Welcome to managing weight an interactive workshop designed to assist general practitioners GPs and

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 cases1 Jenny, 32
years of age, works from home and has a young
family2 Paul, 52 years of age, has type 2
diabetes3 Damian, 37 years of age, is office
worker with back pain4 Sarah, 32 years of age,
is an office administrator5 Susan, 60 years of
age, has mild osteoarthritis
3
Case study 1 Jenny, 32 years of age, works from
home and has a young family Jenny presents for
a change of dressing from a scald a few days ago
the burn is healing well You notice Jenny has
gained weight since last year she had her last
baby 14 months ago Jenny 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 family Jenny 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
working You 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 familyWhile 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 familySome 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 family Weight
measurements can be a sensitive issue with some
patients, eg. long term overweight or obese
patients Agreement 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 Jennys 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 BMI waist 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 cm weight 79 kg blood
pressure (BP) 121/73 mmHg height 165 cm.3.
What is Jennys 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/m2 asks 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 family Jennys BMI is 29
kg/m2 classified as overweight (range 25 29.9
kg/m2) 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 adultsRisk
of type 2 diabetes, hypertension and
CVD.Adapted from NHMRC 2003b
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
Jennys disease risk relative to normal?
15
Case study 1 Jenny, 32 years of age, works from
home and has a young family Jennys disease
risk relative to normal measures is
high.Risk of type 2 diabetes,
hypertension and CVD.Adapted from NHMRC 2003b
16
Case study 1 Jenny, 32 years of age, works from
home and has a young family Clear relationship
between increasing BMI and increasing
mortality Linear or curvilinear
relationship Begins at BMI 2022 kg/m2 True
for males and females May change with age, race
and fitness Cancer 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 family Jenny is
overweight and has a high disease risk for
type 2 diabetes hypertension CVD There 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 family You ask Jenny if
she would be able to return for another
appointment when her test results are ready
In 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 patients motivation to lose weight by
determining their initiative, and previous
attempts, to lose weight how important it is
for them to lose weight (scale of 110) their
confidence in losing weight (scale of 110) how
much weight they expect to lose and the benefits
of losing weight their 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 dont 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 Jennys 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
modelNPS 2002
23
Case study 1 Jenny, 32 years of age, works from
home and has a young family Factors associated
with weight maintenance and regainEl
fhag 2005, NHMRC 2003b
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 obese suggesting
benefits of behaviour change and ways to reduce
risk pinpointing obstacles and methods of
overcoming these obstacles setting 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 obese the 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 Jennys
case this is 48 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 range be able to answer any
questions that Jenny may have and address
perceived barriers discuss the importance of
moderate activity this does not need to be
strenuous, eg. brisk walking provide knowledge,
eg. health benefits associated with weight loss
of 510.
29
Case study 2 Paul, 52 years of age, has type 2
diabetesPaul presents for review after
starting metformin (he is responding
well) is married with three children has a
Maltese background has a family history of
diabetes.
30
Case study 2 Paul, 52 years of age, has type 2
diabetesPaul tells you he is worried about
having diabetes knows how this condition
affected his sister and grandmother knows 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
diabetesExamples 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
diabetesYou 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
days drinks 34 glasses of red wine at night
and a few beers at the weekend has a
sedentary lifestyle and drives everywhere.
33
Case study 2 Paul, 52 years of age, has type 2
diabetesPaul is happy for you to take
measurements to assess his weight height 176
cm weight 105 kg waist circumference 104
cm blood pressure 145/88 mmHg. 2. What is
Pauls BMI?
34
Case study 2 Paul, 52 years of age, has type 2
diabetes3. With a BMI of 33.9 kg/m2, which
weight category does Paul fit into?A.
OverweightB. Normal weightC. Severe obesityD.
Obesity.
35
Case study 2 Paul, 52 years of age, has type 2
diabetesAnswer D. Obesity.Normal weight
BMI 18.524.9 kg/m2Overweight BMI 2529.9
kg/m2Obesity BMI 3039.9 kg/m2Severe obesity
BMI 40 kg/m2
NHMRC 2003b
36
Case study 2 Paul, 52 years of age, has type 2
diabetes4. What comorbidities does Paul have
and what tests might be required?
