Managing Obesity in Adults: a Role for Occupational Therapy Camille Dieterle, OTD, OTR/L Mrs

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Managing Obesity in Adults: A Role for Occupational Therapy Camille Dieterle, OTD, OTR/L Mrs. T.H. Chan Division of Occupational Science and Occupational Therapy trol and Prevention [CDC], 2017b). Black and Hispanic adults University of Southern California, Los Angeles, CA have a higher rate of obesity than white or Asian adults (Hales et al., 2017). Overweight and obesity are defined by body mass index This CE Article was developed in collaboration with AOTA’s Rehabilitation (BMI), which is the ratio of weight to height. BMI is calculated & Disability Special Interest Section.. in a clinical setting by measuring overall weight and height and then using a chart or online calculator to calculate BMI. A BMI ABSTRACT of 25 to 30 is considered overweight. A BMI 30 or higher is Occupational therapy practitioners commonly encounter clients considered obese (Centers for Disease Control and Prevention diagnosed with or who are at risk for obesity across all popu- [CDC], 2016). Obesity is divided into further categories: class 1 lations and settings. Because obesity can affect participation (BMI 30–35), class 2 (35–40), and class 3 (40 or higher). BMI in occupation, occupational therapy practitioners can treat is a useful screening tool, but it has limitations. For example, it obesity as the primary condition or reason for referral, as well does not indicate how much body fat a person has, and people as in conjunction with various conditions and disabilities. This with high muscle mass and low fat mass may have a high BMI. article focuses on the effects of obesity on occupational perfor- Waist circumference is another measure used. In adults, a waist mance and participation and discusses occupational therapy circumference greater than 35 inches for females and 40 inches lifestyle interventions for treating obesity with adults who are for males indicates a higher risk for obesity-related conditions or who are at risk for obesity, including primary, secondary, and (Jensen et al., 2013). tertiary prevention and bariatric surgery. The article focuses Not all people with high BMI experience poor health, but on intervention in the context of outpatient lifestyle modifica- people who are obese are at an increased risk for all causes tion, although much of the material discussed is useful in most of death (mortality); hypertension; high LDL and low HDL settings. cholesterol; high levels of triglycerides (dyslipidemia); Type 2 diabetes; metabolic syndrome; coronary heart disease; stroke; LEARNING OBJECTIVES gallbladder disease; osteoarthritis (especially both knees); sleep After reading this article, you should be able to: apnea and breathing problems; some cancers (endometrial, 1. Identify the various client factors, performance patterns, con- breast, colon, kidney, gallbladder, and liver); breast cancer texts, and environments that contribute to obesity relapse; fatty liver disease; kidney disease; pregnancy problems; 2. Describe the effects of obesity on occupation and participation low quality of life; mental illness, such as clinical depression, 3. Articulate occupational therapy’s role in treating obesity anxiety, and other mental disorders; body pain; and difficulty 4. Describe evidence-based occupational therapy lifestyle mod- with physical functioning (CDC, 2017a; Dieli-Conwright et al., ification interventions for reducing weight and preventing 2018; National Institute of Diabetes and Digestive and Kidney weight gain Diseases, 2015). Additionally, social stigma and discrimination based on weight can affect mental health, especially in the INTRODUCTION form of mood disorders and decreased quality of life (Barclay More than 70% of American adults are either overweight or & Forwell, 2018). Stigma and discrimination from within the obese. Adult obesity rates have been rising steadily since the health care system and from society at large can contribute 1970s. In 2015 and 2016, 39.8% of adults in the United States to decreased engagement in self-care and decreased access to were categorized as obese (Hales et al., 2017). Another 32.8% of health care, which can lead to additional health problems (Tylka adults were categorized as overweight (Centers for Disease Con- et al., 2014).

