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RECOMMENDATION 4 Using the questions below, determine and record diet quality/dietary
habits
1. Do you usually eat breakfast?
2. Do you usually* eat 5 or more servings of fruit and vegetables/day
3. Do you usually* choose whole grain products?
4. Do you usually* choose low fat or reduced fat alternatives at home and when eating out?
5. How many boxes, cups or cans of fruit juice or pop do you usually drink per day?What do you drink when you are thirsty?
More than one no answer and more than one serving of sweetened beverage per day indicates the
need for nutritional advice from the physician or referral to a registered dietitian or Dial-A-Dietitian
(1 800 667-3438)
*indicate to the patient that usually means 5 or more days of the week, most weeks.
RECOMMENDATION 5 Assess factors that may inuence weight, activity level
and risk levels
1. Ask about family history of overweight, diabetes, high cholesterol, heart disease, hypertension andkidney disease
2. Consider associated health conditions:
Children/youth Adult
Depression Hypertension
Asthma Type 2 diabetes
Being bullied Arthritis
Learning difculties Depression
Type 2 diabetes
3. Assess social conditions
poverty
unemployment/employment issues
education level
workplace and home stresses
current or previous abuse
4. Further diagnostic assessment should be individualized based on risk factors and family history.
Extensive laboratory assessment of overweight, obese and physically inactive patients in the
absence of obvious risk factors or physical ndings is rarely fruitful.
RECOMMENDATION 6 Adults: Assess each individuals readiness for change.
Tailor interventions and support to their current situation
(See Appendix 2)
1. Educate adults about the risks of excess weight and the benets of moderate weight loss and
increased activity. Reinforce the message that even modest weight loss and increased activity can
confer signicant health benets. Increases in physical activity in a stable, overweight person likely
confer greater health advantages than diet in a physically inactive person.
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OVERWEIGHT, OBESITYAND PHYSICAL INACTIVITY
2. Assess readiness to change: Ask the following questions:
Are you considering trying to lose weight or increase activity?
Are you currently trying to lose weight or increase activity?
Would you like some information to help you?
3. Help the patient who is ready to change to set realistic goals:
Emphasize gradual change in lifestyle over time
Recommend increased physical activity (e.g. walking 30 minutes/day) Recommend some level of caloric restriction
Provide self-help materials
Praise success
See Appendix 2 for detailed explanation of stages of change
Physicians are encouraged to provide brief lifestyle advice during the management of
other conditions whenever an opportunity is available and appropriate.
RECOMMENDATION 7 Children and youth-assessment and management
Assessment and management will require:
the involvement of parents or care-givers where possible and may require formal nutritional
counseling by a registered dietitian and or pediatric referral
an understanding and sensitive approach to assessment of potential eating disorders
With growing children and youth, the goals may be weight maintenance and increased
activity while normal linear growth occurs.
RECOMMENDATION 8 Drugs/popular diets/surgical treatment (adults)
1. Pharmacological treatments are of limited benet and have frequent side effects. The long term
benets are unknown. There may be limited use of one agent in adolescence.
2. Popular diets are becoming extremely prevalent and controversial. Evidence shows that over thelong term, their efcacy is due to caloric decit (energy in and out) and duration. Diets that are
restrictive in particular food groups offer no long-term benet and impose considerable risk of
micronutrient deciencies.
3. The surgical treatment of obesity involves risks and complications. Patients should only consider
surgery if their BMI is greater than 40 or if it is greater than 35 and there is a related condition such
as hypertension, type 2 diabetes or cardiovascular disease.
4. Very frequent weigh-in sessions (for example, weekly visits) have shown no long term benets.
Rationale
Obesity in adults is indicated by a body-mass index (BMI) of 30 or more. About 33% of adult
Canadians had a BMI greater than 25 (overweight) and 14.9% had a BMI of >30 in 20031. The Brit-ish Columbia Nutrition Survey showed that 56% of British Columbians are overweight or obese2. The
prevalence of obesity in both children and adults has been increasing in BC and throughout Canada in
children, adolescents and adults 2,3,4. Obesity is a major risk factor for hypertension, type 2 diabetes,
dyslipidemia, gallbladder disease, cancer and cardiovascular disease 5.
Physicians and patients have requested a coherent reproducible approach to medical assistance in
the management of obesity and inactivity. Recommendations for screening and intervention for obesity
have recently been developed by the American College of Family Physicians5. The recommendations
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focus on using BMI as an indicator of obesity and advice regarding weight loss, increased physical
activity and the risk of more serious diseases. Efforts to reduce calorie and fat intake have been shown
to cause weight loss, particularly if they are applied together with a physical exercise program.
