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[Physio Explained] Physiotherapy’s role in obesity management and behavioural change with Dr Jennifer James

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In this episode with Dr Jennifer James we explore the complex topic of managing obese patients. We discuss: 

  • Common musculoskeletal conditions within the obese population
  • Role of inflammation in this population
  • How to broach difficult conversations with these patients
  • Importance of dietary changes over exercise 
  • Recommendations we can give these patients within our scope of Physiotherapy
  • Motivational Interviewing/Behaviour change techniques 

Dr Jennifer James is a physiotherapist who specialises in obesity care. She has a PhD in which the focus was the development of a complex behaviour change intervention targeting physical activity and sedentary behaviour in patients after bariatric surgery. She was recently a NICE specialist committee member for digital weight management services +/- pharmacotherapy support, had an intervention development paper published in the journal Physiotherapy and also recently had an article published in The Conversation.  

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Our host is @James_Armstrong_Physio from Physio Network

UNKNOWN:

Thank you.

SPEAKER_02:

The other point of reflection for me is that these patients are often really hard on themselves, patients with obesity, and they can say, oh, no, it's all my fault and I should make these changes. And to be honest, we're not there to bully patients or to be unkind or unhelpful. You're there as the expert from a physiotherapeutic perspective to help that patient to make the changes that they need to make and that they want to make. And it should feel like a dance. As soon as it starts to feel like it's going from a dance to a tug-of-war or a duel, then it becomes very adversarial. It's not going to be nice for anyone.

SPEAKER_00:

In today's episode, we're diving into physiotherapy's role in obesity management and behaviour change with Dr Jennifer James, a specialist physiotherapist in obesity care. With a PhD focused on developing behaviour change interventions for patients post bariatric surgery, she brings invaluable expertise to this important topic. In today's episode, we'll be covering everything from common musculoskeletal conditions seen in patients with obesity, the role of inflammation and its impact on pain and recovery, how to approach this sensitive conversation with patients and why dietary changes matter more than exercise for weight management we also look at what physiotherapists can recommend within their scope of practice and how to use motivational interviewing and behavior change techniques effectively jennifer also known as the obesity physio on instagram has published in physiotherapy the conversation and has been nice specialist committee member for digital weight management services she also provides training for healthcare professionals looking to improve improve their approach to obesity care. Join us as we explore how physiotherapists can play a key role in supporting patients with obesity. I'm James Armstrong and this is Physio Explained. Jennifer, thank you so much for coming on to the Physio Explained podcast. It's great to have you on. I'm really looking forward to this episode.

SPEAKER_02:

Thank you very much for having me. I'm really pleased to be here talking about obesity.

SPEAKER_00:

Brilliant. And as you say there, we're going to be talking about obesity and the management of that and particularly under the umbrella, as most of the listeners are going to be, as a physiotherapist. So I thought what better way to start with why this is actually a really important area for physiotherapists to be involved in. We're going to talk a bit about in a minute how we can broach that conversation because it's often quite difficult. So we'll start with why do physios need to be discussing obesity with their patients and why do we need to get involved in this?

SPEAKER_02:

The short answer to that is because an increasing number of people who we see in clinical practice either have overweight or obesity. So we need to be open to these conversations with patients, but we also need to be open to ourselves in terms of being comfortable helping people with obesity to manage whatever it is that they're coming to see you with. And I think sometimes... My own personal reflection is that people can see, physios can see someone with a higher BMI and think, oh gosh, you know, it's an eye roll or a heart sink because they just think, I'm never going to get anywhere with this patient or why did they just lose weight? But the reality is that obesity and the causes of obesity are really complex. We know that from research, there's peer reviews, evidence and research out there. So we need to be comfortable talking about it and we need to be comfortable talking to patients about it because an increased number of people have obesity. And also obesity is linked with a number of medical conditions that we might end up seeing our patients because of. So things like cardiovascular disease, diabetes, joint pains. There's all manner of conditions where obesity may well be a risk factor for it or just make the rehabilitation of that patient that little bit more difficult. So we need to get comfortable with this. We need to be open to having conversations with patients about weight and open to having to treat people with higher weights. You just need to get comfortable with it because it's the reality now.

SPEAKER_00:

You mentioned there obviously has an impact on a lot of conditions, a lot of things we've been seeing. I'm sure we've got listeners who are physiotherapists working in specialist areas such as respiratory and neurological conditions and sort of cardio things and also MSK. And we know obesity and weight has a big impact on MSK conditions. Talk to us a bit more about what impact that might be. I know this is a big, big subject, but just a broad overview of what that impact might be, just to highlight actually why this might be such an important conversation to have, maybe quite early on in the cycle of rehab.

