ASK

ASSESS

ADVISE step 1

ASSI

ST

AGREE

of Obesity

Management

tIM

e

WAIst

Obesity is a Chronic Condition•Obesityisachronicandoftenprogressivecondition

notunlikediabetesorhypertension.

•Successfulobesitymanagementrequiresrealistic

andsustainabletreatmentstrategies.

•Short-term“quick-fix”solutionsfocusingon

maximizingweightlossaregenerallyunsustainable

andthereforeassociatedwithhighratesofweight

regain.

Key Principles

Obesity Management is About Improving Health and Well-being, and not Simply Reducing Numbers on the Scale•Thesuccessofobesitymanagementshouldbe

measuredinimprovementsinhealthandwell-

beingratherthanintheamountofweightlost.

•Formanypatients,evenmodestreductionsin

bodyweightcanleadtosignificantimprovements

inhealthandwell-being.

Key Principles

Early Intervention Means Addressing Root Causes and Removing Roadblocks•Successfulobesitymanagementrequires

identifyingandaddressingboththe‘rootcauses’

ofweightgainaswellasthebarrierstoweight

management.

•Weightgainmayresultfromareductionin

metabolicrate,overeating,orreducedphysical

activitysecondarytobiological,psychologicalor

socioeconomicfactors.

•Manyofthesefactorsalsoposesignificant

barrierstoweightmanagement.

Key Principles

Detour

Success is different for every individual •Patientsvaryconsiderablyintheirreadinessand

capacityforweightmanagement.

•‘Success’canbedefinedasbetterquality-of-

life,greaterself-esteem,higherenergylevels,

improvedoverallhealth,preventionoffurther

weightgain,modest(5%)weightloss,or

maintenanceofthepatient’s‘best’weight.

Key Principlest

IMe

WAIst CIrCuMFereNCe

A patient’s ‘Best’ weight may never be an ‘ideal’ weight •An‘ideal’weightorBMIisnotarealisticgoal

formanypatientswithobesity,andsetting

unachievabletargetssimplysetsuppatients

forfailure.

•Instead,helppatientssetweighttargetsbased

onthe‘best’weighttheycansustainwhilestill

enjoyingtheirlifeandreapingthebenefitsof

improvedhealth.

Key Principles

Be t

Weightisasensitiveissue.Manypatientsare

embarrassedorfearblameandstigma.

ASK for permission to discuss weight

ASK

• Be non-judgemental

• Explore readiness for change

• Use motivational interviewing

• Create weight-friendly practice

ASK

Be Non-judgemental•DoNOTblame,threaten,orprovokeguiltin

yourpatient.

•DoNOTmakeassumptionsabouttheir

lifestylesormotivation.

(yourpatientmayalreadybeonadietor

havealreadylostweight)

•Doacknowledgethatweightmanagement

isdifficultandhardtosustain.

Judgement

ASK

Use Motivational Interviewing to Move Patients Along the Stages of Change

Mo

tIV

At

IoN

CHANGe

•Askquestions,listentopatients’comments

andrespondinawaythatvalidatestheir

experienceandacknowledgesthattheyarein

controloftheirdecisiontochange.

•IfpatientsareNOTreadytoaddresstheir

weight,bepreparedtoaddresstheirconcerns

andotherotherhealthissuesandthenaskif

youcanspeakwiththemabouttheirweight

againinthefuture.

ASK

Explore Readiness for Change•Determiningyourpatient’sreadinessfor

behaviourchangeisessentialforsuccess.

•Useapatient-centredcollaborative

approach.

•Initiatingchangewhenpatientsarenot

readycanresultinfrustrationandmay

hamperfutureefforts.

CHANGe

ASKM

ot

IVA

tIo

N

CHANGe

Sample Questions on How to Begin a Conversation About Weight:•“Woulditbealrightifwediscussedyourweight?”

•“Areyouconcernedaboutyourweight?”

•“Wouldyoubeinterestedinaddressingyourweight

atthistime?”

•“Onascaleof0to10,howimportantisitforyouto

loseweightatthistime?”

•“Onascaleof0to10,howconfidentareyouthat

youcanloseweightatthistime?”

