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Conversations about Weight Management

4. Ongoing Management

This section covers:

  • Onward referrals
  • More information on nutrition
  • More information on exercise
  • More information on sleep
  • More information on food addictions

Ongoing management is set up to support patients making lifestyle changes based on issues highlighted in the Comprehensive Assessment. At this point patient should be passed over to their GP/nurse in their ‘health care home’. Other funding streams such as CarePlus can be utilised for these appointments.

Funded appointments are very important for high need patients who may not be able to afford a general practice appointment to support weight management (may be able to see a nurse). These high need patients are often the individuals with the greatest need. Agree with the patient how often they would like to be seen, be aware that patients may need more input initially.

The initial aspect of the on-going management strongly depends on utilising the results from the Comprehensive Assessment as it provides a holistic overview giving insight into the reasons why people may overeat. Completion of the assessment form can be spaced over time or given to people to take away and review for themselves and return at another time.


Onward referrals

Ongoing management also includes ‘onward referral’ e.g. green prescription, self-management groups, local community programmes. The expectation is that other referral and support services can be utilised to support weight management. Referrals can be made to social and coaching support, or other medical, psychological and surgical services, with primary care clinicians having the skills to coordinate and ‘support weight management in primary care’.

Funding Streams

Health practitioners should access any funding available for chronic conditions or diabetes to fund weight management appointments once project funding is no longer available. Examples of this are Careplus and Diabetes Care Improvement Package (DCIP). For some people, paying to receive weight management follow up at their health centre may be cheaper than other commercial options.

At each ongoing management appointment:

  • Consider any attempts/changes made and congratulate them
  • Utilise ‘patient resources’ comprising of recipes, meal plans, posters, food diary etc.
  • Repeat anthropometrical measurements (weight, waist circumference etc.)
  • Reassess and update goals using the ‘patient plan of action’
  • Review and promote physical activity/moving more
  • Consider onward referral for physical activity, counselling/psychology, smoking cessation, self-management groups, dietitian, community/marae support, diabetes care – follow up on referrals
  • Review metabolic status and repeat any abnormal blood results
  • Utilised motivational interviewing and micro-skills, to ‘hear’ the persons problem and support person led problem solving
  • Promote smoking cessation
  • Be alert to alcohol and other drug issues

More information on nutrition

Wholefood/real food that is minimally processed is best19. A wholefood diet rich in micronutriens is the most appropriate for preventing weight gain, assisting weight loss, and decreasing risks of most cancers, and (partially) reversing many degenerative diseases, such as diabetes, CVD, autoimmune, and neurodegenerative disorders.

Definition: “Whole/real food” – foods that have had no or little processing. They have a low human intervention factor from growing to consumption. They are micronutrient dense and generally don’t contain additives like salt, fat, sugar and preservatives. Examples of whole foods include vegetables, fruits, legumes, nuts, seeds, meat, seafood, eggs (see the ‘eat real food not labels’ poster). Often whole foods are found around the outside of the supermarket, while the highly refined processed foods are in the middle aisles.

Benefits of eating high nutrient vegetables and fruit are:

  • Large volumes can be eaten daily – no need to restrict portion size (positive message)
  • The quality of the food eaten is more important than the timing/number of meals
  • High micronutrient density and beneficial plant chemicals essential for health
  • Increasing the quality of someone’s diet even if no other changes are made
  • Potential for displacement of unhealthy foods.
  • A whole/real food diet high in vegetable and fruits can result in sustainable weight loss

Single items of whole foods can have thousands of useful micronutrients20. There is a high likelihood, that as these foods contain so many micronutrients, some of these will suit each person’s metabolism genes. Micronutrients include vitamins, minerals and phytochemicals.

Fluid/Beverages

Water is best. Keeping bottles of water in the fridge can be more appealing than tap water. Other beverage choices include tea (no sugar), coffee (no sugar) and plain milk. Fruit juices – real fruit juices have more nutrients than artificial flavoured soft drinks. If these are watered down they can be refreshing while reducing the sugar content. However, some fruit juices have added sugars and preservatives and are mistakenly interpreted as healthy, but far from their nutritional whole fruit counterpart. The sugar content is often comparable to fizzy drinks.

  • It is much better to eat the actual whole fruit instead of just the juice, this way you are getting the nutritive, digestive and satiating benefits of the fruit fibre.
  • Blending (retains the fibre unlike juicing) fruit can be the base of a smoothie.

