This section covers:
Many people find it difficult to bring up the topic of weight management. The following questions have been validated1 and can be used to initiate a discussion about weight management:
Remain understanding and non-judgmental, check with them if you can ask these questions in a year’s time, or less. You can still give them a few handouts, encourage more vegetables and fruit for overall good health.
You can progress to the brief intervention
Overall, humans have a high energy turnover due to the brain using a large amount of energy compared with the rest of the body.
Humans have special ways of increasing energy uptake and conserving energy. We have an expanded part of the brain that drives us to acquire (or latterly use technology to ‘make’) refined energy dense food. This same recently-evolved brain area (the cortico-limbic-striatal area) includes the pleasure-reward-motivation-perseverance pathway, and affects many basic drives (eating rich foods, sex, but also computer gaming, gambling). This system uses high levels of brain transmitters that are also chemicals of addiction2,3. The drivers of obesity are complex, however on stimulation by easily available over-appetising ‘moreish food’, humans can lose control of energy intake, ignore healthy food, gain weight and develop related diseases such as diabetes and cardiovascular disease.
Humans tend to be born with extra, safe fat reserves or potential fat reserves under the skin and a naturally high fat: muscle ratio compared with other mammals. These fat reserves help keep the brain functioning when food is scarce. Fat reserves are also necessary for pregnancy and breastfeeding women, when there are two brains needing lots of energy, as well as nutrients. Neonate brains take up around 4/5ths of their total energy, and even at 5 years of age 50% of a child’s energy is directed to the brain5. Fat reserves can be extremely variable, differing even between quite closely related family members.
No one wants to lose control or gain weight but this drive is very strong in our current food environment, and hard to address with logic. Nobody logically eats until they are overfull and overweight. Management of people with eating control problems needs to be understanding and compassionate. Non-judgemental help with pre-setting rules around addictions has been used with nicotine addiction and smoking cessation4. This has been adapted for overweight people or those with eating control issues to:
Overall good health and protection from disease can be achieved through increased levels of micronutrients that are packed into healthy, minimally processed, real/whole food. These micronutrients appear to make energy metabolism highly efficient in humans by enhancing a specific cell protection system6-8. There is good evidence that this high functioning anti-oxidant, anti-toxicant, cell repair system allows humans special longevity, protection from infection, diabetes, heart disease, cancers as well as protection from a variety of degenerative disease and central obesity6. Thus, increasing whole foods, especially vegetables and fruit should be encouraged and supported at all times.
Staff Attitude barriers – This is a serious consideration. Each clinician must look at attitudes to obesity in society, people & most of all in themselves. If this is done then providing a non-judgemental welcome to all people who are overweight or have some sort of eating disorder (binge) makes for trust and best results. Having an empathetic clinician helps those with eating problems better and irrespective of the method or programme used9. People with addictions are often angry and defensive10. Helping remove their feelings of self-blame (blame the obesogenic environment), then allows them to get on and deal with their tasks of managing their weight in their own space, at their own pace.
Physical Barriers – Lack of adequate equipment (large scales, tapes, stadiometers). All clinics need to have scales which weigh people up to a minimum of 200Kg (best if >250kg) and routine weighing of all people attending clinic should be automatic. However, it should be noted that many people are ‘frightened’ of their weight and may prefer to close their eyes when on the scales and not know the results. Other equipment that can be useful includes: long tape measure, large blood pressure cuff, chairs with no sides, height measure (stadiometer), scales in discreet location, access to weight management tools and non-judgmental staff.
Communication skills – open questions, reflective listening, raising ambivalence, summarising, roll with resistance. These are all skills utilised in motivational interviewing11,12. This can be effective in brief interventions. Often people know what needs to be changed but require a non-judgemental supportive environment where they can acknowledge their concerns and be guided towards developing an effective action plan to support positive behavioural changes. Avoid providing solutions as the people are the experts in their own lives, but some suggestions can be helpful. Providing solutions can often build resistance and therefore should be avoided. There will be more information about motivational interviewing later on.
It is extremely important that clinicians recognise the genetic fat distributions in people or they risk giving the wrong advice and set people up for failure. Genetic abnormalities that lead to obesity usually show up in children or teens, and often have physical and cognitive/behavioural problems Such as Prada Willi syndrome.
The different types of weight distributions are as follows:
More adult women than men have large subcutaneous (under the skin) fat depots, sometimes over most of the body, and these people can have massive amounts of fat with surprisingly little metabolic problems.
Although exercise is always encouraged, people with a lot of subcutaneous fat may find it difficult to do much physical activity due to the large amount of pressure/weight on their joints. Start low and go slow is the message with people afflicted by this type of adipose distribution. This is pivotal in getting very large people even starting physical activity and once they start losing weight and they almost all move more, as they are enabled physically and mentally.
When there are limited genetically programmed subcutaneous fat cells, fat gets forced around the gut (omentum) and into organs. Unlike in peripheral, subcutaneous cells, the fat in these cells are toxic and associated with oxidative stress, inflammation and protein damage. Fat is forced into upper body skin; dowagers hump, skin around neck, tongue, shoulders, and into the liver, heart, skeletal muscle, pancreas and other organs.
Note that there can be a mix of the two types of fat distributions above, especially as people age.
New Zealand Māori and Pacific groups can have a mix of both visceral and subcutaneous fat distributions which affect morbidity. They tend to have large overall fat mass, significant central fat and co-morbidities, with some protective aspects such as increased muscle mass and bone density which is associated with lower risk of fracture than for other population groups. Even a seemingly slight increase in ectopic visceral, abdominal and intradermal fat in these groups (when fat has infiltrated areas it would not usually be found), will markedly increase the risk for diabetes, cardiovascular disease, cancer and many chronic degenerative diseases.