Title : Obesity as a state of impaired energy accessibility rather than energy excess: A physiotherapy-led hypothesis supported by preliminary clinical findings
Abstract:
Background: Obesity is traditionally understood as a consequence of chronic positive energy balance. Although this concept remains fundamental, it does not fully explain why some patients demonstrate limited early response despite appropriate adherence to dietary intervention. We propose that, in a subgroup of patients, functional barriers may contribute to this early non-response and may represent modifiable targets within multidisciplinary obesity care.
Objective: To introduce a physiotherapy-led hypothesis that complements the traditional energy-balance model and to present preliminary clinical findings exploring whether addressing functional barriers may enhance responsiveness to dietary intervention in adults with central obesity.
Methods: A randomized pilot clinical study was conducted in adults with central obesity. Following a standardized two-week dietary run-in phase, participants achieving less than 1% reduction in body weight were classified as early non-responders and randomized to continue dietary intervention alone or to receive the same dietary intervention combined with a physiotherapy-led functional program. The physiotherapy pathway targeted clinically relevant barriers through pain modulation, tissue-mobility techniques, diaphragmatic breathing, and interventions aimed at supporting lymphatic function and tissue homeostasis. These interventions were not intended to directly induce fat loss, but to address functional factors that might limit response to nutritional therapy. Waist circumference was the primary outcome, with body-fat percentage assessed as a secondary outcome.
Results: Both groups improved following continued dietary intervention. However, the combined physiotherapy and nutrition group demonstrated a greater reduction in waist circumference (5 cm versus 3 cm) and body-fat percentage (4% versus 2%) than the diet-only group. The consistent direction of change across outcomes provides preliminary support for further investigation of the proposed functional hypothesis.
Conclusion: These preliminary findings suggest that functional barriers may contribute to early resistance to dietary intervention in selected patients with obesity. Physiotherapy is not proposed as a treatment for obesity or a replacement for nutrition; rather, it may serve as a complementary strategy to address pain, impaired tissue mobility, altered breathing mechanics, and tissue-fluid dysfunction that could influence treatment responsiveness. This physiotherapy-led hypothesis offers a complementary functional perspective on obesity management and warrants validation through larger, adequately powered randomized clinical trials.
Keywords: Obesity; Physiotherapy; Clinical Nutrition; Functional Barriers; Early Non-Response; Rehabilitation; Multidisciplinary Obesity Management.