37
Case study 2 Paul, 52 years of age, has type 2
diabetes Paul has diabetes and is borderline
for developing hypertension The 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
diabetesPauls 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 cholesterol 5.9 mmol/L triglycerides 4.0
mmol/L (target level Foundation CSANZ 2001 2005
39
Case study 2 Paul, 52 years of age, has type 2
diabetesYou 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
diabetesPaul replies, I know that weight is
important in diabetes had an appointment with
a dietician which he didnt attend, but is
willing to give it another try rates his
current motivation at 7/10 may have an
increased motivation of 9/10 if he believes that
losing 57 kg could help him to manage his
diabetes.5. What is Pauls stage of change?
41
Case study 2 Paul, 52 years of age, has type 2
diabetesPaul is in the contemplative
stage.Stages of change modelNPS 2002
42
Case study 2 Paul, 52 years of age, has type 2
diabetes6. 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
diabetes Weight 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 more Paul
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
diabetes7. 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
diabetes With Paul at the contemplative stage,
keep advice simple and realistic A 510 loss
of initial body weight can result in significant
improvements in metabolic health Around 14
kg per month would be a good start, and 14 cm
around the waist per month.
46
Case study 2 Paul, 52 years of age, has type 2
diabetes8. 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
diabetesYou could discuss with Paul disease
risk from being overweight or obese dietary
guidelines and information on the importance of
being in a healthy weight range any questions
that he may have about a weight management
program simple advice to reduce alcohol
consumption importance of moderate intensity
activity.
48
Case study 2 Paul, 52 years of age, has type 2
diabetes9. What advice should you give Paul on
his alcohol intake?
49
Case study 2 Paul, 52 years of age, has type 2
diabetesAlcohol 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
diabetes10. What would be your follow up plan
for Paul?
51
Case study 2 Paul, 52 years of age, has type 2
diabetesPaul should be regularly weighed
when he visits the practice for his diabetes
monitoring have his BP and lipid level checked
regularly be reviewed over time for his stage
of change have his referral to the dietician
followed up.
52
Case study 3 Damian, aged 37 years, is an office
worker with back painDamian presents for a
review of work related back pain after a
consultation with another doctor a month
ago is now much improved, has no pain, and is
back in full time work has 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 pain Raise the topic
of weight gain in the context of comorbidities
You 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 painDamian lets you
know that he lives alone and has been working
full time for the past 4 years generally
eats takeaway as he is too tired to cook does
not do any physical activity drinks about 34
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 painDamian agrees that
you can take measurements to assess his
weight height 182 cm weight 93.2 kg waist
circumference 112 cm blood pressure 135/92
mmHg. 2. What is Damians BMI?
56
Case study 3 Damian, 37 years of age, is an
office worker with back pain3. With a BMI of
28.1 kg/m2, how would you classify Damians
weight?A. Normal weightB. OverweightC.
ObeseD. Severely obese.
57
Case study 3 Damian, 37 years of age, is an
office worker with back painAnswer B.
Overweight.Normal weight BMI 18.524.9
kg/m2Overweight BMI 2529.9
kg/m2Obesity BMI 3039.9 kg/m2Severe obesity
BMI 40 kg/m2
NHMRC 2003b
58
Case study 3 Damian, 37 years of age, is an
office worker with back pain4. Considering
Damians waist circumference and BMI, what is his
disease risk relative to normal
measurements?A. HighB. Extremely highC. Very
HighD. Normal.
59
Case study 3 Damian, 37 years of age, is an
office worker with back painAnswer A.
High.Risk of type 2 diabetes,
hypertension and CVD.Adapted from NHMRC 2003b
60
Case study 3 Damian, 37 years of age, is an
office worker with back painFurther
investigation into Damians family history
reveals that his father died of a heart attack at
48 years of age.5. What are possible
comorbidities associated with Damians
weight?
61
Case study 3 Damian, 37 years of age, is an
office worker with back painDiseases associated
with being overweight or obese include hyperten
sion and dyslipidaemia CHD stroke insulin
resistance and type 2 diabetes.Conditions
associated with excess weight can
include sleep apnoea, daytime sleepiness and
fatigue social isolation and depression lower
back pain, musculoskeletal problems.NHMRC2003a

62
Case study 3 Damian, 37 years of age, is an
office worker with back painDamian is at high
risk of CVD because he is overweight has a
significant family history of CHD (a first degree
relative affected at Damian require a blood lipid test? A. YesB.
No.
