Box B: Common barriers to weight management ...

Advice for patients ...
 

Box A: Obesity related diseases and conditions5 Hypertension Dyslipidaemia Coronary heart disease Impaired glucose tolerance Type 2 diabetes mellitus Sleep apnoea Restrictive pulmonary dysfunction Obesity-hypoventilation syndrome Ischaemic stroke Gallstones Non-alcoholic steatohepatitis Musculoskeletal disease: Osteoarthritis Hyperuricaemia Gout Malignancy: Cancer of the colon Endometrial cancer Postmenopausal breast cancer Reproductive function: Menstrual irregularity Infertility Gestational diabetes Neural tube defects Other health conditions: Carpal tunnel syndrome Venous insufficiency Deep vein thrombosis Poor wound healing

Box B: Common barriers to weight management and strategies to overcome them Attitudinal/psychological Patient has failed past diets Encourage patient to forgo the "diet mentality" and emphasise the overall benefits of "lifestyle change." Emphasise modest weight loss goals and gradual weight reduction over time. Encourage patient to be forgiving when goals are not met, and stress that with each attempt the likelihood of success increases. Unrealistic goals; patient seems overwhelmed or discouraged Caution patient not to make too many dietary changes at once or to be overly ambitious when beginning exercise programme. Emphasise small behavioural changes over time. Patient complains of cravings or feelings of deprivation Caution patient not to fast or "skip" meals as this may lead to subsequent episodes of overeating or binge eating. Similarly, designation of "forbidden foods" may set patient up for failure. Allow all foods in moderation (within total caloric goals). Patients with severe difficulties may benefit from increased protein consumption. Patient has poor understanding of basic nutritional principles If available, refer to nutritionist. Provide printed or web based educational resources. Patient dislikes or does not have enough time for exercise Stress the total health benefits of increased physical activity. Encourage patient to increase overall level of physical activity in all aspects of life (for example, by using stairs instead of lifts or escalators, parking as far away from building entrances as possible, walking dog, dancing with partner, taking children on outings, gardening). Depression, substance misuse, or binge eating disorder Refer for psychological assessment or treatment Physical Patient has comorbidities or is too physically debilitated or afraid to exercise Assure patient that all can safely increase level of physical activity. If needed, arrange for initial medical supervision or assistance (for example, physical therapy). Modify exercise regimen to adapt to physical restrictions and gradually increase duration and intensity when possible Socioeconomic status Patient believes that "healthy" foods are too expensive Point out that eating less costs less. Emphasise the health costs of processed and fast foods. Discourage reliance on prepackaged "diet" foods, which are often expensive. Recommend consumption of low cost, high nutritional value foods such as beans, eggs, fruits, and vegetables. Patient "can’t afford" to join private health club or buy expensive exercise equipment Assure patient that one of the best exercises is walking. Other resources may be available at community centres. Family Patient believes that he or she must eat "different" foods from spouse and children Persuade patient that all family members will obtain health benefits from a change in lifestyle. Suggest introducing dietary changes to family slowly and gradually. "Sabotage" by spouse or partner Educate spouse on need or ways to be supportive; refer couples for counselling if needed. Cultural High fat traditional foods Negotiate reductions in the frequency or amount of traditional foods consumed or assist patient in finding low fat modifications Environmental Patient lives in high crime area and is afraid to exercise outdoors Explore other venues with patient (for example, does patient feel safer exercising near workplace or in neighbourhood of relative or friend? Are exercise facilities available at a community centre? Could patient organise a walking group?)

Advice for patients (adapted from NHLBI Obesity Education Initiative^W1 and Brownell^W2)

Forget about fad diets that rely on short term "quick fixes." Make a commitment to long term lifestyle change, which includes reducing caloric intake and increasing the level of physical activity.

Aim for a modest weight loss of 5-10% of initial body weight. With success, and if warranted, further weight loss can be attempted. Plan for an average weight loss of 1 or 2 lb (0.45 or 0.90 kg) per week over a period of 6 months, with subsequent goals based on the amount of weight lost. Even with the best effort, weight loss may not be consistent, so do not be discouraged by short term plateaus or minor increases from week to week. Look for a downward trend over time.

Focus on gradually changing behaviour over time. Do not try to make too many changes at once. Do not commit to any changes that cannot be maintained over a lifetime (for example, I’m never going to eat cookies), which can set yourself up for failure.

The use of a diary to monitor your daily food intake and level of physical activity can help you become more aware of your behaviour and help you achieve your weight loss goals. Remember, if you change your behaviour, the weight loss will follow.

An eating plan that reduces your caloric intake by 500 to 1000 kcal a day should be an integral part of any programme aimed at achieving a weight loss of 1 or 2 lb (0.45 or 0.90 kg) a week.

Reducing dietary fat is a practical way to reduce calories, but this alone is not sufficient for weight loss. Reducing dietary fat along with reducing dietary carbohydrates can help reduce calories.

Decrease your intake of products containing refined sugar and flour; choose complex carbohydrates instead (whole grains, vegetables, and fruits). Eat adequate amounts of protein and fibre rich carbohydrates to meet basic nutritional needs and to control hunger. Avoid fried foods when possible and explore other methods of cooking (for example, broiling, steaming).

Do not skip meals or fast as this may cause you to overeat at subsequent meals.

Increasing physical activity:

· Helps to promote and maintain weight loss

· May decrease abdominal fat

· Increases cardiorespiratory fitness.

If you are currently active, initially strive for a gradual increase to moderate levels of physical activity of 30 to 45 minutes, 3 to 5 days a week. Aim for a longer term goal of a total of 30 minutes or more of moderate intensity activity on most, or preferably all, days of the week.

If you are currently inactive or have one or more chronic medical illnesses, ask your physician for advice on the best way to begin and gradually increase your level of activity. Almost all patients can safely participate in and benefit from increased physical activity.

If you avoid exercise because you are too embarrassed or equate it with competitive sports, remember that the goal is to increase your overall level of movement. Many enjoyable activities, such as walking and dancing, can fulfil this purpose. Incorporating increased physical activity into your daily routine (such as using stairs instead of the lifts or escalators) can also be helpful. The more physically active you are, the more likely you are to be successful in losing weight.

W1 NHLBI Obesity Education Initiative. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: the evidence report. Washington: National Institutes of Health; Jun 1998.

W2 Brownell KD. LEARN program for weight management 2000. Dallas, TX: American Health, 2000.