0:00

Thank you.

0:05

The other point of reflection for me is that these patients

0:07

are often really hard on themselves, patients

0:09

with obesity, and they can say, oh, no, it's all my

0:12

fault and I should make these changes.

0:14

And to be honest, we're not there to bully patients

0:17

or to be unkind or unhelpful.

0:19

You're there as the expert from

0:22

a physiotherapeutic perspective to

0:24

help that patient to make the changes that

0:26

they need to make and that they want to make. And

0:28

it should feel like a dance. As soon as it

0:30

starts to feel like it's going from a

0:33

dance to a tug-of-war or a

0:35

duel, then it becomes very

0:37

adversarial. It's not going to be nice for anyone.

0:42

In today's episode, we're diving into physiotherapy's

0:45

role in obesity management and behaviour

0:47

change with Dr Jennifer James, a

0:49

specialist physiotherapist in obesity

0:51

care. With a PhD focused

0:53

on developing behaviour change interventions

0:56

for patients post bariatric surgery,

0:58

she brings invaluable expertise to

1:00

this important topic. In today's

1:03

episode, we'll be covering everything from common

1:05

musculoskeletal conditions seen in patients

1:07

with obesity, the role of inflammation

1:09

and its impact on pain and recovery, how

1:12

to approach this sensitive conversation

1:14

with patients and why dietary changes

1:16

matter more than exercise for weight

1:18

management we also look at what physiotherapists

1:21

can recommend within their scope of practice

1:23

and how to use motivational interviewing

1:26

and behavior change techniques effectively

1:28

jennifer also known as the obesity physio

1:30

on instagram has published in physiotherapy

1:33

the conversation and has been nice

1:35

specialist committee member for digital

1:37

weight management services she also

1:39

provides training for healthcare professionals looking

1:42

to improve improve their approach to obesity care.

1:44

Join us as we explore how physiotherapists

1:46

can play a key role in supporting

1:49

patients with obesity. I'm

1:51

James Armstrong and this is Physio

1:53

Explained. Jennifer,

2:00

thank you so much for coming on to the

2:02

Physio Explained podcast. It's great to have you on. I'm

2:04

really looking forward to this episode.

2:05

Thank you very much for having me. I'm really pleased to be

2:07

here talking about obesity.

2:09

Brilliant. And as you say there, we're going to be talking about obesity

2:12

and the management of that and particularly under

2:15

the umbrella, as most of the listeners are going to be,

2:17

as a physiotherapist. So I thought

2:19

what better way to start with why

2:22

this is actually a really important area

2:24

for physiotherapists to be involved in. We're

2:26

going to talk a bit about in a minute how we can

2:29

broach that conversation because it's often quite difficult.

2:32

So we'll start with why do physios

2:34

need to be discussing obesity with

2:36

their patients and why do we need to get involved

2:38

in this?

2:39

The short answer to that is because an

2:42

increasing number of people who we

2:44

see in clinical practice either have

2:46

overweight or obesity. So

2:48

we need to be open to these conversations

2:51

with patients, but we also need

2:53

to be open to ourselves

2:55

in terms of being comfortable helping

2:57

people with obesity to manage

3:00

whatever it is that they're coming to see you with. And

3:02

I think sometimes... My own personal

3:04

reflection is that people can see, physios

3:06

can see someone with a higher BMI and think,

3:08

oh gosh, you know, it's an eye roll

3:11

or a heart sink because they just think, I'm

3:13

never going to get anywhere with this patient or

3:16

why did they just lose weight? But

3:18

the reality is that obesity and the causes

3:20

of obesity are really complex. We

3:23

know that from research, there's peer reviews,

3:25

evidence and research out there. So

3:27

we need to be comfortable talking about it and we need

3:29

to be comfortable talking to patients about

3:32

it because an increased number of people

3:34

have obesity. And also obesity

3:36

is linked with a number of

3:38

medical conditions that we might end up seeing

3:40

our patients because of. So things

3:43

like cardiovascular disease, diabetes,

3:46

joint pains. There's all manner

3:48

of conditions where obesity may well be

3:50

a risk factor for it or just make the rehabilitation

3:53

of that patient that little bit more difficult. So

3:55

we need to get comfortable with this. We need to

3:57

be open to having conversations

4:00

with patients about weight and open to having to

4:02

treat people with higher weights.

4:05

You just need to get comfortable with it because it's

4:07

the reality now.

