1. health and fitness
2. disease
3. diabetes

Welcome to managing weight – an interactive
workshop designed to assist general practitioners
(GPs) and their practice staff to address weight
management with patients who are overweight or
obese to improve their health and prevent disease.
SLIDE PRESENTATION
5 mini cases
1: Jenny, 32 years of age, works from home and has a young family
2: Paul, 52 years of age, has type 2 diabetes
3: Damian, 37 years of age, is office worker with back pain
4: Sarah, 32 years of age, is an office administrator
5: Susan, 60 years of age, has mild osteoarthritis
Case study 1: Jenny, 32 years of age, works from
home and has a young family
• Jenny presents for a change of dressing from a scald a few days
ago – the burn is healing well
• You notice Jenny has gained weight since last year; she had her
last baby 14 months ago
• Jenny is otherwise well and has no family history of cardiovascular
disease (CVD).
Case study 1: Jenny, 32 years of age, works from
home and has a young family
• Jenny lives with her husband and two children (14 months and
3 years) and works from home
– most of her time is spent looking after the children and working
• You ask Jenny about her diet, which is quite good:
– eats plenty of vegetables
– fat intake seems quite high (full fat milk, cream, cheese, eating
out)
• Jenny has never had a cholesterol or blood lipid test done.
Case study 1: Jenny, 32 years of age, works from
home and has a young family
While you are changing the dressing you decide to raise the topic of
weight gain.
This may be a sensitive topic to bring up and a nonjudgmental
approach is important.
1. How would you raise the topic of weight gain with Jenny?
Case study 1: Jenny, 32 years of age, works from
home and has a young family
Some examples of specific weight related questions could be:
• Have you noticed a change in your weight over the past year
or so?
• Have you had any concerns about your weight?
• Is your weight a concern for you?
Case study 1: Jenny, 32 years of age, works from
home and has a young family
• Weight measurements can be a sensitive issue with some
patients, eg. long term overweight or obese patients
• Agreement should be reached between the clinician and the
patient about:
– whether to take measurements
– whether/when, if measurements are taken, the patient wishes to
be told the results.
Case study 1: Jenny, 32 years of age, works from
home and has a young family
While sensitively discussing Jenny’s weight with her, you ask if you
can take some measurements and she agrees.
2. What is the most appropriate method of assessing health risks
associated with excess weight?
Case study 1: Jenny, 32 years of age, works from
home and has a young family
The most useful indicator of risk and relative change is a
combination of:
• BMI
• waist circumference.
Case study 1: Jenny, 32 years of age, works from
home and has a young family
You take some measurements and, just out of interest, Jenny would
like to know what these are:
• waist circumference 90 cm
• weight 79 kg
• blood pressure (BP) 121/73 mmHg
• height 165 cm.
3. What is Jenny’s BMI?
Case study 1: Jenny, 32 years of age, works from
home and has a young family
Jenny:
• has a BMI of 29 kg/m2
• asks you if she is overweight.
4. What level of BMI indicates that a person may be overweight?
Case study 1: Jenny, 32 years of age, works from
home and has a young family
• Jenny’s BMI is 29 kg/m2; classified as overweight (range 25–
29.9 kg/m2)
• However, BMI is not always an accurate predictor of body fat or fat
distribution, particularly in:
– older people
– muscular and mesomorphic individuals, eg. athletes.
Case study 1: Jenny, 32 years of age, works from
home and has a young family
Combining BMI and waist measurement to assess overweight and
obesity and disease risk* in adults
DISEASE RISK*
Waist circumference
BMI (kg/m2)
Male <102 cm; Female <88 cm
Male >102 cm; Female >88 cm
18.5–24.9 (normal)
–
High
25–29.9 (overweight)
Elevated
High
30–39.9 (obesity)
High–very high
Very high
≥40 (severe obesity)
Extremely high
Extremely high
*Risk of type 2 diabetes, hypertension and CVD.
Adapted from NHMRC 2003b
Case study 1: Jenny, 32 years of age, works from
home and has a young family
Being overweight or obese is associated with a number of
comorbidities caused by metabolic complications and/or the excess
weight itself.
5. What is Jenny’s disease risk relative to normal?
Case study 1: Jenny, 32 years of age, works from
home and has a young family
Jenny’s disease risk relative to normal measures is high.
DISEASE RISK*
Waist circumference
BMI (kg/m2)
Male <102 cm; Female <88 cm
Male >102 cm; Female >88 cm
18.5–24.9 (normal)
–
High
25–29.9 (overweight)
Elevated
High
30–39.9 (obesity)
High–very high
Very high
≥40 (severe obesity)
Extremely high
Extremely high
*Risk of type 2 diabetes, hypertension and CVD.
Adapted from NHMRC 2003b
Case study 1: Jenny, 32 years of age, works from
home and has a young family
Clear relationship between increasing BMI and increasing mortality
• Linear or curvilinear relationship
• Begins at BMI ~20–22 kg/m2
• True for males and females
• May change with age, race and fitness
• Cancer and CVD are the main causes of the elevated mortality.