ASK

Create a Weight-Friendly Practice

Mo

tIV

At

IoN

CHANGe

•Facilities:handicappedaccessibility,widedoors,

largerestrooms,floor-mountedtoilets

•WaitingRoom:sturdy,armlesschairs,

appropriatereadingmaterial

•ExamRoom:oversizedgowns,scalesover350

lbs/160kg,wideandsturdyexamtables,extra-

largebloodpressurecuffs,longerneedlesand

tourniquets,long-handledshoehorns

ASK

ASSESS obesity related risk and potential ‘root causes’ of weight gain

ASSESS

• Assess Obesity Class and Stage

• Assess for Obesity Drivers,

Complications, and Barriers (4Ms)

• Assess for Root Causes of Weight Gain

ASSESS

Obesity Stages (EOSS*)

*EdmontonObesityStagingSystem

BMI kg/m2

Underweight <18.5

NormalWeight 18.6-24.9

Overweight 25.0-29.9

ObesityClassI 30.0-34.9

ObesityClassII 35.0-39.9

ObesityClassIII >40

WaistCircumferenceRiskThreshold:Europid:>94cm;>80cm;AsianandHispanic:>90cm;>80cm

Stage0:NoApparentRiskFactors

Stage2:EstablishedCo-Morbidity

Stage1:PreclinicalRiskFactors

Stage3:End-OrganDamage

Stage4:End-Stage

Obesity Class

Assess Obesity Class and Stage• ObesityClass(I-III)isbasedonBMIandisameasureofhowBIGthepatientis.

• ObesityStage(0-4)isbasedontheMEDICAl,MENTAl,andFUNCTIONAlimpactof

obesityandisameasureofhowHEAlTHythepatientis.

• WaistcircumferenceprovidesadditionalinformationregardingCARDIOMETABOlICrisk.

ASSESS

The 4Ms of Obesity

Mental CognitionDepressionAttentionDeficitAddictionPsychosisEatingDisorderTraumaInsomnia

Metabolic Type2DiabetesDyslipidemiaHypertensionGoutFattyliverGallstonesPCOSCancer

MechanicalSleepApneaOsteoarthritisChronicPainRefluxDiseaseIncontinenceThrombosisIntertrigoPlantarFasciitis

MonetaryEducationEmploymentIncomeDisabilityInsuranceBenefitsBariatricSuppliesWeight-lossPrograms

A+

Assess for Obesity Drivers, Complications, and Barriers• Usethe4MsframeworktoassessMental,Mechanical,Metabolic,andMonetarydrivers,

complications,andbarrierstoweightmanagement.

ASSESS

Assess for Root Causes of Weight Gain

Is weight gain due to slow metabolism?

Is weight gain due to increased food intake?

Is weight gain due to reduced activity?

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 metabolism Address root causes of overeating Address root causes of reduced activity

ASSESS

ADVISE on obesity risks, discussbenefits&options

step 1

ADVISEstep 1

• Advise on Obesity Risks

• ExplainBenefitsofModestWeightLoss

• Explain Need for Long-Term Strategy

• Discuss Treatment Options

ADVISEstep 1

Advise on Obesity Risks•ObesityrisksaremorerelatedtoobesityStage

thantoBMI.

•FocusoftreatmentshouldbeonIMPROVING

HEAlTHandWEll-BEINGratherthansimply

losingweight.

ADVISEstep 1

Advise on Treatment Options•Averagesustainableweightlosswithbehavioural

interventionisabout3-5%ofinitialweight.

DIETARY INTERVENTIONS

SLEEP, TIME, AND STRESS

LOW CALORIE DIETSC

Al

or

Ie

ANTI-OBESITY MEDICATIONS

PHYSICAL ACTIVITY

BARIATRIC SURGERY

PSYCHOLOGICAL

ADVISEstep 1

SLEEP, TIME, AND STRESSmanagementinterventionscansignificantlyimprove

eatingandactivitybehaviours.

ADVISEstep 1

DIETARY INTERVENTIONS shouldfocusondecreasingcaloricintakebyimproving

eatingpattern,nutritionalhygiene,andportionsize.

Extremeand‘fad’dietsaregenerallynotsustainablein

thelong-term.

ADVISEstep 1

PHYSICAL ACTIVITY orexercisealoneisgenerallynotasuccessfulweight-lossstrategy.

Ratherthanfocusingon‘burning’calories,activity

interventionsshouldaimatreducingsedentariness

andincreasingdailyphysicalactivitylevelstopromote

fitness,overallhealth,andgeneralwell-being.

ADVISEstep 1

PSYCHOLOGICALinterventionscanimproveself-esteem,reduceemotionaleating,andpromotenon-

foodcopingstrategies.

ADVISEstep 1

LOW CALORIE DIETS (medicallysupervised)andmealreplacementscanbesafeandeffective

approachesforpatientsrequiringagreaterdegreeof

weightloss.