The American Academy of Pediatrics has provided some recommendations for the prevention of
pediatric overweight and obesity6 . The Canadian Pediatric Society, the College of Family Physicians,
Dietitians of Canada and the Community Health Nurses Association have prepared a summary regard-
ing the use of growth charts in Canadian infants and children 7. Although therapeutic options remainto be optimized, behavioural approaches that involve the child and family have demonstrated success.
The recommendations suggest as a guideline that children and adolescents should be considered
overweight if they are between the 85th and 95th percentiles using Centers for Disease Control (CDC)
growth charts8,9. Obesity in children and youth is a BMI for age of greater than the 95th percentile.
Physicians can use clinical judgment to address overweight and obesity in children and adolescents
and to advise them about the benets of weight loss, increased physical activity and increased risk of
complications.
Recent evidence indicates that adult BMI of between 25 and 30 is not associated with increased
mortality. Attempts at intervention should focus on more overweight 27 with comorbidities such as
hypertension or diabetes and obese patients, particularly those with comorbidities10.
References
1. Statistics Canada Health Indicators. June 2004.
2. British Columbia Ministry of Health Services. British Columbia Nutrition Survey. Report on Physical
Activity and Body Weight. March 2004.
3. Katzmaryk PT. The Canadian obesity epidemic, 1985-1998. CMAJ 2002;166:1039-1040.
4. Tremblay MS and Willms JD 2000. Secular trends in the body mass index of Canadian children
CMAJ 2000;163:1429-33.
5. McTigue KM, Harris R, Hemphill B et al. Screening and intervention for obesity in adults: Summary
of the evidence for the US Preventive Services Task Force. Ann Intern Med 2003;139:933-949.
6. American Academy of Pediatrics. prevention of pediatric overweight and obesity.Pediatrics 2003;112: 424-430.
7. Canadian Paediatric Society. Use of growth charts for assessing and monitoring growth in
Canadian infants and children: Executive summary. Paediatr Child Health 2004;9:171-173.
8. Centres for Disease Control 2005. http://www.cdc.gov/nchs/about/major/nhanes/
growthcharts/charts.htm9. Cole TJ, Bellizzi MC, Flegal KM and WH Dietz. Establishing a standard denition for child over-
weight and obesity worldwide: international survey. BMJ 2000;320:1-6.
10. Flegal KM, Graubard BI, Williamson DF and MH Gail. Excess deaths associated with underweight,
overweight and obesity. JAMA 2005;293:1861-67.
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Sponsors
This guideline was developed by the Guidelines and Protocols Advisory Committee, approved by the
British Columbia Medical Association and adopted by the Medical Services Commission. Partial fund-
ing for this guideline was provided by the Health Canada Primary Health Care Transition Fund.
Effective Date: September 1, 2005
This guideline is based on the scientic evidence at the time of the effective date.
The principles of the Guidelines and Protocols Advisory Committee are:
to encourage appropriate responses to common medical situations
to recommend actions that are sufcient and efcient, neither excessive nor decient
to permit exceptions when justied by clinical circumstances.
Guidelines and Protocols Advisory Committee
1515 Blanshard Street 2-3
Victoria BC V8W 3C8
Phone: (250) 952-1347 E-mail: [email protected]
Fax: (250) 952-1417 Web site: www.healthservices.gov.bc.ca/msp/protoguides
G&P2005-098
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Appendix 1
International BMI (kg/m2) by age and sex
(overweight > 85th percentile and obese >95th percentile9)
Appendix 2 Stages of Change
PRE-CONTEMPLATION
Person may be unaware of health consequences of increased weight or inadequate activity. May be
resistant due to past failures.
Provide non-judgemental information and advice on health consequences of increased weight orinadequate activity
Tools: Provide patient resources for reducing sedentary activity, increasing activity level and healthy
eating using one-page handouts and brief advice.
Dialogue: I am concerned about your weight. Losing some weight could really help you feel
better and help your health. Would you like to read some information about why
reducing your weight or increasing your activity level is important to your health?
CONTEMPLATION
Person is aware of problem, but not yet ready to change their behaviour/lifestyle
Provide encouragement, positive support, and focus on health consequences of excess
weight/inactivity.
Tools: share examples of people who have successfully increased activity/lost weight. Encourage
self-evaluation focussing on the pros and cons of changing.
Dialogue: Lets consider the benets of weight loss and what you might need to do.
