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ASK
step1
AGREE
ofObesity
Manage
ment
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tIMe
WAIst
Obesity is a Chronic ConditionObesitisachronicandoftenprogressivecondition
notunikediabetesorhpertension.
Successfuobesitmanagementrequiresreaisticandsustainabetreatmentstrategies.
Short-termquick-xsoutionsfocusingon
maximizingweightossaregeneraunsustainabe
andthereforeassociatedwithhighratesofweight
regain.
Key Principles
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Obesity Management is About ImprovingHealth and Well-being, and not SimplyReducing Numbers on the Scale
Thesuccessofobesitmanagementshoudbe
measuredinimprovementsinheathandwe-
beingratherthanintheamountofweightost.
Formanpatients,evenmodestreductionsin
bodweightcaneadtosignicantimprovements
inheathandwe-being.
Key Principles
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Early Intervention Means AddressingRoot Causes and Removing RoadblocksSuccessfuobesitmanagementrequires
identifingandaddressingboththerootcauses
ofweightgainasweasthebarrierstoweight
management.
Weightgainmaresutfromareductionin
metaboicrate,overeating,orreducedphsica
activitsecondartobioogica,pschoogicaor
socioeconomicfactors.
Manofthesefactorsasoposesignicant
barrierstoweightmanagement.
Key Principles
Detour
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Success is different for every individualPatientsvarconsiderabintheirreadinessand
capacitforweightmanagement.
Successcanbedenedasbetterquait-of-ife,greatersef-esteem,higherenergeves,
improvedoveraheath,preventionoffurther
weightgain,modest(5%)weightoss,or
maintenanceofthepatientsbestweight.
Key Principles
tIMe
WAIst
CIrCuMFereNCe
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A patients Best weight may neverbe an ideal weightAnideaweightorBMIisnotareaisticgoa
formanpatientswithobesit,andsettingunachievabetargetssimpsetsuppatients
forfaiure.
Instead,heppatientssetweighttargetsbased
onthebestweightthecansustainwhiesti
enjoingtheirifeandreapingthebenetsof
improvedheath.
Key Principles
Bet
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Weightisasensitiveissue.Manpatientsare
embarrassedorfearbameandstigma.
ASK for permission to discuss weight
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ASK
Be non-judgemental
Explore readiness for change Use motivational interviewing
Create weight-friendly practice
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ASK
Be Non-judgemental
DoNOTbame,threaten,orprovokeguitin
ourpatient.
DoNOTmakeassumptionsabouttheirifestesormotivation.
(ourpatientmaareadbeonadietor
haveareadostweight)
Doacknowedgethatweightmanagement
isdifcutandhardtosustain.
Judgement
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ASK
Use Motivational Interviewing to MovePatients Along the Stages of Change
MotIVAtIoN
CHANGe
Askquestions,istentopatientscomments
andrespondinawathatvaidatestheir
experienceandacknowedgesthatthearein
controoftheirdecisiontochange.
IfpatientsareNOTreadtoaddresstheir
weight,bepreparedtoaddresstheirconcerns
andotherotherheathissuesandthenaskifoucanspeakwiththemabouttheirweight
againinthefuture.
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ASK
Explore Readiness for ChangeDeterminingourpatientsreadinessfor
behaviourchangeisessentiaforsuccess.
Useapatient-centredcoaborative
approach.
Initiatingchangewhenpatientsarenot
readcanresutinfrustrationandma
hamperfutureefforts.
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ASK
MotIVAtIoN
CHANGe
Sample Questions on How to Begin aConversation About Weight:Wouditbearightifwediscussedourweight?
Areouconcernedaboutourweight?Woudoubeinterestedinaddressingourweight
atthistime?
Onascaeof0to10,howimportantisitforouto
oseweightatthistime?
Onascaeof0to10,howcondentareouthat
oucanoseweightatthistime?
