ASK

ASSESS

ADVISE

step 1

ASSI

ST

AGREE

of Obesi

ty

Managem

ent

tIM

e

WAIst

Obesity is a Chronic ConditionObesityisachronicandoftenprogressiveconditionnotunlikediabetesorhypertension.

Successfulobesitymanagementrequiresrealisticandsustainabletreatmentstrategies.

Short-termquick-fixsolutionsfocusingonmaximizingweightlossaregenerallyunsustainableandthereforeassociatedwithhighratesofweightregain.

Key Principles

Obesity Management is About Improving Health and Well-being, and not Simply Reducing Numbers on the ScaleThesuccessofobesitymanagementshouldbemeasuredinimprovementsinhealthandwell-beingratherthanintheamountofweightlost.

Formanypatients,evenmodestreductionsinbodyweightcanleadtosignificantimprovementsinhealthandwell-being.

Key Principles

Early Intervention Means Addressing Root Causes and Removing RoadblocksSuccessfulobesitymanagementrequiresidentifyingandaddressingboththerootcausesofweightgainaswellasthebarrierstoweightmanagement.

Weightgainmayresultfromareductioninmetabolicrate,overeating,orreducedphysicalactivitysecondarytobiological,psychologicalorsocioeconomicfactors.

Manyofthesefactorsalsoposesignificantbarrierstoweightmanagement.

Key Principles

Detour

Success is different for every individual Patientsvaryconsiderablyintheirreadinessandcapacityforweightmanagement.

Successcanbedefinedasbetterquality-of-life,greaterself-esteem,higherenergylevels,improvedoverallhealth,preventionoffurtherweightgain,modest(5%)weightloss,ormaintenanceofthepatientsbestweight.

Key Principlest

IMe

WAIst CIrCuMFereNCe

A patients Best weight may never be an ideal weight AnidealweightorBMIisnotarealisticgoalformanypatientswithobesity,andsettingunachievabletargetssimplysetsuppatientsforfailure.

Instead,helppatientssetweighttargetsbasedonthebestweighttheycansustainwhilestillenjoyingtheirlifeandreapingthebenefitsofimprovedhealth.

Key Principles

Be t

Weightisasensitiveissue.Manypatientsareembarrassedorfearblameandstigma.

ASK for permission to discuss weight

ASK

Be non-judgemental

Explore readiness for change

Use motivational interviewing

Create weight-friendly practice

ASK

Be Non-judgementalDoNOTblame,threaten,orprovokeguiltinyourpatient.

DoNOTmakeassumptionsabouttheirlifestylesormotivation.(yourpatientmayalreadybeonadietorhavealreadylostweight)

Doacknowledgethatweightmanagementisdifficultandhardtosustain.

Judgement

ASK

Use Motivational Interviewing to Move Patients Along the Stages of Change

Mo

tIV

At

IoN

CHANGe

Askquestions,listentopatientscommentsandrespondinawaythatvalidatestheirexperienceandacknowledgesthattheyareincontroloftheirdecisiontochange.

IfpatientsareNOTreadytoaddresstheirweight,bepreparedtoaddresstheirconcernsandotherotherhealthissuesandthenaskifyoucanspeakwiththemabouttheirweightagaininthefuture.

ASK

Explore Readiness for ChangeDeterminingyourpatientsreadinessforbehaviourchangeisessentialforsuccess.

Useapatient-centredcollaborativeapproach.

Initiatingchangewhenpatientsarenotreadycanresultinfrustrationandmayhamperfutureefforts.

CHANGe

ASKM

ot

IVA

tIo

N

CHANGe

Sample Questions on How to Begin a Conversation About Weight:Woulditbealrightifwediscussedyourweight?Areyouconcernedaboutyourweight?Wouldyoubeinterestedinaddressingyourweightatthistime?

Onascaleof0to10,howimportantisitforyoutoloseweightatthistime?

Onascaleof0to10,howconfidentareyouthatyoucanloseweightatthistime?

