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Welcome to managing weight – an interactive workshop designed to assist general practitioners (GPs) and their practice staff to address weight management.

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Presentation on theme: "Welcome to managing weight – an interactive workshop designed to assist general practitioners (GPs) and their practice staff to address weight management."— Presentation transcript:

1 Welcome to managing weight – an interactive workshop designed to assist general practitioners (GPs) and their practice staff to address weight management with patients who are overweight or obese to improve their health and prevent disease.

2 SLIDE PRESENTATION 5 mini cases 1: Jenny, 32 years of age, works from home and has a young family 2: Paul, 52 years of age, has type 2 diabetes 3: Damian, 37 years of age, is office worker with back pain 4: Sarah, 32 years of age, is an office administrator 5: Susan, 60 years of age, has mild osteoarthritis

3 Case study 1: Jenny, 32 years of age, works from home and has a young familyJenny presents for a change of dressing from a scald a few days ago – the burn is healing wellYou notice Jenny has gained weight since last year; she had her last baby 14 months agoJenny is otherwise well and has no family history of cardiovascular disease (CVD).

4 Case study 1: Jenny, 32 years of age, works from home and has a young familyJenny lives with her husband and two children (14 months and 3 years) and works from home – most of her time is spent looking after the children and workingYou ask Jenny about her diet, which is quite good: – eats plenty of vegetables – fat intake seems quite high (full fat milk, cream, cheese, eating out)Jenny has never had a cholesterol or blood lipid test done.

5 Case study 1: Jenny, 32 years of age, works from home and has a young family While you are changing the dressing you decide to raise the topic of weight gain. This may be a sensitive topic to bring up and a nonjudgmental approach is important. 1. How would you raise the topic of weight gain with Jenny?

6 Case study 1: Jenny, 32 years of age, works from home and has a young family Some examples of specific weight related questions could be:Have you noticed a change in your weight over the past year or so?Have you had any concerns about your weight?Is your weight a concern for you?

7 Case study 1: Jenny, 32 years of age, works from home and has a young familyWeight measurements can be a sensitive issue with some patients, eg. long term overweight or obese patientsAgreement should be reached between the clinician and the patient about: – whether to take measurements – whether/when, if measurements are taken, the patient wishes to be told the results.

8 Case study 1: Jenny, 32 years of age, works from home and has a young family While sensitively discussing Jenny’s weight with her, you ask if you can take some measurements and she agrees. 2. What is the most appropriate method of assessing health risks associated with excess weight?

9 Case study 1: Jenny, 32 years of age, works from home and has a young family The most useful indicator of risk and relative change is a combination of:BMIwaist circumference.

10 Case study 1: Jenny, 32 years of age, works from home and has a young family You take some measurements and, just out of interest, Jenny would like to know what these are:waist circumference 90 cmweight 79 kgblood pressure (BP) 121/73 mmHgheight 165 cm. 3. What is Jenny’s BMI?

11 Case study 1: Jenny, 32 years of age, works from home and has a young family Jenny:has a BMI of 29 kg/m 2asks you if she is overweight. 4. What level of BMI indicates that a person may be overweight?

12 Case study 1: Jenny, 32 years of age, works from home and has a young familyJenny’s BMI is 29 kg/m 2 ; classified as overweight (range 25– 29.9 kg/m 2 )However, BMI is not always an accurate predictor of body fat or fat distribution, particularly in: – older people – muscular and mesomorphic individuals, eg. athletes.

13 Case study 1: Jenny, 32 years of age, works from home and has a young family Combining BMI and waist measurement to assess overweight and obesity and disease risk* in adults *Risk of type 2 diabetes, hypertension and CVD. Adapted from NHMRC 2003b DISEASE RISK* Waist circumference BMI (kg/m 2 ) Male <102 cm; Female <88 cmMale >102 cm; Female >88 cm 18.5–24.9 (normal)–High 25–29.9 (overweight)ElevatedHigh 30–39.9 (obesity)High–very highVery high ≥40 (severe obesity)Extremely high

14 Case study 1: Jenny, 32 years of age, works from home and has a young family Being overweight or obese is associated with a number of comorbidities caused by metabolic complications and/or the excess weight itself. 5. What is Jenny’s disease risk relative to normal?

