Every day, family physicians (FPs) work with obese patients in order to prevent and treat the consequences of obesity mainly through counselling on improving diets and engaging in regular exercise. Usually, the most important difficulty they encounter is in making obese patients move. Randomized controlled trials have shown that physician intervention can encourage exercise and improve physical fitness among previously non-obese sedentary patients,^1-3 so an FP’s intervention can very likely reduce sedentary behaviours in obese patients too. What’s needed is a practical approach for FPs that can achieve weight loss in the context of a busy clinical practice.

Case description

K.C., an obese woman in her 50s, presents to the clinic to lose weight. She has no specific medical history, except for a positive family history of obesity, T2DM and CHD. She takes no medication and consumes limited alcohol. Manager of a public institution, she has a busy lifestyle that’s primarily sedentary and has no time for regular exercise. On physical examination, her weight is 71 kg, her height 152 cm, for a BMI of 30.9 kg/m². Laboratory assessment is normal. She’s tried several diets previously with minimal success and refuses to follow any diets. How would you proceed to help her lose weight?

Assessment of readiness for change

The first step is to evaluate your patient’s readiness to change his or her behaviours.^4,5 Table 1 presents strategies for counselling patients according to their stage of change.

Because K.C. refused to follow weight loss diets and has no time for regular exercise, patient and physician mutually decided to focus on reducing her sedentary behaviours. Using elements presented in Table 1, the components of motivational interviewing (MI) and the questions presented in Table 2, she was encouraged to find her own ways of reducing her sedentary behaviours to progress to the action stage. Changes made were noted in daily activity logs and reviewed every 2 to 3 weeks during brief motivational counselling sessions. To better guide her throughout her SB changes, a self-administered questionnaire helped to identify and quantify the specific sedentary behaviours that should be prioritized for intervention (Table 3).

Motivational interviewing

Rather than telling a patient what should be done, as per traditional advice-giving, FPs can use motivational interviewing to empower their patients to change their behaviours according to their personal values, strengths, resources and self-efficacy.^6-16 To illustrate the process, Table 2 presents the components of motivational interviewing and some of the questions asked of the patient. FPs can adapt this approach as treatment progresses. There’s strong evidence from randomized trials, systematic reviews, meta-analyses, prospective and observational studies that brief motivational interviewing outperforms traditional advice-giving in the treatment of a broad range of behavioural problems and diseases.^6-14 It can be effective in chronic care management intervention, assist in promoting dietary behaviours and obesity treatment in patients with T2DM, or those who experience difficulty losing weight. A meta-analysis by Martins and McNeil¹⁵ confirms its efficacy in increasing exercise, fruit and vegetable consumption, as well as reducing caloric intake and BMI values. A non-randomized clinical trial also confirms that motivational interviewing by pediatricians and dieticians is a promising office-based strategy for preventing childhood obesity.¹⁶ Based on this evidence, motivational interviewing can be readily adapted as an effective technique for reducing sedentary behaviours in the FP clinical practice.

Assessment of sedentary behaviour

FPs can use the Sedentary Behaviours Questionnaire (SBQ) for overweight adults validated by Rosenberg et al¹⁷ to assess the amount of time spent doing 9 common activities (watching TV, playing computers/video games, sitting while listening to music, sitting and talking on the phone, doing paperwork or office work, sitting and reading, playing a musical instrument, doing arts and crafts, and driving/riding in a vehicle). In validating this SBQ, it was found that there was a significant relationship of the SBQ items with BMI and with sitting time as measured by the International Physical Activity Questionnaire.

The amount of time spent in the above 9 activities was calculated for K.C. (Table 3). Total scores of sedentary behaviours were summed separately for week and weekend days, in hours per day, for each item as suggested by Rosenberg et al.¹⁷ Then to obtain weekly estimates, weekday hours were multiplied by 5 and weekend day hours were multiplied by 2. These values were tallied for total hours per week. From these numbers the weekly amount of time spent in sedentary activities can be calculated as follows: [(13.5 x 5) + (10.0 x 2)] = 87.5 hours of sedentary behaviours per week. The challenge wass to find ways of reducing her sedentary behaviours without disrupting necessary sedentary tasks such as paperwork during the week, since this represents her working obligations as a manager.

Interventions

Interventions to reduce sedentary behaviours should target the 9 activities mentioned above. For the purpose of this review, we’ll limit our discussion to the 3 main targets identified with the SBQ (Table 3) and agreed to by our patient: office/paperwork, TV watching and driving.

Office/paperwork: A recent systematic review has established that light-intensity exercise is associated with lower rates of CHD and CVD, that increasing the amount of exercise is linked to additional risk reductions and that higher levels of physical fitness appear to be able to offset the increased risk of CVD associated with being overweight or obese.¹⁸ In another systematic review by Marshall and Ramirez,¹⁹ it was ascertained that integrating frequent breaks between sitting at work, can be beneficial and that reducing sedentary behaviours, even without increasing moderate-to-vigorous exercise, should be considered as a priority in obesity interventions. This is also supported by the single-blinded study of McCrady and Levine which demonstrates that work days were associated with more sitting and less walking time than leisure days.²⁰ This suggests that more emphasis needs to be placed on getting people more active on weekdays.

K.C. decided to replace some office/paperwork with light-intensity exercise such as using the stairs instead of the elevator at work, walking to a farther bathroom, taking a 5-minute break every hour for stretching and having a short walk at lunch time.

