to the 3-Minute Empowerment approach^12,13 and the BCW resources,¹⁴ other knowledge-translation resources are available to assist practice change that provide background information in addition to specific tools and techniques.^15–17 Indeed, this area of practice change is ideally suited for the application of the principles underpinning knowledge translation: engagement of stakeholders, identification of barriers, targeted implementation strategies addressing each barrier, relevant evaluation of the effectiveness of the implementation strategies, and a plan to ensure sustainability of change.¹⁸

You and colleagues¹ highlight the opportunities for the physiotherapy profession to enrich the scope of services that have traditionally been offered to the patient population with obesity. Their study is a timely trigger for physiotherapists to accept greater responsibility for addressing a major risk factor for, and often a contributing cause of, the impairment that initiates the referral to physiotherapy. Finally, given the resources available to facilitate change in the behaviours of both clients and therapists, we are well positioned to better meet the needs of this population. Let us move ahead together, before the obesity epidemic becomes unmanageable.