CA

lo

rIe

ADVISEstep 1

ANTI-OBESITY MEDICATIONS, inconjunctionwithbehaviouralinterventions,can

helppatientsachieveandsustain5-10%weightloss.

Discontinuationofmedicationsgenerallyresultsin

weightregain.

ADVISEstep 1

BARIATRIC SURGERY shouldbeconsideredforallpatientsrequiringmorethan

15%sustainableweightloss.Modernlaparoscopic

bariatricsurgeryisbothsafeandeffective,and

substantiallyreducesmorbidityandmortality.All

surgicalpatientsrequiremultidisciplinarypresurgical

assessmentandlong-termmedical,nutritional,and

psychosocialsupport.

ADVISEstep 1

AGREE on realistic weight-loss expectations and on a SMART plan to

achieve behavioural goals

AGREE

• Agree on Weight Loss Expectations

• Agree on Sustainable Behavioural Goals and Health Outcomes

• Agree on Treatment Plan

AGREE

Agree on Weight Loss Expectations•Unrealisticweight-lossexpectationscanleadto

DISAPPOINTMENTandNON-ADHERENCE.

•Areasonableweight-losstargetwithbehaviouraland

medicalinterventionsis0.5to1.0kgperweekforatotal

of5to10%ofinitialweight,afterwhichweightlosswill

generallyplateau.

•Agreaterormorerapidweightlosswithnon-surgical

interventionsdoesnotresultinbetterlong-term

outcomes.

•Forsomepatients,PREVENTIONorSlOWINGofWEIGHT

GAINmaybetheonlyrealisticweighttarget.

AGREE

Agree on Sustainable Behavioural Goals and Health Outcomes•Focusonsustainablebehaviouralchangesrather

thanonspecificweighttargets.

•BehaviouralgoalsshouldbeSMART:

•Specific

•Measurable

•Achievable

•Rewarding

•Timely

•Self-monitoringwithalifestylejournalhelps

initiateandsustainbehaviouralchange.

plAN

AGREE

Agree on Treatment Plan•TreatmentplansshouldbeREAlISTICandSUSTAINABlE.

•ObesitytreatmentshouldbeginwithADDRESSING

theDRIVERSofweightgain(e.g.stress,lackoftime,

depression,sleepapnea,chronicpain,etc.).

•TheSUCCESSoftreatmentshouldbemeasuredin

improvementsinHEAlTHandWEll-BEING(e.g.improve

bloodpressure,increasefitness,increaseenergy,increase

mobility,etc.).

AGREE

ASSISTinaddressingdrivers&barriers,offereducation&resources,referto

provider, and arrange follow-up

ASSIST

• Assist Patient in Identifying and Addressing Drivers and Barriers

• Provide Education and Resources

• Refer to Appropriate Provider

• Arrange Follow-Up

ASSIST

Assist Patient in Identifying and Addressing Drivers and Barriers•DriversandbarriersmayincludeENVIRONMENTAl,

SOCIOECONOMICAl,EMOTIONAl,orMEDICAlfactors.

•Obesogenicmedications(e.g.atypicalantipsychotics,

anti-diabetics,anti-convulsants,etc.)maymakeobesity

managementdifficult.

•PHySICAlBARRIERSthatlimitaccess(transportation,

turnstiles,limitedseating,etc.)ininstitutionalsettings,

workplaces,andrecreationalfacilities,maydeterfrom

activeparticipationineverydaylife.

probleM

ASSIST

Provide Education and Resources

•PatientEDUCATIONiscentraltoself-management.

•HelppatientsidentifyandseekoutCREDIBlE

weight-managementinformationandresources.

probleM

ASSIST

Refer to Appropriate Provider•EvidencesupportstheneedforanINTERDISCIPlINARy

teamapproachtoobesitymanagement.

•Choiceofappropriateprovider(e.g.physician,nurse,

dietitian,psychologist,socialworker,exercisephysiologist,

PT/OT,surgeon,etc.)shouldreflectidentifiedDRIVERS

andCOMPlICATIONSofobesityaswellasBARRIERSto

weightmanagement.

ASSIST

Arrange Follow-Up

•Giventhechronicrelapsingnatureofobesity,

lONG-TERMfollow-upisESSENTIAl.

•SuccessisdirectlyrelatedtoFREQUENCyof

providercontact.

•Weight-regain(relapse)shouldnotbeframedas

‘failure’—rather,itisthenaturalandEXPECTED

consequenceofdealingwithachroniccondition.

Appt.

