Management of obesity
Limitations of anthropometric
classifications of obesity
• Although BMI and WC are useful in population studies,
• they lack sensitivity and specificity when applied to individuals.
• Several factors (e.g. cardiorespiratory fitness) may substantially modify
the mortality risk associated with a higher BMI.
• BMI alone is insufficient to guide clinical decision making in individuals.
• Does not assess the presence of concomitant comorbid conditions or
disease risk
• Reasons for limited use of BMI or WC measures in clinical practice
– limited time during office visits,
– lack of training in counseling, competing demands,
– fear of stigmatization and low confidence in ability to treat and change
patient behaviors
Complementing anthropometric parameters with a simple
disease-related and functional staging system would provide
additional clinical information to guide and evaluate treatment.
Sharma AM, Kushner RF. A proposed clinical staging system for obesity. Int J Obes, 2009, 33(3):289-95. doi: 10.1038/ijo.2009.2.
Edmonton Obesity Staging System (EOSS)
• provide additional guidance for therapeutic
interventions in individual patients.
• Current anthropometric classification systems, based
on simple clinical measures (height, weight, waist
circumference), do not accurately reflect the
presence or severity of obesity-related health risks,
comorbidities or reduced quality of life.
• EOSS includes
– medical history,
– clinical and functional assessments, simple routine
diagnostic investigations
Sharma AM, Kushner RF. A proposed clinical staging system for obesity. Int J Obes, 2009, 33(3):289-95. doi: 10.1038/ijo.2009.2.
4
5
http://www.drsharma.ca/wp-content/uploads/edmonton-obesity-staging-system-pocket-card.pdf
Obesity Treatment Algorithm
Remember
http://www.nhlbi.nih.gov/health-pro/guidelines/current/obesity-guidelines/e_textbook/txgd/algorthm/algorthm.htm
Algorithm for the stepwise management of
adult patients with overweight or obesity
Dietz WH et al. Management of obesity: improvement of health-care training
and systems for prevention and care. The Lancet, 2015.
http://dx.doi.org/10.1016/S0140-6736(14)61748-7
Cont.
Minimal intervention for obesity
(5 As)
• ASK for permission to discuss weight and
explore readiness
• ASSESS obesity related risks and 'root causes'
of obesity
• ADVISE on health risks and treatment options
• AGREE on health outcomes and behavioural
goals
• ASSIST in accessing appropriate resources and
providers
Vallis M et al.: Clinical review: modified 5 As: minimal intervention for obesity counseling in primary care. Can Fam Physician, 2013, 59(1):27-31.
1. ASK
• Ask permission to discuss weight; be nonjudgmental; explore readiness for change.
• Weight is a sensitive issue; avoid verbal cues that imply judgment; indication of
readiness might predict outcomes
Vallis M et al.: Clinical review: modified 5 As: minimal intervention for obesity counseling in primary care. Can Fam Physician, 2013, 59(1):27-31.
2. ASSESS
Assess BMI, WC, obesity stage; explore drivers and complications of excess weight.
BMI alone should never serve as an indicator for obesity interventions;
obesity is a complex and heterogeneous disorder with multiple causes— drivers and
complications of obesity will vary among individuals
Vallis M et al.: Clinical review: modified 5 As: minimal intervention for obesity counseling in primary care. Can Fam Physician, 2013, 59(1):27-31.
3. ADVISE
• Advise on health risks of obesity, benefits of modest weight loss, the need for a
long-term strategy, and treatment options.
• Health risks of excess weight can vary;
• avoidance of weight gain or modest weight loss can have health benefits;
• considerations of treatment options should account for risks.
Vallis M et al.: Clinical review: modified 5 As: minimal intervention for obesity counseling in primary care. Can Fam Physician, 2013, 59(1):27-31.
4. AGREE
• Agree on realistic weight loss expectations and targets, behavioural changes using the
SMART framework, and specific details of the treatment options.
• Most patients and many physicians have unrealistic expectations;
• Interventions should focus on changing behaviour;
• Providers should seek patients’ “buyin” to proposed treatment.
SMART—specific, measureable, achievable, rewarding, timely.
Vallis M et al.: Clinical review: modified 5 As: minimal intervention for obesity counseling in primary care. Can Fam Physician, 2013, 59(1):27-31.
5. ASSIST
• Assist in identifying and addressing barriers;
• provide resources and assist in identifying and consulting with appropriate providers;
• arrange regular follow-up.
• Most patients have substantial barriers to weight management;
• patients are confused and cannot distinguish credible and noncredible sources of
• information;
• follow-up is an essential principle of chronic disease management.
Vallis M et al.: Clinical review: modified 5 As: minimal intervention for obesity counseling in primary care. Can Fam Physician, 2013, 59(1):27-31.
Weight bias in medical education
Attitudes
• that patients with
obesity are lazy,
• non-compliant with • Feelings of discomfort, and
treatment, • obesity treatment is
• less responsive to ineffective.
counselling,
• Medical students report as
• responsible for their a barrier to discussing
condition, weight with patients.
• have no willpower,
• deserve to be targets
of derogatory humor.
Dietz WH et al. Management of obesity: improvement of health-care training and systems for prevention and care. The Lancet, 2015. http://dx.doi.org/10.1016/S0140-6736(14)61748-7
Weight biases in medical settings by
health-care professionals
• Spend less time in appointments,
• provide less education about health,
• more reluctant to do some screening tests in patients with
obesity,
• physicians report less respect for their patients with obesity,
• perceive them as less adherent to medications,
• express less desire to help their patients,
• report that treating obesity is more annoying and a greater
waste of their time. 19% of adults and 24% of parents would
avoid future medical appointments if they
perceived a doctor had stigmatised them or
their child because of their weight. (in USA)
Dietz WH et al. Management of obesity: improvement of health-care training and systems for prevention and care. The Lancet, 2015. http://dx.doi.org/10.1016/S0140-6736(14)61748-7
Weight bias & stigma
Weight management in healthcare practice
• http://www.uconnruddcenter.org/weight-
bias-stigma-videos-exposing-weight-bias
• http://biastoolkit.uconnruddcenter.org/
– Free online toolkit
– Motivational interviewing for obesity
http://biastoolkit.uconnruddcenter.org/toolkit/Mod
ule-2/2-07-MotivationalStrategies.pdf
WHO – The 3 Fives
http://www.who.int/foodsafety/areas_work/food-hygiene/3_fives/en/
