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The “supporting weight management
in primary care” programme
The Western Bay of Plenty PHO (WBOPPHO), in conjunction with the University of Auckland, has launched
a pilot weight management programme for primary care. The programme uses a brief opportunistic
approach to make it easier for health professionals to engage with patients with weight- or diet-related
health issues. The programme provides health professionals with support material that covers diet, exercise
and stress management. The format of the intervention is similar to the “ABC” smoking cessation tool,
which is familiar to most primary care clinicians. The three-tiered approach focuses on: Ask, Brief advice
and Offer ongoing support or onward referral – “ABO”. If this approach proves successful in the pilot
programme, the ABO toolkit will be made available nationally.
The scale of the problem
Obesity is a major global health challenge. The proportion
of adults who are overweight or obese has increased
substantially over the past 30 years, and there have been no
reports of “success stories” from any nation during this time.1
In New Zealand, it is estimated that over one-third of adults
are obese – this includes nearly one-half of Māori and over
two-thirds of Pacific peoples.2
There have been many major studies on lifestyle interventions
to aid with weight management and diabetes prevention,
along with findings from “real life” programmes in the
community. However, there is little evidence that these
interventions result in large-scale (i.e. population level),
long-term improvements in weight loss (and maintenance) or
metabolic health indicators, such as type 2 diabetes.1, 3, 4
This raises the questions of whether researchers and clinicians
have the biology of human physiology, nutrition and physical
activity basics correct and/or whether the socioeconomic
environment is just too difficult to get people to change
to healthier lifestyles. There is evidence that both issues
have played a part in nations failing to improve normal
weight maintenance and metabolic management for their
populations.
How the ABO programme can
make a difference
The WBOPPHO programme adopts
a sympathetic approach to weight
management that helps patients
understand how our obesogenic society,
via aggressive marketing, promotes
the consumption of energy-dense
food. Through the weight management
programme, people are given planning
advice so they can find time in their busy lives
to overcome their obesogenic environment and
regularly eat healthy and nutritious food.
The basis for the dietary advice provided by the ABO
programme is evidence that populations that consume large
quantities of unprocessed, high-nutrient foods have good
metabolic health and central weight management. 5, 6 An
important part of the programme is that health professionals
acknowledge that people often find it difficult to choose to eat
these high-nutrient foods as they prefer refined, energy-dense
food.7 Health professionals are encouraged to think of this
preference for energy-dense food as a type of “addiction”; this
approach highlights similarities with how smoking cessation
is being managed in primary care.
BPJ Issue 65 21
Overcoming barriers to weight-loss interventions
A key part of the weight management programme is to help
health professionals overcome barriers to discussing weightor diet-related issues with patients.
These barriers include:
Fear of offending patients
Discomfort at bringing up the issue of weight if the
health professional themselves is overweight
Not being able to offer a service due to lack of
knowledge
In order to provide a non-judgemental opportunity for
people to discuss issues relating to weight or body shape,
it is important that all patients, of any size, can be weighed
and measured during the consultation. This may necessitate
purchasing a new set of scales, particularly in communities
with large numbers of Māori and Pacific peoples who have
some of the highest rates of morbid obesity (BMI >40 kg/m2)
and super obesity (BMI >55 kg/m2) in the world.8
Asking patients if they have any concerns about weight
management
Health professionals can initiate discussions with patients
about body weight or dietary patterns by asking one or
two open-ended questions to identify if the patient has any
concerns. For example, “How do you feel about your body
shape?”, or “Are you happy with your diet or eating patterns at the
moment?” Patients who demonstrate a willingness to discuss
body weight or diet-related issues should then be encouraged
to do so using open, non-judgemental, reflective questions;
the focus should be on making the patient feel heard.
Patients who are struggling with weight-related issues need
to know that they are not alone, and that many other people
are confronting the same problems. Talking about how
society creates an obesogenic environment with prominent
advertising and the ready availability of energy-dense food is
likely to reduce any sense of isolation felt by these patients.
During the “Ask” phase of the intervention health professionals
assess the patient’s current consumption of plant based,
nutrient dense foods, such as vegetables, fruit and nuts, using
validated questions.
Giving brief advice
The main dietary advice provided by the intervention is
to encourage people to increase their intake of fruit and
22 BPJ Issue 65
vegetables (limiting high-starch vegetables such as potato).
The goal is for these healthy forms of food to eventually replace
“addictive” energy-dense foods. Calorie counting or weighing
food is not part of the intervention as this may be perceived by
the patient as being negative. A guiding, partnering approach
is adopted in order to develop a management plan for the
patient, as opposed to a “telling” approach.
A reduction in sedentary activities and an increase in
the frequency and volume of physical activity is strongly
recommended to all patients.
During the consultation an offer of annual weight, height,
waist and hip measurements should be made, if these are
not already being recorded. The patient is also offered
routine blood tests, e.g. lipid profile, and then asked to return
for a follow-up consultation to construct a plan for weight
management and ongoing support.
Offering ongoing support or onward referral
Health professionals need to individualise weight-loss support
according to patient requirements. For some patients dietary
and exercise advice, along with a plan to maintain high levels
of fruit and vegetable intake is sufficient. For other patients
cognitive behavioural techniques are required to encourage
patients to maintain healthy lifestyle changes.
Patients are contacted with reminders to attend quarterly
follow-up consultations to encourage them to adhere to
agreed behavioural changes.
Pharmacological assistance may be appropriate for some
patients
Patients who are obese, i.e. a body mass index (BMI) > 30 kg/
m2, who are unable to achieve clinically significant weight-loss
through diet and physical activity alone, may benefit from
taking an anti-obesity medicine. None of these medications
are currently funded in New Zealand.
