Q&A - The heavier side of practice - A Dietitian's advice on discussing obesity with patients

Even if you disagree with the advice your patient is presenting, ask them more about it. Whatever diet or advice they have been told to follow or whatever they have been told to restrict, or eat or whatever rules to follow, ask your patient:

• If they can see themselves following that ‘diet’ exactly as it is prescribed or if they can see that ‘diet’ working for them and practically fitting into their current lifestyle. Eg: often something ‘sounds’ like a great idea, but when they really think about what it involves and what it means for them (drastic/extreme changes, restrictions, unusual/expensive foods/supplements etc.) they realise they’re not actually willing to even want to commit to it


• If they say yes, they can see themselves following that poor advice, ask them “for how long?” Could they see themselves maintaining and sticking to this change 5 years from now? How sustainable is it? Eg: we know quick fixes don’t work, and whilst the poor advice that’s been provided may get quick results, it often has required a very intensive regiment to get those results. Commend them on their commitment, motivation and drive. Then ask your patients if these changes are maintainable long term. Encourage them to pull out 1-2 of the things that they can see themselves maintaining long term and emphasise the sustainability of these positive behaviour changes long term.


• Ask them if they’ve actually tried it themselves. What have they found the outcome/impact to be? Eg: Your patient has been taking x herbal supplements ‘for energy’ for 12 months now and they’ve stated how very expensive it is. They want your advice on whether they should continue to fork out money for this supplement. Ask them “well, have you seen a benefit from taking this?” Often it’s a no and they’ve got their answer then and there!

*If the ‘poor advice’ was actually, in your opinion ‘harmful or dangerous advice’ or contraindicated then you should consider warning the patient and actively advising against it.

 

• With any patients in these situations it’s important to look for success measures other than ‘numbers on the scales’ because it can be physically harder for these patients to lose weight. That doesn’t mean they can’t lose weight but sometimes having weight as the only measure can be disheartening for them. Also consider that sometimes not gaining weight is an achievement in itself and not to overlook this.


• A great approach is to suggest they focus on other non-weight measures. For example, the goal might be fitting into their favourite jeans that they haven’t been able to fit into for a long time, or they are choosing more nutritious foods and so they are feeling more energised for it.


• I would also really encourage these patients to seek out fun and enjoyable ways to move their bodies more. This is extremely beneficial for not only their physical health but also has a significant, positive impact on their mental health. This might involve setting a goal to meet up with friends a few times per week for a regular scheduled walk, taking up gardening, walking the kids/grandkids to school a few times per week, joining a dance class or getting involved in a local community group.

• Yes, ask them what they have tried! Get them to go through it with you. Often when we dig a little deeper, we realise that their idea of ‘everything’ is not actually everything. When they have identified what they have tried (that did not work), ask them why. What was successful about that past experience? What was a challenge? Why was it a challenge? What could you do differently if you were to consider doing it again? It might require a bit of ‘mix and match’ or a combination of aspects from a few different experiences put together to come up with the best strategy for that individual.


• For example, they may have tried a restrictive, VLC diet and rigorous exercise regime, and it was successful in that they lost x amount of weight, but as soon as they stopped the regime, they put the weight back on. Ask them to pull out the aspects that they enjoyed or felt worked well. For example, they enjoyed doing regular exercise, but wouldn’t mind if it was not so high intensity. So you could encourage regular walks. They also really enjoyed eating a lot more vegetables and salad on their VLC diet but hated the shakes. Encourage them to get back into eating lots of vegetables and high fibre foods, and to focus on achieving that consistently. You can reassure your patient that breaking these individual successes down into simple, maintainable long term changes will ensure longer term outcomes.

• % of calorie reduction recommended:
  In my experience, calorie counting is not for everyone, as it can often be quite complex, require additional time and energy to weight/measure/count everything, and it does not reflect nutritional value or quality of foods consumed. For those who are willing and/or interested to ‘know the numbers’ I would recommend referring to an accredited practising dietitian who can design a nutritionally balanced dietary intervention that produces a 2500 kilojoule per day energy deficit (for adults who are in overweight or obese ranges). A dietitian can also tailor the intervention to the dietary preferences of that individual which is very important for adherence and long term changes. For those wanting to count calories, you could suggest an accurate mobile app that can help them to get an idea of the amount of calories in foods (My Fitness Pal, Calorie King etc.)


• Amount of exercise encouraged:
  For adults who are overweight or obese, prescribe approximately 300 minutes of moderate-intensity activity, or 150 minutes of vigorous activity, or an equivalent combination of moderate-intensity and vigorous activities each week combined with reduced dietary intake. For adults who are overweight or obese, particularly those who are older than 40 years, there should be an individualised approach to increasing physical activity – refer to an exercise physiologist. Again, encourage your members to ‘just move more’ as sometimes minutes per week can seem overwhelming. Emphasise the approach that anything is better than the amount they are currently doing, and it can be achieved in many different ways: do 2 laps of the shopping centre/block/building instead of 1 on your way to get your morning coffee, park further away or get off from the bus/tram 2 stops earlier and walk the difference, see stairs as an opportunity to get some more steps in.


• How much weight loss per week/month to aim for?
  It really depends on the amount of weight to be lost. In practice, I would say that around 0.5kg – 1.0kgs per week is realistic and achievable. Losing more than this is often achieved by unsustainable means. Regardless of what the agreed weight loss plan is, the plan should be reviewed after 2 weeks of commencing it to determine if its suitable for that individual and to assess whether it needs to be modified.

• The data presented did not compare efficacy between these different interventions as they are fundamentally two separate streams of intervention (primary care vs additional interventions beyond primary care). For the purpose of this webinar, data presented was on the effectiveness of interventions in primary care. Efficacy of the 5As is evidenced by a twofold increase in the initiation of obesity management (19 vs. 39%, P = 0.03), and a statistically significant increase in the perceived follow-up/coordination efforts. The data shows that using the 5As of Obesity Management facilitates weight management in primary care by promoting clinician–patient communications, medical assessments for obesity and plans for follow-up care. Additional information is available from Rueda-Clausen et al., Clinical Obesity, 2014.


• It’s important to note that the 5As approach provides a general framework for starting conversations and exploring referral options to allied health professionals, community-based programs and specialist services (e.g. specialist weight management clinic – such as the examples mentioned). In my professional experience, these specialist weight loss clinics/programs are successful for the right individuals, but they shouldn’t be in place of or replace a weight loss intervention delivered and monitored by the patients’ primary healthcare provider. Further information on levels of evidence is also available in the Clinical practice guidelines for the management of overweight and obesity in adults, adolescents and children in Australia, NHMRC, 2014.

If it sounds too good to be true, it probably is! I always ask my patients how sustainable they think this fad is, does it negatively impact or impede on their day-to-day activities (e.g. “I’m on a detox so can’t go out to dinner with friends tonight”), are they having to pay a hefty sum of money for a ‘quick fix’. I will always go back to “Can you see yourself maintaining this ____ (eating like this/ restricting/limiting/having select foods only) in 2-5 years from now?” That usually helps patients to see that it is not sustainable and gets them thinking about what would be achievable/manageable in the long term.