15 Case study 1: Jenny, 32 years of age, works from home and has a young family Jenny’s disease risk relative to normal measures is high. *Risk of type 2 diabetes, hypertension and CVD. Adapted from NHMRC 2003b DISEASE RISK* Waist circumference BMI (kg/m 2 ) Male <102 cm; Female <88 cmMale >102 cm; Female >88 cm 18.5–24.9 (normal)–High 25–29.9 (overweight)ElevatedHigh 30–39.9 (obesity)High–very highVery high ≥40 (severe obesity)Extremely high

16 Case study 1: Jenny, 32 years of age, works from home and has a young family Clear relationship between increasing BMI and increasing mortalityLinear or curvilinear relationshipBegins at BMI ~20–22 kg/m 2True for males and femalesMay change with age, race and fitnessCancer and CVD are the main causes of the elevated mortality. NHMRC 2003a

17 Case study 1: Jenny, 32 years of age, works from home and has a young family You let Jenny know that according to current recommended levels she is overweight, and discuss possible comorbidities and the need for screening tests. 6. What are the:potential comorbidities that Jenny may be facing?screening tests that may be required?

18 Case study 1: Jenny, 32 years of age, works from home and has a young familyJenny is overweight and has a high disease risk for: – type 2 diabetes – hypertension – CVDThere is a need to consider the following tests: – fasting glucose – fasting cholesterol/lipid screening.

19 Case study 1: Jenny, 32 years of age, works from home and has a young familyYou ask Jenny if she would be able to return for another appointment when her test results are readyIn the meantime, you talk to Jenny about the benefits of losing weight as a preventive action to reduce disease risk. 7. What questions could you ask Jenny to gauge her motivation to lose weight?

20 Case study 1: Jenny, 32 years of age, works from home and has a young family The GP can assess the patient’s motivation to lose weight by determining:their initiative, and previous attempts, to lose weighthow important it is for them to lose weight (scale of 1–10)their confidence in losing weight (scale of 1–10)how much weight they expect to lose and the benefits of losing weighttheir readiness to change.

21 Case study 1: Jenny, 32 years of age, works from home and has a young family Weight gain is common at various life stages, eg. after pregnancy. Jenny says, ‘Putting on weight after pregnancy is normal. I don’t think there would be too many benefits of trying to lose weight at the moment. And anyway with a young child and a 3 year old, exercise is the last thing on my mind’. 8. What is Jenny’s stage of change?

22 Case study 1: Jenny, 32 years of age, works from home and has a young family Jenny is in the precontemplative stage. Stages of change model NPS 2002 PrecontemplationContemplationPreparationActionMaintenance No changing behaviour thoughts Having need for change thoughts but no action taken Ready to act to change Trying to change behaviour and avoid triggers Behaviour has changed, adjustment being made, and working to avoid relapse

23 Case study 1: Jenny, 32 years of age, works from home and has a young family Factors associated with weight maintenance and regain Elfhag 2005, NHMRC 2003b RegainMaintenance Uninhibited eating Emotion/stress eating Psychological stressors Psychopathology Sedentary lifestyle Dichotomous thinking Very low energy diets not followed up with other treatments Achieving a weight loss goal Regular meals Having breakfast Self monitoring Coping capacity Life stability

24 Case study 1: Jenny, 32 years of age, works from home and has a young family At the moment Jenny is NOT motivated to change. 9. How would you assist Jenny to manage her weight?

25 Case study 1: Jenny, 32 years of age, works from home and has a young family Patients in the early stages of readiness (precontemplation, contemplation and preparation) respond best to cognitive approaches, such as:pointing out the risks of being overweight or obesesuggesting benefits of behaviour change and ways to reduce riskpinpointing obstacles and methods of overcoming these obstaclessetting manageable goals.

26 Case study 1: Jenny, 32 years of age, works from home and has a young family 10. What are some of the issues you could discuss in a brief intervention that could help Jenny?

27 Case study 1: Jenny, 32 years of age, works from home and has a young family In a brief intervention, provide written information, and discuss:and personalise disease risk due to being overweight or obesethe benefits of losing weight, and how much weight needs to be lost for a benefit to be gained. Highlight that losing as little as 5– 10% of starting weight can have important health benefits. In Jenny’s case this is 4–8 kg.

28 Case study 1: Jenny, 32 years of age, works from home and has a young family In a brief intervention:discuss dietary guidelines and information on the importance of being in a healthy weight rangebe able to answer any questions that Jenny may have and address perceived barriersdiscuss the importance of moderate activity; this does not need to be strenuous, eg. brisk walkingprovide knowledge, eg. health benefits associated with weight loss of 5–10%.

29 Case study 2: Paul, 52 years of age, has type 2 diabetes Paul:presents for review after starting metformin (he is responding well)is married with three childrenhas a Maltese backgroundhas a family history of diabetes.

30 Case study 2: Paul, 52 years of age, has type 2 diabetes Paul:tells you he is worried about having diabetesknows how this condition affected his sister and grandmotherknows that Maltese people have a higher rate of diabetes. 1. How would you raise the topic of weight management with Paul?

31 Case study 2: Paul, 52 years of age, has type 2 diabetes Examples of appropriate questions could be:Are you aware of the link between diabetes and being overweight?Are you happy with your current weight?Have you considered losing weight as part of your diabetes management?

