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Excellent overview of the essential elements of intensive behavioral therapy for obesity management.
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ASK
ASSESS
ADVISE
step 1
ASSI
ST
AGREE
of Obesi
ty
Managem
ent
tIM
e
WAIst
Obesity is a Chronic ConditionObesityisachronicandoftenprogressiveconditionnotunlikediabetesorhypertension.
Successfulobesitymanagementrequiresrealisticandsustainabletreatmentstrategies.
Short-termquick-fixsolutionsfocusingonmaximizingweightlossaregenerallyunsustainableandthereforeassociatedwithhighratesofweightregain.
Key Principles
Obesity Management is About Improving Health and Well-being, and not Simply Reducing Numbers on the ScaleThesuccessofobesitymanagementshouldbemeasuredinimprovementsinhealthandwell-beingratherthanintheamountofweightlost.
Formanypatients,evenmodestreductionsinbodyweightcanleadtosignificantimprovementsinhealthandwell-being.
Key Principles
Early Intervention Means Addressing Root Causes and Removing RoadblocksSuccessfulobesitymanagementrequiresidentifyingandaddressingboththerootcausesofweightgainaswellasthebarrierstoweightmanagement.
Weightgainmayresultfromareductioninmetabolicrate,overeating,orreducedphysicalactivitysecondarytobiological,psychologicalorsocioeconomicfactors.
Manyofthesefactorsalsoposesignificantbarrierstoweightmanagement.
Key Principles
Detour
Success is different for every individual Patientsvaryconsiderablyintheirreadinessandcapacityforweightmanagement.
Successcanbedefinedasbetterquality-of-life,greaterself-esteem,higherenergylevels,improvedoverallhealth,preventionoffurtherweightgain,modest(5%)weightloss,ormaintenanceofthepatientsbestweight.
Key Principlest
IMe
WAIst CIrCuMFereNCe
A patients Best weight may never be an ideal weight AnidealweightorBMIisnotarealisticgoalformanypatientswithobesity,andsettingunachievabletargetssimplysetsuppatientsforfailure.
Instead,helppatientssetweighttargetsbasedonthebestweighttheycansustainwhilestillenjoyingtheirlifeandreapingthebenefitsofimprovedhealth.
Key Principles
Be t
Weightisasensitiveissue.Manypatientsareembarrassedorfearblameandstigma.
ASK for permission to discuss weight
ASK
Be non-judgemental
Explore readiness for change
Use motivational interviewing
Create weight-friendly practice
ASK
Be Non-judgementalDoNOTblame,threaten,orprovokeguiltinyourpatient.
DoNOTmakeassumptionsabouttheirlifestylesormotivation.(yourpatientmayalreadybeonadietorhavealreadylostweight)
Doacknowledgethatweightmanagementisdifficultandhardtosustain.
Judgement
ASK
Use Motivational Interviewing to Move Patients Along the Stages of Change
Mo
tIV
At
IoN
CHANGe
Askquestions,listentopatientscommentsandrespondinawaythatvalidatestheirexperienceandacknowledgesthattheyareincontroloftheirdecisiontochange.
IfpatientsareNOTreadytoaddresstheirweight,bepreparedtoaddresstheirconcernsandotherotherhealthissuesandthenaskifyoucanspeakwiththemabouttheirweightagaininthefuture.
ASK
Explore Readiness for ChangeDeterminingyourpatientsreadinessforbehaviourchangeisessentialforsuccess.
Useapatient-centredcollaborativeapproach.
Initiatingchangewhenpatientsarenotreadycanresultinfrustrationandmayhamperfutureefforts.
CHANGe
ASKM
ot
IVA
tIo
N
CHANGe
Sample Questions on How to Begin a Conversation About Weight:Woulditbealrightifwediscussedyourweight?Areyouconcernedaboutyourweight?Wouldyoubeinterestedinaddressingyourweightatthistime?
Onascaleof0to10,howimportantisitforyoutoloseweightatthistime?
Onascaleof0to10,howconfidentareyouthatyoucanloseweightatthistime?