16

ASSIST

• lauDC,DouketisJD,MorrisonKM,HramiakIM,SharmaAM,UrE;ObesityCanadaClinicalPracticeGuidelinesExpertPanel.2006CanadianClinicalPracticeGuidelinesOnTheManagementAndPreventionOfObesityInAdultsAndChildren.CMAJ.2007;176:S1-13.

• PadwalRS,PajewskiNM,AllisonDB,SharmaAM.UsingtheEdmontonobesitystagingsystemtopredictmortalityinapopulation-representativecohortofpeoplewithoverweightandobesity.CMAJ.2011;183:E1059-66

• SharmaAM.M,M,M&M:amnemonicforassessingobesity.ObesRev.2010;11:808-9.

• MauroM,TaylorV,WhartonS,SharmaAM.BarriersToObesityTreatment.EurJInternMed.2008;3:173-80.

• SharmaAM,PadwalR.ObesityIsASign-Over-EatingIsASymptom:AnAetiologicalFrameworkForTheAssessmentAndManagementOfObesity.ObesRev.2010;11:362-370.

• KirkSF,PenneyTl,McHughTl,SharmaAM.Effectiveweightmanagementpractice:areviewofthelifestyleinterventionevidence.IntJObes2011;36:178-85.

• TaylorVH,McIntyreRS,RemingtonG,levitanRD,StonehockerB,SharmaAM.Beyondpharmacotherapy:understandingthelinksbetweenobesityandchronicmentalillness.CanJPsychiatry.2012;57:5-12.

• KarmaliS,StoklossaCJ,SharmaA,StadnykJ,ChristiansenS,CottreauD,BirchDW.BariatricSurgery:aPrimer.CanFamPhys.2010;56:873-9.

Professional ResourcesSignupatwww.obesitynetwork.catobecomeamemberoftheCanadianObesityNetwork,Canada’snationalobesityNGOwithaccessto

additionalobesityeducation,resources,andnetworkingopportunitieswithnationalobesityexperts.

TheOnlineBestEvidenceServiceInTacklingobesity+(OBESITy+)providedbyMcMasterUniversity’sHealthInformationResearchUnit

(accessibleatwww.obesitynetwork.ca)providesaccesstothecurrentbestevidenceaboutthecauses,course,diagnosis,prevention,

treatment,andeconomicsofobesityanditsrelatedmetabolicandmechanicalcomplications.

TheCanadianAssociationofBariatricPhysiciansandSurgeons(www.cabps.ca)representsCanadianspecialistsinterestedinthetreatment

ofobesityandsevereobesityforthepurposesofprofessionaldevelopmentandcoordinationandpromotionofcommongoals.

DietitiansofCanada(www.dietitians.ca)isthenationalprofessionalassociationfordietitians,representingalmost6000membersatthe

local,provincialandnationallevels.Practice-basedEvidenceinNutrition(PEN),designedforbusyhealthprofessionals,isanonlinedatabase

availablebysubscriptionthatprovidesevidence-basedanswerstoeverydayfoodandnutritionpracticequestions.

TheCanadianSocietyforExercisePhysiology(www.csep.ca)isavoluntaryorganizationcomposedofprofessionalsinterestedandinvolved

inthescientificstudyofexercisephysiology,exercisebiochemistry,fitnessandhealth.VisittodownloadCanadianPhysicalActivityand

SedentaryBehaviourGuidelines.

Key References

GeetaAchyuthan,MD,MCFP(Regina,SK),AndrewCave,MD,FCFP,FRCGP(UniversityofAlberta,AB),Eleanor

Benterud,RN,BN,MN,(SouthCalgaryPrimaryCareNetwork,AB),DeniseCampbell-Scherer,MD,PhD,CCFP

(UniversityofAlberta,AB),CydCourchesne,OMM,CD,MD,MCFP,DAvMed,CHE,(CanadianArmedForces),Heather

Davis,MD,FRCPC,(Health&Wellness,Gov.ofNS),RobertDent,MD,FRCPC,(OttawaHospital,ON),EricDucet,

PhD,(UniversityofOttawa,ON),AngelaEstey,RN,MSc,(AlbertaHealthServices),MaryForhan,OTReg(Ont),PhD

(McMasterUniversity,ON),yoniFreedhoff,MD,CCFP,(BariatricMedicalInstitute,Ottawa,ON),TraceyHusseyMSc,

RD,(HamiltonFamilyHealthTeam,ON),BrendaGluska,(OntarioMinistryofHealthandlongTermCare),Shahzeer

Karmali,MD,FRCSC,(UniversityofAlberta,AB),SaraKirk,PhD,(DalhousieUniversity,NS),Marie-Francelanglois