32 Case study 2: Paul, 52 years of age, has type 2 diabetes You ask Paul about his current lifestyle in relation to diet and exercise. He:is ‘not good with vegetables’frequently eats restaurants and buys lunch on most daysdrinks 3–4 glasses of red wine at night and a ‘few beers’ at the weekendhas a sedentary lifestyle and drives everywhere.

33 Case study 2: Paul, 52 years of age, has type 2 diabetes Paul is happy for you to take measurements to assess his weight:height 176 cmweight 105 kgwaist circumference 104 cmblood pressure 145/88 mmHg. 2. What is Paul’s BMI?

34 Case study 2: Paul, 52 years of age, has type 2 diabetes 3. With a BMI of 33.9 kg/m 2, which weight category does Paul fit into? A. Overweight B. Normal weight C. Severe obesity D. Obesity.

35 Case study 2: Paul, 52 years of age, has type 2 diabetes Answer D. Obesity. Normal weight: BMI 18.5–24.9 kg/m 2 Overweight: BMI 25–29.9 kg/m 2 Obesity:BMI 30–39.9 kg/m 2 Severe obesity: BMI ≥40 kg/m 2 NHMRC 2003b

36 Case study 2: Paul, 52 years of age, has type 2 diabetes 4. What comorbidities does Paul have and what tests might be required?

37 Case study 2: Paul, 52 years of age, has type 2 diabetesPaul has diabetes and is borderline for developing hypertensionThe following tests are required: – fasting glucose – cholesterol/lipid testing – absolute cardiovascular risk assessment.

38 Case study 2: Paul, 52 years of age, has type 2 diabetes Paul’s last cholesterol screen was taken over 1 year ago and his LDL-C and triglyceride levels were not on target:HDL-C – 1.8 mmol/L (target level >1.0 mmol/L)LDL-C – 3.1 mmol/L (target level <2.5 mmol/L)total cholesterol – 5.9 mmol/Ltriglycerides – 4.0 mmol/L (target level <1.5 mmol/L). Heart Foundation & CSANZ 2001 & 2005

39 Case study 2: Paul, 52 years of age, has type 2 diabetes You emphasise to Paul how weight reduction and an increase in activity will help his diabetes, cardiovascular risk and general wellbeing.

40 Case study 2: Paul, 52 years of age, has type 2 diabetes Paul:replies, ‘I know that weight is important in diabetes’had an appointment with a dietician which he didn’t attend, but is willing to give it another tryrates his current motivation at 7/10may have an increased motivation of 9/10 if he believes that losing 5–7 kg could help him to manage his diabetes. 5. What is Paul’s stage of change?

41 Case study 2: Paul, 52 years of age, has type 2 diabetes Paul is in the contemplative stage. Stages of change model NPS 2002 PrecontemplationContemplationPreparationActionMaintenance No changing behaviour thoughts Having need for change thoughts but no action taken Ready to act to change Trying to change behaviour and avoid triggers Behaviour has changed, adjustment being made, and working to avoid relapse

42 Case study 2: Paul, 52 years of age, has type 2 diabetes 6. Paul asks you about the benefits of losing weight. What is your answer?

43 Case study 2: Paul, 52 years of age, has type 2 diabetesWeight loss may help Paul to: – improve his blood glucose control – lower his BP – reduce his risk of developing other conditions such as osteoarthritis – feel better in general and be able to do morePaul also needs to know that diabetes is a condition that will not go away.

44 Case study 2: Paul, 52 years of age, has type 2 diabetes 7. Paul asks you how much weight he would have to lose in order to gain these benefits. What is your answer?

45 Case study 2: Paul, 52 years of age, has type 2 diabetesWith Paul at the contemplative stage, keep advice simple and realisticA 5–10% loss of initial body weight can result in significant improvements in metabolic healthAround 1–4 kg per month would be a good start, and 1–4 cm around the waist per month.

46 Case study 2: Paul, 52 years of age, has type 2 diabetes 8. What other types of brief advice could you discuss with Paul at this stage?

47 Case study 2: Paul, 52 years of age, has type 2 diabetes You could discuss with Paul:disease risk from being overweight or obesedietary guidelines and information on the importance of being in a healthy weight rangeany questions that he may have about a weight management programsimple advice to reduce alcohol consumptionimportance of moderate intensity activity.

48 Case study 2: Paul, 52 years of age, has type 2 diabetes 9. What advice should you give Paul on his alcohol intake?

49 Case study 2: Paul, 52 years of age, has type 2 diabetes Alcohol intake should be limited to low risk drinking levels, ie. no more than 2 standard drinks per day.