Phentermine is a medicine that has not been extensively studied,
despite it having a long history as an anti-obesity medicine.
There have been concerns about the addictive potential of
phentermine, as it is derived from an amphetamine base.9
There have also been concerns raised about phentermine
because of an association with other anti-obesity medicines
that have been previously withdrawn from the market due to
their potential for causing cardiovascular and psychological
adverse effects.9, 10 Current anti-obesity medicine combinations,
such as phentermine + topiramate or phentermine + lorcaserin,
which are available overseas, continue to be widely studied and
research indicates that adverse effects due to phentermine are
unlikely to be a problem short- or long-term in these medicine
combinations.11, 12, 13
Orlistat, a lipase inhibitor that blocks intestinal fat absorption,
can produce modest weight loss in patients who have a highfat diet.
Metformin may be an appropriate medicine for people who are
overweight and who also have raised HbA1c levels. Metformin
is thought to counteract central obesity by normalising
metabolism and is recommended for use in the treatment
of people with intermediate hyperglycaemia (HbA1c 41 – 49
mmol/mol) in New Zealand,14 however, it is not approved for
use as an anti-obesity medicine.
For further information see: “Managing patients who are
obese: a growing problem for primary care”, Page 8.
Referral may be appropriate for patients with psychological
issues
If a patient is suspected of having an obsessive-compulsive
eating disorder (e.g. binge eating or bulimia), or delusional
shape/weight thoughts (e.g. anorexia), they should be
referred to a psychiatrist, psychologist or health professional
with expertise in eating disorders. Fluoxetine is known to
reduce binge eating, and is also associated with weight loss.
Fluoxetine may be a treatment option for patients who are
obese and who also have a mood disorder.15, 16
The support material provided with the weight management
programme includes contact details of community and
culturally appropriate health professionals who are able
to provide assistance to patients with issues relating to
the psychological, social, dietary and physical fitness
requirements.
For further information or questions about the ABO
programme, contact Dr Anne-Thea McGill:
at.mcgill@auckland.ac.nz
ACKNOWLEDGEMENT: Thank you to Dr Anne-Thea
McGill for contributing to this article. Dr McGill is a
General Practitioner, Senior Lecturer and Research
Clinician at the University of Auckland. Dr McGill is a
lead researcher on the WBOPPHO “supporting weight
management in primary care” programme.
References
1.
Ng M, Fleming T, Robinson M, et al. Global, regional, and national
prevalence of overweight and obesity in children and adults
during 1980—2013: a systematic analysis for the Global Burden
of Disease Study 2013. Lancet 2014;384:766–81.
2.
Ministry of Health (MoH). New Zealand Health Survey: Annual
update of key findings 2012/13. Wellington: MoH, 2013.
Available from: www.health.govt.nz/publication/new-zealandhealth-survey-annual-update-key-findings-2012-13 (Accessed
Nov, 2014).
3.
Look AHEAD Research Group, Wing R, Bolin P, et al. Cardiovascular
effects of intensive lifestyle intervention in type 2 diabetes. N
Eng J Med 2013;369:145–54.
4.
Kahn R, Davidson M. The reality of type 2 diabetes prevention.
Diabetes Care 2014;37:943–9.
5.
Mente A, de Koning L, Shannon HS, et al. A systematic review of
the evidence supporting a causal link between dietary factors
and coronary heart disease. Arch Intern Med 2009;169:659–9.
6.
Estruch R, Ros E, Salas-Salvadó J, et al. Primary prevention of
cardiovascular disease with a Mediterranean diet. N Engl J Med
2013;368:1279–90.
7.
Avena NM, Gold MS. Food and addiction - sugars, fats and
hedonic overeating. Addiction 2011;106:1214–5; discussion
1219–20.
8.
Midlands Health Network. Midlands Health Network Māori
Health Profile 2012 - Part A. 2012.
9.
Acosta A, Abu Dayyeh BK, Port JD, et al. Recent advances in clinical
practice challenges and opportunities in the management of
obesity. Gut 2014;63:687–95.
10. George M, Rajaram M, Shanmugam E. New and emerging
drug molecules against obesity. J Cardiovasc Pharmacol Ther
2014;19:65–76.
11. Hendricks EJ, Greenway FL. A study of abrupt phentermine
cessation in patients in a weight management program. Am J
Ther 2011;18:292–9.
12. Xiong G, Gadde K. Combination phentermine/topiramate for
obesity treatment in primary care: a review. Postgrad Med
2014;126:110–6.
13. Smith S, Garvey W, Greenway F, et al. Combination weight
management pharmacotherapy with lorcaserin and immediate
release phentermine - Abstract TLB-2053-P. Available from: http://
obesityweek.com/wp/uploads/2014/10/TLB_2053_P-Late-LateBreaking-TOS-at-OW2014-1.pdf (Accessed Nov, 2014).
14. Ministry of Health (MoH). Pre-diabetes advice. MoH, 2013.
Available from: www.comprehensivecare.co.nz/wp-content/
uploads/2013/03/Pre-Diabetes_Advice.pdf (Accessed Nov,
2014).
15. Grilo CM, Masheb RM, Crosby RD. Predictors and moderators of
response to cognitive behavioral therapy and medication for
the treatment of binge eating disorder. J Consult Clin Psychol
2012;80:897–906.
16. Devlin MJ, Goldfein JA, Petkova E, et al. Cognitive behavioral
therapy and fluoxetine for binge eating disorder: two-year
follow-up. Obesity (Silver Spring) 2007;15:1702–9.
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