NHMRC 2003a
Case study 1: Jenny, 32 years of age, works from
home and has a young family
You let Jenny know that according to current recommended levels
she is overweight, and discuss possible comorbidities and the need
for screening tests.
6. What are the:
• potential comorbidities that Jenny may be facing?
• screening tests that may be required?
Case study 1: Jenny, 32 years of age, works from
home and has a young family
• Jenny is overweight and has a high disease risk for:
– type 2 diabetes
– hypertension
– CVD
• There is a need to consider the following tests:
– fasting glucose
– fasting cholesterol/lipid screening.
Case study 1: Jenny, 32 years of age, works from
home and has a young family
• You ask Jenny if she would be able to return for another
appointment when her test results are ready
• In the meantime, you talk to Jenny about the benefits of losing
weight as a preventive action to reduce disease risk.
7. What questions could you ask Jenny to gauge her motivation to
lose weight?
Case study 1: Jenny, 32 years of age, works from
home and has a young family
The GP can assess the patient’s motivation to lose weight by
determining:
• their initiative, and previous attempts, to lose weight
• how important it is for them to lose weight (scale of 1–10)
• their confidence in losing weight (scale of 1–10)
• how much weight they expect to lose and the benefits of losing
weight
• their readiness to change.
Case study 1: Jenny, 32 years of age, works from
home and has a young family
Weight gain is common at various life stages, eg. after pregnancy.
Jenny says, ‘Putting on weight after pregnancy is normal. I don’t
think there would be too many benefits of trying to lose weight at the
moment. And anyway with a young child and a 3 year old, exercise
is the last thing on my mind’.
8. What is Jenny’s stage of change?
Case study 1: Jenny, 32 years of age, works from
home and has a young family
Jenny is in the precontemplative stage.
Stages of change model
Precontemplation Contemplation
Preparation
Action
Maintenance
No changing
behaviour
thoughts
Ready to act to
change
Trying to change
behaviour and
avoid triggers
Behaviour has
changed,
adjustment being
made, and
working to avoid
relapse
NPS 2002
Having need for
change thoughts
but no action
taken
Case study 1: Jenny, 32 years of age, works from
home and has a young family
Factors associated with weight maintenance and regain
Regain
Maintenance
Uninhibited eating
Emotion/stress eating
Psychological stressors
Psychopathology
Sedentary lifestyle
Dichotomous thinking
Very low energy diets not followed up with
other treatments
Achieving a weight loss goal
Regular meals
Having breakfast
Self monitoring
Coping capacity
Life stability
Elfhag 2005, NHMRC 2003b
Case study 1: Jenny, 32 years of age, works from
home and has a young family
At the moment Jenny is NOT motivated to change.
9. How would you assist Jenny to manage her weight?
Case study 1: Jenny, 32 years of age, works from
home and has a young family
Patients in the early stages of readiness (precontemplation,
contemplation and preparation) respond best to cognitive
approaches, such as:
• pointing out the risks of being overweight or obese
• suggesting benefits of behaviour change and ways to reduce risk
• pinpointing obstacles and methods of overcoming these obstacles
• setting manageable goals.
Case study 1: Jenny, 32 years of age, works from
home and has a young family
10. What are some of the issues you could discuss in a brief
intervention that could help Jenny?
Case study 1: Jenny, 32 years of age, works from
home and has a young family
In a brief intervention, provide written information, and discuss:
• and personalise disease risk due to being overweight or obese
• the benefits of losing weight, and how much weight needs to be
lost for a benefit to be gained. Highlight that losing as little as 5–
10% of starting weight can have important health benefits. In
Jenny’s case this is 4–8 kg.
Case study 1: Jenny, 32 years of age, works from
home and has a young family
In a brief intervention:
• discuss dietary guidelines and information on the importance of
being in a healthy weight range
• be able to answer any questions that Jenny may have and
address perceived barriers
• discuss the importance of moderate activity; this does not need to
be strenuous, eg. brisk walking
• provide knowledge, eg. health benefits associated with weight loss
of 5–10%.
Case study 2: Paul, 52 years of age, has type 2
diabetes
Paul:
• presents for review after starting metformin (he is
responding well)
• is married with three children
• has a Maltese background
• has a family history of diabetes.
Case study 2: Paul, 52 years of age, has type 2
diabetes
Paul:
• tells you he is worried about having diabetes
• knows how this condition affected his sister and grandmother
• knows that Maltese people have a higher rate of diabetes.
1. How would you raise the topic of weight management with Paul?
Case study 2: Paul, 52 years of age, has type 2
diabetes
Examples of appropriate questions could be:
• Are you aware of the link between diabetes and being overweight?
• Are you happy with your current weight?
• Have you considered losing weight as part of your diabetes
management?