ASK
Create a Weight-Friendly Practice
Mo
tIV
At
IoN
CHANGe
Facilities:handicappedaccessibility,widedoors,largerestrooms,floor-mountedtoilets
WaitingRoom:sturdy,armlesschairs,appropriatereadingmaterial
ExamRoom:oversizedgowns,scalesover350lbs/160kg,wideandsturdyexamtables,extra-largebloodpressurecuffs,longerneedlesandtourniquets,long-handledshoehorns
ASK
ASSESS obesity related risk and potential root causes of weight gain
ASSESS
Assess Obesity Class and Stage
Assess for Obesity Drivers,
Complications, and Barriers (4Ms)
Assess for Root Causes of Weight Gain
ASSESS
Obesity Stages (EOSS*)
*EdmontonObesityStagingSystem
BMI kg/m2
Underweight 40
WaistCircumferenceRiskThreshold:Europid:>94cm;>80cm;AsianandHispanic:>90cm;>80cm
Stage0:NoApparentRiskFactors
Stage2:EstablishedCo-Morbidity
Stage1:PreclinicalRiskFactors
Stage3:End-OrganDamage
Stage4:End-Stage
Obesity Class
Assess Obesity Class and Stage ObesityClass(I-III)isbasedonBMIandisameasureofhowBIGthepatientis. ObesityStage(0-4)isbasedontheMEDICAl,MENTAl,andFUNCTIONAlimpactofobesityandisameasureofhowHEAlTHythepatientis.
WaistcircumferenceprovidesadditionalinformationregardingCARDIOMETABOlICrisk.
ASSESS
The 4Ms of Obesity
Mental CognitionDepressionAttentionDeficitAddictionPsychosisEatingDisorderTraumaInsomnia
Metabolic Type2DiabetesDyslipidemiaHypertensionGoutFattyliverGallstonesPCOSCancer
MechanicalSleepApneaOsteoarthritisChronicPainRefluxDiseaseIncontinenceThrombosisIntertrigoPlantarFasciitis
MonetaryEducationEmploymentIncomeDisabilityInsuranceBenefitsBariatricSuppliesWeight-lossPrograms
A+
Assess for Obesity Drivers, Complications, and Barriers Usethe4MsframeworktoassessMental,Mechanical,Metabolic,andMonetarydrivers,complications,andbarrierstoweightmanagement.
ASSESS
Assess for Root Causes of Weight Gain
Is weight gain due to slow metabolism?
Is weight gain due to increased food intake?
Is weight gain due to reduced activity?
AgeHormonesGenetics
Low Muscle MassWeight LossMedication
Socio-Cultural FactorsPhysical HungerEmotional Eating
Mental Health IssuesMedication
Socio-Cultural FactorsSocio-Economical Limitations
Physical Limitations / PainEmotional Factors
Medication
Address root causes of low metabolism Address root causes of overeating Address root causes of reduced activity
ASSESS
ADVISE on obesity risks, discussbenefits&options
step 1
ADVISEstep 1
Advise on Obesity Risks
ExplainBenefitsofModestWeightLoss
Explain Need for Long-Term Strategy
Discuss Treatment Options
ADVISEstep 1
Advise on Obesity RisksObesityrisksaremorerelatedtoobesityStagethantoBMI.
FocusoftreatmentshouldbeonIMPROVINGHEAlTHandWEll-BEINGratherthansimplylosingweight.
ADVISEstep 1
Advise on Treatment OptionsAveragesustainableweightlosswithbehaviouralinterventionisabout3-5%ofinitialweight.
DIETARY INTERVENTIONS
SLEEP, TIME, AND STRESS
LOW CALORIE DIETSC
Al
or
Ie
ANTI-OBESITY MEDICATIONS
PHYSICAL ACTIVITY
BARIATRIC SURGERY
PSYCHOLOGICAL
ADVISEstep 1
SLEEP, TIME, AND STRESSmanagementinterventionscansignificantlyimproveeatingandactivitybehaviours.
ADVISEstep 1
DIETARY INTERVENTIONS shouldfocusondecreasingcaloricintakebyimprovingeatingpattern,nutritionalhygiene,andportionsize.Extremeandfaddietsaregenerallynotsustainableinthelong-term.
ADVISEstep 1
PHYSICAL ACTIVITY orexercisealoneisgenerallynotasuccessfulweight-lossstrategy.Ratherthanfocusingonburningcalories,activityinterventionsshouldaimatreducingsedentarinessandincreasingdailyphysicalactivitylevelstopromotefitness,overallhealth,andgeneralwell-being.
ADVISEstep 1
PSYCHOLOGICALinterventionscanimproveself-esteem,reduceemotionaleating,andpromotenon-foodcopingstrategies.
ADVISEstep 1
LOW CALORIE DIETS (medicallysupervised)andmealreplacementscanbesafeandeffectiveapproachesforpatientsrequiringagreaterdegreeofweightloss.