For people who are not keen on plain water try:

  • Water with limes/lemons/cucumber/mint/berries/oranges/tea/ginger – try soaking overnight
  • Soda water/sparkling water as it has the same mouth feel as fizzy drinks and can be used as an intermediate between sugary drinks and water.

More information on exercise

The benefits of regular physical activity are well referenced in the literature

  • Improved cardiorespiratory fitness is related to reduced risk of CVD
  • Improved HDL
  • Improved glucose tolerance and uptake
  • Improvements in mood especially for anxiety and depression
  • Reduced systolic blood pressure

The focus is on ‘moving more’ for overall improved health and wellbeing, as opposed to focusing on exercise for weight loss.

The key concept is the basic message of “be more active”. Ask the person about their history of physical activity or exercise.

  • The activities they did as children or young people will be easier to re-instate than new activities due to ‘muscle memory’
  • Consider existing conditions (Congestive Heart Failure, diabetes, CVD, renal) as well as musculoskeletal concerns and previous injuries. Refer for an assessment with a clinical exercise physiologist
  • Ask about long periods of sitting e.g. people with desk jobs or truck drivers. See if they can stand up to stretch or walk for a few minutes every hour.

Start into exercise slowly, especially when the person has been sedentary for a number of years and/or is very overweight

  • Short bouts of activity may be better than one long session21.
  • E.g. 3 x 10min walks instead of 30min.

Consider how to increase incidental activity on a daily basis e.g. Park the car a block from work and walk the extra distance.

Consider how uncomfortable activity can be:

  • Sweating / chafing (advise people how to minimise discomfort).
  • Aching muscles after exercise – rest, ice, compress to reduce inflammatory effects. It is best not to do so much exercise that inflammatory effects are produced – these reduce with gradual practice and increase in fitness.

Resistance exercise is an important consideration for a balanced activity programme.

  • Body weight exercises are best initially.
  • Resistance exercise should be part of an initial programme for anyone with pre-diabetes, diabetes, metabolic syndrome.
  • Avoid breath holding especially with hypertension.

25% of activity should involve ‘huffing and puffing’ activity but activity every day is the goal.

Weight management programmes that combine dietary intervention with increases in exercise typically result in a 9-10% reduction in body weight. It is the combination of dietary intervention with adequate levels of activity that maximises weight loss in overweight conditions. In addition regular physical activity is important to prevent weight regain.


American College of Sports Medicine Guidelines for Overweight and Obesity

Frequency: ≥ 5day/week

Intensity: moderate to vigorous aerobic activity should be encouraged. Initial exercise intensity should be appropriate to suit the individual but should be progressed to ensure physiological adaptation

Time: minimum of 30min/day (150min/week) progressing to 60min/day (300m/week) of moderate intensity aerobic activity. Incorporating bouts of vigorous exercise should be encouraged in those who are motivated and physically capable – although the risk of injury obviously increases with increased intensity. Accumulation of intermittent exercise of at least 10min is an option.

Type: primary mode of activity should be aerobic that involves the largest muscle groups. Resistance training and flexibility is highly recommended as part of a balanced regime.

In people who are peripherally overweight, i.e. have a lot of weight in the lower limbs, joint mal-alignment and damage is quite common22,23, including in children24. People with this sort of adipose tissue distribution usually have better metabolic health25 and require lower intensity, lower impact physical activities.

For the centrally overweight, initial breathlessness (abdominal compartment syndrome26,27) coupled with hypertension and other metabolic abnormalities, predisposes people to injury (especially the Achilles tendon). It is very important that high nutrient diets are started and very gradual increase in PA intensity is managed. Once diet is established and fitness regained this group of people will need to continue higher intensity activity to maintain cardiovascular and general health28. Any physical activity will cause imperceptible micro-damage29 and micro-shear stress in vessels30 that stimulates repair in body cells31. This is why we do physical activity for metabolic health and repair. Even stiffness is a signal that excess stress in the muscle is occurring; pain is unnecessary.

Making sure that people are not put off or ‘set up to fail’ is imperative. Note that it is hoped that GP’s and Practice Nurses will work with people to ensure that they learn to choose appropriate physical activity that they (learn to) enjoy or eat least can form into a habit.

