Weight management in general practice

This Clinical Update outlines the role of the practice nurse in weight management involving patients with obesity.

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Introduction

AUSTRALIA is one of the fattest nations in the world – 60% of the population are now overweight or obese.1 

The gravity of this epidemic is even more disturbing given that obesity is a greater contributor to ill health than tobacco smoking.2 Obesity also drives many chronic diseases, including type 2 diabetes, cardiovascular disease, cancer, osteoarthritis, depression and dementia, and it also undermines quality of life itself.

Adipose tissue is now understood to be pro-inflammatory and increases insulin resistance.3 On a social level, obesity perpetuates overweight families; overweight parents tend to raise overweight children. On an economic level, obesity is costly both to the individual and to the nation.4

Aetiology

There are many contributing factors to this epidemic. Western society is by definition an obesogenic environment: inexpensive calorie-rich food is available 24 hours a day; portion sizes have increased; physical exertion has decreased; and  the time to prepare and plan nutritious meals is scarce. 

Also, curbing the appetite is no longer a simple task. The primitive drive to eat is one of the strongest physiological drivers for survival and is hard wired with the physiological response of pleasure, placing it in the same category of addictions such as gambling and drug taking.5

All these factors contribute to the complexity of the issue of obesity and challenge our approach to its management. 

Diagnosis and treatment

Historically, BMI has been used to determine the measure of overweight. However, recently there has been a shift to waist measurement as the better diagnostic tool. 

Pharmacotherapy can be used to assist with weight loss, with medications that work on the neurotransmitters serotonin and noradrenaline to suppress the appetite or to block the absorption of fat in the gut. 

Bariatric surgery is becoming more prevalent, with laparoscopic gastric banding, gastric bypass and biliopancreatic diversion. However, surgical risk is associated with these treatments. As well, the underlying aetiological factors of obesity are not always resolved. 

Patient empowerment and successful weight loss is a better option if possible.

Nursing management principles 

While the focus has been on diet and exercise as the key drivers for weight loss, encouraging patients to start a program as well as maintain the weight loss is by far the greatest challenge. 

Recognition of the biological and social factors, such as metabolic rate, stress, satiation, appetite, lifestyle and culture, is now seen as essential to the success formula. 

The practice nurse can be instrumental to the success of enabling patients to lose weight. This is due to the time factor, which often is not available to GPs. By positively coaching patients, the opportunity presents itself to develop a nurse-patient relationship of trust over time. 

The recruitment of patients can also be managed and directed by the practice nurse. Discussion may arise in the general management and interaction of patients, thereby setting the groundwork for patients to become involved in a weight loss program. 

Brochures in the waiting room also result in a very positive response. These may outline a weight loss management program offered by the clinic.

Key factors for a successful weight loss program

1. Structure is essential

A good example is a 10-week program with weekly appointments. This allows patients to become committed to lifestyle change. 

Weekly one-on-one sessions of 15–20 minutes also provide an opportunity for education, discussion of any issues and checking progress. 

Patients are more likely to be compliant if they feel they are being heard and supported. Listening enables the nurse to find out why the patient wants to lose weight and what they want to achieve. This can provide strong bargaining tools throughout the program. 

Encouragement and positive, supportive coaching are essential to maintain motivation. 

Many patients see weight management as a ‘loss’. The nurse can emphasise that it is a program to gain health and achieve wellness.

2. Breaking bad habits

Many patients are psychologically motivated to eat. This may be due to boredom, anxiety, stress, emotional eating patterns or to provide and ‘activity of momentary pleasure’. Breaking these habits and providing insight into this is essential. 

Encouraging substitutionary activities, such as exercise, yoga or massage, or cultivating a hobby can prevent the yo-yo syndrome and provide the feel-good experience or an outlet for stress and anxiety. 

Hypnotherapy and counselling may also be useful to resolve or manage some of these issues.

3. Holistic education

Holistic education about a healthy lifestyle is vital for long-term results. This includes education on good and bad fats, glycaemic index, the importance of dietary protein, label reading, portion size and stress management. Many resources are available from health magazines and websites. 

Introducing a new topic at each consultation will empower the patient to change their lifestyle. Our program designs an individually tailor-made healthy eating program on a daily basis and promotes an achievable experience of success for that patient. Discussing and negotiating a daily menu with the patient increases the likelihood of long-term compliance. 

4. Use blood tests to motivate

Encouraging early blood tests (such as lipids and glucose) can also provide powerful motivational goals, with follow-up tests at the end of the program. 

A low vitamin D level is now recognised as a contributor to increasing insulin resistance, and ensuring levels are adequate can help the patient feel they are taking better control of their life.
 Treatment options

Running a 10-week one-on-one session can achieve better results than group sessions for many people.

Patients are less inhibited, tend to be more honest and open, and do not compare themselves with others. Also, remuneration is more tangible when run with the doctor. 

The first consultation is usually the longest, around 45 minutes, as the ground rules can be set here (see box points 1-7). The repeat consultations over the 10-week period are usually 15-20 minutes, with the recording of weight (by patient consent), and appropriate feedback and ongoing education (points 8–10 below). 