MD,FRCPC,CSPQ(UniversitédeSherbrooke,QC),DavidC.W.lau,MD,FRCPC,(UniversityofCalgary,AB),Anthony

levinson,MD,FRCPC,(McMasterUniversity,ON),PatriciaMarturano,(TheCollegeofFamilyPhysiciansofCanada),

RajPadwal,MD,FRCPC,(UniversityofAlberta,AB),HelenaPiccinini-Vallis,MD,CCFP,(Halifax,NS),PaulPoirier,MD,

PhD,FRCPC,(Universitélaval,QC),ValerieTaylor,MD,PhD,FRCPC,(UniversityofToronto,ON),RickTytus,MD,

CCFP,(HamiltonAcademyofMedicine),ShahebinaWaljiMD,CCFP,(CalgaryWeightManagementCentre,AB),Sean

WhartonMD,FRCPC,(WhartonMedicalClinic,ON),RonWilsonMD,CCFP,(Vancouver,BC).

NoticeandDisclaimer:Nopartofthesematerialsmaybereproduced,storedinaretrievalsystem,ortransmitted,inanyformorbyanymeans,electronic,

mechanical,photocopying,recordingorotherwisewithoutpriorwrittenpermissionfromtheCanadianObesityNetwork-Réseau

canadienenobésité(CON-RCO).TheopinionsinthisbookletarethoseoftheauthorsanddonotnecessarilyrepresentthoseofCON-

RCO.Thisbookletisprovidedontheunderstandingandbasisthatnoneofthepublisher,theauthors,orotherpersonsinvolvedinits

creationshallberesponsiblefortheaccuracyorcurrencyofthecontents,orfortheresultsofanyactiontakenonthebasisofthe

informationcontainedinthisbookorforanyerrorsoromissionscontainedherein.Noreadershouldactonthebasisofanymatter

containedinthisbookletwithoutobtainingappropriateprofessionaladvice.Thepublisher,theauthors,andotherpersonsinvolvedin

thisbookletdisclaimliabilityandresponsibilityresultingfromanyideas,products,orpracticesmentionedinthetextanddisclaimalland

anyliabilityandresponsibilitytoanyperson,regardlessofwhethersuchpersonpurchasedthisbooklet,forlossordamageduetoerrors

andomissionsinthisbookandinrespectofanythingandoftheconsequenceofanythingdoneoromittedtobedonebysuchpersonin

relianceuponthecontentofthisbooklet.

Foradditionalinformationandresourcesonobesitypreventionandmanagement,

pleaserefertoourwebsiteatwww.obesitynetwork.ca

ThisbookletwasdevelopedbyAryaM.Sharma,MD/PhD,FRCPC,andMichaelVallis,PhD,

withtheCON-RCOCanadianObesityNetworkPrimaryPracticeWorkingGroup.*

ThisbookletispublishedbytheCanadianObesityNetworkwithsupportfromthe

PublicHealthAgencyofCanadaandtheCanadianInstitutesofHealthResearch.

*WorkingGroupMembers:

Patient ResourcesPublicHealthAgencyofCanada

Thissite(www.publichealth.gc.ca)hasimportant

informationforpatientsonhealthyactiveliving

andonnumerousobesity-relatedhealthproblems

includinghypertension,diabetes,sleepapnea,

mentalillness,andarthritis.

CanadianObesityNetwork

Additionalpatienteducationalandinformation

materialsonobesitymanagementcanbe

orderedinbulkfromCONbycontacting

info@obesitynetwork.ca

Informationonotherobesityrelated

healthproblemscanbefoundat:

CanadianMentalHealthAssociationwww.cmha.caHeartDisease:www.heartandstroke.caHypertension:www.hypertension.caDiabetes:www.diabetes.caArthritis:www.arthritis.caSleepApnea:www.lung.caFattyliverDisease:www.liver.caReproductiveHealth:www.cwhn.caBariatricSurgery:www.asmbs.orgIncontinence:www.canadiancontinence.caChronicPain:www.canadianpainsociety.caPsychology:www.psychologyfoundation.orgAbdominalAdiposity:www.myhealthywaist.org

ASK for Permission to Discuss Weight

ASSESS obesity related risk and potential ‘root causes’ of weight gain

ADVISE on obesity risks, discuss benefits&options

step 1

AGREE on realistic weight-loss expectations and on a SMART plan to

achieve behavioural goals

ASSISTinaddressingdrivers&barriers,offereducation&resources,referto

provider, and arrange follow-up

http://www.obesitynetwork.ca