50 Case study 2: Paul, 52 years of age, has type 2 diabetes 10. What would be your follow up plan for Paul?

51 Case study 2: Paul, 52 years of age, has type 2 diabetes Paul should:be regularly weighed when he visits the practice for his diabetes monitoringhave his BP and lipid level checked regularlybe reviewed over time for his stage of changehave his referral to the dietician followed up.

52 Case study 3: Damian, aged 37 years, is an office worker with back pain Damian:presents for a review of work related back pain after a consultation with another doctor a month agois now much improved, has no pain, and is back in full time workhas gained a lot of weight since you last saw him, which was at a visit 3 years ago. 1. How would you raise the topic of weight gain with Damian?

53 Case study 3: Damian, 37 years of age, is an office worker with back painRaise the topic of weight gain in the context of comorbiditiesYou could ask Damian, ‘Are you aware that being overweight makes you more prone to back problems?’

54 Case study 3: Damian, 37 years of age, is an office worker with back pain Damian:lets you know that he lives alone and has been working full time for the past 4 yearsgenerally eats ‘takeaway’ as he is too tired to cookdoes not do any physical activitydrinks about 3–4 glasses of red wine when he goes out to dinner (about 2 nights a week) and also drinks beer at the pub.

55 Case study 3: Damian, 37 years of age, is an office worker with back pain Damian agrees that you can take measurements to assess his weight:height 182 cmweight 93.2 kgwaist circumference 112 cmblood pressure 135/92 mmHg. 2. What is Damian’s BMI?

56 Case study 3: Damian, 37 years of age, is an office worker with back pain 3. With a BMI of 28.1 kg/m 2, how would you classify Damian’s weight? A. Normal weight B. Overweight C. Obese D. Severely obese.

57 Case study 3: Damian, 37 years of age, is an office worker with back pain Answer B. Overweight. Normal weight: BMI 18.5–24.9 kg/m 2 Overweight: BMI 25–29.9 kg/m 2 Obesity:BMI 30–39.9 kg/m 2 Severe obesity: BMI ≥40 kg/m 2 NHMRC 2003b

58 Case study 3: Damian, 37 years of age, is an office worker with back pain 4. Considering Damian’s waist circumference and BMI, what is his disease risk relative to normal measurements? A. High B. Extremely high C. Very High D. Normal.

59 Case study 3: Damian, 37 years of age, is an office worker with back pain Answer A. High. *Risk of type 2 diabetes, hypertension and CVD. Adapted from NHMRC 2003b DISEASE RISK* Waist circumference BMI (kg/m 2 ) Male <102 cm; Female <88 cmMale >102 cm; Female >88 cm 18.5–24.9 (normal)–High 25–29.9 (overweight)ElevatedHigh 30–39.9 (obesity)High–very highVery high ≥ 40 (severe obesity)Extremely high

60 Case study 3: Damian, 37 years of age, is an office worker with back pain Further investigation into Damian’s family history reveals that his father died of a heart attack at 48 years of age. 5. What are possible comorbidities associated with Damian’s weight?

61 Case study 3: Damian, 37 years of age, is an office worker with back pain Diseases associated with being overweight or obese include:hypertension and dyslipidaemiaCHDstrokeinsulin resistance and type 2 diabetes. Conditions associated with excess weight can include:sleep apnoea, daytime sleepiness and fatiguesocial isolation and depressionlower back pain, musculoskeletal problems. NHMRC2003a

62 Case study 3: Damian, 37 years of age, is an office worker with back pain Damian is at high risk of CVD because he:is overweighthas a significant family history of CHD (a first degree relative affected at <60 years). 6. Does Damian require a blood lipid test? A. Yes B. No.

63 Case study 3: Damian, 37 years of age, is an office worker with back pain Answer: Yes.Absolute cardiovascular risk assessmentInitial blood lipid testing is recommended for adults at high risk of CVDDamian will also require a fasting blood glucose test.

64 Case study 3: Damian, 37 years of age, is an office worker with back pain You explain to Damian how weight reduction and being physically active will help his cardiovascular risk and general wellbeing.

65 Case study 3: Damian, 37 years of age, is an office worker with back pain Damian knows he should do ‘something’ about his current weight but at the moment it is not one of his highest priorities. Damian explains:my weight has slowly gone up and I don’t like itI really have to do something about it or it will kill meI‘ve started to think about what I eat, and I have been going for walks every day, but I think I need some help – it’s all pretty confusing.

66 Case study 3: Damian, 37 years of age, is an office worker with back pain Damian rates importance of weight reduction as 8/10, and confidence of losing weight at 2–3/ What is Damian’s stage of change?