63
Case study 3 Damian, 37 years of age, is an
office worker with back painAnswer
Yes. Absolute cardiovascular risk
assessment Initial blood lipid testing is
recommended for adults at high risk of CVD
Damian will also require a fasting blood
glucose test.
64
Case study 3 Damian, 37 years of age, is an
office worker with back painYou 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 painDamian 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 dont like it I really
have to do something about it or it will kill
me Ive started to think about what I eat, and
I have been going for walks every day, but I
think I need some help its all pretty
confusing.
66
Case study 3 Damian, 37 years of age, is an
office worker with back painDamian rates
importance of weight reduction as 8/10, and
confidence of losing weight at 23/10.7. What
is Damians stage of change?
67
Case study 3 Damian, 37 years of age, is an
office worker with back painDamian is in the
preparation stage for healthy eating and the
action stage for physical activity.Stages of
change modelNPS 2002
68
Case study 3 Damian, 37 years of age, is an
office worker with back pain8. 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 painDamian is most
likely to respond best to behavioural approaches,
such as rewarding effort social
support making change in incremental
steps self monitoring.
70
Case study 3 Damian, 37 years of age, is an
office worker with back painMore complex
behavioural interventions, which can be organised
through a psychologist, exercise physiologist or
dietician include self monitoring stimulus
control problem solving cognitive
restructuring social support.
71
Case study 3 Damian, 37 years of age, is an
office worker with back painBefore 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 painAssess why an
energy imbalance has occurred the patients
confidence to change eating and physical
activity behaviours and possible barriers.
73
Case study 3 Damian, 37 years of age, is an
office worker with back pain10. What are some
of the factors that may have influenced
Damians weight gain?
74
Case study 3 Damian, 37 years of age, is an
office worker with back painContributing
factors to Damians weight could
include genetic influences, such as genetic
predisposition previous history of weight loss
and the effects of weight cycling weight gain
at certain life stages, eg. with aging weight
gain with certain life events, eg. giving up
sport family, work, cultural and social
environments stress medical
conditions medical treatments.
75
Case study 3 Damian, 37 years of age, is an
office worker with back pain Food intake and
physical activity are the main components of any
weight loss program An energy imbalance occurs
when rates of energy intake and expenditure
differ over an extended period A positive
energy balance occurs when energy intake exceeds
energy expenditure.11. What sort of
information would you need to assess Damians
energy intake?
76
Case study 3 Damian, 37 years of age, is an
office worker with back painIt is possible to
assess meal patterns, eg. three regular meals
versus a grazing pattern type and amount
(serving sizes) of food eaten eating
behaviours, eg. food preferences, consumption of
fruits, vegetables, grains, and portion
sizes the 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 pain12. How would you
assess Damians physical activity behaviours?
78
Case study 3 Damian, 37 years of age, is an
office worker with back pain GPs 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 pain13. What level of
intervention is required in Damians case?A.
Use public health measures for the general
populationB. Use individual education and skills
trainingC. Use behaviour modification and
medical weight reduction treatmentD.
Medical weight reduction treatment and surgical
treatmentE. Use individual education and skills
training, and behaviour modification.
80
Case study 3 Damian, 37 years of age, is an
office worker with back painAnswer 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 painA stepped model for
overweight/obesity managementAdapted
from NHMRC 2003b
82
Case study 3 Damian, 37 years of age, is an
office worker with back painAlthough not
directly relevant to Damians 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 painContraindications
to physical activity in patients with stable CVD
include unstable angina symptoms (eg. chest
discomfort, shortness of breath) on low
intensity activity uncontrolled cardiac
failure severe aortic stenosis uncontrolled
hypertension (eg. systolic BP 180 mmHg and
diastolic BP 110 mmHg) acute infection or
fever resting tachycardia/arrhythmia uncontrol
led diabetes (eg. blood glucose 15 mmol/L).
84
Case study 3 Damian, 37 years of age, is an
office worker with back pain15. 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 pain The main goals of
any weight loss program are to improve health
outcomes and reduce the risk of disease Men
should aim, long term, for a waist circumference
of 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 painRealistic,
measurable goals for weight and waist size
reduction are shown in the table.Adapte
d from NHMRC 2003b
87
Case study 3 Damian, 37 years of age, is an
office worker with back pain16. How is the
weight management strategy determined?
