Arya M. Sharma, MD

Dr. Clarke and his 'Lifestyles' team, Cardston, AB

Yesterday, my role as Clinical Co-Director of Alberta’s Provincial Obesity Initiative took me to the “South Zone” of our province, where I visited primary care colleagues in Cardston and Pincher Creek (both part of the Chinook Primary Care Network).

In Cardston, I was welcomed by Dr. Clarke and his team that offers a “Lifestyles’ program to patients at their clinic. Variants of this program have been in operation for the last six years and the current team includes LInda, a Registered Nurse “Lifestyle” Lead and Shelly, a Licensed Practical “Lifestyle” Nurse Educator - the lifeblood of the program. Other members include a mental health counsellor and a registered dietitian as well as admin and data analyst staff.

According to Dr. Clarke, the program started in 2006 with one RN and has enrolled about 1400 patients to date (for a total weight loss of over 12,000 lbs and counting). More important than the absolute amount of weight lost, is the fact that 56% of their patients appear to have maintained much of their weight loss - some for several years now.

An impressive 10 patients have lost over 100 lbs, 18 patients have lost 50-100 lbs, 145 patients have lost between 20-50 lbs.

A recently started CORE Strength Program targeting adolescents has so far enrolled 40 youth and early results appear promising.

The important issue here, is that these services and successes were entirely funded out of the clinic’s primary care budget with minimal cost to patients - clear evidence that successful weight management is indeed possible in a rural primary care setting.

My second stop was in Pincher Creek, another small rural Southern Alberta community, where I was greeted by the primary care team and learnt about their interest and ideas about obesity management in complex patients. Dr. Irving, one of the physicians in the clinic, proudly presented some of his weight management results - again some very impressive sustained weight loss.

I was particularly pleased to see how this clinic has already embraced my 4 M’s of obesity assessment and the Edmonton Obesity Staging System. Again, a sign that obesity management is achievable in a primary care setting and can very much improve the health of patients with weight-related comorbidities.

Overall, this intense day of interaction with passionate and enthusiastic frontline health providers, leaves me optimistic that clinically meaningful obesity management can indeed be integrated into primary care.

As I have said before, obesity is a very treatable and manageable condition if we only put the same resources into preventing and treating obesity as we put into managing other health problems.

AMS
Edmonton, Alberta

About four years ago, when I came to Alberta to take on the role as Medical Director of the Edmonton Weight Wise Program, there was a waiting list of over 2000 patients to be seen in the adult speciality clinic at the Royal Alexandra Hospital. This waiting list was growing by about 50-100 new referrals a month, a rate far exceeding capacity to see new patients.

Since then, as long-term readers of these pages may recall, a number of important measures were implemented, that have brought down wait times from over 24 months to currently less than 6 months - a situation readily explained by the fact that patients are now moving through the program (and, if required, on to bariatric surgery) at a rate almost one-third faster, than when I first took over the program.

Thus, through a combination of changes to how patients are referred to the program, what they do while on the ‘waiting list’ and due to efficiencies and increased capacity within the program, more patients are being seen within waiting periods that are shorter than ever before.

Much of this starts with the referral process - by ensuring that family doctors refer only patients, who do not have obvious barriers to participating in a speciality care bariatric program (like for e.g. complex and uncontrolled mental health problems), resources within the program were freed to deal with patients who can actually be helped at a bariatric centre.

Offering patients ‘education modules’ in the community setting prior to entering the program also resulted in patients being better informed and prepared by the time they were seen at the speciality centre, thereby significantly cutting times spent within the clinic.

Once patients enter the specialty clinic, a designated nurse case-manager ensures that they see the appropriate allied health professionals (dieticians, psychologists, occupational and physiotherapists, etc.) at the right time for the right level of intervention. Where possible, delivering counselling in group settings rather than one-on-one further increases efficiencies and takes advantage of the substantial benefits of ‘group learning’.

Finally, increased medical and surgical capacity has further shortened waiting times for patients approved for surgery within the program (down to a few weeks from previously several months).

As a result of these changes, progressively implemented over the past several years, we are now thankfully in a situation where new patients referred to the Edmonton Weight Wise program can be seen in the clinic within a few short months of referral.

Obviously, once word gets around that patients are no longer faced with a two-year wait, referrals may quickly increase to once again extend waiting times. However, with the recent announcement of additional resources for community and primary care (so that more patients can be managed there or at least be better prepared for speciality care) and additional capacity in speciality centres across the province, it is very likely that more Albertans with severe obesity can receive medical, and, if necessary, surgical attention quicker than ever before.

This is obviously good news for patients, who have decided that it is high time to tackle their obesity problem as well as for their caregivers, who can now help their patients access a wider range of treatment options within a reasonable time frame.

As the recently announced Alberta Obesity Initiative continues to roll out, I certainly hope that eventually all Albertans struggling with excess weight will have access to the level of care required to help them better manage their weight and reduce associated health risks.