67 Case study 3: Damian, 37 years of age, is an office worker with back pain Damian is in the preparation stage for healthy eating and the action stage for physical activity. Stages of change model NPS 2002 PrecontemplationContemplationPreparationActionMaintenance No changing behaviour thoughts Having need for change thoughts but no action taken Ready to act to change Trying to change behaviour and avoid triggers Behaviour has changed, adjustment being made, and working to avoid relapse

68 Case study 3: Damian, 37 years of age, is an office worker with back pain 8. What would be the most appropriate way of managing Damian in this stage of change?

69 Case study 3: Damian, 37 years of age, is an office worker with back pain Damian is most likely to respond best to behavioural approaches, such as:rewarding effortsocial supportmaking change in incremental stepsself monitoring.

70 Case study 3: Damian, 37 years of age, is an office worker with back pain More complex behavioural interventions, which can be organised through a psychologist, exercise physiologist or dietician include:self monitoringstimulus controlproblem solvingcognitive restructuringsocial support.

71 Case study 3: Damian, 37 years of age, is an office worker with back pain Before deciding on an appropriate weight management plan, further patient assessments need to be made. 9. Identify three important further assessments before deciding your course of treatment.

72 Case study 3: Damian, 37 years of age, is an office worker with back pain Assess:why an energy imbalance has occurredthe patient’s confidence to changeeating and physical activity behaviours and possible barriers.

73 Case study 3: Damian, 37 years of age, is an office worker with back pain 10. What are some of the factors that may have influenced Damian’s weight gain?

74 Case study 3: Damian, 37 years of age, is an office worker with back pain Contributing factors to Damian’s weight could include:genetic influences, such as genetic predispositionprevious history of weight loss and the effects of weight cyclingweight gain at certain life stages, eg. with agingweight gain with certain life events, eg. giving up sportfamily, work, cultural and social environmentsstressmedical conditionsmedical treatments.

75 Case study 3: Damian, 37 years of age, is an office worker with back painFood intake and physical activity are the main components of any weight loss programAn energy imbalance occurs when rates of energy intake and expenditure differ over an extended periodA positive energy balance occurs when energy intake exceeds energy expenditure. 11. What sort of information would you need to assess Damian’s energy intake?

76 Case study 3: Damian, 37 years of age, is an office worker with back pain It is possible to assess:meal patterns, eg. three regular meals versus a grazing patterntype and amount (serving sizes) of food eateneating behaviours, eg. food preferences, consumption of fruits, vegetables, grains, and portion sizesthe presence of a disordered eating pattern in addition to obesity, eg. binge eating, night eating, or comfort eating.

77 Case study 3: Damian, 37 years of age, is an office worker with back pain 12. How would you assess Damian’s physical activity behaviours?

78 Case study 3: Damian, 37 years of age, is an office worker with back painGPs can assess: – hours of television viewing – hours of sedentary activity – amount of activity at work – participation in organised physical activity – minutes of moderate/vigorous intensity activity/day – amount of incidental activity/day (such as gardening)It may also be useful for Damian to keep a dairy of daily sedentary activity and physical activity.

79 Case study 3: Damian, 37 years of age, is an office worker with back pain 13. What level of intervention is required in Damian’s case? A. Use public health measures for the general population B. Use individual education and skills training C. Use behaviour modification and medical weight reduction treatment D. Medical weight reduction treatment and surgical treatment E. Use individual education and skills training, and behaviour modification.

80 Case study 3: Damian, 37 years of age, is an office worker with back pain Answer: E. Use individual education and skills training, and behaviour modification. NHMRC 2003b

81 Case study 3: Damian, 37 years of age, is an office worker with back pain A stepped model for overweight/obesity management Adapted from NHMRC 2003b Education and awareness Education & skills Behaviour modification Medication and/or surgery General population Overweight/obese individuals Overweight/obese individuals + disordered eating/cognition BMI >30kg/m 2 or BMI >27kg/m 2 + risk factors Target population Interventions

82 Case study 3: Damian, 37 years of age, is an office worker with back pain Although not directly relevant to Damian’s case, we need to know when recommending physical activity is contraindicated. 14. What are the contraindications for recommending increased physical activity in someone with CVD?

83 Case study 3: Damian, 37 years of age, is an office worker with back pain Contraindications to physical activity in patients with stable CVD include:unstable anginasymptoms (eg. chest discomfort, shortness of breath) on low intensity activityuncontrolled cardiac failuresevere aortic stenosisuncontrolled hypertension (eg. systolic BP ≥180 mmHg and diastolic BP ≥110 mmHg)acute infection or feverresting tachycardia/arrhythmiauncontrolled diabetes (eg. blood glucose 15 mmol/L).

84 Case study 3: Damian, 37 years of age, is an office worker with back pain 15. What should be the main goals of a weight loss program?