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Etiology 30% of American adults aged 30 to 64 years get fewer than 6 The most common causes of weight gain, which leads to obesity, hours of sleep per night (Bahrami-Nejad et al., 2018). With include genetics, environmental influences, medical conditions, regard to food, most nutrition research indicates that excessive disabilities, medications, food choices, meal timing, chronic consumption of sugar and refined carbohydrates contribute sleep deprivation, long-term stress (elevated cortisol), and to the most weight gain (Astley et al., 2018). In a long-term aging. Some of these causes are modifiable and some are not. study of more than 120,000 American adults, potato chips, A tendency for obesity can be passed down through genetics French fries, sugar-sweetened beverages, and processed meats (Tylka et al., 2014). Environmental causes for weight gain can were the foods found to be most associated with weight gain start in utero with maternal nutrition (Parlee & MacDougald, (Bahrami-Nejad et al., 2018). The timing of eating is another 2014), and physical and social environments can have signifi- factor that can affect weight gain. Nightime eating is associ- cant effects on weight gain throughout the life span. Elements ated with weight gain and maintaining higher weight (Allison of an “obesogenic” environment include unhealthy food choices/ & Goelb, 2018). Increased intake of high-calorie foods and energy intake, poverty, sleep deprivation, sedentary lifestyle, and decreased physical activity are considered the two main causes inactive work (Bellisari, 2013; Kuo et al., 2013). Lack of access of obesity worldwide, and a growing body of evidence also to healthy food, opportunities for physical activities, and access indicates that a history of childhood trauma, especially sexual to green spaces are also identified causes, as is an increase in abuse, may increase the risk for severe obesity in adulthood sedentary leisure activities (González et al., 2017; Kuo et al., (Bhurosy & Jeewon, 2014; Richardson et al., 2013). There 2013). Drieling and colleagues (2014) found that community is also evidence that the social environment can also affect resources that provide health education are associated with weight. For example, in a recent study of military families who more physical activity and better diet, which can be an asset for relocate, families who moved to communities with a higher obesity-reduction strategies. However, there is a need for better average weight gained weight themselves (Datar & Nicosia, resource promotion, given the low utilization of these afford- 2018). Poverty and lower education levels are also associated able educational community resources (Drieling et al., 2014). with higher weight (Saliman Reingold & Jordan, 2013). Weight Exposure to obesogenic chemicals, such as nicotine, flame gain is usually caused by a combination of multiple factors. retardants, bisphenol A, some pesticides, and polychlorinated Most often the combination includes reduced physical activity, biphenyls may increase the risk for weight gain and are thought unhealthy diet, decreased physical function, mental distress, to be most hazardous in utero and in early childhood, when the social isolation, the presence of obesity-associated diseases, body’s weight control mechanisms are being formed (Kelishadi and perceived physical and psychological barriers (Nossum et al., 2013). et al., 2018). As body mass increases, the degree of disability Medical conditions that commonly cause weight gain include increases. The risk for occupational performance problems underactive thyroid; polycystic ovarian syndrome; Cushing’s increases significantly with moderate and severe obesity syndrome; and mental illnesses, such as depression, anxiety, (Nossum et al., 2018). Clients seeking occupational therapy posttraumatic stress disorder, binge eating disorder, and night may be more likely to be obese than the general public because eating syndrome (Assari, 2014; National Health System, 2017). of decreased mobility, additional conditions, medications, and Conditions that limit mobility and engagement in occupation other contextual factors. Obesity is considered a chronic con- can also increase the likelihood of weight gain, including phys- dition and losing weight often requires lifelong maintenance. ical disabilities and mental illness (Saliman Reingold & Jordan, Obesity is often preventable. 2013). Menopause, perimenopause, and aging can cause weight gain as well (Porter, 2016). Medications that commonly cause Effect on Occupation weight gain include steroid therapies; diabetes medications Obesity increases the risk for decreased physical function, (e.g., insulin, thiazolidinediones, sulfonylureas); psychiatric/ reduced ability to perform everyday activities, social isolation, neurologic therapies (e.g., tricyclic antidepressants, selective and mental distress (Nossum et al., 2018). People who are obese serotonin reuptake inhibitors); antipsychotics, which are the can experience functional impairments such as difficulty with most likely to cause weight gain; antiseizure/anticonvulsants; mobility, less tolerance of physical activity, and decreased qual- antihistamines; and beta-adrenergic blockers, used to lower ity of life, and they may avoid activities until losing weight (For- blood pressure (Kyle & Kuehl, 2018). Medical treatment may han et al., 2011, 2012). Obesity increases fall risk and can create also cause weight gain. Chemotherapy can cause weight gain difficulty with walking, and it may affect safety in the home and the development of metabolic syndrome, which is a com- and community (Gill, 2016). The presence of obesity with large bination of high blood pressure, high cholesterol, and excessive waist circumference is associated with slower walking speed body fat (Dieli-Conwright et al., 2018). and inability to walk 400 meters, a measure associated with Chronic sleep deprivation and long-term stress both cause community independence (Gill, 2017). The presence of comor- weight gain by elevating cortisol levels. Chronically elevated bidities and pain, for example from osteoarthritis in the knees cortisol raises blood sugar, which raises insulin levels, which caused by obesity, can further restrict participation in occupa- causes fat storage. Consistently getting fewer than 6 hours tion (Gill, 2017; Forhan et al., 2011, 2012). A study of Canadian of sleep per night is associated with weight gain, and about adults found that participants with a BMI over 40 and over 50

