Weight Management

About the Authors Dympna Pearson is a Registered Dietitian with extensive experience of working in different clinical settings and of providing training for healthcare professionals. Her particular interests are lifestyle change in relation to diabetes, coronary heart disease and weight management. Clare Grace is a Registered Dietitian with many years of experience in the clinical management of obesity and has a particular interest in the research underpinning weight management interventions. She provides regular obesity management training for healthcare professionals and students.

• Foreword xvAcknowledgements xviIntroduction xviiSection 1 Background Information 11 Why Treat Obesity? 3What is the scale of the obesity problem? 3Why does it matter? 3Obesity and early death 4Obesity and type 2 diabetes 4Obesity and cancer 5Obesity and cardiovascular disease 5Quality of life 5Factors that increase the risk of obesity 6Smoking cessation 6Certain medications 7Obesity and its causes 7Why do practitioners need a good understanding of obesity causes? 7What are the causes of obesity? 8Biology and genes 9Eating and activity behaviours 10The obesogenic environment 10Health benefi ts of modest weight loss 11Conclusion 11References 122 Health Professionals’ Attitudes Towards Obesity and its Management 15What does the evidence say about discrimination and weight bias in society? 16In employment 16In education 16In health care 17Where does weight bias come from? 17Media and TV images 17Cultural factors 18Beliefs about the causes of obesity 18What are the consequences of weight bias? 18Psychological consequences 18Social and economic consequences 18Physical consequences 18What is the impact of weight bias in the health care setting? 18What can we do to reduce weight bias? 19Conclusion 19Reflective exercises 20Recommendations for reducing weight bias in your practice 21References 213 Treatment Options: The Evidence for What Works 24Introduction 24Combined approaches 24Dietary treatments 25Eating frequency and patterns 25Improving the quality of the diet 25Low-fat diets 25The 600 kcal defi cit approach 26Meal replacements 26Very-low-calorie diets 27Low-glycaemic-index diets 28Low-carbohydrate diets 29Fad diets 29Physical-activity treatments 29How much activity is needed? 30Intensity and type of activity 31Behaviour modification 32An integrated approach 32Key strategies 33Drug treatment 36Surgical treatment 37Conclusion 38References 38Section 2 Practical Application 454 Preventing Overweight and Obesity 47Prevention of overweight and obesity 47Pre-conception and antenatal care 47The early years 47As life goes by 48Medications 49What to do? 49If the response is negative 50Support materials 50Conclusion 51References 515 Providing A Person-centred Weight-management Service 53Integrating a behavioural approach 53Working in a person-centred way 53How to integrate a behavioural approach in practice? 54Identifying overweight and obesity 57Interpreting BMI 57Planning weight-management interventions in your setting 58Aiming for a coordinated and structured approach 58Deciding on the duration and frequency of appointments 59How and when to begin conversations about weight 60Exploring whether this is the right time to begin 62More on motivation… 63Is the patient really sure they have the time and commitment required? 63Discussing and agreeing a way forward 64Exploring treatment options 64Lifestyle treatment 64Group-based programmes 64Commercial and self-help programmes 67Drug treatment 67Surgery 68Conclusion 68References 686 Building a Picture: The Assessment 70Undertaking a comprehensive assessment 70What are the components of the assessment? 70The Beginning 71The Story So Far 72Dealing with Expectations 74The Here and Now 76The Ending 81References 827 Finding Solutions: Supporting Patients to Establish a Solid Foundation 83Introduction 83Integrating a behavioural approach 83Step 1: Identify the Problem 84Step 2: Explore Options 84Step 3: Choose Preferred Option/s 85Step 4: Develop a Plan 85Step 5: Implement the Plan 87Step 6: Review the Plan 88The building blocks needed for a solid foundation 89Providing information in a helpful way – an essential practitioner skill 90Understanding energy balance 91Calories in vs calories out 91Recommended rates of weight loss 91How many calories? 