Case study 2: Paul, 52 years of age, has type 2
diabetes
You ask Paul about his current lifestyle in relation to diet and
exercise. He:
• is ‘not good with vegetables’
• frequently eats restaurants and buys lunch on most days
• drinks 3–4 glasses of red wine at night and a ‘few beers’ at the
weekend
• has a sedentary lifestyle and drives everywhere.
Case study 2: Paul, 52 years of age, has type 2
diabetes
Paul is happy for you to take measurements to assess his weight:
• height 176 cm
• weight 105 kg
• waist circumference 104 cm
• blood pressure 145/88 mmHg.
2. What is Paul’s BMI?
Case study 2: Paul, 52 years of age, has type 2
diabetes
3. With a BMI of 33.9 kg/m2, which weight category does Paul fit
into?
A. Overweight
B. Normal weight
C. Severe obesity
D. Obesity.
Case study 2: Paul, 52 years of age, has type 2
diabetes
Answer D. Obesity.
Normal weight:
Overweight:
Obesity:
Severe obesity:
NHMRC 2003b
BMI 18.5–24.9 kg/m2
BMI 25–29.9 kg/m2
BMI 30–39.9 kg/m2
BMI ≥40 kg/m2
Case study 2: Paul, 52 years of age, has type 2
diabetes
4. What comorbidities does Paul have and what tests might be
required?
Case study 2: Paul, 52 years of age, has type 2
diabetes
• Paul has diabetes and is borderline for developing
hypertension
• The following tests are required:
– fasting glucose
– cholesterol/lipid testing
– absolute cardiovascular risk assessment.
Case study 2: Paul, 52 years of age, has type 2
diabetes
Paul’s last cholesterol screen was taken over 1 year ago and his
LDL-C and triglyceride levels were not on target:
• HDL-C – 1.8 mmol/L (target level >1.0 mmol/L)
• LDL-C – 3.1 mmol/L (target level <2.5 mmol/L)
• total cholesterol – 5.9 mmol/L
• triglycerides – 4.0 mmol/L (target level <1.5 mmol/L).
Heart Foundation & CSANZ 2001 & 2005
Case study 2: Paul, 52 years of age, has type 2
diabetes
You emphasise to Paul how weight reduction and an increase in
activity will help his diabetes, cardiovascular risk and general
wellbeing.
Case study 2: Paul, 52 years of age, has type 2
diabetes
Paul:
• replies, ‘I know that weight is important in diabetes’
• had an appointment with a dietician which he didn’t attend, but is
willing to give it another try
• rates his current motivation at 7/10
• may have an increased motivation of 9/10 if he believes that losing
5–7 kg could help him to manage his diabetes.
5. What is Paul’s stage of change?
Case study 2: Paul, 52 years of age, has type 2
diabetes
Paul is in the contemplative stage.
Stages of change model
Precontemplation Contemplation
Preparation
Action
Maintenance
No changing
behaviour
thoughts
Ready to act to
change
Trying to change
behaviour and
avoid triggers
Behaviour has
changed,
adjustment being
made, and
working to avoid
relapse
NPS 2002
Having need for
change thoughts
but no action
taken
Case study 2: Paul, 52 years of age, has type 2
diabetes
6. Paul asks you about the benefits of losing weight. What is your
answer?
Case study 2: Paul, 52 years of age, has type 2
diabetes
• Weight loss may help Paul to:
– improve his blood glucose control
– lower his BP
– reduce his risk of developing other conditions such as
osteoarthritis
– feel better in general and be able to do more
• Paul also needs to know that diabetes is a condition that will not
go away.
Case study 2: Paul, 52 years of age, has type 2
diabetes
7. Paul asks you how much weight he would have to lose in order to
gain these benefits. What is your answer?
Case study 2: Paul, 52 years of age, has type 2
diabetes
• With Paul at the contemplative stage, keep advice simple and
realistic
• A 5–10% loss of initial body weight can result in significant
improvements in metabolic health
• Around 1–4 kg per month would be a good start, and 1–4 cm
around the waist per month.
Case study 2: Paul, 52 years of age, has type 2
diabetes
8. What other types of brief advice could you discuss with Paul at
this stage?
Case study 2: Paul, 52 years of age, has type 2
diabetes
You could discuss with Paul:
• disease risk from being overweight or obese
• dietary guidelines and information on the importance of being in a
healthy weight range
• any questions that he may have about a weight management
program
• simple advice to reduce alcohol consumption
• importance of moderate intensity activity.
Case study 2: Paul, 52 years of age, has type 2
diabetes
9. What advice should you give Paul on his alcohol intake?
Case study 2: Paul, 52 years of age, has type 2
diabetes
Alcohol intake should be limited to low risk drinking levels, ie. no
more than 2 standard drinks per day.
Case study 2: Paul, 52 years of age, has type 2
diabetes
10. What would be your follow up plan for Paul?
Case study 2: Paul, 52 years of age, has type 2
diabetes
Paul should:
• be regularly weighed when he visits the practice for his diabetes
monitoring
• have his BP and lipid level checked regularly
• be reviewed over time for his stage of change
• have his referral to the dietician followed up.
