in General Practice Part 1 COMPaRE-PHC is funded by the Australian - - PowerPoint PPT Presentation

COMPaRE-PHC is funded by the Australian Primary Health Care Research Institute, which is supported by a grant from the Commonwealth of Australia as represented by the Department of Health and Ageing

Better Management of Weight in General Practice Part 1

BMWGP Research Team

Outline

• Principles of weight

management in general practice

• Taking health literacy into

consideration in weight management

Some questions about overweight trends (True or False)

• 1. Overweight in Australian population since 1995?
• a. Increased by 20%
• b. Doubled in children
• 2. The causes of these trends?
• a. Increased energy intake in adults
• b. Increased energy intake in children
• c. Decreased physical activity and increased sedentary

behaviour in adults

• d. Decreased physical activity and increased sedentary

behaviour in children

Trends in weight (measured) by age cohort 1980 to 2000

Proportion of adults who are obese

Disparities in Obesity (%) by IRSD Quintile, Males and Females Aged 25-64, 1989 to 2001

Management of obesity in Primary Health Care

Case study

Joe is 68 years of age having retired at 65 years. He has a BMI of 33, waist of

• 115cm. He is diagnosed with

hypertension, type 2 diabetes, ischaemic heart disease and early renal disease with an eGFR of 35. He suffers from severe osteoarthritis in his knees. He has restricted mobility. He has been attending the practice for

• ver 30 years at least once a year. Was

there a missed opportunity to intervene?

Lifestyle intervention pathway for adults: 5As Model

* All patients but especially higher risk patients: physiological risk factors (hypertension, high cholesterol, pre- diabetes) ; indigenous and CALD groups; family history of CVD, diabetes, renal disease, OA

Assess

• BMI = weight (kg) / height (m2)

Classification BMI (kg/m2) Risk of co- morbidities Normal range 18.5-24.9 Average Overweight 25-29.9 Increased Obese class I 30-34.9 Moderate Obese class II 35-39.9 Severe Obese class III ≥ 40 Very severe

WHO, 1998

Waist circumference is a surrogate measure of abdominal or visceral fat

Women Increased risk >80cm Greatly increased risk >88cm

www.measureup.gov.au

Men Increased risk >94cm Greatly increased risk >102cm

Assess cont….

Medications causing weight gain Atypical antipsychotics including clozapine, olanzapine Beta-adrenergic blockers particularly propranolol Insulin Sulphonylureas including chlorpropamide, glibenclamide, glimepiride and glipizide, Thiazolidinediones, including pioglitazone Lithium, Pizotifen, Sodium valproate Tricyclic antidepressants including amitriptyline Diet Portions of fruit and vegetables, energy intake, fat, portion size, soft drinks Physical activity Minutes of moderate and vigorous activity Sedentary activity Behaviours Binge eating, eating disorders, drivers of unhealthy eating Motivation Previous attempts, readiness to change Other health problems Sleep apnoea, arthritis, GORD, diabetes or pre-diabetes, cardiovascular risk factors or disease

Advise

What How Benefits

• Cardiovascular risk
• Diabetes risk
• Reduced pain/Increased

mobility

• Better sleep

Life expectancy +2-4 years Show change in risk Less stress on joints, back Less snoring and apnoea Physical activity

• Reduce sedentary time
• Increase minutes of moderate

and vigorous activity

• Muscle strengthening

Less sitting. More standing Moderate: Walking, swimming, gardening Vigorous: running, gym, bike Lifting weight Diet

• 2500 energy deficit
• Reduce fat
• Reduce snacking/binge eating

2 fruit and 5 vegetable portions Reduced portion/plate size No soft drink Low fat milk products, cooking Behaviour • Avoid situations

• Environmental control
• Self monitoring

Avoiding triggers, shopping after eating, public transport, group activity, food and exercise diary.

Modest weight loss of 5-10% is sufficient to achieve clinically significant benefits

• Blood pressure: 1% fall in weight = 1% fall in

SBP, 2% fall in DBP

• LDL reduces by 1% for every kg lost
• 55% reduction in incidence Prevention of

diabetes in high risk patients and improved glycaemic control

• Reduced risk of CVD and CVD death especially

if reductions in visceral fat occur

Effective interventions for diet and PA

• Support to change both diet and physical

activity

• Use problem solving, self-monitoring, goal-

setting, action plans, relapse prevention

• Encourage social support (i.e. engage others

who are important such as family, friends, and colleagues)

• Greaves et al. Systematic review of reviews of intervention

components associated with increased effectiveness in dietary and physical activity interventions. BMC Public Health 2011, 11:119

• 6
• 5
• 4
• 3
• 2
• 1

1 2 3

3 m 6m 12m 24 m

Weight Change kg

• 2.3
• 4.2
• 3.3
• 3.0

One in 6 achieve >5% weight loss at 12 or 24 months

The Counterweight Programme Br J Gen Pract. 2008; 58: 548-554

Counterweight

Advise: aids cont….

Risks and Benefits Australian absolute risk CVD calculator – www.cvdcheck.org.au AUSDRISK diabetes risk tool http://www.health.gov.au/internet/main/publishing.nsf/Conte nt/diabetesRiskAssessmentTool Diet and physical activity Australian Dietary Guidelines www.eatforhealth.gov.au NSW Health 8700: http://www.8700.com.au/ Shape up Australia http://shapeup.gov.au/ Health Active Australia: http://www.healthyactive.gov.au/ Multi-language resources (NSW Health) http://www.mhcs.health.nsw.gov.au/publicationsandresourc es/pdf/copy_of_topics/exercise#c5=eng&b_start=0

Agree: goal setting and planning

• Given all that we’ve just discussed,

what specific changes would you like to make?

• 1-3 behaviour change goals that are

specific and proximal e.g. “I would like to walk 20 minutes, 5 days per week with my dog after work and I will record my progress in an exercise diary until

• ur next visit.”
• Document goals both in the electronic

medical record and on paper for the patient to take home, with the expectation that they will be asked about these goals at the following visit.

Assist: Referral options

• Dietician
• Exercise physiologist
• Get Healthy

http://www.gethealthynsw.com.au/

• HEAL Program

http://www.swsml.com.au/site/HEAL--Program---Local

• Other community programs

Mean Weight Change According to Randomised Group.

Appel LJ et al. N Engl J Med 2011;365:1959-1968

Arrange: Follow up

• Review progress with diet,

physical activity and weight in 2-6 weeks

• Review attendance
• Solve problems/ prevent or

manage relapse

Case study

Joe had presented to the GP at age 54years with early signs of arthritis in his knees. He was prescribed an NSAID. At the time his BMI was 31, waist of 108 cm. BP 145/90, TC 5.5 HDL 1.1. He was a non smoker with a FH of diabetes.

• 1. What other assessment could have been

done?

• 2. What advice could have been given?
• 3. What goals could have been agreed?
• 4. What options for referral could have been
• ffered?
• 5. When could he have been followed up?