ASK

Create a Weight-Friendly Practice

Mo

tIV

At

IoN

CHANGe

Facilities:handicappedaccessibility,widedoors,largerestrooms,floor-mountedtoilets

WaitingRoom:sturdy,armlesschairs,appropriatereadingmaterial

ExamRoom:oversizedgowns,scalesover350lbs/160kg,wideandsturdyexamtables,extra-largebloodpressurecuffs,longerneedlesandtourniquets,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 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,andFUNCTIONAlimpactofobesityandisameasureofhowHEAlTHythepatientis.

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 RisksObesityrisksaremorerelatedtoobesityStagethantoBMI.

FocusoftreatmentshouldbeonIMPROVINGHEAlTHandWEll-BEINGratherthansimplylosingweight.

ADVISEstep 1

Advise on Treatment OptionsAveragesustainableweightlosswithbehaviouralinterventionisabout3-5%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 STRESSmanagementinterventionscansignificantlyimproveeatingandactivitybehaviours.

ADVISEstep 1

DIETARY INTERVENTIONS shouldfocusondecreasingcaloricintakebyimprovingeatingpattern,nutritionalhygiene,andportionsize.Extremeandfaddietsaregenerallynotsustainableinthelong-term.

ADVISEstep 1

PHYSICAL ACTIVITY orexercisealoneisgenerallynotasuccessfulweight-lossstrategy.Ratherthanfocusingonburningcalories,activityinterventionsshouldaimatreducingsedentarinessandincreasingdailyphysicalactivitylevelstopromotefitness,overallhealth,andgeneralwell-being.

ADVISEstep 1

PSYCHOLOGICALinterventionscanimproveself-esteem,reduceemotionaleating,andpromotenon-foodcopingstrategies.

ADVISEstep 1

LOW CALORIE DIETS (medicallysupervised)andmealreplacementscanbesafeandeffectiveapproachesforpatientsrequiringagreaterdegreeofweightloss.

CA

lo

rIe

ADVISEstep 1

ANTI-OBESITY MEDICATIONS, inconjunctionwithbehaviouralinterventions,canhelppatientsachieveandsustain5-10%weightloss.Discontinuationofmedicationsgenerallyresultsinweightregain.

ADVISEstep 1

BARIATRIC SURGERY shouldbeconsideredforallpatientsrequiringmorethan15%sustainableweightloss.Modernlaparoscopicbariatricsurgeryisbothsafeandeffective,andsubstantiallyreducesmorbidityandmortality.Allsurgicalpatientsrequiremultidisciplinarypresurgicalassessmentandlong-termmedical,nutritional,andpsychosocialsupport.

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 ExpectationsUnrealisticweight-lossexpectationscanleadtoDISAPPOINTMENTandNON-ADHERENCE.

Areasonableweight-losstargetwithbehaviouralandmedicalinterventionsis0.5to1.0kgperweekforatotalof5to10%ofinitialweight,afterwhichweightlosswillgenerallyplateau.

Agreaterormorerapidweightlosswithnon-surgicalinterventionsdoesnotresultinbetterlong-termoutcomes.

Forsomepatients,PREVENTIONorSlOWINGofWEIGHTGAINmaybetheonlyrealisticweighttarget.

AGREE

Agree on Sustainable Behavioural Goals and Health OutcomesFocusonsustainablebehaviouralchangesratherthanonspecificweighttargets.

BehaviouralgoalsshouldbeSMART:SpecificMeasurableAchievableRewardingTimely

Self-monitoringwithalifestylejournalhelpsinitiateandsustainbehaviouralchange.

plAN

AGREE

Agree on Treatment PlanTreatmentplansshouldbeREAlISTICandSUSTAINABlE.

ObesitytreatmentshouldbeginwithADDRESSINGtheDRIVERSofweightgain(e.g.stress,lackoftime,depression,sleepapnea,chronicpain,etc.).

TheSUCCESSoftreatmentshouldbemeasuredinimprovementsinHEAlTHandWEll-BEING(e.g.improvebloodpressure,increasefitness,increaseenergy,increasemobility,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 BarriersDriversandbarriersmayincludeENVIRONMENTAl,SOCIOECONOMICAl,EMOTIONAl,orMEDICAlfactors.