AMS
Edmonton, Alberta

Current approaches to managing childhood obesity recommend family-centred-care (FCC), as previous work has established that interventions focusing largely on the child alone, are rarely successful.

In order to better understand how collaboration between clinicians working in pediatric weight management and parents of overweight children looks in real life, Biagina-Carla Farnesi and colleagues from the University of Alberta, conducted focus groups and one-on-one interviews with parents and clinicians working in our paediatric obesity clinic, the results of which are now published in Patient Education and Counseling.

A family-centered, collaborative model of care was used to frame the data and develop codes/themes for analysis. Member checking and external reviews were conducted to verify emergent themes.

Not surprisingly, analyses revealed that effective collaboration between clinicians and parents included a positive therapeutic relationship, negotiation of health care delivery, and regular monitoring and evaluation.

These elements, consistent with a philosophy of family-centered care, emphasize the importance of tailoring health services to families’ needs, respect parents as experts, and identify clinician responsiveness as pivotal to partnerships with families.

In fact, parents consistently described dissatisfaction with care and a lower likelihood of seeking future care when clinicians deviated from these principles.

These results certainly suggest that pediatric weight management should not only be family-centered but must give parents the opportunity to actively engage in health services and negotiate their family’s care.

Or, as one parent remarked:

“I think it’s always a little bit frustrating to go into something like that and have somebody start firing solutions at you before they even know what the problems are”

This is important, as even the health professionals will unlikely have all the answers or can even be expected to know what works best for each family:

Clinician:

“[I]it’s kind of sending them away with, OK, this is what you want to do, let’s give it a try, and them coming back and saying OK, that didn’t work and figuring out why. And try and understand where they’re coming from”

The key findings of this study are perhaps best summarized in the following paragraph:

“Parents in our study disapproved of clinicians who provided lifestyle information and weight management recommendations before they spent time to ask families about their experiences, concerns, and needs. Parents perceived a lack of reciprocity and involvement when priorities and decisions are determined by clinicians exclusively; the implicit message communicated by clinicians in such encounters is that they are the ‘experts’, which tends to undervalue parents’ wisdom and family experiences. Not only do these situations represent a power imbalance, but they are the antithetical to the FCC philosophy whereby parents are ‘experts’ about their children and families, and this information is on par with the health information provided by professionals.”

For clinicians it is important to realize, that in order to engage collaboratively and effectively with families, their sensitivity about obesity and weight management should be heightened to ensure that their verbal (and non-verbal) communication conveys respect, trust, and openness towards the family.

Such an approach will be essential to create an environment that can enhance collaboration, establish rapport, and improve health outcomes.

AMS
New York, NY

Farnesi BC, Newton AS, Holt NL, Sharma AM, & Ball GD (2011). Exploring collaboration between clinicians and parents to optimize pediatric weight management. Patient education and counseling PMID: 21925825

In the past few posts, I have discussed some of the recommendations in the recent Scientific Statement on New and Emerging Weight Management Strategies for Busy Ambulatory Settings From the American Heart Association.

The Statement includes a number of suggestions on how to assess eating behaviour and physical activity in a busy clinical setting and touches on the use of internet and other electronic resources for assessment and management.

In summary, the Statement concludes that:

- Discussions of weight should be performed in a nonjudgmental, respectful, and unhurried manner.

- Readiness and self-efficacy to change behaviors should be assessed before weight loss strategies are initiated, and this information should be factored into decisions about what type of approach to use.

- Validated tools such as the Eating Pattern Questionnaire, the Starting the Conversation tool, and the WAVE and REAP-S tools should be used to assess behaviors that contribute to excess body weight gain.

- Central planning and training should be incorporated into collaborative approaches that involve physicians, nurses, or other providers.

- Studies of Internet and other technologies for weight loss have shown promise, but at this time, there is insufficient evidence to make recommendations about their use in busy clinical settings.

The authors also make the following pertinent suggestion:

“…because many weight management interventions involve understanding and applying detailed and sometimes complex information by patients, the health literacy of patients should be taken into account in the design and selection of interventions.”

While all of this is a good start, I do wish that the statement had given greater emphasis to the fact that obesity is a heterogeneous and complex disorder and that it may be more important to spend time evaluating the ‘whys’ than the ‘whats’.

Thus, while it is certainly informative to assess ‘what’ people are doing, it is perhaps of even greater value to evaluate the underlying drivers (the ‘whys’) of these behaviours, be they environmental, cultural, biological or psychological.

Unfortunately, the Statement remains largely locked into the ‘how-do-we-get-obese-people-to-eat-less-and-move-more‘ paradigm, an approach that has so far largely failed to deliver.

Indeed, there is yet no convincing evidence that ‘traditional’ approaches to ‘lifestyle’ intervention for obesity can produce lasting effects - nor is there hard evidence that any such approaches will actually reduce morbidity or mortality in the long term.