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were somewhat dissatisfied with their participation in daily Transtheoretical, or Stages of Change Model, is commonly used occupations. A BMI over 50 showed a greater negative effect on in obesity and lifestyle modification treatment (Ceccarini et al., participants’ ability to perform ADLs. Several personal factors 2015). contributed to obese participants being labeled with a disabil- ity, including difficulty with standing and walking tolerance, Medical Treatment for Obesity washing the whole body, and getting dressed (Forhan et al., Recent obesity guidelines published in the Journal of the Ameri- 2012). In a study of 63 Norwegian adults with a BMI over 35, can Medical Association and designed for primary care physicians the most common occupational performance problems reported include the following: identifying clients who are overweight were playing with grandchildren; buying clothes; having regular and obese, providing education and counseling on the benefits meals; avoiding unhealthy food; and doing active recreation, of weight loss and nutrition/dietary therapy, facilitating lifestyle including swimming. Barriers to participation in the community intervention, and electing bariatric surgery (Jensen & Ryan, included dyspnea, poor pacing and exhaustion during physical 2014). Lifestyle intervention is described as the gold standard activity, musculoskeletal disorders, narrow chairs and seats, and the approach with the most far reaching effects. It is recom- fear of glances and comments from others, and social anxiety. mended to be onsite, be high-intensity, last for at least 6 months Limitations in fashion were also frequently cited by participants with more than 14 sessions, and continue for at least a year (Jen- as a barrier to social activity (Nossum et al., 2018). Similar sen & Ryan, 2014). The most successful lifestyle interventions limitations were found in a qualitative study of 10 adults with include exercise and diet and behavior modification and are a BMI over 40. All participants described restricted choices in delivered by a multidisciplinary team. Occupational therapists activities, such as shopping for clothes, joining a social club, can be the team member that delivers the lifestyle intervention planning a vacation, and looking for employment and volunteer (Jensen & Ryan, 2014). work (Forhan et al., 2012). Pain, fatigue, limited tolerance for Medical treatment often starts with the goal of losing 5% mobility, and urinary incontinence were cited as creating limita- to 10% of body weight, because this initial change can cre- tions for employment and leisure activities (Forhan et al., 2012). ate significant health benefits in blood pressure, cholesterol, Environmental barriers—such as inadequate seating in theaters, blood sugar control, sleep apnea, and inflammation in the restaurants, airplanes, cars, and public transportation—were blood, which can decrease the risk for stroke and heart attack described as problematic, and participants also stated that they (Pietrzykowska, 2018). Bariatric surgery typically produces avoided medical care for fear of being reprimanded for their greater weight loss and maintenance than all other methods weight (Forhan et al., 2012). Being overweight or obese can and is recommended for clients with BMI over 40 or a BMI limit a person’s ability to participate in meaningful, satisfying over 35 with obesity-related comorbidities. Weight loss efficacy occupations, which is not only important to health and wellness depends on initial weight and type of surgical procedure (Jensen promotion but also is an issue of social and occupational justice et al., 2013). Bariatric surgery has a greater effect on obesity-re- (Kuo et al., 2013. lated comorbidities like Type 2 diabetes than do other forms Unlike the previously cited studies, in a larger study with of treatment, but, as is usually the case with surgery, there are a sample size of 241 bariatric surgery candidates, Barclay short- and long-term risks involved (Jensen et al., 2013). Bar- and Forwell (2018) found that BMI did not correlate with iatric procedures can also significantly affect occupations after occupational performance, but several psychosocial factors surgery and require behavior modification for long-term success did. Self-esteem; affective and cognitive issues, such as being (Kanerva et al, 2017). preoccupied with thoughts about food and what others think; and depression and anxiety significantly affected occupational OCCUPATIONAL THERAPY INTERVENTION FOR ADULTS performance. For example, the most commonly identified Occupational therapy practitioners have an ideal background barriers to exercise were predominantly psychosocial and and skill set to address obesity in multiple contexts. Prac- included physical discomfort, intimidation, embarrassment, titioners can provide treatment to prevent (primary, sec- and environmental restrictions (Barclay & Forwell, 2018). This ondary, and tertiary) and manage obesity, including helping study is consistent with other findings that portray extensive with weight loss and providing adaptations for occupational stigmatization, discrimination, and bullying related to obesity, challenges caused by obesity (American Occupational Therapy which limit access to participation (Saliman Reingold & Jor- Association [AOTA], 2012). All of the approaches to occupa- dan, 2013). tional therapy intervention listed in Table 8 of the Occupa- tional Therapy Practice Framework: Domain and Process (3rd Occupational Therapy Models ed.; AOTA, 2014) apply to this client population: create and Several occupational therapy models have been used to help promote (health promotion to prevent obesity or to promote understand obesity and guide treatment, including the Ecology weight loss), establish, restore (remediation and restoration of of Human Performance, Occupational Adaptation, the Per- function despite obesity and related comorbidities), maintain, son-Occupation-Environment Model, and the Person-Task-En- modify (compensation and adaptation to increase function vironment Model (Forhan et al., 2010; Nossum et al., 2018). In and participation despite obesity), and prevent (obesity and addition, although not created by an occupational therapist, the disability prevention). As a profession that delivers client-cen-

