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

Better Management of Weight in General Practice Part 1 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

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 over 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 (m 2 ) BMI (kg/m 2 ) Classification 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 ≥ 40 Obese class III Very severe WHO, 1998

Waist circumference is a surrogate measure of abdominal or visceral fat Men Women Increased risk >94cm Increased risk >80cm Greatly increased risk >102cm Greatly increased risk >88cm www.measureup.gov.au

Assess cont …. Medications Atypical antipsychotics including clozapine, olanzapine causing Beta-adrenergic blockers particularly propranolol weight gain 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 Minutes of moderate and vigorous activity activity Sedentary activity Behaviours Binge eating, eating disorders, drivers of unhealthy eating Motivation Previous attempts, readiness to change Other health Sleep apnoea, arthritis, GORD, diabetes or pre-diabetes, problems cardiovascular risk factors or disease

Advise What How • Benefits Cardiovascular risk Life expectancy +2-4 years • Diabetes risk Show change in risk • Reduced pain/Increased Less stress on joints, back mobility Less snoring and apnoea • Better sleep • Physical Reduce sedentary time Less sitting. More standing • activity Increase minutes of moderate Moderate: Walking, swimming, and vigorous activity gardening • Muscle strengthening Vigorous: running, gym, bike Lifting weight • Diet 2500 energy deficit 2 fruit and 5 vegetable portions • Reduce fat Reduced portion/plate size • Reduce snacking/binge eating No soft drink Low fat milk products, cooking Behaviour • Avoid situations Avoiding triggers, shopping after • Environmental control eating, public transport, group • Self monitoring 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

Counterweight 3 2 Weight Change kg 1 0 12m 3 6m 24 m -1 m -2 -3 -2.3 -3.0 -3.3 -4 The Counterweight Programme -4.2 -5 -6 One in 6 achieve >5% weight loss at 12 or 24 months Br J Gen Pract. 2008; 58: 548-554

Advise: aids cont …. Australian absolute risk CVD calculator – Risks and www.cvdcheck.org.au Benefits AUSDRISK diabetes risk tool http://www.health.gov.au/internet/main/publishing.nsf/Conte nt/diabetesRiskAssessmentTool Diet and Australian Dietary Guidelines www.eatforhealth.gov.au physical NSW Health 8700: http://www.8700.com.au/ activity 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 our 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---Loca l • 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 offered? 5. When could he have been followed up?