91Key dietary recommendations 92How to commence self-monitoring to understand current eating patterns 93How to encourage regular eating 94How to ensure a nutritionally adequate diet 94How to use the ‘eatwell plate’ to achieve an energy deficit 94How to read the calorie content on labels 99Keeping a daily record 99How to compare calorie intake with weight-loss achieved 101When to refer on to specialist services 103Further dietary options 104Conclusion 105Recommendations for physical activity 106Current physical activity guidelines for all adults 106Recommendations for weight management 106First steps towards achieving physical-activity recommendations for weight management 107Practical application of physical-activity recommendations 108Developing essential skills: laying the foundations 114Self-monitoring 114Goal-setting 118Conclusion 119References 1198 Next Steps: Continuing to Develop Expertise 121Review appointments 121Introduction 121Suggested structure for review appointments 121Review progress at 3 and 6 months 122Topics for review appointments 123More on healthy eating 146Becoming skilled at weight management 152Exploring motivation (‘ Do I want to, and can I? ’) 153Self-monitoring (keeping a record) 153Stimulus control 153Problem-solving 154Goal-setting (Developing a Plan) 155Dealing with diffi cult situations 156Support 156Rewards 158Exploring ambivalence (‘ I want to, but I can’t …’) 159Relapse prevention (dealing with setbacks) 160Emotional eating 161Dealing with hunger 162Cravings 162More behavioural strategies 163References 1649 Staying on Track: Weight Maintenance 165Introduction 165Defining successful weight maintenance 165Changes in weight 166Causes of weight regain 166What works? 166National Weight Control Registry (NWCR) data 167Implications for practice 168Practical application 169During the assessment 169During the weight-loss phase 169During the weight-maintenance phase 170Learning how to deal with setbacks 172Conclusion 172References 17310 Getting the Most out of Brief Contacts 175Introduction 175What is a brief contact? 175Limitations of brief contacts 176Getting the most out of brief contacts 176Unhelpful approaches 177Raising the issue 178Engaging in a helpful conversation and exploring motivation 179Is now the right time? 179Discussing options 179Signposting the most suitable option 181Continuing to offer support 181Brief interventions (if ongoing support includes brief review appointments) 182What not to do 182Making the best use of available time for ongoing brief contacts 182Implications for services 182Examples of brief contacts 183Conclusion 184References 18411 Evaluating Individual Weight-management Interventions 186Introduction 186What is monitoring and evaluation? 187Some definitions 187The seven pillars 187Evaluation can mean different things to different people 189Evaluation can vary at different times 189What makes evaluation challenging? 191Getting started 192Collecting information 192What to evaluate 194Effectiveness 194Clinical outcomes 194Risk factors 195Activity and eating behaviours 195Psychological health 197Health care utilisation and cost outcomes 198Patient experience 198Safety 202Conclusion 202References 20312 Common Challenges and Misconceptions 204Introduction 204Causes of obesity 204‘It’s my fault I’m obese’ 204‘I must have a slow metabolism’ 205‘It’s my genes, not my lifestyle’ 206‘I’ve been told I’m not eating enough to lose weight’ 207Physical activity 208‘I can’t lose weight because my medical problems stop me from exercising’ 208‘Exercise makes me eat more’ 209‘I’ve been swimming for 20 minutes twice a week for 2 months and haven’t lost any weight’ 210Diet 211‘Certain foods can burn fat’ 211‘I know breakfast is important but I just can’t eat in the morning’ 212‘Carbs are fattening’ 213‘Eating late at night causes weight gain’ 214Note on patient dialogues 215References 215Section 3 Appendices 217Appendix 1 Adult Weighing Scales Specification Guide 219Appendix 2 How to Measure Height 220Appendix 3 How to Measure Weight 222Appendix 4 Measuring Overweight and Obesity using Body Mass Index 226Appendix 5 Measuring-tape Position for Waist Circumference 227Appendix 6 Medications 229Appendix 7 Screening for Binge-eating Disorder 230Appendix 8 General Practice Physical Activity Questionnaire 231Appendix 9 PAR-Q & YOU 233Appendix 10 Estimated Energy Requirement (EER) 235Appendix 11 Prescribed Energy Defi cit (PED)-Ready Reckoner 237Appendix 12 Portions Commonly Used for the ‘Eatwell Plate’ (To Check Nutritional Adequacy of the Diet) 240Appendix 13 Example of 1500 kcal based on ‘Eatwell Plate’ Portions 242Appendix 14 Example of 1800 kcal based on ‘Eatwell Plate’ Portions 244Appendix 15 Cookery Books 246Appendix 16 NICE Guidance on Referral to Slimming Groups 247Appendix 17 Weighed Portions for Where More Precision is Required 248Section 4 Resources 249List of Resources 251Additional Books and Resources 253Section 5 Tools 255Tool 1 Weight History Chart 257Tool 2 Typical Day 258Tool 3 Activity Charts 259Tool 4 My Change Plan 260Tool 5 Plate Model 261Tool 6 Diary Sheet 262Tool 7 Weight Record Chart 263Tool 8 Blank Menu of Options 265Tool 9 Menu of Options A 266Tool 10 Menu of Options B 267Tool 11 Menu Chart 268Tool 12 Assessment of Diet Quality 269Tool 13 Weighing It All Up: ‘ I Want To, But …’ 271Tool 14 Behavioural Strategies 272Index 273