Recognizing this lack of evidence should be humbling to anyone making enthusiastic suggestions on how to change people’s lifestyles to better manage obesity or related health problems.

In Alberta’s Obesity Initiative, we have therefore chosen to speak of ‘promising’ rather than ‘proven’ interventions when it comes to many aspects of dealing with this problem. Unfortunately, whether we like it or not, the best ‘hard-evidence’ of long-term health benefits and cost-effectiveness of obesity management are still largely limited to the bariatric surgery literature.

It is now upon both the prevention and medical management communities to demonstrate the long-term efficacy and cost-effectiveness of their efforts.

Or, as the authors of the Statement rightly conclude:

“In particular, larger studies of longer duration are needed to evaluate the effectiveness of the chronic care model as a framework for weight management interventions.”

Fully acknowledging this ‘uncertainty’ in how best to conservatively prevent and manage obesity should not prevent us from trying ‘promising’ approaches, but should certainly remind us of the importance to objectively measure and evaluate each step that we take in order to determine whether or not it actually offers a good ‘return on investment’.

AMS
Edmonton, Alberta

One of the most pervasive behavioural modification paradigms is Prochaska and DiClemente’s stages of change: precontemplation, contemplation, preparation, action, and maintenance.

It is therefore not surprising, that the recent Scientific Statement on New and Emerging Weight Management Strategies for Busy Ambulatory Settings From the American Heart Association, recommends the use of this paradigm in obesity management.

As the Statement points out:

“…providers should ask whether they want to lose weight and whether they believe they are ready to make changes to promote weight loss.”

The statement describes the use of a simple 5-item questionnaire, used in a descriptive study in a primary care setting, in which patients were asked to choose which of 5 statements best described their readiness for weight loss:

“I have not really thought about it” (pre-contemplation)

“I mean to lose weight but I don’t actually get around to it” (contemplation)

“From time to time, I go on a diet/exercise, but then I stop after a few days” (preparation)

“I have been working on losing weight for the past 6 months” (action)

“I have been working on losing weight for over 6 months, or I have kept my weight I lost off for over 6 months” (maintenance)

According to this study,

“Patients who were in the latter 4 stages of readiness were more likely to recall having received counseling for weight loss than those in the precontemplation stage.”

Based on this and similar studies, the Statement goes on to suggest

“…that although assessing readiness to change adds an extra step in caring for overweight and obese adults, it is a useful indicator of whether any accompanying weight loss counseling will be recalled by the patient. A patient who at least recalls weight loss counseling is better equipped to take steps toward weight loss than one who does not.”

While there is certainly nothing wrong with the ‘Readiness for Change’ paradigm in that someone in the ‘pre-contemplation’ or ‘contemplation’ stage may not be ready to embark on weight management, I often encounter patients, who are more than ready and are already ‘preparing’ or even ‘acting’, but just not preparing for or doing the right thing.

So for e.g., it is not uncommon at all, to meet patients ready to ‘lose weight’ and anxious to follow a diet or exercise plan but completely unready to actually deal with the underlying psychological or other issues that would really need to be tackled for any chance at keeping the weight off.

We see patients ready to exercise but not ready to give up their daily supply of pop, patients ready to eat more fruit and vegetables but not ready to have breakfast, patients ready to join a commercial weight loss program but not ready to tackle their abusive marriage, patients ready to go on a low-calorie diet but not ready to consider treatment for their depression.

These are patients, who are ‘ready’ to do the wrong thing but far from ready to do what is really necessary.

So being ‘ready’ alone is hardly a measure or predictor of ’success’.

I am also not comfortable with how the ‘Readiness for Change’ model is presented in this Statement, as the focus is clearly on weight-loss, which, I cannot emphasize enough, IS NOT A BEHAVIOUR!

To be useful as a behavioural change model, the focus should be on changing a behaviour (keeping a food diary, turning off my lights at 10 pm, adding 20 mins of relaxation exercises to my daily routine, etc.).

A key challenge for health professionals, thus, is not just helping clients across the Stages of Change, but also, ensuring that their readiness is indeed focussed on doing the right thing - this, of course, is easier said than done.

AMS
Edmonton, Alberta

Rao G, Burke LE, Spring BJ, Ewing LJ, Turk M, Lichtenstein AH, Cornier MA, Spence JD, Coons M, & on behalf of the American Heart Association Obesity Committee of the Council on Nutrition, Physical Activity and Metabolism, Council on Clinical Cardiology, Council on Cardiovascular Nursing, Council on the Kidney in Cardiovascular Disease, and Stroke Cou (2011). New and Emerging Weight Management Strategies for Busy Ambulatory Settings: A Scientific Statement From the American Heart Association * Endorsed by the Society of Behavioral Medicine. Circulation, 124 (10), 1182-1203 PMID: 21824925