Obesogenicmedications(e.g.atypicalantipsychotics,anti-diabetics,anti-convulsants,etc.)maymakeobesitymanagementdifficult.

PHySICAlBARRIERSthatlimitaccess(transportation,turnstiles,limitedseating,etc.)ininstitutionalsettings,workplaces,andrecreationalfacilities,maydeterfromactiveparticipationineverydaylife.

probleM

ASSIST

Provide Education and Resources

PatientEDUCATIONiscentraltoself-management.HelppatientsidentifyandseekoutCREDIBlEweight-managementinformationandresources.

probleM

ASSIST

Refer to Appropriate ProviderEvidencesupportstheneedforanINTERDISCIPlINARyteamapproachtoobesitymanagement.

Choiceofappropriateprovider(e.g.physician,nurse,dietitian,psychologist,socialworker,exercisephysiologist,PT/OT,surgeon,etc.)shouldreflectidentifiedDRIVERSandCOMPlICATIONSofobesityaswellasBARRIERStoweightmanagement.

ASSIST

Arrange Follow-Up

Giventhechronicrelapsingnatureofobesity,lONG-TERMfollow-upisESSENTIAl.

SuccessisdirectlyrelatedtoFREQUENCyofprovidercontact.

Weight-regain(relapse)shouldnotbeframedasfailurerather,itisthenaturalandEXPECTEDconsequenceofdealingwithachroniccondition.

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,CanadasnationalobesityNGOwithaccessto

additionalobesityeducation,resources,andnetworkingopportunitieswithnationalobesityexperts.

TheOnlineBestEvidenceServiceInTacklingobesity+(OBESITy+)providedbyMcMasterUniversitysHealthInformationResearchUnit

(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),EleanorBenterud,RN,BN,MN,(SouthCalgaryPrimaryCareNetwork,AB),DeniseCampbell-Scherer,MD,PhD,CCFP(UniversityofAlberta,AB),CydCourchesne,OMM,CD,MD,MCFP,DAvMed,CHE,(CanadianArmedForces),HeatherDavis,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),ShahzeerKarmali,MD,FRCSC,(UniversityofAlberta,AB),SaraKirk,PhD,(DalhousieUniversity,NS),Marie-FrancelangloisMD,FRCPC,CSPQ(UniversitdeSherbrooke,QC),DavidC.W.lau,MD,FRCPC,(UniversityofCalgary,AB),Anthonylevinson,MD,FRCPC,(McMasterUniversity,ON),PatriciaMarturano,(TheCollegeofFamilyPhysiciansofCanada),RajPadwal,MD,FRCPC,(UniversityofAlberta,AB),HelenaPiccinini-Vallis,MD,CCFP,(Halifax,NS),PaulPoirier,MD,PhD,FRCPC,(Universitlaval,QC),ValerieTaylor,MD,PhD,FRCPC,(UniversityofToronto,ON),RickTytus,MD,CCFP,(HamiltonAcademyofMedicine),ShahebinaWaljiMD,CCFP,(CalgaryWeightManagementCentre,AB),SeanWhartonMD,FRCPC,(WhartonMedicalClinic,ON),RonWilsonMD,CCFP,(Vancouver,BC).

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

mechanical,photocopying,recordingorotherwisewithoutpriorwrittenpermissionfromtheCanadianObesityNetwork-Rseau

canadienenobsit(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.*

ThisbookletispublishedbytheCanadianObesityNetworkwithsupportfromthePublicHealthAgencyofCanadaandtheCanadianInstitutesofHealthResearch.

*WorkingGroupMembers:

Patient ResourcesPublicHealthAgencyofCanada

Thissite(www.publichealth.gc.ca)hasimportantinformationforpatientsonhealthyactivelivingandonnumerousobesity-relatedhealthproblemsincludinghypertension,diabetes,sleepapnea,mentalillness,andarthritis.

CanadianObesityNetwork

AdditionalpatienteducationalandinformationmaterialsonobesitymanagementcanbeorderedinbulkfromCONbycontactinginfo@obesitynetwork.ca

Informationonotherobesityrelatedhealthproblemscanbefoundat:

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