88
Case study 3 Damian, 37 years of age, is an
office worker with back pain There is no
single best management strategy for long term
weight loss All successful long term weight
management programs involve some form of
lifestyle modification that either reduces an
individuals 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 pain17. 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 realisticB.
Many patients expect to lose up to 35 of
starting weight with current lifestyle and
medical therapyC. Most patient expectations for
weight loss are unrealisticD. 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 painTrue answers 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.
91
Case 4 Sarah, aged 32 years, is an office
administratorSarah presents to you and asks
for advice about her weight gain over the past 5
years, despite changes in her diet is
particularly concerned, as her brother died of a
heart attack asks you about laproscopic
banding.
92
Case 4 Sarah, aged 32 years, is an office
administratorSarah is keen for you to take
measurements to assess her weight height 179
cm weight 110 kg waist circumference 108
cm.1. What is Sarahs BMI?
93
Case 4 Sarah, aged 32 years, is an office
administrator2. With a BMI of 34.3 kg/m2, which
weight category does Sarah fit into?A.
OverweightB. Normal weightC. Severe obesityD.
Obesity.
94
Case 4 Sarah, aged 32 years, is an office
administratorAnswer D. Obesity.Normal weight
BMI 18.524.9 kg/m2Overweight BMI 2529.9
kg/m2Obesity BMI 3039.9 kg/m2Severe obesity
BMI 40 kg/m2
95
Case 4 Sarah, aged 32 years, is an office
administrator3. Considering Sarahs BMI and
waist circumference, what is her disease
risk relative to normal measurements?A. HighB.
Very HighC. Extremely highD. Normal.
96
Case 4 Sarah, aged 32 years, is an office
administratorRisk of type 2 diabetes,
hypertension and CVD.Adapted from NHMRC 2003b
97
Case 4 Sarah, aged 32 years, is an office
administrator4. 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
administratorSarah is obese with a very high
disease risk of type 2 diabetes hypertension
and CHD.There is a need to undertake the
following tests (as part of an absolute
cardiovascular risk assessment) fasting
glucose blood pressure monitoring cholesterol/
lipid screening.
99
Case 4 Sarah, aged 32 years, is an office
administrator5. What is Sarahs stage of change?
100
Case 4 Sarah, aged 32 years, is an office
administratorSarah is in the preparation stage
for physical activity and in the action stage for
healthy eating.Stages of change
modelNPS 2002
101
Case 4 Sarah, aged 32 years, is an office
administrator6. Obesity surgery is (One or
more answers may be correct)A. Indicated for
people with a BMI 35 kg/m2B. Indicated for
people with a BMI 40 kg/m2C. Indicated for
people with a BMI 35 kg/m2 who also have
serious medical comorbiditiesD. Indicated for
people with a BMI 40 kg/m2 who also have
serious medical comorbiditiesE. Never a suitable
option.
102
Case 4 Sarah, aged 32 years, is an office
administrator True answers B. Indicated for
people with a BMI greater than 40 kg/m2 C.
Indicated for people with a BMI greater than 35
kg/m2 who also have serious medical
comorbidities Obesity surgery is increasingly
being used successfully in patients with BMIs
lower than 3540 kg/m2.
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
administrator Medication 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 use Behaviour
modification includes self monitoring, social
support and stimulus control Stress 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
administratorFour prescription medications have
been approved for use in patients with a BMI 30
kg/m2, and in patients with a BMI 27 kg/m2 with
comorbidities phentermine diethylpropion
orlistat sibutramine.
109
Case 4 Sarah, aged 32 years, is an office
administrator10. Combined with lifestyle
modification, what level of weight
reduction can be realistically expected over 12
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
administratorAnswer C. 9 (1 year), 11 (2
years).
111
Case 4 Sarah, aged 32 years, is an office
administratorSarah 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
administrator There is no evidence that
available alternative treatments are
effective Patients 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
administratorYou 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
administratorVery low energy diets under
supervision, can be useful adjunct to behaviour
or drug therapy program (resulting in an 813
weight loss over 12 years) cannot be
maintained long term and should be restricted to
the short term need care to avoid a
rebound weight gain.NHMRC 2003a 2003b
115
Case 4 Sarah, a 32-year-old office
administratorYou think about meal replacement
programs when considering dietary advice.13. Do
meal replacement programs work?