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ASK
Create a Weight-Friendly Practice
MotIVAtIoN
CHANGe
Faciities:handicappedaccessibiit,widedoors,
argerestrooms,oor-mountedtoiets
WaitingRoom:sturd,armesschairs,
appropriatereadingmateria
ExamRoom:oversizedgowns,scaesover350
bs/160kg,wideandsturdexamtabes,extra-
argeboodpressurecuffs,ongerneedesand
tourniquets,ong-handedshoehorns
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ASK
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*EdmontonObesitStagingSstem
BMI kg/m2
Underweight 40
WaistCircumferenceRiskThreshod:Europid:>94cm;>80cm;AsianandHispanic:>90cm;>80cm
Stage0:NoApparentRiskFactors
Stage2:EstabishedCo-Morbidit
Stage1:PrecinicaRiskFactors
Stage3:End-OrganDamage
Stage4:End-Stage
ObesitCass(I-III)isbasedonBMIandisameasureofhowBIGthepatientis.
ObesitStage(0-4)isbasedontheMEDICAl,MENTAl,andFUNCTIONAlimpactof
obesitandisameasureofhowHEAlTHythepatientis.
WaistcircumferenceprovidesadditionainformationregardingCARDIOMETABOlICrisk.
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Cognition
Depression
AttentionDecit
Addiction
Pschosis
EatingDisorder
Trauma
Insomnia
Tpe2Diabetes
Dsipidemia
Hpertension
Gout
Fattliver
Gastones
PCOS
Cancer
SeepApnea
Osteoarthritis
ChronicPain
ReuxDisease
Incontinence
Thrombosis
Intertrigo
PantarFasciitis
Education
Empoment
Income
Disabiit
Insurance
Benets
BariatricSuppies
Weight-lossPrograms
Usethe4MsframeworktoassessMenta,Mechanica,Metaboic,andMonetardrivers,
compications,andbarrierstoweightmanagement.
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Is weight gain due to slowmetabolism?
Is weight gain due toincreased food intake?
Is weight gain due to reducedactivity?
AgeHormonesGenetics
Low Muscle MassWeight LossMedication
Socio-Cultural FactorsPhysical HungerEmotional Eating
Mental Health IssuesMedication
Socio-Cultural FactorsSocio-Economical Limitations
Physical Limitations / PainEmotional Factors
Medication
Address root causes of low metabolismAddress root causes of overeating
Address root causes of reduced activity
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step1
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ObesitrisksaremorereatedtoobesitStage
thantoBMI.
FocusoftreatmentshoudbeonIMPROVINGHEAlTHandWEll-BEINGratherthansimp
osingweight.
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step1
managementinterventionscansignicantimprove
eatingandactivitbehaviours.
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step1
shoudfocusondecreasingcaoricintakebimproving
eatingpattern,nutritionahgiene,andportionsize.Extremeandfaddietsaregeneranotsustainabein
theong-term.
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step1
orexerciseaone
isgeneranotasuccessfuweight-ossstrateg.
Ratherthanfocusingonburningcaories,activit
interventionsshoudaimatreducingsedentariness
andincreasingdaiphsicaactivitevestopromote
tness,overaheath,andgenerawe-being.
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step1
interventionscanimprovesef-esteem,reduceemotionaeating,andpromotenon-
foodcopingstrategies.
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step1
(medicasupervised)
andmearepacementscanbesafeandeffective
approachesforpatientsrequiringagreaterdegreeofweightoss.
CAlorIe
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step1
inconjunctionwithbehaviourainterventions,can
heppatientsachieveandsustain5-10%weightoss.
Discontinuationofmedicationsgeneraresutsin
weightregain.
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step1
shoudbe
consideredforapatientsrequiringmorethan
15%sustainabeweightoss.Modernaparoscopicbariatricsurgerisbothsafeandeffective,and
substantiareducesmorbiditandmortait.A
surgicapatientsrequiremutidiscipinarpresurgica
assessmentandong-termmedica,nutritiona,and
pschosociasupport.