CA
lo
rIe
ADVISEstep 1
ANTI-OBESITY MEDICATIONS, inconjunctionwithbehaviouralinterventions,canhelppatientsachieveandsustain5-10%weightloss.Discontinuationofmedicationsgenerallyresultsinweightregain.
ADVISEstep 1
BARIATRIC SURGERY shouldbeconsideredforallpatientsrequiringmorethan15%sustainableweightloss.Modernlaparoscopicbariatricsurgeryisbothsafeandeffective,andsubstantiallyreducesmorbidityandmortality.Allsurgicalpatientsrequiremultidisciplinarypresurgicalassessmentandlong-termmedical,nutritional,andpsychosocialsupport.
ADVISEstep 1
AGREE on realistic weight-loss expectations and on a SMART plan to
achieve behavioural goals
AGREE
Agree on Weight Loss Expectations
Agree on Sustainable Behavioural Goals and Health Outcomes
Agree on Treatment Plan
AGREE
Agree on Weight Loss ExpectationsUnrealisticweight-lossexpectationscanleadtoDISAPPOINTMENTandNON-ADHERENCE.
Areasonableweight-losstargetwithbehaviouralandmedicalinterventionsis0.5to1.0kgperweekforatotalof5to10%ofinitialweight,afterwhichweightlosswillgenerallyplateau.
Agreaterormorerapidweightlosswithnon-surgicalinterventionsdoesnotresultinbetterlong-termoutcomes.
Forsomepatients,PREVENTIONorSlOWINGofWEIGHTGAINmaybetheonlyrealisticweighttarget.
AGREE
Agree on Sustainable Behavioural Goals and Health OutcomesFocusonsustainablebehaviouralchangesratherthanonspecificweighttargets.
BehaviouralgoalsshouldbeSMART:SpecificMeasurableAchievableRewardingTimely
Self-monitoringwithalifestylejournalhelpsinitiateandsustainbehaviouralchange.
plAN
AGREE
Agree on Treatment PlanTreatmentplansshouldbeREAlISTICandSUSTAINABlE.
ObesitytreatmentshouldbeginwithADDRESSINGtheDRIVERSofweightgain(e.g.stress,lackoftime,depression,sleepapnea,chronicpain,etc.).
TheSUCCESSoftreatmentshouldbemeasuredinimprovementsinHEAlTHandWEll-BEING(e.g.improvebloodpressure,increasefitness,increaseenergy,increasemobility,etc.).
AGREE
ASSISTinaddressingdrivers&barriers,offereducation&resources,referto
provider, and arrange follow-up
ASSIST
Assist Patient in Identifying and Addressing Drivers and Barriers
Provide Education and Resources
Refer to Appropriate Provider
Arrange Follow-Up
ASSIST
Assist Patient in Identifying and Addressing Drivers and BarriersDriversandbarriersmayincludeENVIRONMENTAl,SOCIOECONOMICAl,EMOTIONAl,orMEDICAlfactors.
Obesogenicmedications(e.g.atypicalantipsychotics,anti-diabetics,anti-convulsants,etc.)maymakeobesitymanagementdifficult.
PHySICAlBARRIERSthatlimitaccess(transportation,turnstiles,limitedseating,etc.)ininstitutionalsettings,workplaces,andrecreationalfacilities,maydeterfromactiveparticipationineverydaylife.
probleM
ASSIST
Provide Education and Resources
PatientEDUCATIONiscentraltoself-management.HelppatientsidentifyandseekoutCREDIBlEweight-managementinformationandresources.
probleM
ASSIST
Refer to Appropriate ProviderEvidencesupportstheneedforanINTERDISCIPlINARyteamapproachtoobesitymanagement.
Choiceofappropriateprovider(e.g.physician,nurse,dietitian,psychologist,socialworker,exercisephysiologist,PT/OT,surgeon,etc.)shouldreflectidentifiedDRIVERSandCOMPlICATIONSofobesityaswellasBARRIERStoweightmanagement.
ASSIST
Arrange Follow-Up
Giventhechronicrelapsingnatureofobesity,lONG-TERMfollow-upisESSENTIAl.
SuccessisdirectlyrelatedtoFREQUENCyofprovidercontact.
Weight-regain(relapse)shouldnotbeframedasfailurerather,itisthenaturalandEXPECTEDconsequenceofdealingwithachroniccondition.
Appt.