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Further evalu- weight, water mass, lean mass, and fat mass. For occupational ation of a client’s occupational performance includes contextual therapy weight loss interventions, it is especially useful to factors, activity demands, and client factors, and it may include measure water, lean mass, and fat mass at each visit to deter- occupational therapy evaluation and assessment tools for ADLs, mine whether the client’s efforts are resulting in the desired IADLs, and any deficits, as needed. With obesity, it may be outcomes. The overall weight measurement alone can be necessary to evaluate the client’s ability to reach and bend, body misleading. For example, when a client exercises more and mobility, endurance, posture, stabilization, ambulation, pace, gains lean mass (muscle) and water, their overall weight may and ability to adjust and problem solve in response to chal- increase. Without body composition data, the client may be lenges. ADLs and IADLs, such as bathing, community mobility, misled and disappointed, despite an actual improvement. This mobility in limited spaces, clothes management, and household level of precision helps to pinpoint more quickly whether the chores, may need to be evaluated as well. lifestyle changes a client is making are effective and helps the occupational therapist build the client’s self-efficacy. There are Assessment multiple ways to measure body composition. In clinical settings, Another client factor to assess is a client’s readiness and a practical method is a body composition analyzer scale that motivation to make changes for weight loss. The Transtheoret- uses bioelectric impendence. Professional models of these scales ical Model of Change (TTM) is a useful model for evaluating are far more accurate than consumer models. For clients with motivation for change and has been used extensively in clinical pacemakers or other electronic implants, which are contraindi- settings with clients who are trying to lose weight (Ceccarini et cated for the bioelectric impendence, measuring BMI and waist al., 2015). This model describes five stages of behavior change, circumference is the next best alternative. including precontemplation, contemplation, preparation, Because mental health and self-esteem are commonly action, and maintenance. Most people do not progress through affected by obesity, using assessments such as the Beck Depres- the stages in a linear fashion. It is difficult to predict exactly sion Inventory II, the Beck Anxiety Inventory, the Rosenberg how and when someone will move through the stages, but the Self-Esteem Scale, and the Eating Disorder Evaluation Ques- TTM provides suggestions as to how to communicate to clients tionnaire are useful and important in this population (Barclay & who are in each stage. The most widely used (although not Forwell, 2018). necessarily by occupational therapists) readiness-for-change formal assessment tool is the University of Rhode Island Change Goal Setting Assessment Scale, a 32-item questionnaire (Ceccarini et al., Occupational therapy intervention for managing obesity must 2015). A shorter assessment of readiness to change for weight focus on occupational goals; in fact some clients may not be loss (5 items) is the S Weight (Andres et al., 2009). In the interested in tracking weight. Many clients are more motivated absence of a formal questionnaire, an occupational therapist can by occupational goals, such as being able to do a specific task or ask questions to gauge readiness for change, such as, “Have you occupation; increasing their endurance to make mobility and tried to lose weight before?” “What has made it difficult to lose ADLs/IADLs easier; participating in enjoyable past occupations weight in the past?” “On a scale of 1 to 10, how likely are you to or a desired new occupation; fitting into previously worn cloth- start implementing a behavior change this week?” ing; and improving other health/biomeasures, such as HbA1c, The Canadian Occupational Performance Measure (COPM) blood pressure, and cholesterol. Concrete biomeasures can be is an ideal occupational therapy assessment tool for obesity. especially motivating when they have meaning for a client. The COPM has been used for obesity-related occupational For example, breast cancer survivors have an increased risk for performance problems and is especially useful for capturing the heart disease, so a survivor may become especially motivated to specific occupational problems that vary among individuals, as lower their risk factors for heart disease, such as blood pressure well as how important each problem is to the client (Nossum et and cholesterol (Daher et al., 2012). For setting weight loss al., 2018). goals, consider the rate of healthy weight loss (1–2 pounds per As a part of interdisciplinary care, and for the purpose week) and the treatment duration (CDC, 2018). Weight loss of communicating with referring physicians and promoting as little as 3% to 5% of initial body weight sustained over time occupational therapy’s role in obesity care, it is useful to track can create clinically meaningful reductions in triglycerides and additional relevant measures, such as body composition, BMI, blood sugar. Greater levels, like 5% to 10% of initial weight, can waist circumference, and additional biomeasures relevant to the improve cholesterol and reduce the need for medications for client’s goals, such as blood pressure; hemoglobin A1c, which blood pressure and blood sugar (Jensen & Ryan, 2014). is a measure of blood sugar levels over the past 2 to 3 months;