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step1
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Unreaisticweight-ossexpectationscaneadto
DISAPPOINTMENTandNON-ADHERENCE.
Areasonabeweight-osstargetwithbehaviouraandmedicainterventionsis0.5to1.0kgperweekforatota
of5to10%ofinitiaweight,afterwhichweightosswi
generapateau.
Agreaterormorerapidweightosswithnon-surgica
interventionsdoesnotresutinbetterong-term
outcomes.
Forsomepatients,PREVENTIONorSlOWINGofWEIGHT
GAINmabetheonreaisticweighttarget.
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Focusonsustainabebehaviourachangesrather
thanonspecicweighttargets.BehaviouragoasshoudbeSMART:
Specic
Measurabe
A
chievabeRewarding
Time
Sef-monitoringwithaifestejournaheps
initiateandsustainbehaviourachange.
plAN
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TreatmentpansshoudbeREAlISTICandSUSTAINABlE.
ObesittreatmentshoudbeginwithADDRESSING
theDRIVERSofweightgain(e.g.stress,ackoftime,depression,seepapnea,chronicpain,etc.).
TheSUCCESSoftreatmentshoudbemeasuredin
improvementsinHEAlTHandWEll-BEING(e.g.improve
boodpressure,increasetness,increaseenerg,increase
mobiit,etc.).
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DriversandbarriersmaincudeENVIRONMENTAl,
SOCIOECONOMICAl,EMOTIONAl,orMEDICAlfactors.Obesogenicmedications(e.g.atpicaantipschotics,
anti-diabetics,anti-convusants,etc.)mamakeobesit
managementdifcut.
PHySICAlBARRIERSthatimitaccess(transportation,
turnsties,imitedseating,etc.)ininstitutionasettings,
workpaces,andrecreationafaciities,madeterfrom
activeparticipationineverdaife.
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PatientEDUCATIONiscentratosef-management.
HeppatientsidentifandseekoutCREDIBlE
weight-managementinformationandresources.
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EvidencesupportstheneedforanINTERDISCIPlINARy
teamapproachtoobesitmanagement.
Choiceofappropriateprovider(e.g.phsician,nurse,
dietitian,pschoogist,sociaworker,exercisephsioogist,
PT/OT,surgeon,etc.)shoudreectidentiedDRIVERS
andCOMPlICATIONSofobesitasweasBARRIERSto
weightmanagement.
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Giventhechronicreapsingnatureofobesit,
lONG-TERMfoow-upisESSENTIAl.
SuccessisdirectreatedtoFREQUENCyof
providercontact.
Weight-regain(reapse)shoudnotbeframedas
faiurerather,itisthenaturaandEXPECTED
consequenceofdeaingwithachroniccondition.
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P f i l R
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lauDC,DouketisJD,MorrisonKM,HramiakIM,SharmaAM,UrE;Obesit
CanadaCinicaPracticeGuideinesExpertPane.2006Canadian
CinicaPracticeGuideinesOnTheManagementAndPreventionOf
ObesitInAdutsAndChidren.CMAJ.2007;176:S1-13.
PadwaRS,PajewskiNM,AisonDB,SharmaAM.UsingtheEdmonton
obesitstagingsstemtopredictmortaitinapopuation-representative
cohortofpeopewithoverweightandobesit.CMAJ.2011;183:E1059-66
SharmaAM.M,M,M&M:amnemonicforassessingobesit.ObesRev.
2010;11:808-9.
MauroM,TaorV,WhartonS,SharmaAM.BarriersToObesit
Treatment.EurJInternMed.2008;3:173-80.
SharmaAM,PadwaR.ObesitIsASign-Over-EatingIsASmptom:An
AetioogicaFrameworkForTheAssessmentAndManagementOfObesit.
ObesRev.2010;11:362-370.