SPEAKER_02:

Yeah, absolutely. So I think it's important to understand maybe why obesity is thought to be related to all these different conditions. So there's a hypothesis around this. And the hypothesis is that when someone has obesity, so when they've got this positive energy state where we're filling our fat cells. So the adipocytes that we've got our fat cells, they're increasing in size. It's leading to local inflammation. And as a result, we're having fat stores elsewhere in a top of fatty storage, essentially. So it's going somewhere else. It's fat storage in other organs, which is then leading to systemic inflammation, which leads to insulin resistance and then accelerated development and progression of obesity-related insulin resistance and diseases such as type 2 diabetes. But we also know that with these ectopic fatty deposits and this subacute inflammatory state, we also know that there's a link with musculoskeletal conditions as well. So that's the hypothesis behind it. And it is important to say that this is a hypothesis. This is what we think happens. So it's been seen in rodent models. And what we know is that when people lose weight, they improve their insulin sensitivity and reduce their insulin resistance. So these metabolic changes that we think are implicated in the development of musculoskeletal pain, for instance, because of this subacute inflammatory state. When people lose weight, this improves. But when people have something like liposuction so that fat cells are removed, it doesn't change anything because the fat cells that remain are still exhausted and we've still got these ectopic fatty deposits elsewhere. So there's a biological driver for this, which is essentially this level of subacute inflammation because we've exhausted our fat cells. So I think it's understanding that that there's a biological driver for all of this. And it's not as simple as just weight-bearing joints. So it's not just that we see osteoarthritis in hips and knees. We see it in other places as well. And there's definitely some, I know there's some conversations and some thoughts around this about this sort of acute inflammatory state driving OA and other conditions, other musculoskeletal conditions in the upper limb, for instance. Yeah.

SPEAKER_00:

It's a big part to play, isn't it? And as you mentioned there, not necessarily just about a lot of patients come to me and say, oh, I know this is causing excess load on my knee. And we're thinking it's not quite as simple as that. And that's not necessarily the main factor.

SPEAKER_02:

It's not as simple as that. And I'm sure that you've got experience of seeing a patient who's slim, who's got dreadful OA changes on their x-rays. And conversely, we'll see patients who have got bigger bodies and you think they're definitely going to have OA changes. And the x-rays are beautiful. So if it was a simple biomechanical learning situation, then I don't think we'd see that. But it's not as simple as that, is it? Of course it's not, because that would be too easy.

SPEAKER_00:

Absolutely. And talking of complex and not simple, we then have the big topic of how we broach this conversation with patients. And I'm sure many listeners out there will have had situations where they've wanted to and haven't felt able to, or have tried and maybe failed. And that's absolutely fine. And I think we need to think about maybe how do we do that? And what are your tips for our listeners?

SPEAKER_02:

So a few things. So firstly, you need to be genuinely open and curious when you're asking questions to your patients. but I would encourage all the listeners to never, ever ask why. Because as soon as you say why to a patient, you're asking them to justify. So for instance, to explain this more, I would say to a patient, if you're bringing up about, I don't know, a musculoskeletal condition where you think that waist is relevant, you could say to the patient, is there anything else that you think might be relevant to your pain or to your symptoms? And nine times out of 10, that patient will turn around and say, well, I know that my waist isn't helping. And you could say, okay, could you tell me a little bit more about that? And then the patient might say, do you know what? I'm just really, really struggling. I've been trying for so long to lose weight. I do all these diets and I'm really, really successful and I lose weight, but I really struggle to maintain. And then I gain all the weight back and then some more. And it just puts me at that point again. And I don't really know what I'm doing or, you know, I'm going to get back on it. I'm going to try again. But if you turned around to the patients and said, can you tell me a little bit more about this? What's contributing? And they say, well, I think it could be new weight. And then you say, well, why don't you lose weight then? because you're asking them to justify. You're not being open and you're not exploring why it might be difficult. And I know I've said why, but you're not exploring the factors that are making it more challenging for this patient to lose weight or to put down changes in place. And the other thing to really be mindful of here is that weight is a dependent variable. You cannot change weight directly. If you want someone to lose weight or if they want to lose weight, it should really come from them, of course. But if someone wants to lose weight, then they need to make changes to their diets, to their calorie intake. Because, and as much as it pains me to say it as a physio, exercise and physical activity generally doesn't give a great return. If you're going to invest, don't invest in exercise for weight. Absolutely invest in exercise for health. But there's been some really lovely work done by Jean-Michel Aupert for the EASO Working Group on physical activity. And when they looked at the data, they found that exercise interventions are associated with a two to three kilogram weight loss, which is an awful lot. It's not even really half a stone, is it? So it's two to three kilos. So exercise gives a really core return. Dietary changes give a much better return. If you're going to invest in anything, invest in that. But if you're going to have these conversations with your patients, you just need to be really open and non-judgmental and also try and make it relevant to them and make it relevant to their condition. And a patient might say something like, yeah, it's down to my weight, or it might be something completely unrelated. And they say, oh, it's down to my weight. And you can say, actually, I don't think it is. I don't think your weight's got anything to do with this. The other point of reflection for me is that these patients are often really hard on themselves, patients with obesity, and they can say, oh, no, it's all my fault. And I should make these changes. And to be honest, we're not there to bully patients or to be unkind or unhelpful. You're there as the experts from a physiotherapeutic perspective to help our patients make the changes that they need to make and that they want to make. And it should feel like a dance. But as soon as it starts to feel like it's going from a dance to a tug of war or a duel, then it becomes very adversarial. It's not going to be nice for anyone. So don't ask why, because you're asking the patient to justify it and just be really open and genuinely curious. You know, the patient might turn around and say something like, oh, I've managed to, I managed to do really well with Slingling Wells or Weight Watchers or wherever it might appear. And you can say, okay, what was it that made that difficult for you to maintain? Or can you tell me a little bit more about that? And it might come out that they just find that having that accountability for some people or that peer support is important to them. And then if they're able to access it again, then they might choose to do so. But you're just incredibly compassionate and kind, I think. Don't be judgmental.

SPEAKER_00:

I think patients really can pick up on that as well, can't they?

SPEAKER_01:

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SPEAKER_00:

It's one of those things as well that we then move on to that scope of practice, and I can picture in this patient who we've started this conversation with, And they're at a bit of a loss as to where to go. They want to lose weight. We've established that. But we're looking at that they've sort of giving us those signals that they're ready and they want to engage with that. They understand some of the things you've mentioned there. Where do we take that patient next, which keeps us in our lane, as it were, as physiotherapists? We might not have access to dieticians straight away there and then. What are your tips for physios in that space?

SPEAKER_02:

So you could ask the patient what they think would be a sensible change or an acceptable change. And I think that's the key there, an acceptable alternative. So that acceptable word is really important. So a patient might turn around and say, oh, do you know what? I've made some simple changes in the past, but I just didn't keep them up long term. And there could be a number of reasons for that. It might have been that these weight platters, because the calories they were taking in against their new level weight was just equal. Essentially, they were in an energy balance. So it might be that you say to the patient, well, what have you done in the past that worked for you? And could you maybe try that again? So it's things like acceptable swaps, like swapping from full fat milk to whole milk to semi-skinned milk. Or it might be things like moving from thick sliced bread to medium sliced bread. It might be things like instead of having two rounds of toast with breakfast with beans on, you have one round of toast with beans on. It might be that they've developed a habitual behavior where every time they have a cup of tea, they have a biscuit. And actually as a physio student, she stopped drinking tea for that reason because every time he had a cup of tea, he had a biscuit. And I think really, do you know what? The patient's the expert of them. They know what kinds of things they're doing that may be on help on them with their weight and with their weight loss attempts. And they are the experts of them. You're the expert from a physio side of things. They're the experts of them. There's some really great resources from the British Dietetic Association that patients could look at and they're easily accessible and I would definitely stay away from Instagram influencers and people who maybe aren't quite as knowledgeable as they might like to think. The other thing is I'd encourage patients to avoid moralizing food. So patients will say things like, oh, I was really bad. I had a chocolate bar or, you know, I was really bad. We had some food from the chip or we had to take away or something. I'd always pull my patience on this and say, well, there is no goals or bad foods. There's no inherent moral value to having a chocolate bar or a takeaway. There is no inherent moral value. It might be that there's better choices that you can make in terms of your health or calories if you're trying to lose weight. But you're not bad because you have the chocolate bar. And I think also, like, you know, kinds of removing that, this kind of good, bad language and discourse around it is really helpful. So I'd always pull my patience on that. Because you're not inherently virtuous by having water over a coach. It's just not.

SPEAKER_00:

Absolutely. And another thing you were saying there is about the patient being the expert. And we know as well from behavioural change is if we can allow the patient to choose the changes, to come up with the changes themselves, which they can do if we give them time and facilitate that conversation. I'm sure we're going to get better outcomes as well, aren't we?