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Managing Obesity and Obesity-Related Disability is understanding the need for customized, client-centered analy- To improve occupational performance and participation, treat- sis of the many complex factors that contribute to each client’s ment may include adaptive equipment, home modifications, weight gain and barriers to weight loss. and compensatory approaches to ADLs and IADLs. Occupa- tional therapy practitioners can address challenges such as fear Lifestyle Modification Strategies of falling, mental health challenges, and mobility and inde- Changing behaviors for weight loss can be overwhelming, pendence, with interventions including home modifications, require a high amount of effort, and typically do not create sig- adaptive equipment, and caregiver training. Rehabilitation nificant results quickly. Occupational therapy treatment helps after surgery (bariatric or otherwise) may include increasing clients go slowly, find the just-right challenge, and stay moti- physical activity, problem-solving daily tasks, addressing ADLs vated despite setbacks. In addition to the occupational self-anal- and IADLs, doing environmental modifications, and increasing ysis process, techniques occupational therapy practitioners can engagement in occupation. use include education about related occupations, such as meal planning and physical activity; stress management/relaxation; Lifestyle Modification for Weight Loss motivational interviewing; and creating accountability struc- In addition to the benefit of reducing the risk for comorbidities, tures and continual goal setting. Often in behavior modification weight loss can improve functional limitations and lessen pain treatment sessions, occupational therapy practitioners help and perceived disability in clients who are obese. An occupa- clients get organized, make specific plans, and problem solve tional therapy lifestyle modification intervention for obesity and through anticipated barriers. Practitioners are particularly well the prevention of obesity and related conditions includes educa- suited to address obesity because of their ability to learn the tion, performance patterns (habits, routines, roles) and behavior unique needs and interests of their clients and to find what modification strategies, problem-solving, and reflection. is most motivating for them. A common weight management Lifestyle RedesignTM is an occupational therapy lifestyle lifestyle intervention is to help clients find one or more physical modification intervention that has been shown to help clients activities they enjoy and find convenient to incorporate into change habits and routines in order to meet health-related goals their existing routines. (Clark et al., 2015). Education is a common and critical com- ponent of occupational therapy treatment for obesity because Lifestyle Modification Before and After Bariatric Surgery clients have often been misinformed by the many conflicting Occupational therapy practitioners can be part of the care team and confusing messages about food and weight loss circulating before and after bariatric surgery. A lifestyle modification inter- throughout culture, the media, and advertising (Haracz et al., vention to reduce weight before surgery can improve surgical 2013). Education topics may include basic nutritional infor- outcomes and is often required by payers (Barclay & Forwell, mation and food preparation techniques tailored to the client’s 2018). Occupational therapy prepares also prepares clients for level of knowledge, culture, preferences, healthy eating routines the occupational changes that will take place after surgery, such for weight loss, physical activity, time management, stress man- as new habits and routines when eating much smaller meals, agement, sleep hygiene, and their expectations about the weight taking supplements, building and maintaining strength through loss process. Because of the high prevalence of fad diets and physical activity, and social eating. Lifestyle interventions after misinformation about quick weight loss, which can be harmful, surgery typically occur if a client experiences weight gain after it is important to educate clients about healthy expectations for the initial loss. weight loss (about 1–2 pounds per week). Occupational therapy practitioners can distinguish them- Outcomes selves by providing education that is individualized, highly Occupational outcomes often include increased participation, relevant, occupation focused, and delivered in a highly engaging increased ease during ADLs and IADLs that require physical and motivating format, such as while engaging in occupation. activity and endurance, improved self-esteem, and decreased Targeting performance patterns is another distinct part of occu- symptoms of depression and anxiety. Biomeasures such as blood pational therapy treatment for obesity. pressure, cholesterol, A1c, and weight loss also often improve. Occupational self-analysis is a method for analyzing perfor- Some clients significantly change their body composition to mance patterns, including habits, routines, rituals and roles, increase muscle and decrease fat, and their overall weight does and the client and environmental factors that affect engage- not change. Occupational therapy interventions for obesity ment in health-promoting activities. Originally created as part occur individually and in groups, and there is some evidence of the Lifestyle RedesignTM intervention process, occupational that weight management groups are slightly more effective. self-analysis is a process in the which occupational therapist This difference is thought be a result of increased social support trains clients to analyze their occupations to determine what when in groups (Duttom et al., 2014). contributes to obesity and what they would like to change (Clark, et al., 2015). Clients have time to discuss their needs, Reimbursement and Program Development desires, barriers, supports, and lived experience of making life- Occupational therapy practitioners can treat obesity as the pri- style changes over time. One of occupational therapy’s strengths mary reason for referral or as a secondary condition. Medicare,