“I volunteered to review the text on publication and hope you find it as helpful as I do.”  (The Newsletter of the Irish Nutrition & Dietetic Institute, 1 August 2013)“This will be useful for practitioners who are not as experienced in working with the overweight and obese population. However, even practitioners with experience can benefit from the chapters on behavioral approaches that can be used when engaging in one-on-one counseling sessions.”  (Doody’s, 17 May 2013)Weight Management: A Practitioner’s guideDympna Pearson & Clare Grace£37.99; Wiley-Blackwell 2012ISBN: 978-1-4051-9771-7 (also available as an e-book)This important book bridges the gap between behaviour change theory and the treatments that research has been shown to be effective. It aims to demonstrate how behavioural approaches can be embedded within practice to encourage patient empowerment and active decision-making. It’s major strengths are the breadth and depth of material presented, the engaging conversational style of writing and the huge number of resources and tools included. Written by two well known and respected practitioners in the field of weight management, it benefits from their academic, clinical and training expertise. It is different from other books in this area because of the experience of the authors - this gives the book a practical element often missing from more theoretical publications.Progression throughout the book is logical. Section 1 starts with setting the scene (obesity prevalence, causes & consequences). Healthcare professionals’ attitudes towards obesity and the potential effects of these upon patients are explored and the evidence for treatment options presented. Section 2 is devoted to practical application of the evidence, and how behavioural theory can be embedded in practice. It moves sequentially through prevention, assessment, finding and implementing solutions & maintaining change. Additional sections include the use of brief contacts, evaluation of individual weight management interventions and common challenges and misconceptions. The role of the healthcare professional is clarified at every stage of the consultation, and although the authors recognise the many difficulties that exist in weight management, they suggest how to incorporate best practice within realistic constraints. Structure and clarity are emphasised throughout.For anyone with an interest in weight management this is a great read. Written in an engaging style, it breaks complex ideas and theories into more accessible ‘chunks’, and concrete examples of using behavioural approaches are given throughout to illustrate how theory can be embedded into practice.For those involved in weight management it is a must. Behaviour change is recognised as central to effective weight management and the practical applications of theory throughout are invaluable. However the authors are careful to emphasise that training is needed – reading this book will not equate to effectively facilitating behaviour change in others. Anyone who has already undertaken behaviour change training will find in this book a useful tool to help embed the training, and for those thinking of doing the training it puts the current thinking and evidence into context.For the public health practitioner or those commissioning weight management services, this book helps to clarify and pull together evidence on what treatments and approaches have been shown to be effective, and to increase understanding of what should be included in commissioned services. The useful and comprehensive chapter on evaluation of individual weight management services gives examples of evaluation at different stages of interventions and what can be measured for each, emphasising the importance of considering evaluation from the beginning of the planning process. In addition the emphasis throughout on evidence-based practice clarifies treatments shown to be effective.All in all this is a great addition to the published work on weight management, written by practitioners uniquely equipped to do so. It is good value for money and thoroughly recommended.  Statement on conflict of interest:Hilda Mulrooney has served as a Committee member of domUK with both Clare Grace and Dympna Pearson, and has worked with Dympna Pearson in LNDS in the past. In addition she facilitates regularly on Behaviour Training courses run by Dympna Pearson.