85 Case study 3: Damian, 37 years of age, is an office worker with back painThe main goals of any weight loss program are to improve health outcomes and reduce the risk of diseaseMen should aim, long term, for a waist circumference of <102 cm and women <88 cmAchieving a 5–10% loss of initial body weight can result in significant improvements in metabolic health.

86 Case study 3: Damian, 37 years of age, is an office worker with back pain Realistic, measurable goals for weight and waist size reduction are shown in the table. Adapted from NHMRC 2003b TimeframeWeight lossWaist circumference Short term1–4 kg/month1–4 cm/month Medium term10% of start weight5% (6 weeks) Long term10–20% of start weight ♀ < 88 cm (Europid) ♂ < 102 cm (Europid)

87 Case study 3: Damian, 37 years of age, is an office worker with back pain 16. How is the weight management strategy determined?

88 Case study 3: Damian, 37 years of age, is an office worker with back painThere is no single best management strategy for long term weight lossAll successful long term weight management programs involve some form of lifestyle modification that either: – reduces an individual’s energy intake (fewer kilojoules) – increases his or her energy expenditure (more physical activity), creating a net energy deficit.

89 Case study 3: Damian, 37 years of age, is an office worker with back pain 17. How do patients’ expectations for weight loss compare with reality? Which of the following patient expectations or statements are TRUE? One or more answers may be correct. A. Most patient expectations for weight loss are realistic B. Many patients expect to lose up to 35% of starting weight with current lifestyle and medical therapy C. Most patient expectations for weight loss are unrealistic D. Many patients expect to lose up to 20% of starting weight with current lifestyle and medical therapy.

90 Case study 3: Damian, 37 years of age, is an office worker with back pain True answers:B. Many patients expect to lose up to 35% of starting weight with current lifestyle and medical therapyC. Most patient expectations for weight loss are unrealistic.

91 Case 4: Sarah, aged 32 years, is an office administrator Sarah:presents to you and asks for advice about her weight gain over the past 5 years, despite changes in her dietis particularly concerned, as her brother died of a heart attackasks you about laproscopic banding.

92 Case 4: Sarah, aged 32 years, is an office administrator Sarah is keen for you to take measurements to assess her weight:height 179 cmweight 110 kgwaist circumference 108 cm. 1. What is Sarah’s BMI?

93 Case 4: Sarah, aged 32 years, is an office administrator 2. With a BMI of 34.3 kg/m 2, which weight category does Sarah fit into? A. Overweight B. Normal weight C. Severe obesity D. Obesity.

94 Case 4: Sarah, aged 32 years, is an office administrator Answer D. Obesity. Normal weight: BMI 18.5–24.9 kg/m 2 Overweight: BMI 25–29.9 kg/m 2 Obesity:BMI 30–39.9 kg/m 2 Severe obesity: BMI ≥40 kg/m 2

95 Case 4: Sarah, aged 32 years, is an office administrator 3. Considering Sarah’s BMI and waist circumference, what is her disease risk relative to normal measurements? A. High B. Very High C. Extremely high D. Normal.

96 Case 4: Sarah, aged 32 years, is an office administrator *Risk of type 2 diabetes, hypertension and CVD. Adapted from NHMRC 2003b Answer B. Very high.DISEASE RISK* Waist circumference BMI (kg/m 2 ) Male <102 cm; Female <88 cmMale >102 cm; Female >88 cm 18.5–24.9 (normal)–High 25–29.9 (overweight)ElevatedHigh 30–39.9 (obesity)High–very highVery high ≥ 40 (severe obesity)Extremely high

97 Case 4: Sarah, aged 32 years, is an office administrator 4. Discuss any potential obesity associated conditions that Sarah may be facing and tests that may be required.

98 Case 4: aged 32 years, is an office administrator Sarah is obese with a very high disease risk of:type 2 diabeteshypertension and CHD. There is a need to undertake the following tests (as part of an absolute cardiovascular risk assessment):fasting glucoseblood pressure monitoringcholesterol/lipid screening.

99 Case 4: Sarah, aged 32 years, is an office administrator 5. What is Sarah’s stage of change?

100 Case 4: Sarah, aged 32 years, is an office administrator Sarah is in the preparation stage for physical activity and in the action stage for healthy eating. Stages of change model NPS 2002 PrecontemplationContemplationPreparationActionMaintenance No changing behaviour thoughts Having need for change thoughts but no action taken Ready to act to change Trying to change behaviour and avoid triggers Behaviour has changed, adjustment being made, and working to avoid relapse

101 Case 4: Sarah, aged 32 years, is an office administrator 6. Obesity surgery is: (One or more answers may be correct) A. Indicated for people with a BMI > 35 kg/m 2 B. Indicated for people with a BMI > 40 kg/m 2 C. Indicated for people with a BMI > 35 kg/m 2 who also have serious medical comorbidities D. Indicated for people with a BMI > 40 kg/m 2 who also have serious medical comorbidities E. Never a suitable option.

