Weight Management

Foreword xv

Acknowledgements xvi

Introduction xvii

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