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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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step1

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step1

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

info@obesitnetwork.ca

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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