Weight Management

An increasingly wide range of patients of different age, ethnicity and social background often combined with other clinical conditions such as diabetes, cardiovascular disease or osteoporosis now find themselves battling against obesity and many health professionals become frustrated, feeling ill-equipped to handle each unique case with the one-size-fits-all approach offered by the "eat less, exercise more" mantra. Weight Management: A Practitioner′s Guide explains how effective evidence-based programmes structured in a manner addressing the key components of diet and physical activity integrated with a behavioural approach could offer the solution to the obesity epidemic. This exciting new book from renowned experts Dympna Pearson and Clare Grace provides practitioners and those studying to become practitioners and public health professionals with a much needed modern guide that clearly presents the latest evidence underpinning treatments and uses a step-wise approach to implementing programmes and building skills and confidence. Written with the express needs of practitioners and related health professionals at its core, this book will be a ready reference for those working in both acute and community settings throughout the different and demanding stages of the weight management process. ∗ A practical guide to tackling weight management ∗ Covers diet, exercise and behavioural therapy ∗ Written for health professionals, by health professionals ∗ Includes advice on continuity of care and handling group programmes CONTENTS Section 1 Background Information 1 1 Why Treat Obesity? 3 What is the scale of the obesity problem? 3 Why does it matter? 3 Obesity and early death 4 Obesity and type 2 diabetes 4 Obesity and cancer 5 Obesity and cardiovascular disease 5 Quality of life 5 Factors that increase the risk of obesity 6 Smoking cessation 6 Certain medications 7 Obesity and its causes 7 Why do practitioners need a good understanding of obesity causes? 7 What are the causes of obesity? 8 Biology and genes 9 Eating and activity behaviours 10 The obesogenic environment 10 Health benefi ts of modest weight loss 11 Conclusion 11 References 12 2 Health Professionals’ Attitudes Towards Obesity and its Management 15 What does the evidence say about discrimination and weight bias in society? 16 In employment 16 In education 16 In health care 17 Where does weight bias come from? 17 Media and TV images 17 Cultural factors 18 Beliefs about the causes of obesity 18 What are the consequences of weight bias? 18 Psychological consequences 18 Social and economic consequences 18 Physical consequences 18 What is the impact of weight bias in the health care setting? 18 What can we do to reduce weight bias? 19 Conclusion 19 Reflective exercises 20 Recommendations for reducing weight bias in your practice 21 References 21 3 Treatment Options: The Evidence for What Works 24 Introduction 24 Combined approaches 24 Dietary treatments 25 Eating frequency and patterns 25 Improving the quality of the diet 25 Low-fat diets 25 The 600 kcal defi cit approach 26 Meal replacements 26 Very-low-calorie diets 27 Low-glycaemic-index diets 28 Low-carbohydrate diets 29 Fad diets 29 Physical-activity treatments 29 How much activity is needed? 30 Intensity and type of activity 31 Behaviour modification 32 An integrated approach 32 Key strategies 33 Drug treatment 36 Surgical treatment 37 Conclusion 38 References 38 Section 2 Practical Application 45 4 Preventing Overweight and Obesity 47 Prevention of overweight and obesity 47 Pre-conception and antenatal care 47 The early years 47 As life goes by 48 Medications 49 What to do? 49 If the response is negative 50 Support materials 50 Conclusion 51 References 51 5 Providing A Person-centred Weight-management Service 53 Integrating a behavioural approach 53 Working in a person-centred way 53 How to integrate a behavioural approach in practice? 54 Identifying overweight and obesity 57 Interpreting BMI 57 Planning weight-management interventions in your setting 58 Aiming for a coordinated and structured approach 58 Deciding on the duration and frequency of appointments 59 How and when to begin conversations about weight 60 Exploring whether this is the right time to begin 62 More on motivation… 63 Is the patient really sure they have the time and commitment required? 63 Discussing and agreeing a way forward 64 Exploring treatment options 64 Lifestyle treatment 64 Group-based programmes 64 Commercial and self-help programmes 67 Drug treatment 67 Surgery 68 Conclusion 68 References 68 6 Building a Picture: The Assessment 70 Undertaking a comprehensive assessment 70 What are the components of the assessment? 70 The Beginning 71 The Story So Far 72 Dealing with Expectations 74 The Here and Now 76 The Ending 81 References 82 7 Finding Solutions: Supporting Patients to Establish a Solid Foundation 83 Introduction 83 Integrating a behavioural approach 83 Step 1: Identify the Problem 84 Step 2: Explore Options 84 Step 3: Choose Preferred Option/s 85 Step 4: Develop a Plan 85 Step 5: Implement the Plan 87 Step 6: Review the Plan 88 The building blocks needed for a solid foundation 89 Providing information in a helpful way – an essential practitioner skill 90 Understanding energy balance 91 Calories in vs calories out 91 Recommended rates of weight loss 91 How many calories? 