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Medicaid, and private health insurance may cover occupational Centers for Disease Control and Prevention. (2016). Defining adult overweight therapy services for obesity and related conditions (Saliman and obesity. Retrieved from https://www.cdc.gov/obesity/adult/defining.html Reingold & Jordan, 2013). Tracking individual client biomea- Centers for Disease Control and Prevention. (2017a). Adult obesity causes and sures and functional participation, and communicating these consequences. Retrieved from https://www.cdc.gov/obesity/adult/causes.html changes to the referring physician, is strongly recommended for Centers for Disease Control and Prevention. (2017b). Obesity and overweight. program development. Clear communication about the role of https://www.cdc.gov/nchs/fastats/obesity-overweight.htm occupational therapy with everyone on the care team, as well as Centers for Disease Control and Prevention. (2018). What is healthy weight loss? Retrieved from https://www.cdc.gov/healthyweight/losing_weight/index.html anyone in a facility or network who treats clients who are obese Clark, F. A., Blanchard, J., Sleight, A., Cogan, A., Eallonardo, L., Floríndez, L., and might refer to occupational therapy, is critical. … Zemke, R. (2015). Lifestyle redesign: The intervention tested in the USC Well Elderly Studies (2nd ed.). Bethesda, MD: AOTA Press. CONCLUSION Daher, I., Daigle, T., Bhatia, N., & Durand, J. (2012). The prevention of Occupational therapy is an ideal fit to conduct lifestyle inter- cardiovascular disease in cancer survivors. Texas Heart Institute Journal, 39, ventions for treating obesity with adults who have or are at 190–198. risk for obesity, including supports for primary, secondary, and Datar, A., & Nicosia, N. (2018). Association of exposure to communities with higher ratios of obesity with increased body mass index and risk of over- tertiary prevention and bariatric surgery. The profession’s cli- weight and obesity among parents and children. Journal of the American Medi- ent-centered and individualized approach, which trains clients cal Association Pediatrics. https://doi.org/10.1001/jamapediatrics.2017.4882 in problem solving the daily occupational challenges of obesity Dieli-Conwright, C., Courneya, K., Demark-Wahnefried, W., Sami, N., Lee, K., and weight loss, is especially valuable in the current health care Buchanan, T., … Mortimer, J. (2018). Effects of aerobic and resistance exer- cise on metabolic syndrome, sarcopenic obesity, and circulating biomarkers system. in overweight or obese survivors of breast cancer: A randomized controlled trial. Journal of Clinical Oncology, 36, 875–883. https://doi.org/10.1200/ REFERENCES JCO.2017.75.7526 Allison, K., & Goelb, N. (2018). Timing of eating in adults across the weight Drieling, R. L., Rosas, L. G., Ma, J., & Stafford, R. S. (2014). Community spectrum: Metabolic factors and potential circadian mechanisms. Physiology resource utilization, psychosocial health, and sociodemographic factors and Behavior, 192, 158–166. https://doi.org/10.1016/j.physbeh.2018.02.047 associated with diet and physical activity among low-income obese Latino immigrants. Journal of the Academy of Nutrition and Dietetics, 114, 257–265. American Occupational Therapy Association. (2012). AOTA’s societal statement https://org/10.1016/j.jand.2013.07.025 on obesity. American Journal of Occupational Therapy, 66, S81–S82. https://doi. org/10.5014/ajot.2012.66S81 Duttom, G., Nackers, L., Dubyak, P., Rushing, N., Tuong-Vi , H., Tan, F., … Per- ri, M. (2014). A randomized trial comparing weight loss treatment delivered American Occupational Therapy Association. (2014). Occupational thera- in large versus small groups. International Journal of Behavioral Nutrition and py practice framework: Domain and process (3rd ed.). American Journal Physical Activity, 11, 123. https://doi.org/10.1186/s12966-014-0123-y of Occupational Therapy, 68 (Suppl_1), S1–S48. https://doi.org/10.5014/ ajot.2014.682006 Forhan, M., Law, M., Vrkljan, B., & Taylor, V. (2010). The experience of partic- ipation in everyday occupations for adults with obesity. Canadian Journal of American Occupational Therapy Association. (2017). AOTA occupational profile Occupational Therapy, 77, 210–218. https://doi.org/10.2182/cjot.2010.77.4.3 template. Retrieved from https://www.aota.org/~/media/Corporate/Files/ Practice/Manage/Documentation/AOTA-Occupational-Profile-Template.pdf Forhan, M., Law, M., Taylor, V., 7 Vrkljan, B. (2011). Participation profile of adults with class III obesity. OTJR: Occupational, Participation and Health, 31, Andres, A., Saldana, C., & Gomez-Benito, J. (2009). Establishing the stages 135–142. https://doi.org/10.3928/15394492-20101025-02 and processes of change for weight loss by consensus of experts. Obesity, 17, 1717–1723. https://doi.org/10.1038/oby.2009.100 Forhan, M., Law, M., Taylor, V., Vrkljan, B. (2012). Factors associated with the satisfaction of participation in daily activities for adults with call III obesity. Assari, S. (2014). The link between mental health and obesity: Role of individual OTJR: Occupational, Participation and Health, 32, 70–78. and contextual factors. International Journal of Preventative Medicine, 5, 247–249. Gill, S. (2016). Changes in motor performance: Indicators of fall risks after bar- iatric surgery. American Journal of Occupational Therapy, 70, 7011505085p1. Astley, C., Todd, J., Salem, R., Vedantam, S., Ebbeling, C., Huang, P., … https://doi.org/10.5014/ajot.2016.70S1-RP103C Florez, J. (2018). Genetic evidence that carbohydrate-stimulated insulin secretion leads to obesity. Clinical Chemistry, 64(1). https://doi.org/10.1373/ Gill, S. (2017). The association of waist circumference with functional mobility clinchem.2017.280727 among adults with obesity and knee osteoarthritis. American Journal of Occu- pational Therapy, 71, 7111505065p1. https://doi.org/10.5014/ajot.2017.71S1- Bahrami-Nejad, Z., Zhao, M., Tholen, S., Hunerdosse, D., Tkach, K., van Schie, RP102B S., … Teruel, M. (2018). A transcription circuit filters oscillating circadian hormonal inputs to regulate fat cell differentiation. Cell Metabolism, 27, González, K., Fuentes, J., & Márquez, J. (2017). Physical inactivity, sedentary 854–868. https://doi.org/10.1016/j.cmet.2018.03.012 behavior, and chronic diseases. Korean Journal of Family Medicine, 38, 111–115. https://doi.org/10.4082/kjfm.2017.38.3.111 Barclay, K. S., & Forwell, S. J. (2018). Occupational performance issues of adults seeking bariatric surgery for obesity. American Journal of Occupation- Hales, C., Carroll, M., Fryar, C., & Ogden, C. (2017). Prevalence of obesity al Therapy, 72, 7205195030p1–7205195030p10. https://doi.org/10.5014/ among adults and youth: United States, 2015-2016. Retrieved from https:// ajot.2018.025924 www.cdc.gov/nchs/products/databriefs/db288.htm Bellisari, A. (2013). The obesity epidemic in North America: Connecting biology and Haracz, K., Ryan, S., Hazelton, M., & James, C. (2013). Occupational therapy culture. Long Grove, IL: Waveland Press. and obesity: An integrative literature review. Australian Occupational Therapy Journal, 60, 356–365. https://doi.org/10.1111/1440-1630.12063 Bhurosy, T., & Jeewon, R. (2014). Overweight and obesity epidemic in devel- oping countries: A problem with diet, physical activity, or socioeconomic Jensen, M. D., & Ryan, D. H. (2014). New obesity guidelines: promise and status? Scientific World Journal, 964236. https://doi.org/10.1155/2014/964236 potential. Journal of the American Medical Association, 311, 23-24. https://doi. org/10.1001/jama.2013.282546 Ceccarini, M., Borrello, M., Pietrabissa, G., Manzoni, G., & Castelnuovo, G. (2015). Assessing motivation and readiness to change for weight manage- Jensen, M. D., Ryan, D. H., Apovian, C. M., Ard, J. D., Comuzzie, A. G., Donato, ment and control: An in-depth evaluation of three sets of instruments. K. A., … Yanovski, S. Z.. (2013). AHA/ACC/TOS guideline for the manage- Frontiers in Psychology, 6, 511. https://doi.org/10.3389/fpsyg.2015.00511 ment of overweight and obesity in adults: A report of the American College