Case study 3: Damian, aged 37 years, is an office
worker with back pain
Damian:
• presents for a review of work related back pain after a consultation
with another doctor a month ago
• is now much improved, has no pain, and is back in full time work
• has gained a lot of weight since you last saw him, which was at a
visit 3 years ago.
1. How would you raise the topic of weight gain with Damian?
Case study 3: Damian, 37 years of age, is an office
worker with back pain
• Raise the topic of weight gain in the context of comorbidities
• You could ask Damian, ‘Are you aware that being overweight
makes you more prone to back problems?’
Case study 3: Damian, 37 years of age, is an office
worker with back pain
Damian:
• lets you know that he lives alone and has been working full time
for the past 4 years
• generally eats ‘takeaway’ as he is too tired to cook
• does not do any physical activity
• drinks about 3–4 glasses of red wine when he goes out to dinner
(about 2 nights a week) and also drinks beer at the pub.
Case study 3: Damian, 37 years of age, is an office
worker with back pain
Damian agrees that you can take measurements to assess his
weight:
• height 182 cm
• weight 93.2 kg
• waist circumference 112 cm
• blood pressure 135/92 mmHg.
2. What is Damian’s BMI?
Case study 3: Damian, 37 years of age, is an office
worker with back pain
3. With a BMI of 28.1 kg/m2, how would you classify Damian’s
weight?
A. Normal weight
B. Overweight
C. Obese
D. Severely obese.
Case study 3: Damian, 37 years of age, is an office
worker with back pain
Answer B. Overweight.
Normal weight:
Overweight:
Obesity:
Severe obesity:
NHMRC 2003b
BMI 18.5–24.9 kg/m2
BMI 25–29.9 kg/m2
BMI 30–39.9 kg/m2
BMI ≥40 kg/m2
Case study 3: Damian, 37 years of age, is an office
worker with back pain
4. Considering Damian’s waist circumference and BMI, what is his
disease risk relative to normal measurements?
A. High
B. Extremely high
C. Very High
D. Normal.
Case study 3: Damian, 37 years of age, is an office
worker with back pain
Answer A. High.
DISEASE RISK*
Waist circumference
BMI (kg/m2)
Male <102 cm; Female <88 cm
Male >102 cm; Female >88 cm
18.5–24.9 (normal)
–
High
25–29.9 (overweight)
Elevated
High
30–39.9 (obesity)
High–very high
Very high
≥ 40 (severe obesity)
Extremely high
Extremely high
*Risk of type 2 diabetes, hypertension and CVD.
Adapted from NHMRC 2003b
Case study 3: Damian, 37 years of age, is an office
worker with back pain
Further investigation into Damian’s family history reveals that his
father died of a heart attack at 48 years of age.
5. What are possible comorbidities associated with Damian’s
weight?
Case study 3: Damian, 37 years of age, is an office
worker with back pain
Diseases associated with being overweight or obese include:
• hypertension and dyslipidaemia
• CHD
• stroke
• insulin resistance and type 2 diabetes.
Conditions associated with excess weight can include:
• sleep apnoea, daytime sleepiness and fatigue
• social isolation and depression
• lower back pain, musculoskeletal problems.
NHMRC2003a
Case study 3: Damian, 37 years of age, is an office
worker with back pain
Damian is at high risk of CVD because he:
• is overweight
• has a significant family history of CHD (a first degree relative
affected at <60 years).
6. Does Damian require a blood lipid test?
A. Yes
B. No.
Case study 3: Damian, 37 years of age, is an office
worker with back pain
Answer: Yes.
• Absolute cardiovascular risk assessment
• Initial blood lipid testing is recommended for adults at high risk of
CVD
• Damian will also require a fasting blood glucose test.
Case study 3: Damian, 37 years of age, is an office
worker with back pain
You explain to Damian how weight reduction and being physically
active will help his cardiovascular risk and general wellbeing.
Case study 3: Damian, 37 years of age, is an office
worker with back pain
Damian knows he should do ‘something’ about his current weight
but at the moment it is not one of his highest priorities.
Damian explains:
• my weight has slowly gone up and I don’t like it
• I really have to do something about it or it will kill me
• I‘ve started to think about what I eat, and I have been going for
walks every day, but I think I need some help – it’s all pretty
confusing.
Case study 3: Damian, 37 years of age, is an office
worker with back pain
Damian rates importance of weight reduction as 8/10, and
confidence of losing weight at 2–3/10.
7. What is Damian’s stage of change?
Case study 3: Damian, 37 years of age, is an office
worker with back pain
Damian is in the preparation stage for healthy eating and the action
stage for physical activity.