KirkSF,PenneTl,McHughTl,SharmaAM.Effectiveweightmanagement
practice:areviewoftheifesteinterventionevidence.IntJObes
2011;36:178-85.
TaorVH,McIntreRS,RemingtonG,levitanRD,StonehockerB,Sharma
AM.Beondpharmacotherap:understandingtheinksbetweenobesit
andchronicmentainess.CanJPschiatr.2012;57:5-12.
KarmaiS,StokossaCJ,SharmaA,StadnkJ,ChristiansenS,Cottreau
D,BirchDW.BariatricSurger:aPrimer.CanFamPhs.2010;56:873-9.
Professional Resources
Signupatwww.obesitnetwork.catobecomeamemberofthe CanadianObesitNetwork ,CanadasnationaobesitNGOwithaccessto
additionaobesiteducation,resources,andnetworkingopportunitieswithnationaobesitexperts.
TheOnineBestEvidenceServiceInTackingobesity+ (OBESITy+)providedbMcMasterUniversitsHeathInformationResearchUnit
(accessibeatwww.obesitnetwork.ca)providesaccesstothecurrentbestevidenceaboutthecauses,course,diagnosis,prevention,
treatment,andeconomicsofobesitanditsreatedmetaboicandmechanicacompications.
TheCanadianAssociationofBariatricPhsiciansandSurgeons(www.cabps.ca)representsCanadianspeciaistsinterestedinthetreatment
ofobesitandsevereobesitforthepurposesofprofessionadeveopmentandcoordinationandpromotionofcommongoas.
DietitiansofCanada(www.dietitians.ca)isthenationaprofessionaassociationfordietitians,representingamost6000membersatthe
oca,provinciaandnationaeves.Practice-basedEvidenceinNutrition(PEN),designedforbusheathprofessionas,isanoninedatabase
avaiabebsubscriptionthatprovidesevidence-basedanswerstoeverdafoodandnutritionpracticequestions.
TheCanadianSocietforExercisePhsioog (www.csep.ca)isavountarorganizationcomposedofprofessionasinterestedandinvoved
inthescienticstudofexercisephsioog,exercisebiochemistr,tnessandheath.VisittodownoadCanadianPhsicaActivitand
SedentarBehaviourGuideines.
Key References
P ti t R
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GeetaAchuthan,MD,MCFP(Regina,SK),AndrewCave,MD,FCFP,FRCGP(UniversitofAberta,AB),Eeanor
Benterud,RN,BN,MN,(SouthCagarPrimarCareNetwork,AB),DeniseCampbe-Scherer,MD,PhD,CCFP
(UniversitofAberta,AB),CdCourchesne,OMM,CD,MD,MCFP,DAvMed,CHE,(CanadianArmedForces),Heather
Davis,MD,FRCPC,(Heath&Weness,Gov.ofNS),RobertDent,MD,FRCPC,(OttawaHospita,ON),EricDucet,
PhD,(UniversitofOttawa,ON),AngeaEste,RN,MSc,(AbertaHeathServices),MarForhan,OTReg(Ont),PhD
(McMasterUniversit,ON),yoniFreedhoff,MD,CCFP,(BariatricMedicaInstitute,Ottawa,ON),TraceHusseMSc,
RD,(HamitonFamiHeathTeam,ON),BrendaGuska,(OntarioMinistrofHeathandlongTermCare),Shahzeer
Karmai,MD,FRCSC,(UniversitofAberta,AB),SaraKirk,PhD,(DahousieUniversit,NS),Marie-Francelangois
MD,FRCPC,CSPQ(UniversitdeSherbrooke,QC),DavidC.W.lau,MD,FRCPC,(UniversitofCagar,AB),Anthon
levinson,MD,FRCPC,(McMasterUniversit,ON),PatriciaMarturano,(TheCoegeofFamiPhsiciansofCanada),
RajPadwa,MD,FRCPC,(UniversitofAberta,AB),HeenaPiccinini-Vais,MD,CCFP,(Haifax,NS),PauPoirier,MD,
PhD,FRCPC,(Universitlava,QC),VaerieTaor,MD,PhD,FRCPC,(UniversitofToronto,ON),RickTtus,MD,
CCFP,(HamitonAcademofMedicine),ShahebinaWajiMD,CCFP,(CagarWeightManagementCentre,AB),Sean
WhartonMD,FRCPC,(WhartonMedicaCinic,ON),RonWisonMD,CCFP,(Vancouver,BC).