116
Case 4 Sarah, a 32-year-old office
administratorMeal replacements under close
supervision, can result in clinically significant
long term weight losses (58 weight loss over
45 years) are an expensive option need 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
administrator14. What level of intervention
should be used for Sarah? (One or more
options may be correct)A. Public health
measures for the general populationB. Individual
education and skills trainingC. Behaviour
modification and medical weight reduction
treatmentD. Medical weight reduction treatment
and/or surgical treatmentE. Individual education
and skills training, and behaviour
modification.
118
Case 4 Sarah, aged 32 years, is an office
administratorAnswer C. Use behaviour
modification and medical weight reduction
treatment.
119
Case 4 Sarah, aged 32 years, is an office
administratorYou are now considering referring
Sarah.15. What would be appropriate choice(s)
for referral?
120
Case 4 Sarah, aged 32 years, is an office
administratorGeneral practitioners should seek
assistance from health professionals in other
disciplines with specialist knowledge in obesity
management, such as dieticians exercise
physiologists specialist physicians psychologi
sts general practitioners specialising in
weight loss, as part of further referral or
shared care.
121
Case 4 Sarah, aged 32 years, is an office
administratorSarah 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
administratorEffective 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 (6090 mins/day) technique
s available to deal with overeating
sessions regular monitoring of
behaviour pharmacotherapy effective in
maintaining weight loss by lifestyle
modification, provided medication continues to
be used.
123
Case 4 Sarah, aged 32 years, is an office
administrator It 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 people Follow
up may change in form and intensity for weight
loss maintenance.
124
Case 4 Sarah, aged 32 years, is an office
administratorPatient progress should be
reviewed with a fortnightly review
initially monthly after this occasionally
when a healthy weight is achieved to reduce the
risk of weight regain.
125
Case 5 Susan, 60 years of age, has mild
osteoarthritisSusan comes to you for advice
about losing weight, including exercise and
diet is overweight with mild osteoarthritis in
load bearing joints sometimes has mild pain at
the end of the day.
126
Case 5 Susan, 60 years of age, has mild
osteoarthritisSusan says, I really need to
work out what to do How to lose weight. I do
have time during the day to exercise but Im not
sure how much I should exercise, and I think I
also need some help with my diet and Im sure I
would exercise more but Im 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
osteoarthritisMain requirements for dietary
weight loss are reducing total energy
intake sustaining reduced energy intake over
time providing all essential nutrients in
sufficient quantities.NHMRC 2003a
2003b
128
Case 5 Susan, 60 years of age, has mild
osteoarthritis2. What key eating strategies
would you suggest to Susan?
129
Case 5 Susan, 60 years of age, has mild
osteoarthritis Key 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 foods
Other 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
osteoarthritisSusan 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
osteoarthritisMost diet plans work over the
short term because of a reduction in
energy cannot 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
osteoarthritis4. What are the benefits of
physical activity compared to diet in weight
loss?
133
Case 5 Susan, 60 years of age, has mild
osteoarthritis Immediate weight losses are
greater with dietary restriction Long term
weight loss is more likely to be maintained if
patients participate in a regular level of
increased, accumulated physical activity
Pain is a major consideration in Susans 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
osteoarthritisYou 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 Susans
case?A. 30 mins of moderate intensity physical
activity B. 60 mins of lightmoderate intensity
activity over the day C. 60 mins of
moderatehigh intensity activity over the day D.
90 mins of moderatehigh intensity activity over
the day.
135
Case 5 Susan, 60 years of age, has mild
osteoarthritisAnswer B. 60 minutes of
lightmoderate 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
osteoarthritis To demonstrate a health
benefit, prescribe moderate intensity physical
activity (eg. brisk walking or equivalent)
accumulated over 30 mins on most days of the
week To achieve weight loss, prescribe 60 mins
of lightmoderate intensity activity
accumulated over the course of the day on most
days of the week To achieve weight
maintenance, prescribe 6090 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
osteoarthritisPhysical activity advice for
Susan is hydrotherapy or swimming exercise
bicycles simple reductions in sedentary time
(such as watching television).
138
Case 5 Susan, 60 years of age, has mild
osteoarthritis6. How should healthy
eating/physical activity programs be managed?
139
Case 5 Susan, 60 years of age, has mild
osteoarthritisHealthy eating/physical activity
programs can be managed by providing patients
with correct, up-to-date information about
healthy eating and physical activity
providing this information personally, if
possible considering shared care with other
professional disciplines.