Stages of change model
Precontemplation Contemplation
Preparation
Action
Maintenance
No changing
behaviour
thoughts
Ready to act to
change
Trying to change
behaviour and
avoid triggers
Behaviour has
changed,
adjustment being
made, and
working to avoid
relapse
NPS 2002
Having need for
change thoughts
but no action
taken
Case study 3: Damian, 37 years of age, is an office
worker with back pain
8. What would be the most appropriate way of managing Damian in
this stage of change?
Case study 3: Damian, 37 years of age, is an office
worker with back pain
Damian is most likely to respond best to behavioural approaches,
such as:
• rewarding effort
• social support
• making change in incremental steps
• self monitoring.
Case study 3: Damian, 37 years of age, is an office
worker with back pain
More complex behavioural interventions, which can be organised
through a psychologist, exercise physiologist or dietician include:
• self monitoring
• stimulus control
• problem solving
• cognitive restructuring
• social support.
Case study 3: Damian, 37 years of age, is an office
worker with back pain
Before deciding on an appropriate weight management plan, further
patient assessments need to be made.
9. Identify three important further assessments before deciding your
course of treatment.
Case study 3: Damian, 37 years of age, is an office
worker with back pain
Assess:
• why an energy imbalance has occurred
• the patient’s confidence to change
• eating and physical activity behaviours and possible barriers.
Case study 3: Damian, 37 years of age, is an office
worker with back pain
10. What are some of the factors that may have influenced
Damian’s weight gain?
Case study 3: Damian, 37 years of age, is an office
worker with back pain
Contributing factors to Damian’s weight could include:
• genetic influences, such as genetic predisposition
• previous history of weight loss and the effects of weight cycling
• weight gain at certain life stages, eg. with aging
• weight gain with certain life events, eg. giving up sport
• family, work, cultural and social environments
• stress
• medical conditions
• medical treatments.
Case study 3: Damian, 37 years of age, is an office
worker with back pain
• Food intake and physical activity are the main components of any
weight loss program
• An energy imbalance occurs when rates of energy intake and
expenditure differ over an extended period
• A positive energy balance occurs when energy intake exceeds
energy expenditure.
11. What sort of information would you need to assess Damian’s
energy intake?
Case study 3: Damian, 37 years of age, is an office
worker with back pain
It is possible to assess:
• meal patterns, eg. three regular meals versus a grazing pattern
• type and amount (serving sizes) of food eaten
• eating behaviours, eg. food preferences, consumption of fruits,
vegetables, grains, and portion sizes
• the presence of a disordered eating pattern in addition to obesity,
eg. binge eating, night eating, or comfort eating.
Case study 3: Damian, 37 years of age, is an office
worker with back pain
12. How would you assess Damian’s physical activity behaviours?
Case study 3: Damian, 37 years of age, is an office
worker with back pain
• GPs can assess:
– hours of television viewing
– hours of sedentary activity
– amount of activity at work
– participation in organised physical activity
– minutes of moderate/vigorous intensity activity/day
– amount of incidental activity/day (such as gardening)
• It may also be useful for Damian to keep a dairy of daily sedentary
activity and physical activity.
Case study 3: Damian, 37 years of age, is an office
worker with back pain
13. What level of intervention is required in Damian’s case?
A. Use public health measures for the general population
B. Use individual education and skills training
C. Use behaviour modification and medical weight reduction
treatment
D. Medical weight reduction treatment and surgical treatment
E. Use individual education and skills training, and behaviour
modification.
Case study 3: Damian, 37 years of age, is an office
worker with back pain
Answer: E. Use individual education and skills training, and
behaviour modification.
NHMRC 2003b
Case study 3: Damian, 37 years of age, is an office
worker with back pain
A stepped model for overweight/obesity management
Target population
BMI >30kg/m2 or BMI >27kg/m2 + risk factors
Overweight/obese individuals + disordered eating/cognition
Overweight/obese individuals
General population
Adapted from NHMRC 2003b
Interventions
Medication and/or surgery
Behaviour modification
Education & skills
Education and awareness
Case study 3: Damian, 37 years of age, is an office
worker with back pain
Although not directly relevant to Damian’s case, we need to know
when recommending physical activity is contraindicated.
14. What are the contraindications for recommending increased
physical activity in someone with CVD?
Case study 3: Damian, 37 years of age, is an office
worker with back pain
Contraindications to physical activity in patients with stable CVD
include:
• unstable angina
• symptoms (eg. chest discomfort, shortness of breath) on low
intensity activity
• uncontrolled cardiac failure
• severe aortic stenosis
• uncontrolled hypertension (eg. systolic BP ≥180 mmHg and
diastolic BP ≥110 mmHg)
• acute infection or fever
• resting tachycardia/arrhythmia
• uncontrolled diabetes (eg. blood glucose <6 mmol/L or
>15 mmol/L).
Case study 3: Damian, 37 years of age, is an office
worker with back pain
15. What should be the main goals of a weight loss program?
Case study 3: Damian, 37 years of age, is an office
worker with back pain
• The main goals of any weight loss program are to improve health
outcomes and reduce the risk of disease
• Men should aim, long term, for a waist circumference of <102 cm
and women <88 cm
• Achieving a 5–10% loss of initial body weight can result in
significant improvements in metabolic health.