4:09

You mentioned there obviously has an impact on

4:11

a lot of conditions, a lot of things we've been seeing. I'm

4:13

sure we've got listeners who are physiotherapists working

4:16

in specialist areas such as respiratory and

4:18

neurological conditions and sort of cardio

4:21

things and also MSK. And we

4:23

know obesity and weight has

4:25

a big impact on MSK conditions. Talk

4:27

to us a bit more about what impact

4:29

that might be. I know this is a big, big

4:31

subject, but just a broad overview of what that impact

4:33

might be, just to highlight actually why this

4:36

might be such an important conversation to have, maybe quite

4:38

early on in the cycle of rehab.

4:40

Yeah, absolutely. So I think it's

4:42

important to understand maybe why

4:44

obesity is thought to be related to all these

4:46

different conditions. So there's

4:48

a hypothesis around this. And the hypothesis

4:51

is that when someone has obesity,

4:54

so when they've got this positive energy

4:56

state where we're filling our fat cells.

4:58

So the adipocytes that we've got our fat

5:00

cells, they're increasing in size. It's leading

5:02

to local inflammation. And as a result,

5:05

we're having fat stores elsewhere in

5:07

a top of fatty storage, essentially.

5:09

So it's going somewhere else. It's

5:11

fat storage in other organs, which is then leading

5:13

to systemic inflammation, which leads

5:15

to insulin resistance and then accelerated development

5:18

and progression of obesity-related insulin

5:20

resistance and diseases such as

5:22

type 2 diabetes. But we also know that

5:25

with these ectopic fatty deposits and this subacute

5:28

inflammatory state, we also know that there's

5:30

a link with musculoskeletal conditions

5:32

as well. So that's the

5:35

hypothesis behind it. And it is

5:37

important to say that this is a hypothesis.

5:39

This is what we think happens. So it's been seen

5:41

in rodent models. And what we know is

5:44

that when people lose weight,

5:46

they improve their insulin sensitivity

5:48

and reduce their insulin resistance. So these metabolic

5:51

changes that we think are implicated

5:53

in the development of musculoskeletal

5:55

pain, for instance, because of this subacute

5:58

inflammatory state. When people lose weight,

6:00

this improves. But when people

6:02

have something like liposuction so

6:04

that fat cells are removed, it doesn't change

6:07

anything because the fat cells

6:09

that remain are still exhausted and we've

6:11

still got these ectopic fatty deposits elsewhere.

6:14

So there's a biological

6:16

driver for this, which is essentially this level

6:18

of subacute inflammation because we've

6:20

exhausted our fat cells. So I think

6:23

it's understanding that that there's

6:25

a biological driver for all of this. And

6:28

it's not as simple as just

6:30

weight-bearing joints. So it's not just

6:32

that we see osteoarthritis in hips

6:35

and knees. We see it in other places as well.

6:37

And there's definitely some,

6:39

I know there's some conversations and some thoughts

6:42

around this about this sort of acute inflammatory

6:44

state driving OA

6:47

and other conditions, other musculoskeletal

6:49

conditions in the upper limb, for instance.

6:51

Yeah.

6:52

It's a big part to play, isn't it? And

6:54

as you mentioned there, not necessarily just about a lot

6:56

of patients come to me and say, oh, I know

6:59

this is causing excess load on my knee.

7:01

And we're thinking it's not quite as simple

7:03

as that. And that's not necessarily the main factor.

7:06

It's not as simple as that. And I'm sure that you've

7:08

got experience of seeing a patient who's slim,

7:11

who's got dreadful OA changes on

7:13

their x-rays. And conversely, we'll see

7:15

patients who have got bigger bodies and you

7:17

think they're definitely going to have OA changes. And

7:20

the x-rays are beautiful. So if it was

7:22

a simple biomechanical learning situation,

7:25

then I don't think we'd see that. But

7:27

it's not as simple as that, is it? Of course it's not,

7:29

because that would be too easy.

7:31

Absolutely. And talking

7:33

of complex and not simple, we

7:35

then have the big topic of how we

7:37

broach this conversation with patients.

7:40

And I'm sure many listeners out there will have had

7:42

situations where they've wanted to and

7:44

haven't felt able to, or have tried

7:46

and maybe failed. And that's absolutely

7:48

fine. And I think we need to think about maybe how

7:51

do we do that? And what are your tips for

7:53

our listeners?

7:54

So a few things. So firstly,

7:56

you need to be genuinely open and curious

7:59

when you're asking questions to your patients. but

8:01

I would encourage all the listeners to never, ever

8:04

ask why. Because

8:06

as soon as you say why to a patient,

8:08

you're asking them to justify. So for

8:10

instance, to explain this more,

8:13

I would say to a patient, if

8:15

you're bringing up about, I don't know, a musculoskeletal

8:18

condition where you think that waist is relevant, you could say

8:20

to the patient, is there anything else that you think

8:22

might be relevant to your pain or to your symptoms?