NoticeandDiscaimer:
Nopartofthesemateriasmabereproduced,storedinaretrievasstem,ortransmitted,inanformorbanmeans,eectronic,
mechanica,photocoping,recordingorotherwisewithoutpriorwrittenpermissionfromtheCanadianObesitNetwork-Rseau
canadienenobsit(CON-RCO).TheopinionsinthisbooketarethoseoftheauthorsanddonotnecessarirepresentthoseofCON-
RCO.Thisbooketisprovidedontheunderstandingandbasisthatnoneofthepubisher,theauthors,orotherpersonsinvovedinits
creationshaberesponsibefortheaccuracorcurrencofthecontents,orfortheresutsofanactiontakenonthebasisofthe
informationcontainedinthisbookorforanerrorsoromissionscontainedherein.Noreadershoudactonthebasisofanmatter
containedinthisbooketwithoutobtainingappropriateprofessionaadvice.Thepubisher,theauthors,andotherpersonsinvovedin
thisbooketdiscaimiabiitandresponsibiitresutingfromanideas,products,orpracticesmentionedinthetextanddiscaimaand
aniabiitandresponsibiittoanperson,regardessofwhethersuchpersonpurchasedthisbooket,forossordamageduetoerrors
andomissionsinthisbookandinrespectofanthingandoftheconsequenceofanthingdoneoromittedtobedonebsuchpersonin
reianceuponthecontentofthisbooket.
Foradditionainformationandresourcesonobesitpreventionandmanagement,
peaserefertoourwebsiteatwww.obesitnetwork.ca
ThisbooketwasdeveopedbAraM.Sharma,MD/PhD,FRCPC,andMichaeVais,PhD,
withtheCON-RCOCanadianObesitNetworkPrimarPracticeWorkingGroup.*
ThisbooketispubishedbtheCanadianObesitNetworkwithsupportfromthe
PubicHeathAgencofCanadaandtheCanadianInstitutesofHeathResearch.
*WorkingGroupMembers:
Patient ResourcesPubicHeathAgencofCanada
Thissite(www.pubicheath.gc.ca)hasimportant
informationforpatientsonheathactiveiving
andonnumerousobesit-reatedheathprobems
incudinghpertension,diabetes,seepapnea,
mentainess,andarthritis.
CanadianObesitNetwork
Additionapatienteducationaandinformation
materiasonobesitmanagementcanbe
orderedinbukfromCONbcontacting
Informationonotherobesitreated
heathprobemscanbefoundat:
CanadianMentaHeathAssociationwww.cmha.ca
HeartDisease:www.heartandstroke.ca
Hpertension:www.hpertension.ca
Diabetes:www.diabetes.ca
Arthritis:www.arthritis.ca
SeepApnea:www.ung.ca
FattliverDisease:www.iver.ca
ReproductiveHeath:www.cwhn.ca
BariatricSurger:www.asmbs.org
Incontinence:www.canadiancontinence.ca
ChronicPain:www.canadianpainsociet.ca
Pschoog:www.pschoogfoundation.org
AbdominaAdiposit:www.mheathwaist.org
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ASK for Permissionto Discuss Weight
step1
AGREE on realistic weight-lossexpectations and on a SMART plan to
achieve behavioural goals
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Order your 5As of Obesity ManagementTM
toolkit at: www.obesitynetwork.ca
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