Consultations can then move to monthly or three-monthly sessions to prevent rebound weight gain, or ongoing weight loss with a focus on wellness and health education. Some patients do not lose weight and drop out early. This does not imply failure but simply that the patient is not yet ready for lifestyle change.

There are a couple of group-orientated options. Reset Your Life6 provides training for practice nurses on the web, and facilitators structure the group sessions using an educational manual. This program is for patients aged 40–49 years. 

The Life! program7 is directed towards diabetes prevention but also has a large weight loss and dietary component. Patients qualify if they score over 12 on the Australian Diabetes Risk Assessment Tool.

Conclusion

Obesity is no longer an issue of aesthetics. It has become the hallmark of contemporary Western culture and is the epidemic of our age along with its counterpart – chronic disease. 

Due to its complex aetiology, many doctors have had insufficient time to deal with this issue in a comprehensive way. 

Nurses can play a vital role in attempting to stem the tide. By educating, supporting and empowering patients now to promote long-term lifestyle change, this work has the capacity to recalibrate our culture towards health and wellbeing. This is a significant and timely challenge for primary health care today.

Medicare funding

A weight loss program can be run in the same way as a diabetes clinic. The patient’s doctor can join the nurse towards the end of the consultation to endorse progress. This helps to reinforce a sense of teamwork and support for the patient. Other issues may also arise in the context of overall health and can be dealt with at this time. 

Item numbers to use

Item 23 -  Time-based consultation for the GPItem 10997 - Nurse item numbersItem 701, 703, 705,707, 715, 723  - health care planning items including type 2 diabetes risk review, 45- to 49-year-old health check, Indigenous adult 15- to 54-year-old health check.

10 point plan for a weight loss program

1. Encourage breakfast, lunch, dinner and two snacks a day. This helps raise metabolic rate and controls appetite.

2. Eat low fat, good quality protein at each meal. A good guide on quantity is the size and thickness of the palm. This also promotes metabolic rate, satiation,8 thermogenesis9 and good blood sugar coverage.

3. Reduce starchy carbohydrates, especially at dinner. Eat low GI vegetables and fruit as often as possible. Drink 6-8 glasses of water a day to promote hydration and health. 

4. Incorporate achievable exercise options to maintain muscle mass and increase thermogenesis of brown fat.10

5. Encourage incidental exercise. Take the stairs at work and park the car at a reasonable distance.

6. Ask the patient to maintain a daily diary for food and water intake, and exercise. This holds the patient accountable and provides the nurse with something to work with at each session.

7. Adapt a dietary plan for the patient that is a healthier version of their own diet. This promotes incremental lifestyle change. The program needs to be individualized and achievable for successful outcomes.

8. Teach the calorie content of foods and label reading so that the patient has a greater awareness of the value of different foods, enabling them to make wiser meal choices.

9. Encourage the patient to plan all meals for the day so they are not controlled by food or mood.

10. Provide strategies for stress management such as breathing exercises, meditation, positive thinking, massage, yoga and exercise. 

This Update is by Jackie Turner, a practice nurse, allied health practitioner and diabetes educator at the Coliban Medical Centre in Kyneton, Victoria.

The author has no disclosures. Any reference to products throughout this review does not constitute endorsement.

Resources

www.heartfoundation.org.au    

www.CalorieKing.com.au - 10-week weight loss diary and calorie counter

www.heartwise.com.au

The CSIRO Total Wellbeing Diet Book 2 - on diet, fats, carbohydrates, exercise.

References

1. The Australia and N.Z. Obesity Society: Fast Facts - Statistics. 2009 Cited in Sept 2010 (available from http://www.asso.org.au/home/obesityinfo/stats/fastfacts)

2. Hoad, V, Somerford, P, Katzenellenbogen, J. Aust NZ J Public Health 2010; 34: 214-215

3. Handschin C, Spiegelman BM. The role of exercise and PGC1 alpha in inflammation and chronic disease. Nature 2008; 454: 463-9

4. Colagiuri S. The cost of overweight and obesity in Australia. MJA 2010; 192: 260-4

5. Yanovski S. Sugar and fat cravings and aversions. J Nutrition 2003; 133: 835S-837S

6. 'Reset Your Life' - a healthy lifestyle program developed by the Australian government to prevent diabetes http://www.resetyourlife.com.au/index.php

7. The 'Life' program is a diabetes prevention program developed by Diabetes Australia http://www.diabeteslife.org.au/

8. Smeets, AT, Soenen, S, Luscombe-Marsh, ND, Ueland, Ø, Westererp-Plantenga, MS. Energy expenditure, satiety, and plasma ghrelin, glucagon-like peptide 1, and peptide tyrosine-tyrosine concentrations following a single high-protein lunch. J Nutrition 2008; 138: 698-702

9. Johnson, CS, Day, CS, Swan, PD. Postprandial thermogenesis is increased 100% on a high-protein, low fat diet versus a high-carbohydrate, low-fat diet in healthy, young women. J Am Coll Nutrition 2002; 21: 55-61

10. Stob NR, Bell C, Van Baak MA, Seals DR. Thermic effect of food and beta-adrenergic thermogenic responsiveness in habitually exercising and sedentary healthy adult humans. J Appl Physiol. 2007; 103: 616-622