Obesity has reached pandemic proportions globally and its management requires a multipronged approach to ensure an effectual and sustainable response. Integrating behavioural therapy is an important component in obesity management and would often lead to improvement in the quality of care provided to patients with obesity. Though important, it is often complex and difficult to administer in a busy outpatient department. We propose a Motivation-Opportunity-Capability(MOC) model, using Michie et al's COM-B ideation as an inspiration. This provides a simple framework to understand the behaviour of a patient with obesity and suggest therapeutic strategies more likely to be effective in a person centric manner. Integration of the MOC model in existing obesity management protocols would further help in improving outcomes of therapy and help in providing sustained weight loss.
Keywords: Behavioral therapy, Motivation, Obesity management, Opportunity, Overweight, Person centred care.
Obesity has reached pandemic proportions across the world.1 The syndrome of obesity is characterized by multiple risk and etiologic factors, wide spectrum of presentations and complications, and diverse treatment strategies.2 One aspect, however, is common to all management plans: behavioural therapy.
The management of obesity is challenging, partly because of limited efficacy of current medical interventions and partly due to suboptimal adherence to therapy.3 One reason for inability to achieve optimal weight, in many individuals, is the difficulty in modifying behaviour and poor recognition of common underlying psychological factors.4
Understanding Behavioural Change
Many theories have been proposed to explain the concepts of motivation and behavioural change. The COM-B (capability, opportunity, motivation-behaviour) behaviour change wheel, proposed by Michie S et al (2011) is a useful tool to understand barriers to patient adherence.5 This framework can also be used to help improve adherence to therapy in various chronic conditions including tobacco cessation.5
It is also important to ensure that behavioural therapy is administered in patient centric manner.6 The factors related to obesity that affect the health-related quality of life in different individuals has shown to be different across different quartiles of BMI and will need to be addressed specifically.7 For obesity care, the COM-B behaviour change wheel, proposed by Michie S et al, 2011, is better analyzed it its reverse: MOC. We use the MOC framework to explore the journey of a person with obesity, and identify potential blocks to therapy (Table).
This rubric also helps suggest interventions to overcome these blocks.
Each individual has differing reasons for motivation. Based upon needs, wishes and preferences at a particular time, motivation to reduce weight may be short term or long term. Someone, for example, may be motivated by the need to 'look good' before marriage, while another person may wish to achieve better cardiovascular health. The 'need for achievement' of a preferred weight may predominate in some, while 'fear of failure' of slipping into unwanted weight category may operate elsewhere.
The comorbid conditions and complications associated with obesity, and the discomfort and disability associated with them, may be motivating cues as well. These can be addressed as the 4M mnemonic: metabolic, musculoskeletal/ mechanical, mood-related and monetary/psychosocial.8 The barophysician who understands the spectrum of obesity and its ramifications can identify the correct motivational strategy for each person with obesity.
The first step to successful obesity care will be acceptance of the need for change, along with willingness to acquire new skills. This must be tempered with appreciation of available support system, as well as barriers that need to be modified.9
Once the individual is motivated to achieve weight loss, the next bridge, or block, towards behavioural change, is opportunity.
Health care may or may not be available, accessible and/ or affordable to many people. Even if health care is available, chronic metabolic care provision may be suboptimal. All metabolic care teams may not focus adequately on weight management, due to several reasons. It is also possible that the health care team is unable to demonstrate empathy in an affable manner. This too, may limit opportunity for sustained interaction.
The concept of affability overlaps with capability. The health care team should be capable of delivering good quality care for weight management. Obesity care is a multidisciplinary effort, and the team should be able to offer dietary and exercise advice, behavioural support pharmacological and surgical therapy, as required. All this should be done in a flexible, person-friendly, non-judgmental manner. The person with obesity should feel empowered, and feel that the obesity care team supports her or him with the required empathy and expertise.
The team should be able to help her or him attain required information and knowledge to self-manage lifestyle, adhere to therapy, and address unexpected barriers, with or without the help of the physician. The team itself should also encourage active participation by the person's family, and make them capable of providing a weight-friendly environment at home.
The MOC framework can be used by the obesity team for introspection. This will help improve our service quality. We should be able to improve
1. Motivational skills, for individual patients and the public at large
2. Opportunity for persons to get obesity care, by improving our availability, accessibility, affordability
3. Capability to deliver good quality care, by improving our skills (both soft and hard), and being more responsive to the individual's needs.
A multipronged approach is required to address the problems associated with obesity in any given patient. Integrating behavioural therapy is an important component in obesity management and would often lead to improvement in the quality of care provided to patients with obesity. Integration of the MOC (Motivation, Opportunity and Capability) model in existing obesity management protocols would further help in improving outcomes of therapy and help in providing sustained weight loss.
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