CE-6 ARTICLE CODE CEA1118 | NOVEMBER 2018 Continuing Education Article Earn .1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See page CE-7 for details.

of Cardiology/American Heart Association Task Force on Practice Guide- lines and the Obesity Society. Journal of the American College of Cardiology, 63, 2985–3023. https://doi.org/10.1016/j.jacc.2013.11.004 Kanerva, N., Larson, P., Peltonen, M., Lindroos, A., & Carlsson, L. (2017). How to Apply for Sociodemographic and lifestyle factors as determinants of energy intake and macronutrient composition: A 10-year follow-up after bariatric surgery. Continuing Education Credit Surgery Obesity Related Disease, 1399, 1572–1583. https://doi.org/10.1016/j. soard.2017.05.025 A. To get pricing information and to register to take the exam online for the Kelishadi, R., Poursafa, P., & Jamshidi, F. (2013). Role of environmental chem- article Managing Obesity in Adults: A Role for Occupational Therapy, go to icals in obesity: A systematic review on the current evidence. Journal of Envi- http://store.aota.org, or call toll-free 800-729-2682. ronmental and Public Health, 896789. https://doi.org/10.1155/2013/896789 B. Once registered and payment received, you will receive instant email Kuo, F., Goebel, L., Satkamp, N., Beauchamp, R., Kurrasch, J., Smith, A., & confirmation. Maguire, J. (2013). Service learning in a pediatric weight management program to address childhood obesity. Occupational Therapy in Health Care, C. Answer the questions to the final exam found on pages CE-7 & CE-8 by 27, 142–162. https://doi.org/10.3109/07380577.2013.780318 November 30, 2020. Kyle, T., & Kuehl, B. (2018). Prescription medications and weight gain. Retrieved D. On successful completion of the exam (a score of 75% or more), you will from https://www.obesityaction.org/community/article-library/prescrip- immediately receive your printable certificate. tion-medications-weight-gain/ National Health System. (2017). Nine medical reasons for putting on weight. Retrieved from https://www.nhs.uk/live-well/healthy-weight/nine-medical- reasons-for-putting-on-weight/ National Institute of Diabetes and Digestive and Kidney Diseases. (2015). Health risks of being overweight. Retrieved from: https://www.niddk.nih.gov/ Managing Obesity in Adults: health-information/weight-management/health-risks-overweight Nossum, R., Johansen, A., & Kjeken, I. (2018). Occupational problems and A Role for Occupational Therapy barriers reported by individuals with obesity. Scandinavian Journal of Occu- pational Therapy, 25, 136–144. https://doi.org/10.1080/11038128.2017 To receive CE credit, exam must be completed by November Parlee, S., & MacDougald, O. (2014). Maternal nutrition and risk of obesity in 30, 2020. offspring: The Trojan horse of developmental plasticity. Biochim Biophy Acta, 1842, 495–506. https://doi.org/10.1016/j.bbadis.2013.07.007 Learning Level: Intermediate Pietrzykowska, N. (2018). Benefits of 5-10 percent weight loss. Retrieved from Target Audience: O ccupational Therapists and Occupational Therapy https://www.obesityaction.org/community/article-library/benefits-of-5-10- percent-weight-loss/ Assistants Porter, L. (2016). Menopause and weight gain. Glendale, CA: Cinahl Informa- Content Focus: Professional Issues; Occupational Therapy Interventions tion Systems. https://www.ebscohost.com/assets-sample content/NutrRC_ QL_Menopause_and_Weight_Gain.pdf Richardson, A., Dietz, W., & Gordon-Larson, P. (2013). The association 1. Occupational causes of weight gain/obesity include all of the between childhood sexual and physical abuse with incident adult severe following except: obesity across 13 years of the National Longitudinal Study of Adolescent Health. Pediatric Obesity, 9, 351–361. https://doi.org/10.1111/j.2047- A. Coping with chronic stress through poor eating habits 6310.2013.00196.x B. Consistently getting less than 6 hours of sleep per night Saliman Reingold, F., & Jordan, K. (2013). Obesity and occupational therapy. C. Decreasing engagement in sedentary leisure activities American Journal of Occupational Therapy, 67, S39–S46. https://doi. org/10.5014/ajot.2013.67S39 D. Reducing activity because of increased pain Tylka, T., Annunziato, R., Burgard, D., Danielsdottir, S., Shuman, E., Davis, C. & Calogero, R. (2014). The weight-inclusive versus weight-normative 2. Common barriers to exercise/physical activity with this popu- approach to health: Evaluation the evidence for prioritizing well-be- ing over weight loss. Journal of Obesity, Article ID 983495. https://doi. lation include: org/10.1155/2014/983495 A. Lack of physical discomfort and pain B. Embarrassment or intimidation C. Nonsupportive family members D. Lack of time