Case study 3: Damian, 37 years of age, is an office
worker with back pain
Realistic, measurable goals for weight and waist size reduction are
shown in the table.
Timeframe
Weight loss
Waist circumference
Short term
1–4 kg/month
1–4 cm/month
Medium term
10% of start weight
5% (6 weeks)
Long term
10–20% of start weight
♀ <88 cm (Europid)
♂ <102 cm (Europid)
Adapted from NHMRC 2003b
Case study 3: Damian, 37 years of age, is an office
worker with back pain
16. How is the weight management strategy determined?
Case study 3: Damian, 37 years of age, is an office
worker with back pain
• There is no single best management strategy for long term weight
loss
• All successful long term weight management programs involve
some form of lifestyle modification that either:
– reduces an individual’s energy intake (fewer kilojoules)
– increases his or her energy expenditure (more physical activity),
creating a net energy deficit.
Case study 3: Damian, 37 years of age, is an office
worker with back pain
17. How do patients’ expectations for weight loss compare with
reality?
Which of the following patient expectations or statements are
TRUE? One or more answers may be correct.
A. Most patient expectations for weight loss are realistic
B. Many patients expect to lose up to 35% of starting weight with
current lifestyle and medical therapy
C. Most patient expectations for weight loss are unrealistic
D. Many patients expect to lose up to 20% of starting weight with
current lifestyle and medical therapy.
Case study 3: Damian, 37 years of age, is an office
worker with back pain
True answers:
• B. Many patients expect to lose up to 35% of starting weight with
current lifestyle and medical therapy
• C. Most patient expectations for weight loss are unrealistic.
Case 4: Sarah, aged 32 years, is an office
administrator
Sarah:
• presents to you and asks for advice about her weight gain over the
past 5 years, despite changes in her diet
• is particularly concerned, as her brother died of a heart attack
• asks you about laproscopic banding.
Case 4: Sarah, aged 32 years, is an office
administrator
Sarah is keen for you to take measurements to assess her weight:
• height 179 cm
• weight 110 kg
• waist circumference 108 cm.
1. What is Sarah’s BMI?
Case 4: Sarah, aged 32 years, is an office
administrator
2. With a BMI of 34.3 kg/m2, which weight category does Sarah fit
into?
A. Overweight
B. Normal weight
C. Severe obesity
D. Obesity.
Case 4: Sarah, aged 32 years, is an office
administrator
Answer D. Obesity.
Normal weight:
Overweight:
Obesity:
Severe obesity:
BMI 18.5–24.9 kg/m2
BMI 25–29.9 kg/m2
BMI 30–39.9 kg/m2
BMI ≥40 kg/m2
Case 4: Sarah, aged 32 years, is an office
administrator
3. Considering Sarah’s BMI and waist circumference, what is her
disease risk relative to normal measurements?
A. High
B. Very High
C. Extremely high
D. Normal.
Case 4: Sarah, aged 32 years, is an office
administrator
Answer B. Very high.
DISEASE RISK*
Waist circumference
BMI (kg/m2)
Male <102 cm; Female <88 cm
Male >102 cm; Female >88 cm
18.5–24.9 (normal)
–
High
25–29.9 (overweight)
Elevated
High
30–39.9 (obesity)
High–very high
Very high
≥ 40 (severe obesity)
Extremely high
Extremely high
*Risk of type 2 diabetes, hypertension and CVD.
Adapted from NHMRC 2003b
Case 4: Sarah, aged 32 years, is an office
administrator
4. Discuss any potential obesity associated conditions that Sarah
may be facing and tests that may be required.
Case 4: aged 32 years, is an office administrator
Sarah is obese with a very high disease risk of:
• type 2 diabetes
• hypertension and CHD.
There is a need to undertake the following tests (as part of an
absolute cardiovascular risk assessment):
• fasting glucose
• blood pressure monitoring
• cholesterol/lipid screening.
Case 4: Sarah, aged 32 years, is an office
administrator
5. What is Sarah’s stage of change?
Case 4: Sarah, aged 32 years, is an office administrator
Sarah is in the preparation stage for physical activity and in the
action stage for healthy eating.
Stages of change model
Precontemplation Contemplation
Preparation
Action
Maintenance
No changing
behaviour
thoughts
Ready to act to
change
Trying to change
behaviour and
avoid triggers
Behaviour has
changed,
adjustment being
made, and
working to avoid
relapse
NPS 2002
Having need for
change thoughts
but no action
taken
Case 4: Sarah, aged 32 years, is an office
administrator
6. Obesity surgery is: (One or more answers may be correct)
A. Indicated for people with a BMI >35 kg/m2
B. Indicated for people with a BMI >40 kg/m2
C. Indicated for people with a BMI >35 kg/m2 who also have
serious medical comorbidities
D. Indicated for people with a BMI >40 kg/m2 who also have
serious medical comorbidities
E. Never a suitable option.
Case 4: Sarah, aged 32 years, is an office
administrator
• True answers:
B. Indicated for people with a BMI greater than 40 kg/m2
C. Indicated for people with a BMI greater than 35 kg/m2 who
also have serious medical comorbidities
• Obesity surgery is increasingly being used successfully in patients
with BMIs lower than 35–40 kg/m2.