8:25

And nine times out of 10, that patient

8:28

will turn around and say, well, I know that my waist isn't helping.

8:31

And you could say, okay, could you tell me a little bit more about

8:33

that? And then the patient might say, do you know what?

8:35

I'm just really, really struggling. I've been trying

8:37

for so long to lose weight. I do all these diets

8:40

and I'm really, really successful and I lose

8:42

weight, but I really struggle to maintain. And then

8:44

I gain all the weight back and then some more. And it

8:46

just puts me at that point again. And

8:48

I don't really know what I'm doing or, you

8:50

know, I'm going to get back on it. I'm going to try again. But

8:52

if you turned around to the patients and said, can

8:54

you tell me a little bit more about this? What's contributing?

8:57

And they say, well, I think it could be new weight. And then you

8:59

say, well, why don't you lose weight then? because

9:01

you're asking them to justify. You're not being

9:04

open and you're not exploring why it

9:06

might be difficult. And I know I've said why, but you're

9:08

not exploring the factors that

9:10

are making it more challenging for this

9:12

patient to lose weight or to put down

9:15

changes in place. And the other thing to really be

9:17

mindful of here is that weight is a

9:19

dependent variable. You cannot change

9:21

weight directly. If you want someone

9:24

to lose weight or if they want to lose weight,

9:26

it should really come from them, of course. But

9:28

if someone wants to lose weight, then

9:30

they need to make changes to their diets,

9:32

to their calorie intake. Because,

9:34

and as much as it pains me to say it as a physio,

9:37

exercise and physical activity generally doesn't

9:39

give a great return. If you're going to invest,

9:42

don't invest in exercise for weight.

9:45

Absolutely invest in exercise for

9:47

health. But there's been some really lovely work

9:49

done by Jean-Michel Aupert for the EASO Working

9:52

Group on physical activity. And when

9:54

they looked at the data, they found that

9:56

exercise interventions are associated

9:59

with a two to three kilogram weight loss, which

10:01

is an awful lot. It's not even really

10:04

half a stone, is it? So it's two to

10:06

three kilos. So exercise

10:08

gives a really core return. Dietary

10:10

changes give a much better return.

10:13

If you're going to invest in anything, invest in that.

10:15

But if you're going to have these conversations with your

10:17

patients, you just need to be really open

10:19

and non-judgmental and also try and

10:21

make it relevant to them and make it relevant

10:24

to their condition. And a patient might say something like,

10:27

yeah, it's down to my weight, or it might be

10:29

something completely unrelated. And they say, oh, it's

10:31

down to my weight. And you can say, actually, I don't think

10:33

it is. I don't think your weight's got anything to do with this.

10:36

The other point of reflection for me is that these patients

10:38

are often really hard on themselves, patients

10:40

with obesity, and they can say, oh, no, it's all my

10:42

fault. And I should make these changes.

10:45

And to be honest, we're not there to bully patients

10:47

or to be unkind or

10:49

unhelpful. You're there as the experts

10:52

from a physiotherapeutic perspective

10:55

to help our patients make the changes that

10:57

they need to make and that they want to make. And

11:00

it should feel like a dance. But as soon

11:02

as it starts to feel like it's going from

11:04

a dance to a tug of war or

11:06

a duel, then it becomes

11:09

very adversarial. It's not going to be nice for anyone.

11:12

So don't ask why, because you're asking the

11:14

patient to justify it and just be really open

11:16

and genuinely curious. You know, the patient

11:18

might turn around and say something like, oh, I've

11:20

managed to, I managed to do really well with Slingling

11:22

Wells or Weight Watchers or wherever it might appear. And

11:24

you can say, okay, what was it that made that

11:27

difficult for you to maintain? Or can

11:29

you tell me a little bit more about that? And it might come

11:31

out that they just find that having that accountability

11:34

for some people or that peer support is

11:36

important to them. And then if they're able to access

11:38

it again, then they might choose to do so. But you're

11:41

just incredibly compassionate and kind, I think. Don't

11:43

be judgmental.

11:44

I think patients really can pick up on that

11:46

as well, can't they?

11:47

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11:51

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12:12

It's one of those

12:14

things as well that we then move on to that scope

12:16

of practice, and I can picture

12:18

in this patient who we've started this conversation

12:21

with, And they're at a bit of a loss as

12:23

to where to go. They want to lose weight. We've

12:25

established that. But we're looking at that they've

12:27

sort of giving us those signals that they're

12:29

ready and they want to engage with that. They understand

12:32

some of the things you've mentioned there. Where

12:34

do we take that patient next, which keeps us in our

12:36

lane, as it were, as physiotherapists?