16
ASSIST
lauDC,DouketisJD,MorrisonKM,HramiakIM,SharmaAM,UrE;ObesityCanadaClinicalPracticeGuidelinesExpertPanel.2006CanadianClinicalPracticeGuidelinesOnTheManagementAndPreventionOfObesityInAdultsAndChildren.CMAJ.2007;176:S1-13.
PadwalRS,PajewskiNM,AllisonDB,SharmaAM.UsingtheEdmontonobesitystagingsystemtopredictmortalityinapopulation-representativecohortofpeoplewithoverweightandobesity.CMAJ.2011;183:E1059-66
SharmaAM.M,M,M&M:amnemonicforassessingobesity.ObesRev.2010;11:808-9.
MauroM,TaylorV,WhartonS,SharmaAM.BarriersToObesityTreatment.EurJInternMed.2008;3:173-80.
SharmaAM,PadwalR.ObesityIsASign-Over-EatingIsASymptom:AnAetiologicalFrameworkForTheAssessmentAndManagementOfObesity.ObesRev.2010;11:362-370.
KirkSF,PenneyTl,McHughTl,SharmaAM.Effectiveweightmanagementpractice:areviewofthelifestyleinterventionevidence.IntJObes2011;36:178-85.
TaylorVH,McIntyreRS,RemingtonG,levitanRD,StonehockerB,SharmaAM.Beyondpharmacotherapy:understandingthelinksbetweenobesityandchronicmentalillness.CanJPsychiatry.2012;57:5-12.
KarmaliS,StoklossaCJ,SharmaA,StadnykJ,ChristiansenS,CottreauD,BirchDW.BariatricSurgery:aPrimer.CanFamPhys.2010;56:873-9.
Professional ResourcesSignupatwww.obesitynetwork.catobecomeamemberoftheCanadianObesityNetwork,CanadasnationalobesityNGOwithaccessto
additionalobesityeducation,resources,andnetworkingopportunitieswithnationalobesityexperts.
TheOnlineBestEvidenceServiceInTacklingobesity+(OBESITy+)providedbyMcMasterUniversitysHealthInformationResearchUnit
(accessibleatwww.obesitynetwork.ca)providesaccesstothecurrentbestevidenceaboutthecauses,course,diagnosis,prevention,
treatment,andeconomicsofobesityanditsrelatedmetabolicandmechanicalcomplications.
TheCanadianAssociationofBariatricPhysiciansandSurgeons(www.cabps.ca)representsCanadianspecialistsinterestedinthetreatment
ofobesityandsevereobesityforthepurposesofprofessionaldevelopmentandcoordinationandpromotionofcommongoals.
DietitiansofCanada(www.dietitians.ca)isthenationalprofessionalassociationfordietitians,representingalmost6000membersatthe
local,provincialandnationallevels.Practice-basedEvidenceinNutrition(PEN),designedforbusyhealthprofessionals,isanonlinedatabase
availablebysubscriptionthatprovidesevidence-basedanswerstoeverydayfoodandnutritionpracticequestions.
TheCanadianSocietyforExercisePhysiology(www.csep.ca)isavoluntaryorganizationcomposedofprofessionalsinterestedandinvolved
inthescientificstudyofexercisephysiology,exercisebiochemistry,fitnessandhealth.VisittodownloadCanadianPhysicalActivityand
SedentaryBehaviourGuidelines.
Key References
GeetaAchyuthan,MD,MCFP(Regina,SK),AndrewCave,MD,FCFP,FRCGP(UniversityofAlberta,AB),EleanorBenterud,RN,BN,MN,(SouthCalgaryPrimaryCareNetwork,AB),DeniseCampbell-Scherer,MD,PhD,CCFP(UniversityofAlberta,AB),CydCourchesne,OMM,CD,MD,MCFP,DAvMed,CHE,(CanadianArmedForces),HeatherDavis,MD,FRCPC,(Health&Wellness,Gov.ofNS),RobertDent,MD,FRCPC,(OttawaHospital,ON),EricDucet,PhD,(UniversityofOttawa,ON),AngelaEstey,RN,MSc,(AlbertaHealthServices),MaryForhan,OTReg(Ont),PhD(McMasterUniversity,ON),yoniFreedhoff,MD,CCFP,(BariatricMedicalInstitute,Ottawa,ON),TraceyHusseyMSc,RD,(HamiltonFamilyHealthTeam,ON),BrendaGluska,(OntarioMinistryofHealthandlongTermCare),ShahzeerKarmali,MD,FRCSC,(UniversityofAlberta,AB),SaraKirk,PhD,(DalhousieUniversity,NS),Marie-FrancelangloisMD,FRCPC,CSPQ(UniversitdeSherbrooke,QC),DavidC.W.lau,MD,FRCPC,(UniversityofCalgary,AB),Anthonylevinson,MD,FRCPC,(McMasterUniversity,ON),PatriciaMarturano,(TheCollegeofFamilyPhysiciansofCanada),RajPadwal,MD,FRCPC,(UniversityofAlberta,AB),HelenaPiccinini-Vallis,MD,CCFP,(Halifax,NS),PaulPoirier,MD,PhD,FRCPC,(Universitlaval,QC),ValerieTaylor,MD,PhD,FRCPC,(UniversityofToronto,ON),RickTytus,MD,CCFP,(HamiltonAcademyofMedicine),ShahebinaWaljiMD,CCFP,(CalgaryWeightManagementCentre,AB),SeanWhartonMD,FRCPC,(WhartonMedicalClinic,ON),RonWilsonMD,CCFP,(Vancouver,BC).