Case 4: Sarah, aged 32 years, is an office
administrator
7. What are the specific risks of obesity surgery?
Case 4: Sarah, aged 32 years, is an office
administrator
Obesity surgery, like other treatments resulting in sudden weight
loss, is often associated with impaired absorption of micronutrients.
This requires close monitoring, and frequently folate or vitamin B
supplements.
Case 4: Sarah, aged 32 years, is an office
administrator
8. Are there other options for Sarah at this stage?
Case 4: Sarah, aged 32 years, is an office
administrator
• Medication:
– is a useful adjunct to lifestyle change for weight loss in specific
circumstances, in conjunction with a comprehensive weight loss
program
– may be one of the four prescription pharmacotherapies that have
been approved for use
• Behaviour modification:
– includes self monitoring, social support and stimulus control
• Stress management:
– may help other treatments, although there is little evidence for
this.
Case 4: Sarah, aged 32 years, is an office
administrator
9. What are the current medications available for obesity?
Case 4: Sarah, aged 32 years, is an office
administrator
Four prescription medications have been approved for use in
patients with a BMI >30 kg/m2, and in patients with a BMI >27 kg/m2
with comorbidities:
• phentermine
• diethylpropion
• orlistat
• sibutramine.
Case 4: Sarah, aged 32 years, is an office
administrator
10. Combined with lifestyle modification, what level of weight
reduction can be realistically expected over 1–2 years with
medication (orlistat or sibutramine)?
A. 5% (1 year), 10% (2 years)
B. 10% (1 year), 11% (2 years)
C. 9% (1 year), 11% (2 years)
D. 7% (1 year), 10% (2 years).
Case 4: Sarah, aged 32 years, is an office
administrator
Answer C. 9% (1 year), 11% (2 years).
Case 4: Sarah, aged 32 years, is an office
administrator
Sarah asks you if a natural weight loss medication she saw in a
health food store that increases metabolism can help her lose
weight?
11. How do you reply to Sarah?
Case 4: Sarah, aged 32 years, is an office
administrator
• There is no evidence that available alternative treatments are
effective
• Patients should be advised about the lack of evidence for using
over-the-counter weight loss medications.
Case 4: Sarah, aged 32 years, is an office
administrator
You take into account the effectiveness of very low energy diets
when considering dietary advice.
12. What is the role of very low energy diets?
Case 4: Sarah, a 32-year-old office administrator
Very low energy diets:
• under supervision, can be useful adjunct to behaviour or drug
therapy program (resulting in an 8–13% weight loss over
1–2 years)
• cannot be maintained long term and should be restricted to the
short term
• need care to avoid a ‘rebound’ weight gain.
NHMRC 2003a & 2003b
Case 4: Sarah, a 32-year-old office administrator
You think about meal replacement programs when considering
dietary advice.
13. Do meal replacement programs work?
Case 4: Sarah, a 32-year-old office administrator
Meal replacements:
• under close supervision, can result in clinically significant long
term weight losses (5–8% weight loss over 4–5 years)
• are an expensive option
• need to be used in conjunction with nutritional management and
dietary changes for successful longer term weight maintenance.
NHMRC 2003a & 2003b
Case 4: Sarah, aged 32 years, is an office
administrator
14. What level of intervention should be used for Sarah? (One or
more options may be correct)
A. Public health measures for the general population
B. Individual education and skills training
C. Behaviour modification and medical weight reduction treatment
D. Medical weight reduction treatment and/or surgical treatment
E. Individual education and skills training, and behaviour
modification.
Case 4: Sarah, aged 32 years, is an office
administrator
Answer C. Use behaviour modification and medical weight reduction
treatment.
Case 4: Sarah, aged 32 years, is an office
administrator
You are now considering referring Sarah.
15. What would be appropriate choice(s) for referral?
Case 4: Sarah, aged 32 years, is an office
administrator
General practitioners should seek assistance from health
professionals in other disciplines with specialist knowledge in
obesity management, such as:
• dieticians
• exercise physiologists
• specialist physicians
• psychologists
• general practitioners specialising in weight loss, as part of further
referral or shared care.
Case 4: Sarah, aged 32 years, is an office
administrator
Sarah is motivated to lose weight and wants to know the best way
of keeping her weight down in the longer term.