102 Case 4: Sarah, aged 32 years, is an office administratorTrue answers: B. Indicated for people with a BMI greater than 40 kg/m 2 C. Indicated for people with a BMI greater than 35 kg/m 2 who also have serious medical comorbiditiesObesity surgery is increasingly being used successfully in patients with BMIs lower than 35–40 kg/m 2.

103 Case 4: Sarah, aged 32 years, is an office administrator 7. What are the specific risks of obesity surgery?

104 Case 4: Sarah, aged 32 years, is an office administrator Obesity surgery, like other treatments resulting in sudden weight loss, is often associated with impaired absorption of micronutrients. This requires close monitoring, and frequently folate or vitamin B supplements.

105 Case 4: Sarah, aged 32 years, is an office administrator 8. Are there other options for Sarah at this stage?

106 Case 4: Sarah, aged 32 years, is an office administratorMedication: – is a useful adjunct to lifestyle change for weight loss in specific circumstances, in conjunction with a comprehensive weight loss program – may be one of the four prescription pharmacotherapies that have been approved for useBehaviour modification: – includes self monitoring, social support and stimulus controlStress management: – may help other treatments, although there is little evidence for this.

107 Case 4: Sarah, aged 32 years, is an office administrator 9. What are the current medications available for obesity?

108 Case 4: Sarah, aged 32 years, is an office administrator Four prescription medications have been approved for use in patients with a BMI >30 kg/m 2, and in patients with a BMI >27 kg/m 2 with comorbidities:phenterminediethylpropionorlistatsibutramine.

109 Case 4: Sarah, aged 32 years, is an office administrator 10. Combined with lifestyle modification, what level of weight reduction can be realistically expected over 1–2 years with medication (orlistat or sibutramine)? A. 5% (1 year), 10% (2 years) B. 10% (1 year), 11% (2 years) C. 9% (1 year), 11% (2 years) D. 7% (1 year), 10% (2 years).

110 Case 4: Sarah, aged 32 years, is an office administrator Answer C. 9% (1 year), 11% (2 years).

111 Case 4: Sarah, aged 32 years, is an office administrator Sarah asks you if a natural weight loss medication she saw in a health food store that increases metabolism can help her lose weight? 11. How do you reply to Sarah?

112 Case 4: Sarah, aged 32 years, is an office administratorThere is no evidence that available alternative treatments are effectivePatients should be advised about the lack of evidence for using over-the-counter weight loss medications.

113 Case 4: Sarah, aged 32 years, is an office administrator You take into account the effectiveness of very low energy diets when considering dietary advice. 12. What is the role of very low energy diets?

114 Case 4: Sarah, a 32-year-old office administrator Very low energy diets:under supervision, can be useful adjunct to behaviour or drug therapy program (resulting in an 8–13% weight loss over 1–2 years)cannot be maintained long term and should be restricted to the short termneed care to avoid a ‘rebound’ weight gain. NHMRC 2003a & 2003b

115 Case 4: Sarah, a 32-year-old office administrator You think about meal replacement programs when considering dietary advice. 13. Do meal replacement programs work?

116 Case 4: Sarah, a 32-year-old office administrator Meal replacements:under close supervision, can result in clinically significant long term weight losses (5–8% weight loss over 4–5 years)are an expensive optionneed to be used in conjunction with nutritional management and dietary changes for successful longer term weight maintenance. NHMRC 2003a & 2003b

117 Case 4: Sarah, aged 32 years, is an office administrator 14. What level of intervention should be used for Sarah? (One or more options may be correct) A. Public health measures for the general population B. Individual education and skills training C. Behaviour modification and medical weight reduction treatment D. Medical weight reduction treatment and/or surgical treatment E. Individual education and skills training, and behaviour modification.

118 Case 4: Sarah, aged 32 years, is an office administrator Answer C. Use behaviour modification and medical weight reduction treatment.

119 Case 4: Sarah, aged 32 years, is an office administrator You are now considering referring Sarah. 15. What would be appropriate choice(s) for referral?

120 Case 4: Sarah, aged 32 years, is an office administrator General practitioners should seek assistance from health professionals in other disciplines with specialist knowledge in obesity management, such as:dieticiansexercise physiologistsspecialist physicianspsychologistsgeneral practitioners specialising in weight loss, as part of further referral or shared care.

121 Case 4: Sarah, aged 32 years, is an office administrator Sarah is motivated to lose weight and wants to know the best way of keeping her weight down in the longer term. 16. What factors are associated with long term weight loss?

