Going Beyond Management and Maintenance: Occupational Therapy’s Role in Primary Prevention for Adults at Risk of Obesity

In the past two decades, the prevalence of obesity increased in the United States from 30.5% to 42.4% (Centers for Disease Control and Prevention [CDC], 2022b). Despite widespread health care reform to address the escalation of obesity in our country, the various costs of this public health epidemic continue to rise. In 2016, the overall medical expenditure due to obesity among American adults was $260.6 billion, and a national loss in productivity from obesity-related job absenteeism was estimated to be as high as $6.38 billion annually (Cawley et al., 2021; CDC, 2022a). Although the financial expenses related to obesity are staggering, more concerning may be the costs associated with health and quality of life. People with obesity have been shown to have decreased physical and psychosocial aspects of quality of life as well as increased barriers to engagement in their everyday occupations (Kushner & Foster, 2000,; Nossum et al., 2018). Struggling to perform everyday tasks starts with being overweight (Ilvig & Christensen, 2017). Moreover, obesity is a known risk factor for many chronic diseases that lead to disability and death, including heart disease, type 2 diabetes, hypertension, stroke, and cancer (Kumanyika et al., 2002 ; Xu et al., 2018). This evidence for negative health outcomes underscores the importance of having health care systems invest in solutions that aim to prevent the onset of obesity and target adult populations who are at risk of obesity.

Health care systems in the United States tend to address adult obesity reactively versus proactively. A reactive approach focuses on the management and maintenance of one’s health once obesity has developed (Lemmens et al., 2008,; Pearce et al., 2019). In contrast, a proactive approach, also referred to as primary prevention, focuses on minimizing the onset of a health condition such as obesity (American Occupational Therapy Association [AOTA], 2020a). Primary prevention interventions may be particularly important for mitigating the obesity epidemic because managing and maintaining weight loss is associated with many challenges. Indeed, many people who are classified as obese have demonstrated limited long-term results for weight loss from dietary, lifestyle, and pharmacological interventions (Douketis et al., 2005). In addition, and unfortunately, many of those who see positive results gradually regain the weight (MacLean et al., 2015). Since 2016, the World Health Organization (WHO) has defined obesity as an independent chronic disease (WHO, 2019). Therefore, there is a need for research and practice that further explore primary prevention interventions for obesity specifically. This would involve efforts targeted at individuals known to be at an increased risk for the onset of obesity, including those who are overweight individuals; postmenopausal women; and people with a mental health condition, high blood pressure, type 2 diabetes, chronic pain, or inflammatory diseases (Fruh, 2017). By recognizing current policy and consensus recommendations, the field of occupational therapy can play a key role in moving practice away from a reactive model of health care to a proactive one that emphasizes primary prevention.

Many nationwide initiatives, including the Patient Protection and Affordable Care Act (ACA; 2010; Pub. L. 111-148) and the CDC’s Healthy People initiative, have helped highlight a national shift toward prioritizing primary prevention approaches. The ACA was introduced in 2010 and includes multiple key provisions supporting preventive health services. These provisions included establishing the Prevention and Public Health Fund; creating the National Prevention, Health Promotion and Public Health Council to coordinate national prevention efforts; requiring insurance plans to cover certain preventive care without patient cost-sharing; and increasing Medicare payments for certain preventive services (Berwick et al., 2008; National Conference of State Legislatures, 2011).

The CDC’s Healthy People 2030 initiative added a specific section for preventive care objectives in their update from Healthy People 2020. This section includes 34 goals aimed at improving access to preventive care for people of all ages. One of the goals is to “increase the proportion of adults who get recommended evidence-based preventive health care” (Office of Disease Prevention and Health Promotion, n.d.). Together, the ACA and Healthy People 2030 demonstrate the growing recognition of the need for preventive care in U.S. health services.

These national initiatives have prioritized the coverage of more preventive health services in the United States, including those specific to obesity. For instance, Medicare and multiple insurance providers now cover obesity screening and counseling (Centers for Medicare & Medicaid Services, 2013). Therefore, there are increasing means for reimbursement for providers who intervene in populations who are at risk for acquiring obesity. Policy and payer support should enable occupational therapy practitioners to promote primary prevention services when working with adult populations at risk of obesity.

The foundation of occupational therapy is rooted in the recognition that individuals, their environments, and their occupations dynamically interact to affect their occupational performance (Law et al., 1996). Accordingly, occupational therapy practitioners are uniquely positioned to evaluate people’s personal, environmental, and occupational factors to create a plan of care that is focused on establishing health-promoting routines and habits as well as modifying and optimizing a person’s environment to support appropriate weight management. Occupational therapy’s role in promoting health, including managing routines and habits around food consumption and patterns of occupation, is not new information. The founder of occupational therapy William Rush Dunton, stated back in 1915 that “occupation could be a powerful tool for wellness and health maintenance” (Scaffa et al., 2009). This perspective has been followed up by several influential occupational therapists since then. David Nelson (1997) said, when delivering the Eleanor Clarke Slagle lecture in 1996, “The profession of occupational therapy will flourish [in the 21st century] because occupation, its core, is so basic to human health yet so flexible, depending on the needs of the individual human being” (p. 11). Occupational therapy and health management have thus always been connected. Health management is defined as “occupations focused on developing, managing, and maintaining routines for health and wellness by engaging in self-care with the goal of improving or maintaining health, including self-management, to allow for participation in other occupations” (AOTA, 2020b, p. 77). Seminal papers within the occupational therapy field have demonstrated that health management can be supported by emphasizing preventive health (Hildenbrand & Lamb, 2013 ; Jaffe, 1986; Rider & White, 1986).