91 Key dietary recommendations 92 How to commence self-monitoring to understand current eating patterns 93 How to encourage regular eating 94 How to ensure a nutritionally adequate diet 94 How to use the ‘eatwell plate’ to achieve an energy deficit 94 How to read the calorie content on labels 99 Keeping a daily record 99 How to compare calorie intake with weight-loss achieved 101 When to refer on to specialist services 103 Further dietary options 104 Conclusion 105 Recommendations for physical activity 106 Current physical activity guidelines for all adults 106 Recommendations for weight management 106 First steps towards achieving physical-activity recommendations for weight management 107 Practical application of physical-activity recommendations 108 Developing essential skills: laying the foundations 114 Self-monitoring 114 Goal-setting 118 Conclusion 119 References 119 8 Next Steps: Continuing to Develop Expertise 121 Review appointments 121 Introduction 121 Suggested structure for review appointments 121 Review progress at 3 and 6 months 122 Topics for review appointments 123 More on healthy eating 146 Becoming skilled at weight management 152 Exploring motivation (‘ Do I want to, and can I? ’) 153 Self-monitoring (keeping a record) 153 Stimulus control 153 Problem-solving 154 Goal-setting (Developing a Plan) 155 Dealing with diffi cult situations 156 Support 156 Rewards 158 Exploring ambivalence (‘ I want to, but I can’t …’) 159 Relapse prevention (dealing with setbacks) 160 Emotional eating 161 Dealing with hunger 162 Cravings 162 More behavioural strategies 163 References 164 9 Staying on Track: Weight Maintenance 165 Introduction 165 Defining successful weight maintenance 165 Changes in weight 166 Causes of weight regain 166 What works? 166 National Weight Control Registry (NWCR) data 167 Implications for practice 168 Practical application 169 During the assessment 169 During the weight-loss phase 169 During the weight-maintenance phase 170 Learning how to deal with setbacks 172 Conclusion 172 References 173 10 Getting the Most out of Brief Contacts 175 Introduction 175 What is a brief contact? 175 Limitations of brief contacts 176 Getting the most out of brief contacts 176 Unhelpful approaches 177 Raising the issue 178 Engaging in a helpful conversation and exploring motivation 179 Is now the right time? 179 Discussing options 179 Signposting the most suitable option 181 Continuing to offer support 181 Brief interventions (if ongoing support includes brief review appointments) 182 What not to do 182 Making the best use of available time for ongoing brief contacts 182 Implications for services 182 Examples of brief contacts 183 Conclusion 184 References 184 11 Evaluating Individual Weight-management Interventions 186 Introduction 186 What is monitoring and evaluation? 187 Some definitions 187 The seven pillars 187 Evaluation can mean different things to different people 189 Evaluation can vary at different times 189 What makes evaluation challenging? 191 Getting started 192 Collecting information 192 What to evaluate 194 Effectiveness 194 Clinical outcomes 194 Risk factors 195 Activity and eating behaviours 195 Psychological health 197 Health care utilisation and cost outcomes 198 Patient experience 198 Safety 202 Conclusion 202 References 203 12 Common Challenges and Misconceptions 204 Introduction 204 Causes of obesity 204 ‘It’s my fault I’m obese’ 204 ‘I must have a slow metabolism’ 205 ‘It’s my genes, not my lifestyle’ 206 ‘I’ve been told I’m not eating enough to lose weight’ 207 Physical activity 208 ‘I can’t lose weight because my medical problems stop me from exercising’ 208 ‘Exercise makes me eat more’ 209 ‘I’ve been swimming for 20 minutes twice a week for 2 months and haven’t lost any weight’ 210 Diet 211 ‘Certain foods can burn fat’ 211 ‘I know breakfast is important but I just can’t eat in the morning’ 212 ‘Carbs are fattening’ 213 ‘Eating late at night causes weight gain’ 214 Note on patient dialogues 215 References 215 Section 3 Appendices 217 Appendix 1 Adult Weighing Scales Specification Guide 219 Appendix 2 How to Measure Height 220 Appendix 3 How to Measure Weight 222 Appendix 4 Measuring Overweight and Obesity using Body Mass Index 226 Appendix 5 Measuring-tape Position for Waist Circumference 227 Appendix 6 Medications 229 Appendix 7 Screening for Binge-eating Disorder 230 Appendix 8 General Practice Physical Activity Questionnaire 231 Appendix 9 PAR-Q & YOU 233 Appendix 10 Estimated Energy Requirement (EER) 235 Appendix 11 Prescribed Energy Defi cit (PED)-Ready Reckoner 237 Appendix 12 Portions Commonly Used for the ‘Eatwell Plate’ (To Check Nutritional Adequacy of the Diet) 240 Appendix 13 Example of 1500 kcal based on ‘Eatwell Plate’ Portions 242 Appendix 14 Example of 1800 kcal based on ‘Eatwell Plate’ Portions 244 Appendix 15 Cookery Books 246 Appendix 16 NICE Guidance on Referral to Slimming Groups 247 Appendix 17 Weighed Portions for Where More Precision is Required 248 Section 4 Resources 249 List of Resources 251 Additional Books and Resources 253 Section 5 Tools 255 Tool 1 Weight History Chart 257 Tool 2 Typical Day 258 Tool 3 Activity Charts 259 Tool 4 My Change Plan 260 Tool 5 Plate Model 261 Tool 6 Diary Sheet 262 Tool 7 Weight Record Chart 263 Tool 8 Blank Menu of Options 265 Tool 9 Menu of Options A 266 Tool 10 Menu of Options B 267 Tool 11 Menu Chart 268 Tool 12 Assessment of Diet Quality 269 Tool 13 Weighing It All Up: ‘ I Want To, But …’ 271 Tool 14 Behavioural Strategies 272 Index 273