NoticeandDisclaimer:Nopartofthesematerialsmaybereproduced,storedinaretrievalsystem,ortransmitted,inanyformorbyanymeans,electronic,
mechanical,photocopying,recordingorotherwisewithoutpriorwrittenpermissionfromtheCanadianObesityNetwork-Rseau
canadienenobsit(CON-RCO).TheopinionsinthisbookletarethoseoftheauthorsanddonotnecessarilyrepresentthoseofCON-
RCO.Thisbookletisprovidedontheunderstandingandbasisthatnoneofthepublisher,theauthors,orotherpersonsinvolvedinits
creationshallberesponsiblefortheaccuracyorcurrencyofthecontents,orfortheresultsofanyactiontakenonthebasisofthe
informationcontainedinthisbookorforanyerrorsoromissionscontainedherein.Noreadershouldactonthebasisofanymatter
containedinthisbookletwithoutobtainingappropriateprofessionaladvice.Thepublisher,theauthors,andotherpersonsinvolvedin
thisbookletdisclaimliabilityandresponsibilityresultingfromanyideas,products,orpracticesmentionedinthetextanddisclaimalland
anyliabilityandresponsibilitytoanyperson,regardlessofwhethersuchpersonpurchasedthisbooklet,forlossordamageduetoerrors
andomissionsinthisbookandinrespectofanythingandoftheconsequenceofanythingdoneoromittedtobedonebysuchpersonin
relianceuponthecontentofthisbooklet.
Foradditionalinformationandresourcesonobesitypreventionandmanagement,pleaserefertoourwebsiteatwww.obesitynetwork.ca
ThisbookletwasdevelopedbyAryaM.Sharma,MD/PhD,FRCPC,andMichaelVallis,PhD,withtheCON-RCOCanadianObesityNetworkPrimaryPracticeWorkingGroup.*
ThisbookletispublishedbytheCanadianObesityNetworkwithsupportfromthePublicHealthAgencyofCanadaandtheCanadianInstitutesofHealthResearch.
*WorkingGroupMembers:
Patient ResourcesPublicHealthAgencyofCanada
Thissite(www.publichealth.gc.ca)hasimportantinformationforpatientsonhealthyactivelivingandonnumerousobesity-relatedhealthproblemsincludinghypertension,diabetes,sleepapnea,mentalillness,andarthritis.
CanadianObesityNetwork
AdditionalpatienteducationalandinformationmaterialsonobesitymanagementcanbeorderedinbulkfromCONbycontactinginfo@obesitynetwork.ca
Informationonotherobesityrelatedhealthproblemscanbefoundat:
CanadianMentalHealthAssociationwww.cmha.caHeartDisease:www.heartandstroke.caHypertension:www.hypertension.caDiabetes:www.diabetes.caArthritis:www.arthritis.caSleepApnea:www.lung.caFattyliverDisease:www.liver.caReproductiveHealth:www.cwhn.caBariatricSurgery:www.asmbs.orgIncontinence:www.canadiancontinence.caChronicPain:www.canadianpainsociety.caPsychology:www.psychologyfoundation.orgAbdominalAdiposity:www.myhealthywaist.org
ASK for Permission to Discuss Weight
ASSESS obesity related risk and potential root causes of weight gain
ADVISE on obesity risks, discuss benefits&options
step 1
AGREE on realistic weight-loss expectations and on a SMART plan to
achieve behavioural goals
ASSISTinaddressingdrivers&barriers,offereducation&resources,referto
provider, and arrange follow-up