122 Case 4: Sarah, aged 32 years, is an office administrator Effective methods for long term weight loss maintenance include:sustainable changes in eating program (reduced fat, energy controlled eating plan)regular activity of an increased duration (60–90 mins/day)techniques available to deal with overeating sessionsregular monitoring of behaviourpharmacotherapy – effective in maintaining weight loss by lifestyle modification, provided medication continues to be used.

123 Case 4: Sarah, aged 32 years, is an office administratorIt is also important to review and provide regular assistance for weight management and maintenance of weight change (alter program as required)In general, lifelong monitoring and maintenance is required for post-obese and overweight peopleFollow up may change in form and intensity for weight loss maintenance.

124 Case 4: Sarah, aged 32 years, is an office administrator Patient progress should be reviewed:with a fortnightly review initiallymonthly after thisoccasionally when a healthy weight is achieved to reduce the risk of weight regain.

125 Case 5: Susan, 60 years of age, has mild osteoarthritis Susan:comes to you for advice about losing weight, including exercise and dietis overweight with mild osteoarthritis in load bearing jointssometimes has mild pain at the end of the day.

126 Case 5: Susan, 60 years of age, has mild osteoarthritis Susan says, ‘I really need to work out what to do … How to lose weight. I do have time during the day to exercise but I’m not sure how much I should exercise, and I think I also need some help with my diet and … I’m sure I would exercise more but I’m afraid it will be too painful with the arthritis.’ 1. What are the main goals of dietary change required for weight loss?

127 Case 5: Susan, 60 years of age, has mild osteoarthritis Main requirements for dietary weight loss are:reducing total energy intakesustaining reduced energy intake over timeproviding all essential nutrients in sufficient quantities. NHMRC 2003a & 2003b

128 Case 5: Susan, 60 years of age, has mild osteoarthritis 2. What key eating strategies would you suggest to Susan?

129 Case 5: Susan, 60 years of age, has mild osteoarthritisKey eating strategies include: – restricting saturated fat intake – adopting an energy controlled eating plan – recognising poor nutritional choices and reduce hidden sources of empty kilojoules and saturated fat – consuming high fibre, increased protein, and low glycaemic index foodsOther dietary changes to consider include reducing consumption of energy dense foods and drinks and portion sizes.

130 Case 5: Susan, 60 years of age, has mild osteoarthritis Susan lets you know that she is thinking of trying a new diet that she read about in a magazine. 3. What is the role of special diet plans?

131 Case 5: Susan, 60 years of age, has mild osteoarthritis Most diet plans:work over the short term because of a reduction in energycannot usually be maintained over the longer term and do not result in permanent weight loss. NHMRC 2003a & 2003b

132 Case 5: Susan, 60 years of age, has mild osteoarthritis 4. What are the benefits of physical activity compared to diet in weight loss?

133 Case 5: Susan, 60 years of age, has mild osteoarthritisImmediate weight losses are greater with dietary restrictionLong term weight loss is more likely to be maintained if patients participate in a regular level of increased, accumulated physical activityPain is a major consideration in Susan’s case so: – provide physical activity options that support her weight and protect her joints – assessing which joints are affected may help to tailor a program suited to her needs, eg. cycling or hydrotherapy.

134 Case 5: Susan, 60 years of age, has mild osteoarthritis You talk to Susan about physical activity and the amount of activity she should try to aim for during her day. 5. What amount of physical activity on most days of the week should be prescribed for weight loss in Susan’s case? A. 30 mins of moderate intensity physical activity B. 60 mins of light–moderate intensity activity over the day C. 60 mins of moderate–high intensity activity over the day D. 90 mins of moderate–high intensity activity over the day.

135 Case 5: Susan, 60 years of age, has mild osteoarthritis Answer B. 60 minutes of light–moderate intensity activity over the day.Any movement is better than none; more is better than a little.

136 Case 5: Susan, 60 years of age, has mild osteoarthritisTo demonstrate a health benefit, prescribe moderate intensity physical activity (eg. brisk walking or equivalent) accumulated over 30 mins on most days of the weekTo achieve weight loss, prescribe 60 mins of light–moderate intensity activity accumulated over the course of the day on most days of the weekTo achieve weight maintenance, prescribe 60–90 mins of moderate intensity activity accumulated over the course of the day on most days of the week.

137 Case 5: Susan, 60 years of age, has mild osteoarthritis Physical activity advice for Susan is:hydrotherapy or swimmingexercise bicyclessimple reductions in sedentary time (such as watching television).

138 Case 5: Susan, 60 years of age, has mild osteoarthritis 6. How should healthy eating/physical activity programs be managed?

139 Case 5: Susan, 60 years of age, has mild osteoarthritis Healthy eating/physical activity programs can be managed by:providing patients with correct, up-to-date information about healthy eating and physical activityproviding this information personally, if possibleconsidering shared care with other professional disciplines.


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