WEIGHT MANAGEMENT

IN PRIMARY CAREKate Inglis – Practice Nurse & Project Nurse

Anne-Thea McGill – GP & Obesity researcher

Charlotte Yarnton – WBoP PHO Dietitian

katei@wboppho.org.nz

Weight Management In Primary Care • Ministry of Health wanted GP’s to weigh patients regularly

• Western Bay of Plenty PHO successful in obtaining contract

• Developed ABO weight management project

• Piloted in 12 GP practices in Tauranga

• Team made up of: Dietitians, nutrition researchers, nurses, exercise physiologist,

GP, pharmacist

•Gate Pa Medical

•Fifth Avenue Family

Practice

•Hairini Medical Centre

•Nga Kakano

•Katikati Medical

•Ngati Kahu

•CentralMed

•Papamoa Pines

•Farm St Medical

•Chadwick Healthcare

•Girven Rd Medical

•Otumoetai Doctors

Overview of ABO

• Similar to smoking cessation ABC approach

• Ask

• Brief Intervention

• Ongoing management

• Westernised environments are very difficult

• MALNUTRITIVE & OBESOGENIC

• Availability of high energy nutrient poor foods

• Families & individuals are not to blame

ASK ‘A’

• Are you concerned about your weight or shape?

• Are you concerned about your eating patterns or

control over eating?

• Yes to one or more questions – continue to Brief Intervention

BRIEF INTERVENTION ‘B’

• Encourage all patients to eat more vegetables and fruit

• No limits, no calorie counting

• The focus is on promoting foods which have high nutrient value =

vegetables and fruit (and nuts)

• Fresh, Frozen, Canned, Dried, Stewed, Preserved

• Aim for at least 5+ (2 servings fruit, 3 servings vegetables)

• Or even better 9+ (3-4 Fruit and 5-6 vegetable)

• Move more

Measure & Record

Measurements: Baseline, fat distribution,

Weight, height, BP, BMI, waist, Hip, % fat, Muscle Mass (BIA scales)

Blood tests: Inflammatory markers, baseline before increasing micronutrient

intake

FBC, ESR, CRP. LFT’s, (GGT, AST, ALT, Alk Phos, Bilirubin), Lipids, Iron

studies, Ferritin, B12, Folate, TSH. Uric Acid, eGFR, Electrolytes,

Albumin/creatinine ratio (Urine)

Readiness to change

• Basic change management questions will help you to

recognise which patient should be encouraged to attend

ongoing management ‘O’

• Compared to previous attempts to change your eating, how

motivated are you to improve your eating at this time?

• Considering all outside factors at this time in your life,

(stress at work, family obligations) how confident are you

that you will stay committed to an improved eating pattern

program?

Behavioural Change

• “People would sooner die than change…and most do” Mark Twain

• Utilise the 80/20% rule

• Allow the patient time to explore their concerns

• Patient should have 80% of the conversation

• Use communication micro counselling skills: Open ended questions,

Raising ambivalence, Roll with resistance, Reflective listening,

Summarising

Online learning modules:

• Motivational interviewing in brief consultations through BMJ-• http://learning.bmj.com/learning/module-intro/.html?moduleId=10051582

• Interactive motivational interviewing animation• http://www.kognito.com/changetalk/web/

ONGOING MANAGEMENT ‘O’

• Ongoing support to address lifestyle change in patients

health care centre

• Suggested 4 visits over the year

• SMARTA goals, resources, recipes, handouts, support from

nurse/GP

• CAT (Comprehensive Assessment Tool) to assess why

patient may be overeating

• Formulate individualised plan of action

ONGOING MANAGEMENT ‘O’

• Comprehensive Assessment Tool will highlight:• Emotional problems with eating

• Depression/Anxiety

• Binge Eating/ Bulimia. Diagnosed through SCOFF Eating dsorderquestionnaire

• Nutrient reduced diet, too much ‘beige food’ ‘processed food’

• Attitude towards exercise or moving more

• Problems with sleep

• Onward Referral to existing services • e.g. Self management, Green Prescription, Sleep clinic, Community

mental health/counselling.

pilot.bestpractice.org.nz

http://baynav.bopdhb.govt.nz/

Important Considerations

• Addiction- Recognise the food environment

• Positive message- Compassion, non-judgemental

• Increase Vegetables and Fruit, high nutrient content

Recognise differences in weight distribution

• Peripherally overweight - metabolically Okay. May have

problems with joints, fitting in chairs. Difficult to lose. May

require VLED diet with help

• Centrally overweight- Visceral fat, causes metabolic

problems. Easier to lose and will help reduce

cardiovascular risk

‘THREE’ SYSTEM THEORY:

PROBLEMS HERE ‘CAUSE’

OBESITY RELATED METABOLIC

SYNDROME

Three System Theory on Human Brain Energy Management

• The human brain evolved to be large & has high energy requirements various human specific, unusual co-adaptations were required

• 1) increase dietary energy by a neural self-reward /motivation system on acquisition of energy dense food – the cortico-limbic-striatal system …NOW …refined food addiction

• 2) economise on body energy metabolism by via the hyperactive, plant food micronutrient dependent antioxidant/antitoxicant/cell repair amplifying nuclear factor-E2-related factor 2 (NRF2) cellular protection system …NOW inadequate micronutrients … metabolic/immune decline

• 3) Ability to store plenty of lipid energy in metabolically safe peripheral adipose tissue …NOW… Psychological & physical problems