12:39

We might not have access to dieticians

12:41

straight away there and then. What are your tips

12:43

for physios in that space?

12:45

So you could ask the patient what they think would be

12:47

a sensible change or

12:50

an acceptable change. And I think that's the

12:52

key there, an acceptable alternative. So

12:54

that acceptable word is really important. So

12:57

a patient might turn around and say, oh, do you know what? I've made

12:59

some simple changes in the past, but I just didn't keep

13:01

them up long term. And there could be a number

13:03

of reasons for that. It might have been that these weight platters,

13:05

because the calories they were taking in against their

13:08

new level weight was just equal.

13:10

Essentially, they were in an energy balance. So

13:12

it might be that you say to the patient, well, what have you done in the past

13:14

that worked for you? And could you maybe try that again?

13:17

So it's things like acceptable swaps,

13:19

like swapping from full fat milk

13:21

to whole

13:23

milk to semi-skinned milk. Or it might be things

13:25

like moving from thick sliced bread

13:28

to medium sliced bread. It might be

13:30

things like instead of having two rounds

13:32

of toast with breakfast with beans on, you have one round of toast

13:34

with beans on. It might be that they've developed

13:36

a habitual behavior where every time they have

13:38

a cup of tea, they have a biscuit. And actually

13:41

as a physio student, she stopped drinking tea for that reason

13:43

because every time he had a cup of tea, he had a biscuit.

13:46

And I think really, do you know what? The patient's

13:49

the expert of them. They know what kinds

13:51

of things they're doing that may be on help

13:53

on them with their weight and

13:55

with their weight loss attempts. And they are the

13:57

experts of them. You're the expert from a physio

13:59

side of things. They're the experts of them. There's

14:02

some really great resources from the British Dietetic

14:04

Association that patients could look at and they're

14:07

easily accessible and I would definitely

14:09

stay away from Instagram

14:11

influencers and people who maybe aren't quite

14:14

as knowledgeable as they might like to think.

14:16

The other thing is I'd encourage patients to

14:19

avoid moralizing food. So patients

14:21

will say things like, oh, I was really

14:23

bad. I had a chocolate bar or,

14:26

you know, I was really bad. We had some food

14:28

from the chip or we had to take away or something.

14:30

I'd always pull my patience on this and

14:32

say, well, there is no goals or bad foods. There's

14:34

no inherent moral value to having a chocolate

14:36

bar or a takeaway. There

14:39

is no inherent moral value. It might be that there's better

14:41

choices that you can make in terms of your health or

14:43

calories if you're trying to lose weight. But

14:45

you're not bad because you have the chocolate bar. And I

14:47

think also, like, you know, kinds of

14:49

removing that, this kind of

14:52

good, bad language and discourse

14:54

around it is really helpful. So I'd

14:56

always pull my patience on that. Because

14:59

you're not inherently virtuous by having water

15:01

over a coach. It's just not.

15:04

Absolutely. And another thing you were saying there

15:06

is about the patient being the expert. And we know

15:08

as well from behavioural change is if we can

15:11

allow the patient to choose the changes,

15:13

to come up with the changes themselves, which they

15:15

can do if we give them time

15:17

and facilitate that conversation. I'm

15:20

sure we're going to get better outcomes as well, aren't we?

15:22

Absolutely. Yeah. So that's definitely consistent

15:24

with motivational interviewing where you're looking to elicit

15:26

the person's own motivations to make a change.