SPEAKER_02:

Absolutely. Yeah. So that's definitely consistent with motivational interviewing where you're looking to elicit the person's own motivations to make a change. Another thing that just popped into my head when you were talking then is there's something called behavior change techniques. So behavior change technique is the active ingredient of a behavior change intervention. And there's one which I really, really like called greater tasks. So this is 8.7 on the taxonomy version, one of the taxonomy. And this talks about making a small change, a small behavior change because it's a cumulative effort, really. So it's a small change that you're doing to get to a bigger goal. And I always draw this out for my patients like a mountain. And so you can go up the steep sides if you want to, but that's very all or nothing. That's things like lighter life and cane, which are really very calorie restricted. So we could do a really big calorie deficit or we could do a crazy exercise program, which isn't going to give you much bang for your buck in terms of weight, but will give you other changes. So you can go up the steep sides of the mountain or... We can just pull it back a little bit, avoid this all on often thinking, go for a shade of grey where we go up the mountain kind of, we zigzag up and then we get up to the top of the mountain eventually. And the beauty of this is that although it does take longer, if you have a bump or a blip or a relapse, however you want to deem it, if you want to, you know, birthdays, Christmas, Easter, whatever it might be, if you have a meal out with families or someone's sick and it doesn't go to plan, it doesn't knock you down quite as much. because the change has been more gradual. It's been more nuanced. There's more shades of grey. It's not all or nothing. And I think psychologically, there's a big thing around that as well, because if someone does an all or nothing approach, where they make big changes, get big results, but can't maintain it, and then they go back to where they were very quickly, then I think that really knocks people's confidence. This is the classic union disaster, where there's a more grazed approach, where you're the expert, they're the expert, and you dance together. It will get you where you want to be. I

SPEAKER_00:

love that, dancing together. And it just forms that relationship where you are working together. And that's it, whether you're looking at a purely physical rehabilitation or whether you're bringing these other elements in. It is you're working together, aren't you? And that's important.

SPEAKER_02:

Yeah, absolutely.

SPEAKER_00:

And then if listeners are listening to this as of the time this comes out, we're probably not that long away from Christmas and probably I'm sure many people have had this conversation and then we're probably maybe approaching Easter and a similar situation. And if they've built up this gradually as well, do you think patients are more likely to build in good habits as well?

SPEAKER_02:

Yeah, so what you would hope is that they do develop habitual behaviour. So a habit, a habitual behaviour is a behaviour that you do in a certain context. That's automatic, so you don't need to think about it anymore. So you might start by doing something very purposefully. So for instance, it might be that you put an apple on your back so that when you walk to your car at the end of the day, you see the apple, you have the apple and you're just, you know, you're prompted to eat the apple. It's a very conscious thing at the beginning. But then as time goes on, it's just normal for you to eat an apple on the way to the car. It's a way of getting one of your five a day in or whatever it might be. So hyperformation is a really interesting area actually. And there's a research called Ben Gardner who works, I think he's in King's now. He's done lots of research on this. But yet you would hope that someone is able to repeat these behaviours that are helpful to them to achieve their goal. But it is context specific as well. So if you take that person out of that context, they're probably not going to do that behaviour long term.

SPEAKER_00:

Yeah. Jennifer, really interesting points. I've just looked at the clock and we are out of time today. And it's really unfortunate because I think we could talk about this for a long, long time. And there's some things that we spoke about off air that we haven't had a chance to talk about. So I'm going to definitely get you back on to talk more about weight loss and the massive impact that physiotherapists can have in someone's journey in this area.

SPEAKER_02:

Absolutely. I think the only clues and comments I'd like to make is that GLP-1 drugs, Wig-Ovi, is empathic. And when Jaro, we've definitely got a role to play when we've got patients taking these drugs. So let's talk about that in the future.

SPEAKER_00:

definitely yeah well there's a cliffhanger for all of our listeners we're going to get jennifer back on to talk about those drugs very topical at the moment so we'll do that very soon jennifer thank you so much for your time and if those of you if those listening want to know more about jennifer please do find her across youtube social media at all jennifer

SPEAKER_02:

yes i'm on linkedin so you can find me on there and dr jennifer james and also i've got an instagram account called the obesity physio so yes you find me on there i'm going to be putting some videos up shortly as well there's also been a piece in the conversation fairly recently so if Conversation UK if you want to have a little reason about I think you'll find it interesting it's all relevant

SPEAKER_00:

brilliant Jennifer thank you so much again for your time and I can't wait to speak to you again soon thank you