TV watching: Adult TV viewing has been consistently associated with greater obesity risk in cross-sectional and longitudinal studies.^21-23 Interventions to alter TV viewing appeared effective among obese children. However, it hasn’t been established if the same strategies could be extended to obese adults as well.²⁴ Although there are no specific recommendations on duration of TV watching or screen time for obese adults, we decided to apply the recommendations for obese pediatric patients, which are < 2 hours per day²⁵ In addition, removing any bedroom TV helps reduce total screen time and encourage activity.²⁶ A cross-sectional observational study by Healy et al demonstrated that substituting light-intensity exercise for TV viewing or other sedentary behaviours is a practical and achievable preventive strategy for reducing the risk of T2DM and CVD in overweight patients.²⁷

Our patient easily reduced TV watching to < 2 hours per day by introducing exercise such as walking outside or exercising with Wii fit video games for 30-45 minutes on most days.

Wii fit video games are considered a feasible alternative to more traditional aerobic exercises modalities for middle-aged and older adults. Wii fit video games fulfils the American College of Sports Medicine guidelines for improving and maintaining cardio-respiratory fitness.²⁸

Driving: Driving is a known risk factor for obesity. In a cross-sectional study of commercial drivers, excessive body weight was recorded in 62.2% of the studied population; 45.3% were overweight and 17.4% were obese.²⁹ This indicates a need to minimize the time spent in vehicles, especially by overweight/obese patients.

K.C. was able to reduce her driving activities by incorporating additional walking in her commute. For instance, getting off at an earlier bus stop, or parking her car farther away from her workplace or shopping area.

It’s been reported that walking at 1.1 mph (well under half average human walking speed) results in a calorie expenditure of 191 kcal/hr and the mean increase in energy expenditure for walking-and-working over sitting was 119 kcal/h.³⁰ Thus by implementing walking as a exercise twice a day and replacing other sitting activities mentioned above contributed to our patient’s energy output and weight loss.

The prod of the pedometer: The use of self-reported daily exercise logs can lead to overestimation of exercise. This potential bias was addressed with the use of a digital pedometer worn by the patient from the time she woke up until she went to sleep to validate her changes in sedentary behaviours. The number of steps performed was compiled in the daily activity logs for further assessing exercise during follow-up visits.

At baseline, the patient’s step count was < 5,000 steps per day, which corresponds to the sedentary level. She was able to progressively increase her step count to > 10,000 steps per day, as she found that using a pedometer was a strong motivator.

Pedometers can be used to guide patients’ efforts. Based on currently available evidence, the following numbers can be used to classify exercise levels in healthy adults: a) < 5,000 steps/day may be classified as a “sedentary lifestyle”; b) 5,000-7,499 steps/day is typical of daily activity excluding sports/exercise and might be considered “low active”; c) 7,500-9,999 likely includes some volitional activities (and/or elevated occupational activity demands) and might be considered “somewhat active”; and d) ≥ 10,000 steps/day is used to classify individuals as “active.” Individuals who take > 12,500 steps/day are likely to be classified as “highly active.”³¹ A randomized study demonstrated hat adult sedentary women walk more when told to take 10,000 steps per day with a pedometer than when instructed to take a brisk daily 30-minute walk.³² The motivator effect of using a pedometer was also demonstrated in adult patients at high risk of T2DM.³³

Improving dietary habits

In a recent prospective investigation by Mozaffarian D,³⁴ of a total of 120, 877 U.S. subjects free of chronic disease and not obese at baseline, subjects gained an average of 1.52 kg at every 4-year period. They found that 4-year changes in body weight were associated with servings of potato chips (0.77 kg), potatoes (particularly French fries) (0.58 kg), sugar-sweetened beverages (0.45 kg) unprocessed red meats (0.43 kg) and processed meats (0.42 kg) and inversely related to intake of vegetables (-0.1 kg), whole grains (-1.7 kg), fruits (-0.22 kg), nuts (-0.26 kg) and yogurt (-0.37 kg) (P ≤ .005 for each comparison). It’s therefore relevant to consider that changing these dietary habits could result in considerable weight loss if successfully maintained over years.

With K.C., it was interesting to note that at the same time she was working at reducing her sedentary behaviours, she spontaneously decided to make changes in her dietary habits, by eating fewer desserts, sweetened foods and chips.

Case resolution

After 16 sessions, K.C. had reduced her sedentary behaviours by a mean of 30 to 45 minutes per day. She achieved this by reducing TV watching, increasing exercise in her daily activities, including longer walks or playing Wii fit video games during the evening and golfing during the weekend. She increased her mean step count on a digital pedometer from < 5,000 to > 10,000 steps per day on most days. She made significant improvements in her dietary habits such as eating fewer desserts, sweetened foods, chips and others. Combined with her reduction in sedentary behaviours, these changes in eating habits have enabled her to lose weight. Although her weight loss was minimal during the first sessions, by progressively adding these new habits in her daily routine, she was able to attain the recommended weight loss of 0.5 to 1.0 kg per week towards the end of the 16 sessions for a total weight loss of 6.5 kg. The next steps, once her weight loss goal of having a BMI < 25kg/m² has been achieved, will be to help her maintain these newly self-acquired habits over the long term, using strategies presented in Table 1.

In this real case, clinically significant reductions in sedentary behaviours were obtained in just 16 sessions. K.C. was able to progressively improve her engagement in exercise and eating habits and to lose weight. This clinical practice report demonstrates that brief motivational counselling by FPs, through substituting exercise for sedentary behaviours, can be successful at achieving weight loss in an obese patient.

The authors wish to acknowledge Denis Prud’homme, MD, MSc, School of Human Kinetics, Faculty of Health Sciences, University of Ottawa, for his advice and editorial assistance.