See the Ministry of Health food and activity advice for adults for more information.


More information on sleep

Sleep of good quality and duration is required for good general health.

Many individuals eating nutritionally poor food tend to skip breakfast but eat large quantities at night, when they have time to ‘blob’ and unwind32. Having a stomach full of food, with fat around the organs, can increase gastro-oesophageal reflux (GORD) which may cause acid droplets to be inhaled into the lungs33.

In addition, this eating pattern (large quantities of high energy food in the evening or at night, and a few energy dense snacks during the day) is associated with weight gain34. Central weight gain predisposes to problems with sleeping35.

Often in men and older women a lot of fat accumulates in the neck area - jowls and tongue. The issues with fat around the neck and in the skin of the chest around the ribs, over the back of the neck (dowagers hump), are snoring, sleep apnoea (with raised blood pressure35 and daytime sleepiness36 (with a large increase in motor vehicle accidents even on short journeys). Central overweight with and without metabolic syndrome predisposes to problems with sleeping.

The above eating type and patterns are compounded by electronic screen-related compulsive behaviours that continue late into the night, such as gaming and other pass-times37. Shift work with altered sleep periods also is associated with both disturbed sleep, unhealthy eating habits and weight gain38.

Sleep deprivation puts the body into an insulin resistant pattern, with increased ‘stress chemical’ pathways, upset growth and other hormones and induces metabolic syndrome in the non-overweight39. Poor sleep quality and quantity or chronic sleep deprivation predispose to central overweight and metabolic syndrome. Lack of physical activity worsens the situation40.

The westernised environment tends to induce multiple behaviours that contribute to both central overweight related metabolic syndrome and chronic sleep deprivation, and they worsen each other – setting up a vicious cycle.

This means that a large proportion of people in New Zealand are overweight and chronically sleep deprived.

Sleep Management

Adequate sleep involves ensuring adequate duration, lack of disturbances and undisturbed and comfortable sleep41. Most people need more than 6 hours of unbroken sleep, most nights, preferably in the dark without noise or human disturbance or other biological disturbance such as urinary frequency, babies. Etc. The elderly may need less41.

General sleep hygiene is important but can only go so far to resolve sleep problems if sleep apnoea and day time sleepiness are caused by fat in tongue and neck structures.

Sleep and weight management

Applying a weight management plan aims to reverse the fat in tissues around the neck (as well as generally). As soon as healthy weight loss starts, tongue and jowl fat is relatively quick to mobilise and snoring decreases. It is possible for people who have been on CPAP to lose weight and gain health to the extent that they can be weaned off CPAP. Sleep issues need to be taken seriously, but while people are waiting to be seen they could be looking at lifestyle changes/start the weight management pathway.

Other Sleep Issues

It should be recognised that changing sleep patterns is difficult. Many overweight youth who use screens have moved their days to early morning bedtime, rising late morning37. Disturbed and poor sleep is often a long term problem.

Manage chronic pain (especially joint pain) adequately. As the physical aspects (sleep apnoea, pain etc.) are dealt with, the psychological aspects need managing.

It is worth noting that peri-menopausal women, of whom the previously slim particularly, are at risk of central weight gain, and their hot flushes (of new onset oestrogen lack) are a potent cause of waking/sleeplessness at night.

Before prescribing medication for sleep, assess psychological health. Depression and anxiety, having classical sleep issues, often relate to eating patterns and weight issues dealt with in this work book.

It is very important to decrease the prescription of addictive sleep medication, including the benzodiazepines. Low dose, bedtime, tricyclic antidepressants work well in most and can be added to antidepressants such as fluoxetine (discussed below). Neither is usually a problem to stop and start.

Finally, once the above are addressed, educate on sleep hygiene41.

Sleep Hygiene

Bed time patterns may need reassessing and moving towards a more usual pattern. Sleep and eating timing may be out of synchrony – and night eating can become a problem.

It is best to catch the first sleep cycle that occurs every 1.5 hours when tired, but ‘busy’ people may override this and ‘feel awake again’ for the next 1.5 hours, until the next sleep cycle42 (example of Sleep cycle graphs).

Reducing exposures to all stimulants (light, caffeine, other drugs) is generally useful, but also chronic sedative use (alcohol, cannabis etc.), also need addressing – including prescription medicine.

