A Resource from the American College of Preventive Medicine
A TIME TOOL FOR NURSES
ACPM's Time Tools provide an executive summary of the most up-to-date information on delivering preventive services to patients in the context of a clinical visit. Information presented is based on evidence presented in peer-reviewed journals. Please refer to the Adult Obesity Clinical Reference for Nurses for more information.
ADULT OBESITY: Countering pessimism with effective action
The significance of the obesity epidemic can no longer be ignored -
- prevalence has doubled in last 20 years,
- 1 in 3 adults are now obese, another 1 in 3 are overweight,
- a major factor in many disease processes,
- significant psychological harm and impact on quality of life, and
- approaching smoking as our greatest preventable cause of morbidity and mortality.
Obesity today is like smoking 40 years ago: epidemic, serious consequences, with no simple answer. Health professionals have clear responsibilities to address the problem, but many find it difficult to do within the scope of a busy practice.
The USPSTF, the NIH/NHLBI, the AAFP and the AMA all recommend documenting weight status as a vital sign, and counseling overweight patients on healthy weight loss.
Advice from a health professional remains one of the strongest predictors of an attempt to lose fat weight.
But… only 4 of every 10 obese patients are advised by their doctors or other health care professionals to lose weight. Even fewer are given a specific plan. Why? Skepticism about success, frustration over reimbursement, inadequate training, lack of staff and referral networks, lack of tools to facilitate the process, and, of course, not enough time.
The result – obesity not being addressed, widespread misconceptions, often promoted by a weight loss industry that preys upon innocent and ignorant people -- and only about 1 in 5 using effective strategies to lose weight.
Most obese patients want help from their doctors, but many are reluctant to ask. Obesity is a public health problem that demands attention and doctors are a part of the solution.
Changing the culture and the attitude toward obese individuals:
- Creating offices that break down barriers and biases rather than sustain them,
- Implementing office systems that coordinate care and make it more efficient,
- Training staff for specific roles, including education and coaching roles,
- Providing an efficient and effective counseling strategy for office visits,
- Developing a community referral network of professionals and programs, and
- Advocating for more community resources and better reimbursement.
Setting the Stage
Establish a Caring, Supportive, Efficient Office Environment
- Make sure everyone in the office has a positive attitude, and is comfortable with and sensitive to obesity issues. Acknowledge staff discomfort about raising the issue of obesity with patients, when the staff themselves are obese.
- Set up the office so it is comfortable, and uplifting, for the obese patient. Private weighing area with a large capacity scale, large gowns, armless chairs, sturdy step stool to get up on exam table.
- Create a sense of partnership with the obese patient. Emphasize your belief in the patient’s ability to succeed.
- Have supporting roles (greeting, interviewing, weighing, counseling, etc) andmaterials (questionnaires, handouts, BMI chart, etc) ready to use.
The Office Visit
- Complete pre-visit questionnaire if available.
NURSE AND/OR MEDICAL ASSISTANT:
- Review pre-visit questionnaire if available, review current issues
- pre-visitMeasure height and weight – standardized protocol, private
- Determine body mass index (BMI) – chart or calculator
- Exam room: waist measurement and blood pressure
PHYSICIAN AND/OR NURSE:
- Greeting, establish rapport
- Review purpose of the visit – to begin (continue) process toward a healthier weight
- Discuss current weight status – BMI, waist circumference
- BMI category – Overweight (25.0-29.9), Obese (≥ 30.0)
- Health risks increase directly with BMI
- Waist circumference > 35” women, > 40” men
- Abdominal fat - more closely related to heart disease and diabetes.
II. Brief Medical Review
- Individual medical issues affected by weight
- Blood pressure, other CVD risk factors
- Current diagnoses
- Lab tests needed at this time
- Other conditions related to obesity
- Emphasize the benefits of a relatively small reduction of fat (5-10% of body weight)
- Coronary artery disease, Type 2 diabetes, the Metabolic Syndrome, hypertension and dyslipidemia can often be reversed by continued adherence to a low-fat (< 20% of total calories), low-cholesterol diet.
III. Explain the Facts About Managing Obesity(as needed to dispel misconceptions)
- It’s about fat, not weight.
- Diets almost always fail – initial weight loss is water weight, returns with rehydration.
- Fat gain or loss always results from an imbalance between energy consumed and energy expended.
- Genes favor fat storage -- makes losing fat so challenging.
- Approach is the same for all – tip caloric balance to the expenditure side.
- Goals to focus on have to do with changes in behaviors, not weight
- Increase in physical activity – any kind of activity
- Sit less, stand more, walk more, more physical work, exercise classes, tapes
- Add a daily walk – begin with 10-15 minutes, work up to 30-60 minutes
- Ensuring the volume of food eaten is satisfying, but reducing the energy density to cut calories
- More fruits, vegetables, fiber, whole grains, legumes
- Low fat/low cholesterol foods, eliminate sugar sweetened drinks
IV. Ask About Readiness to Make Some Changes
- "On a scale from 0 to 10, with 0 being not as important and 10 being very important, how important is it for you to lose weight at this time?”
- "Also, on a scale from 0 to 10, with 0 being not confident and 10 being very confident, how confident are you that you can lose weight at this time?”
- If not ready, focus on moving through stages of readiness – no plan at this time
- Emphasize effects of weight on lifestyle and benefits of losing weight,
- Think about how it would feel to be a little lighter and healthier,
- Provide a handout on health risks of obesity,
- Emphasize your support, and belief that they can do it, when ready. Tell the patient that you will probably bring this up again in the future because you care about his or her health.
- If ready now, continue through developing a plan
V. Outline a Plan That Works
Use the 5A approach (Assess, Advise, Agree, Assist, and Arrange) to guide discussion.
- Assess current eating and activity habits from questionnaire
- Advise changes that could shift energy balance.
- Elicit thoughts on these, which could most easily be changed.
- Avoid being too directive - "don’t eat this, don’t eat that”
- Get patient to figure out what he/she can change.
- Agree on one or two changes to focus on.
- Elicit thoughts on ability and confidence to change the behavior(s) – 1-10 scale
- Identify barriers – "what would it take for you to move from a 4 to 6?”
- Assist with plan to follow [see the AMA Roadmap in the Resources of the Clinical Reference]
- Discuss strategies to overcome barriers
- Realistic goals about behaviors – write them down in a contract form
- Keep a diary of eating and activity
- Discuss the other professionals that you have on your team to assist (nurses, health educator, nutritionist, exercise specialist), or provide referrals
- Provide educational materials on the principles of effective weight loss, healthy nutrition
- Arrange for a phone call within 2 weeks and a follow-up visit in about a month to review progress, adjust program and goals
VI. Close the Encounter
- Summarize: e.g., "Let's review what we’ve worked through. You are going to try to …”
- Express confidence: e.g., "I know that you can do this!”
- Emphasize: "I am here to help you. Remember your goals, take it one step at a time and you will be successful. This is about a healthy lifestyle that will have many more benefits than just losing a few pounds.
Obesity is a chronic disease that requires ongoing attention….this will only help getting patients "started” with treatment. The team is the key. When they come back, describe your team and how they will provide the bulk of the coaching. Emphasize your ongoing support and regular follow-up to see how they are doing. Introduce the staff member who will begin the process.
Supporting references and additional information:
Download printable versions of these resources:
For other information and useful links, visit the American College of Preventive Medicine website at www.acpm.org.
Copyright 2010 American College of Preventive Medicine. All Rights Reserved.