6 17.6 19.8 17.3 19.7
7 17.9 20.6 17.8 20.5
8 18.4 21.6 18.4 21.6
9 19.1 22.8 19.1 22.8
10 19.8 24.0 19.9 24.1
11 20.6 25.1 20.7 25.4
12 21.2 26.0 21.7 26.7
13 21.9 26.8 22.6 27.8
14 22.6 27.3 23.3 28.6
15 23.3 28.3 23.9 29.116 23.9 28.9 24.4 29.4
17 24.5 29.4 24.7 29.7
18 25.0 30.0 25.0 30.0
BOYS GIRLS
Overweight Obese Overweight Obese
AGE
(yrs)
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PREPARATION
The person is ready to change but is uncertain how to get started
Provide support and encouragement, offer information, options and referrals as necessary. Emphasize
the success of gradual incremental change.
Tools: Provide appropriate resource information. Assist in negotiating a plan and setting realistic goals
and timelines.
Dialogue: What two changes do you feel you could you make in your eating habits/activities
this week to start you in the right direction?
ACTION
Person feels empowered to reach goals, and is actively learning or trying new behaviors.
Engagement strategy: develop and discuss strategies to increase activity improve eating habits, afrm
positive changes and encourage modications to behaviour and lifestyle.
Tools: identify community-based and professional programs that will provide support for lifestyle
changes. Assist individual to develop a relapse prevention plan. Encourage them to exercise with a
partner or join a group with similar goals.
Dialogue: Its great to see you making such positive changes. How are you feeling? Have you
run into any problems or difculties? What did you do about that?
RELAPSE
Person feels discouraged and helpless, doesnt feel they have been successful
Engagement strategy: Acknowledge the difculties of real change over time, provide hopeful empathic
support, and encourage them to tryagain.Emphasize again the need for gradual sustained change
over the long term.
Tools: Support with problem solving, identifying realistic goals.
Dialogue: What were the positive changes you tried? What were the tough things to manage?
Every time you make an effort to improve your nutrition and activity you learn somenew things that will help you next time.
MAINTENANCE
Person has made positive lifestyle changes; life skill development and support systems are rened.
Engagement strategies: continue with relapse prevention strategies, provide objectivity and perspective
on accomplishments at time of despair or plateau, discuss and normalize life challenges.
Tools: acknowledge successes, continue to offer support and encouragement and problem solving
help. Normalize the difculties in maintaining weight loss and activity levels in the context of aging,
busy lives, school and family demands.
Dialogue: Tell me how you manage to continue your healthy eating/exercise when you are
ill/busy/stressed/tired? What helps you stay on track?
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152
155
157
160
163
165
168
170
173
175
178
180
183
185
188
191
193
Kg
Lbs
Height
(cm)
Height
(ft/in)
Weight
50
51
52
53
54
55
56
57
58
59
510
511
60
14
14
15
16
16
17
18
18
19
20
20
21
22
22
23
24
24
25
26
26
27
28
28
29
30
61
13
14
15
15
16
16
17
18
18
19
20
20
21
22
22
23
24
24
25
26
26
27
28
28
29
62
13
13
14
15
15
16
17
17
18
19
19
20
21
21
22
22
23
24
24
25
26
26
27
28
28
63
12
13
14
14
15
16
16
17
17
18
19
19
20
21
21
22
22
23
24
24
25
26
26
27
27
64
12
13
13
14
15
15
16
16
17
18
18
19
19
20
21
21
22
23
23
24
24
25
26
26
27
BMI6yrs
kg
20
21
22
23
24
2
26
27
28
29
30
31
32
33
kg
lbs
44
46
48
5
53
5
57
59
62
64
66
68
71
73
lbs
Height(inches
29
39
72
Height (cm)
31
34
35
37
39
40
77
33
30
31
33
34
36
37
39
40
82
35
26
28
29
30
32
33
34
36
37
38
40
87
37
24
25
26
27
28
30
31
32
33
34
35
37
38
39
92
39
21
22
23
24
26
27
28
29
30
31
32
33
34
35
97
41
19
20
21
22
23
24
25
26
27
28
29
30
31
32
102
43
17
18
19
20
21
22
23
24
24
25
26
27
28
29
107
45
16
17
18
18
19
20
21
22
22
23
24
25
26
26
112
47
15
15
16
17
18
18
19
20
20
21
22
23
23
24
117
49
13
14
15
15
16
17
17
18
19
19
20
21
21
22
122
51
12
13
14
14
15
16
16
17
17
18
19
19
20
20
127
53
11
12
13
13
14
14
15
15
16
17
17
18
18
19
132
55
11
11
12
12
13
13
14
14
15
15
16
17
17
18
137
57
10
10
11
11
12
12
13
13
14
14
15
15
16
16
142
59
9
10
10
11
11
12
12
12
13
13
14
14
15
15
147
Mass
kg
34
35
36
37
38
39
40
41
42
43
44
45
46
47
kg
lbs
75
77
79
82
84
86
88
90
93
95
97
99
101
103.4
lbs
Height(inches
37
40
92
Height (cm)
39
36
37
38
39
40
41
97
41
33
34
35
36
37
37
38
39
40
102
43
30