16. What factors are associated with long term weight loss?
Case 4: Sarah, aged 32 years, is an office
administrator
Effective methods for long term weight loss maintenance include:
• sustainable changes in eating program (reduced fat, energy
controlled eating plan)
• regular activity of an increased duration (60–90 mins/day)
• techniques available to deal with overeating sessions
• regular monitoring of behaviour
• pharmacotherapy – effective in maintaining weight loss by lifestyle
modification, provided medication continues to be used.
Case 4: Sarah, aged 32 years, is an office
administrator
• It is also important to review and provide regular assistance for
weight management and maintenance of weight change (alter
program as required)
• In general, lifelong monitoring and maintenance is required for
post-obese and overweight people
• Follow up may change in form and intensity for weight loss
maintenance.
Case 4: Sarah, aged 32 years, is an office
administrator
Patient progress should be reviewed:
• with a fortnightly review initially
• monthly after this
• occasionally when a healthy weight is achieved to reduce the risk
of weight regain.
Case 5: Susan, 60 years of age, has mild
osteoarthritis
Susan:
• comes to you for advice about losing weight, including exercise
and diet
• is overweight with mild osteoarthritis in load bearing joints
• sometimes has mild pain at the end of the day.
Case 5: Susan, 60 years of age, has mild
osteoarthritis
Susan says, ‘I really need to work out what to do … How to lose
weight. I do have time during the day to exercise but I’m not sure
how much I should exercise, and I think I also need some help with
my diet and … I’m sure I would exercise more but I’m afraid it will be
too painful with the arthritis.’
1. What are the main goals of dietary change required for weight
loss?
Case 5: Susan, 60 years of age, has mild
osteoarthritis
Main requirements for dietary weight loss are:
• reducing total energy intake
• sustaining reduced energy intake over time
• providing all essential nutrients in sufficient quantities.
NHMRC 2003a & 2003b
Case 5: Susan, 60 years of age, has mild
osteoarthritis
2. What key eating strategies would you suggest to Susan?
Case 5: Susan, 60 years of age, has mild
osteoarthritis
• Key eating strategies include:
– restricting saturated fat intake
– adopting an energy controlled eating plan
– recognising poor nutritional choices and reduce hidden sources
of empty kilojoules and saturated fat
– consuming high fibre, increased protein, and low glycaemic
index foods
• Other dietary changes to consider include reducing consumption
of energy dense foods and drinks and portion sizes.
Case 5: Susan, 60 years of age, has mild
osteoarthritis
Susan lets you know that she is thinking of trying a new diet that
she read about in a magazine.
3. What is the role of special diet plans?
Case 5: Susan, 60 years of age, has mild
osteoarthritis
Most diet plans:
• work over the short term because of a reduction in energy
• cannot usually be maintained over the longer term and do not
result in permanent weight loss.
NHMRC 2003a & 2003b
Case 5: Susan, 60 years of age, has mild
osteoarthritis
4. What are the benefits of physical activity compared to diet in
weight loss?
Case 5: Susan, 60 years of age, has mild
osteoarthritis
• Immediate weight losses are greater with dietary restriction
• Long term weight loss is more likely to be maintained if patients
participate in a regular level of increased, accumulated physical
activity
• Pain is a major consideration in Susan’s case so:
– provide physical activity options that support her weight and
protect her joints
– assessing which joints are affected may help to tailor a program
suited to her needs, eg. cycling or hydrotherapy.
Case 5: Susan, 60 years of age, has mild
osteoarthritis
You talk to Susan about physical activity and the amount of activity
she should try to aim for during her day.
5. What amount of physical activity on most days of the week
should be prescribed for weight loss in Susan’s case?
A. 30 mins of moderate intensity physical activity
B. 60 mins of light–moderate intensity activity over the day
C. 60 mins of moderate–high intensity activity over the day
D. 90 mins of moderate–high intensity activity over the day.
Case 5: Susan, 60 years of age, has mild
osteoarthritis
Answer B. 60 minutes of light–moderate intensity activity over the
day.
• Any movement is better than none; more is better than a little.
Case 5: Susan, 60 years of age, has mild
osteoarthritis
• To demonstrate a health benefit, prescribe moderate intensity
physical activity (eg. brisk walking or equivalent) accumulated over
30 mins on most days of the week
• To achieve weight loss, prescribe 60 mins of light–moderate
intensity activity accumulated over the course of the day on most
days of the week
• To achieve weight maintenance, prescribe 60–90 mins of
moderate intensity activity accumulated over the course of the
day on most days of the week.
Case 5: Susan, 60 years of age, has mild
osteoarthritis
Physical activity advice for Susan is:
• hydrotherapy or swimming
• exercise bicycles
• simple reductions in sedentary time (such as watching television).
Case 5: Susan, 60 years of age, has mild
osteoarthritis
6. How should healthy eating/physical activity programs be
managed?
Case 5: Susan, 60 years of age, has mild
osteoarthritis
Healthy eating/physical activity programs can be managed by:
• providing patients with correct, up-to-date information about
healthy eating and physical activity
• providing this information personally, if possible
• considering shared care with other professional disciplines.