Despite occupational therapy’s position to promote the prevention of obesity and even decrease weight, the literature has demonstrated that occupational therapists have been underutilized in addressing weight-related interventions (Nielsen & Christensen, 2018). This is due not only to other health professionals, who might not take occupational therapists into account when working to prevent obesity, but also to occupational therapists themselves. Many occupational therapists identify their role more clearly in secondary and tertiary prevention than in primary prevention (Surrow et al., 2021). Similarly, most research that has addressed occupational therapy weight-related interventions has focused on individuals who are already experiencing obesity.

A 2018 scoping review mapped all weight management interventions for people who were both overweight and obese involving occupational therapists, and only 11 studies in total were found. The review demonstrated that the involvement of occupational therapists promoted short-term weight loss (Nielsen & Christensen, 2018). The profession’s beneficial role in weight-related interventions is further underpinned by an interdisciplinary randomized controlled weight loss program led and developed by occupational therapists (Christensen et al., 2011). The program was 1 of the 11 studies from the review and managed to significantly decrease weight as well as affect other health-related outcomes among both overweight and obese women. These results were sustained and further improved in a 1-yr follow-up (Christensen et al., 2012). Although this research included secondary and tertiary prevention approaches, it also highlighted the promising potential of occupational therapy to focus on minimizing the onset of obesity among at-risk adults.

Despite the promising research demonstrating a valuable role for occupational therapists in obesity prevention, the lack of practitioners who address such interventions in practice will likely necessitate ongoing discussions and education as to what it could look like for the profession to serve individuals who are at risk of obesity. Table 1 is intended to stir some initial discussions and ideas for potential primary prevention interventions that occupational therapy practitioners could address in practice for individuals, groups, and populations that are at risk of obesity.

Occupational therapy interventions focused on establishing and maintaining routines and habits are necessary for improving the health of populations at risk of obesity. Interventions in this realm have been conducted and studied both nationally and internationally. One example intervention in this area is Lifestyle Redesign^®, which was created by occupational therapists at the University of Southern California. It focuses on strategies and opportunities to increase sustainable changes that lead to physical and psychosocial health. It promotes the identification of barriers and options to implement changes in the existing habits and routines using an iterative process of self-analysis and reflection about the relationship among occupation, health, and well-being in one’s everyday life. In Lifestyle Redesign, the therapist also evaluates the individual’s existing lifestyle patterns to create meaningful goals for lifestyle change that become the concentration of future occupational therapy sessions. Lifestyle Redesign has generally been used in weight-related interventions when working with people who have preexisting weight problems. However, this model of Lifestyle Redesign should be examined and adapted for use with populations who are at risk for weight concerns.

Another intervention was conducted by a group of occupational therapist researchers in Denmark, Scandinavia. The intervention is called “DO:IT—Danish Obesity Intervention Trial,” and it has been working to develop a weight loss program to prevent obesity for the past 6 yr (Christensen et al., 2019). The program is based on two of the group’s former weight management interventions, FINALE-Health (Christensen et al., 2011) and the FRIDOM study (Christensen et al., 2016), as well as evidence-based practice developed on the basis of evidence-based medicine by Peter Sackett (Jessen-Winge et al., 2020; Jessen-Winge, Ilvig, Jonsson, et al., 2021,; Nielsen & Christensen, 2018,; Timmermans & Kolker, 2004). The DO:IT intervention is also inspired by Lifestyle Redesign and Ann Willcock’s theories on doing, being, becoming, and belonging (see Hitch et al., 2014). Like Lifestyle Redesign, it focuses primarily on habit change, but it also addresses occupational balance, social support, and engagement in meaningful activities. In addition, the intervention focuses on diet behavior and physical activity and exercise (Jessen-Winge, Ilvig, Fritz, et al., 2021).

The occupational therapy field can be a leader in increasing the recognition and implementation of primary prevention interventions when working with adults who are at risk of obesity. To realize this goal, occupational therapy practitioners should address health management by proactively improving clients’ habits and routines through lifestyle interventions. Occupational therapists should further help clients at risk of obesity by promoting occupational balance, appropriate social support, and engagement in meaningful activities. Occupational therapy researchers should collaborate with prevention scientists and health care systems to further evaluate the efficacy of occupational prevention interventions in outcomes related to obesity. Finally, occupational therapy educators should emphasize the potential impact of primary prevention on adult populations at risk of obesity in curricula that meet Accreditation Council for Occupational Therapy Education (2018) Standard B.3.4. Ultimately, establishing a better understanding of primary prevention through practice, research, and education efforts will improve the health and quality of life for people at risk of obesity.

Although national policy and initiatives continue to underscore the need to prioritize a proactive model of care, the obesity epidemic continues to rise (National Prevention, Health Promotion and Public Health Council, 2011). Despite the known challenges associated with losing weight and maintaining weight loss, little attention is placed on primary prevention interventions in adult populations to avoid the onset of obesity. The ACA and other national initiatives have set a precedent to encourage preventive health care in nearly all settings of practice (CDC, 2022b). Holistically minded occupational therapy practitioners have the skills to provide services to individuals, groups, and populations that are vulnerable to the onset of obesity. Occupational therapy practitioners must move into this health crisis with the recognition that establishing health-promoting routines and habits, creating occupational balance, ensuring adequate social support, and engaging in meaningful activities prior to the onset of obesity are crucial in the long-term prevention of obesity.