31
31
32
33
34
35
36
37
38
38
39
40
107
45
27
28
29
29
30
31
32
33
33
34
35
36
37
37
112
47
25
26
26
27
28
28
29
30
31
31
32
33
34
34
117
49
23
24
24
25
26
26
27
28
28
29
30
30
31
32
122
51
21
22
22
23
24
24
25
25
26
27
27
28
29
29
127
53
20
20
21
21
22
22
23
24
24
25
25
26
26
27
132
55
18
19
19
20
20
21
21
22
22
23
23
24
25
25
137
57
17
17
18
18
19
19
20
20
21
21
22
22
23
23
142
Mass
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OVERWEIGHT, OBESITYAND PHYSICAL INACTIVITY
Appendix 5
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Appendix 6
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Healthy Active Living
A GUIDEFOR PATIENTS
Increasing physical activity and reducing body fat around the waist decreases the risk of
hypertension, diabetes, heart disease, stroke and kidney failure. For example, increasedactivity of more than 2.5 hours of walking per week reduces the risk of heart disease by 40%.
The benet was seen for all ages, in different ethnic groups and regardless of whether a
person was normal or overweight.
Diet
1. Eat a healthy breakfast
2. Eat 5 or more servings of fruit and vegetables per day
3. Choose whole grain products
4. Choose low fat or reduced fat alternatives at home and when eating out
5. Reduce boxes, cups or cans of fruit juice or pop to no more than 1 per day.
6. Choose water when thirsty
Recommended activity level
Children and youth 30-90 minutes per day
Adults 30 minutes per day
Tips to increase activity level
Children and Youth
increase the amount of time currently spent being physically active by at least 30 minutes more
per day
decrease the time spent watching TV, playing computer games and surng the Internet by at least30 minutes less per day
Adults
Create a new morning exercise routine with 10 minutes of exercise
Park the car 10 minutes walking distance from work or shopping area
Go for a bike ride
Do a physical activity routine in front of the TV
Expected yearly weight loss with additional activity
kg lb
Weight 50 kg: moderate walk (30 min/day) 5 11
brisk walk (30 min/day) 6.2 14
Weight 70 kg: moderate walk (30 min/day) 7 16
brisk walk (30 min/day) 8.75 20
(110 lb)
(155 lb)
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Resources
BC HealthGuide OnLine has a world of health information just a click away, through the award-
winning Healthwise Knowledgebase. Over 2500 detailed symptom and condition-based
topics are available, including topic overviews, check your symptoms, when to see a doctor,
home treatments, and tips and tools for healthy living. Information specic to B.C. is also
available, including the BC HealthFiles. Web site: http://www.bchealthguide.org
Chronic Disease Self-Management Program
A patient education program offered in communities throughout British Columbia that teaches
practical skills in managing chronic health problems.
Toll-free in B.C.: 1 866-902-3767
Canadian Health Network
Canadian Health Network is Canadas national health information network. Start your search here
for health information developed by leading Canadian health organizations and international healthinformation providers. Web site: http://www.Canadian-health-network.ca
Government-listed Health-Related Internet Resources
This page provides links to other health-related Internet sites. These information resources have been
selected by the Health and Human Services Library to serve the information needs of government
staff and stakeholders.
Diet and Nutrition
Dial-A-Dietitian is a free nutrition information line for B.C. residents. It specializes in easy-to-use
nutrition information for self-care, based on current scientic sources. Dietitians provide brief nutrition
consultation by phone. This is an excellent source of information about special diets for people withchronic illnesses, such as diabetes and cardiovascular atherosclerotic disease.
Toll-free in B.C.: 1 800 667-3438
Greater Vancouver: 604 732-9191
Exercise
Canadas Physical Activity Web site: www.paguide.com
Health Canadas online guide is designed to help you make wise choices about physical activity that
will improve your health, help prevent disease, and allow you to get the most out of life. If you think
your congestive heart failure might prevent you from becoming more active, check out the Physical
Activity Readiness Questionnaire.
Call 1 888 334-9769 for a free activity guide.
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