3. When clients experience stigma and discrimination based on weight: A. They may experience decreased access to adequate health care. B. Mood and mental health is not typically affected. C. Engagement in self-care occupations tends to increase. D. It does not affect their health outcomes overall.

ARTICLE CODE CEA1118 | NOVEMBER 2018 ARTICLE CODE CEA1118 | NOVEMBER 2018 CE-7CE-7 CE Article, exam, and certificate are also available ONLINE. Continuing Education Article Register at http://www.aota.org/cea or Earn .1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See page CE-7 for details. call toll-free 877-404-AOTA (2682).

4. The effect of obesity on occupation: 10. A weight loss goal for lifestyle modification treatment should: A. Typically does not involve safety A. Be 5% to 10% of the client’s original weight B. Usually does not involve social occupations B. Be 3% to 5% of the client’s original weight C. Is multifactorial and can involve many aspects of C. Be based on how long the intervention will last occupation D. Always be determined by the physician D. Is not considered a disability 11. Occupational goals for a client with obesity who is receiving 5. Mental health effects of obesity on occupation and participation lifestyle modification treatment: include all of the following except: A. Are often motivating A. Self-esteem B. Are not recommended for lifestyle modification B. Depression C. Should always include a mental health goal C. Psychosis D. Should always include a physical activity goal D. Anxiety 12. Occupational self-analysis 6. Occupational therapy treatment for bariatric surgery involves A. Is when the occupational therapist analyzes the client’s all of the following except: occupations to determine what is contributing to obesity A. Modifying lifestyle for weight loss to improve surgical B. Emphasizes achieving occupational balance outcomes C. Is a standardized and predictable process B. Preparing for occupational changes post surgery D. Supports clients in identifying and changing lifestyle and C. Beginning treatment after bariatric surgery performance patterns to meet their goals D. Assessing readiness for change

7. Which of the following is not recommended? Education, when Now that you have selected your answers, you are provided by an occupational therapist: only one step away from earning your CE credit. A. Is individualized and highly relevant to the client B. Covers standardized information and topics determined Click here to earn your CE by the physician or medical director C. Is engaging and often includes engagement in activity D. Is responsive to the client’s culture and preferences

8. Models commonly used with obesity include all of the following except: A. Ecology of Human Performance B. Model of Human Occupation (MOHO) C. Occupational Adaptation D. The Person, Occupation, Environment (PEO) Model

9. Which of the following in not true? Assessing readiness for change: A. Is informed by the Transtheoretical or Stages of Change Model B. Informs which approach to take when designing treat- ment activities C. Requires a formal assessment tool D. Is common in treatment for obesity

CE-8 ARTICLE CODE CEA1118 | NOVEMBER 2018