• However there are other important related adaptations, some of which also affect obesity eg omnivory, being overfat/undermuscled, and being slow growing/having a (potentially) long lifespan (McGill A-T, 2014a, 2014b)

Management of Obesity & Related Metabolic Syndrome 1)

• The ‘Ask’ is really asking about ‘out of control’ issues ie Addiction

• Addiction management to any substance needs help using non judgemental techniques, stress the inimical (tending to obstruct or harm, unfriendly hostile) environment

• PROGRAMME item – are you concerned about

• weight/shape obsessive/compulsive or ‘denial’ view of body

• eating patterns/control over eating refined food addiction, craving & unrealistic ideas &++ guilt

• Reducing guilt & blaming environs means patients are MORE likely to change behaviours and get going

• Readiness to change (MI) with assessment of willing (importance?), able (confidence? & where ‘ready’ = manage addiction

• Willingness – increases with realistic ‘myth busting’ education (reduce diabetes drugs, supplements don’t help, decrease sleep apnoea)

• Ability – sort out social, mental and physical health issues

• ‘Ready’ – psychological ‘ducks in a row’, can take the leap away from addiction – with management rules, replace items, abstinence & ++ patience & support thru’ setbacks

• 2) Brief Intervention (increase food micronutrients)

• (always positive, ++supportive of patients ie addiction management, ++briefly ask re/ current intake veg, fruit, nuts – thumbnail sketch)

• Eat more veg, fruit & nuts – learning points about food eg fibre + nutrients (Pal 2013) (de-emphasise energy intake excess ie NOT the most important for health, and gradually declines once patients understand)

• Tips –

• When home from school/work nuts, fruit (to make up for no/low quality lunch)

• Offer raw veg before dinner; also time how long it takes to cut up vegetables ie it’s in the attitude

• Don’t like water ? Have ‘twist of fruit/juice’ in water ie weak natural juice in fridge

• Be more active – no prescription, just more –

• Tips –

• make this fun (less competitive) eg play within family, walk – push on swings, lift for upper body strength, practice etc and emphasise low impact

Management of Obesity & Related Metabolic Syndrome 2)

3) Measure & Grade Body Shape/Fat distribution (waist, weight, height, fat & muscle mass/%) (see BPac form)

• Humans – genetically have high fat to muscle

• Some have a high potential to gain metabolically safe

peripheral subcutaneous, ‘dimpling/cellulite’ adipose

tissue

• Unhealthily fed people without much peripheral fat gain

++ upper body INTRA-dermal fat, + thick waists with intra-

abdominal fat (see figures)

• DISTINGUISH BETWEEN THE TWO and advise on

which patients have (or a mix) as Rx depends on it!

• Work on this so you do not set patients up to fail

• ‘Malnubesity’ (McGill A-T 2014 a, b)

• High nutrient whole food is always helpful but

peripherally overweight may need VLED also

• Supplements work poorly/make metabolism worse and

waste money unless major deficiencies in mineral (&

vitamins)

Management of Obesity & Related Metabolic Syndrome 3)

Metabolically safe fat.

(Klein, Fontana et al 2004)

Eating Disorders in Teens – GP/PN role

• The ‘eating disorders’ are extremes of addictive/obsessive compulsive behaviours of refined high energy food & fear of being overweight

• These patients are correct – current diets are abnormal (75% different from evolutionary diets) & do make most people fat

• Binge Eating Disorder or eating disorders not otherwise defined and overweight unable to compensate

• Bulimia (compensation = purging esp vomiting can be extreme)

• Anorexia nervosa (compensate with PA, purging and successful with starvation Obsessive compulsive ‘addiction’ & control over punishment/pain common

• Body dysmorphism almost always present (& in most of us) with varying fixed false beliefs in specific body shape/weight & attitudes to food

• Guardians – sadly usually not an easy relationship – tussles over control

• Management

• Discuss issues – do HEEADSSS (Home environment, Education and employment, Eating, peer-related Activities, Drugs, Sexuality, Suicide/ depression, and Safety from injury and violence

• Measure/test – factually tell/negotiate hospital admission if serious abnormal parameters due to restriction

• The delusional aspects may need long term psychotherapy

• Educate parents & patients – Self determined, WITH SUPPORT for quality nutrition, refined high-energy food abstinence (using agreed rules, and some medications) & ad libitum whole foods can be helpful at any stage or type of eating disorder (sneakiness is part of addiction-don’t judge, just negotiate with facts)

Basics/Basis – Theory in a Nutshell• This programme is based on evolutionary science –

the biology of HUMAN specific

• brain size & energy use PLUS

• co-adaptations to providing more energy

1) Brain reward centres for high energy food ‘sugar/starch/fat-type food’ attraction

NOW … ‘addiction’

Rx Manage addiction in Motivational Interviewing – Willing, Able, READY = up to addressing addictions

with +++support/compassion.

2) Efficient energy use depends on ++ food micronutrients (especially plant antioxidants + lack of toxins)

NOW … too few & degenerative change

Rx ++ Increase all vegetables/fruit/nuts especially high micronutrient whole foods

3) Genetically variable peripheral safe subcutaneous and/or central/intra-organ metabolically unsafe fat

NOW … overfull can get massive peripheral adipose with physical/locomotor and/or shape/Ψ issues

Rx healthy diet, then very low energy diet, later, ongoing moderate, LOW impact PA (gatherer type)

NOW … overfull central adipose metabolic/degenerative disease

Rx ++ volumes of healthy food, GRADUAL increasingly intense PA (hunter type)