15:29

Another thing that just popped into my head when you were talking

15:31

then is there's something called behavior change

15:34

techniques. So behavior change technique

15:36

is the active ingredient of a

15:38

behavior change intervention. And there's

15:40

one which I really, really like called greater

15:42

tasks. So this is 8.7 on the taxonomy

15:45

version, one of the taxonomy. And

15:47

this talks about making a small

15:49

change, a small behavior change because

15:51

it's a cumulative effort, really. So it's a small

15:53

change that you're doing to get to a bigger goal. And

15:55

I always draw this out for my patients like

15:58

a mountain. And so you

16:00

can go up the steep sides if you want to, but that's very

16:02

all or nothing. That's things like

16:05

lighter life and cane, which are really

16:07

very calorie restricted. So we could do

16:09

a really big calorie deficit or we could do a crazy

16:11

exercise program, which isn't going to give you much

16:13

bang for your buck in terms of weight, but will

16:16

give you other changes. So you can go up the steep

16:18

sides of the mountain or... We can just pull

16:20

it back a little bit, avoid this all on often thinking,

16:23

go for a shade of grey where we go

16:25

up the mountain kind of, we zigzag up

16:27

and then we get up to the top of the mountain eventually. And

16:30

the beauty of this is that although it does take

16:32

longer, if you have a bump or a blip

16:34

or a relapse, however you want to deem

16:37

it, if you want to, you know, birthdays, Christmas,

16:39

Easter, whatever it might be, if you have a meal out with families

16:41

or someone's sick and it doesn't go to plan,

16:43

it doesn't knock you down quite as much. because

16:46

the change has been more gradual. It's

16:48

been more nuanced. There's more shades

16:51

of grey. It's not all or nothing. And

16:53

I think psychologically, there's a big thing around that

16:55

as well, because if someone does an

16:57

all or nothing approach, where they make big

16:59

changes, get big results, but can't maintain

17:02

it, and then they go back

17:04

to where they were very quickly, then I

17:06

think that really knocks people's confidence. This is

17:08

the classic union disaster, where there's

17:10

a more grazed approach, where you're

17:13

the expert, they're the expert, and

17:15

you dance together. It will get you where

17:17

you want to be. I

17:18

love that, dancing together. And it just forms that

17:20

relationship where you are working together. And that's it,

17:22

whether you're looking at a purely physical rehabilitation

17:25

or whether you're bringing these other elements in. It

17:27

is you're working together, aren't you? And that's important.

17:30

Yeah, absolutely.

17:31

And then if listeners are listening to this as of

17:33

the time this comes out, we're probably not that long away

17:36

from Christmas and probably I'm sure many people

17:38

have had this conversation and then we're probably maybe

17:40

approaching Easter and a similar situation.

17:42

And if they've built up this gradually as

17:44

well, do you think patients are more likely to build in good

17:46

habits as well?

17:48

Yeah, so what you would hope is that they do develop

17:50

habitual behaviour. So a habit, a habitual

17:52

behaviour is a behaviour that you do in a certain context.

17:55

That's automatic, so you don't need to think about it anymore.

17:58

So you might start by doing

18:00

something very purposefully. So for instance,

18:03

it might be that you put an apple on your back so that when

18:05

you walk to your car at the end of the day, you

18:07

see the apple, you have the apple and you're just, you know,

18:09

you're prompted to eat the apple. It's a very conscious

18:12

thing at the beginning. But then as time

18:14

goes on, it's just normal for you to eat an apple on

18:16

the way to the car. It's a way of getting one

18:18

of your five a day in or whatever it might be. So hyperformation

18:21

is a really interesting area actually. And there's a research

18:23

called Ben Gardner who works, I think he's in King's

18:26

now. He's done lots of research on this. But

18:28

yet you would hope that someone is able to

18:30

repeat these behaviours that are helpful

18:33

to them to achieve their goal. But it is

18:35

context specific as well. So if you take that person

18:38

out of that context, they're probably not going to do that

18:40

behaviour long term.

18:41

Yeah. Jennifer, really interesting

18:43

points. I've just looked at the clock and we are out of

18:45

time today. And it's really unfortunate because I think

18:47

we could talk about this for a long, long time. And there's some things

18:50

that we spoke about off air that we haven't had a chance to talk about.

18:52

So I'm going to definitely get you back on

18:54

to talk more about weight loss and

18:56

the massive impact that physiotherapists

18:58

can have in someone's journey in this area.

19:01

Absolutely. I think the only clues and comments

19:03

I'd like to make is that GLP-1

19:05

drugs, Wig-Ovi, is empathic.

19:08

And when Jaro, we've definitely got

19:10

a role to play when we've got patients taking

19:12

these drugs. So let's

19:15

talk about that in the future.

19:17

definitely yeah well there's a cliffhanger for all of

19:19

our listeners we're going to get jennifer back on to talk about

19:21

those drugs very topical at the moment so

19:23

we'll do that very soon jennifer thank you

19:25

so much for your time and if those of

19:27

you if those listening want to know more about jennifer

19:29

please do find her across youtube social

19:32

media at all jennifer

19:33

yes i'm on linkedin so you can find me on

19:35

there and dr jennifer james and also

19:37

i've got an instagram account called the obesity physio

19:40

so yes you find me on there i'm going to be putting some

19:42

videos up shortly as well there's also

19:44

been a piece in the conversation fairly recently

19:46

so if Conversation UK if you want to have a little reason

19:49

about I think you'll find it interesting it's

19:51

all relevant

19:52

brilliant Jennifer thank you so much again for your time

19:54

and I can't wait to speak to you again soon thank

19:56

you