There are a number of patterns that people can try. Forming a rhythm is important if possible. Time reminders (alarms) to set a bedtime is helpful especially for shift workers. A low energy bland drink before bed can be helpful, but may just be part of a ‘going to bed’ ritual41.


More information on food addictions

It is possible that many people are addicted to particular food groups. It is important to have a low threshold of bringing up the issue of refined high energy food (sugary, starchy fatty ‘junk’ food) ‘addiction’.

People will often be relieved that you know how out of control they may be, and that you do not judge them

  • Addictions are part of being human
  • The person in front of you is not defined by addictions - all humans are on a continuum, i.e. many of us have genetic and ‘environmental’ issues of some sort here.
  • We need to unlock why slimmer people (often the clinicians) judge more overweight people (their patients)
  • For example, we all should ask ourselves are we actually the weight we think we should be? How good is OUR control? Why can some of us not manage to keep off 5kg? Why is 5 kg extra less blameworthy than 50kg when we have such different genes.

Addiction Definition:

A maladaptive pattern of substance use manifested by 3 or more of the following, over the same 12 month period:

  • Taking larger amounts;
  • Unsuccessful efforts to cut down (loss of control);
  • Over-investment of time;
  • Giving up (neglecting) important social (+ health) activities;
  • Continued use despite negative consequences;
  • Tolerance (greater need, obsessive/compulsive i.e. often no longer enjoyment); and
  • Use continues to avoid unpleasant withdrawal symptoms.

Craving has now been accepted as a new criterion in the Diagnostic and Statistical Management of Mental Disorders (DSM 5)43. The DSM-5 is the 2013 update to the American Psychiatric Association's (APA) classification and diagnostic tool. In the United States the DSM serves as a universal authority for psychiatric diagnosis. It is important to remember that cues to eat are very strong, hence advertising is very powerful.

Habituation is a late stage and moving people on from here is difficult. This latter stage shows how logic does not figure in addiction thinking.

The DSM 5 now has a formal Binge Eating Disorder facts sheet.

Key features of addiction are combination of clinical impairment, loss of control, tolerance, and withdrawal syndrome when the substance is discontinued.

Rules are useful where there is no logic – such as for children. Rules can work for people who need to manage addictions. Aim to agree and set rules (usually supported abstinence/strong control procedures) when not in ‘binge’ mode. Always try to find a ‘safe’ replacement for the item e.g. dried fruit for lollies.

Explanatory Notes: General Addiction

All humans have an enlarged cortico-limbic-striatal (mesolimbic) part of the brain that uses dopamine neurotransmission for basic, driven action. Importantly, dopamine neurotransmission is not connected to any logical part of the brain, although the serotonin part does have some connection with logic. Addiction probably begins with the basic pleasure and reward circuits in the brain. Brain reward centres are designed to activate during pleasurable acts such as eating through various neurotransmitter pathways. Examples of common brain function changing and other organ destructive addictions are alcoholism, cocaine abuse, methamphetamine abuse, narcotic abuse, and other substance abuse. Refined high energy food addiction may spare brain damage and ‘mind altering’, (inebriation, drunk, high, stoned etc.) but does alter brain function and behaviour. Addictive behaviours that are considered damaging, destructive, or ‘mind altering’ have characteristics that distinguish them from normal behaviour.

See this link for an overview on addiction: http://www.emedicinehealth.com/addiction/article_em.htm

Whenever ingesting a substance that causes these reward circuits to activate, addiction and dependence are possible. They involve the chemical dopamine and its receptors that mediate repeating and perseverance of behaviours – pleasure may no longer be present. Dopamine receptors and transporters in humans are still evolving so there is variation and individual genetic differences.

Note: Obsessive/Compulsive fear driven behaviour is similar – no pleasure but repetitive behaviour gives a sense of relief.

High Energy Refined Food Addiction

  • Addiction to substances is well known, but addiction probably stemmed from the extreme drive to procure energy dense foods.
  • Don’t underestimate the ‘fear of being fat’ – the probable root cause of the obsessive/compulsive aspect, and body dysmorphic disorder.
  • In anorexia as well as binging (and computer gaming and other behavioural addictions) there is an inability to stop the behaviour (self-punishment or starvation behaviour).
  • People afflicted with eating disorders may be overly controlling of their lives – but with food they may be out of control. Some people are out of control of the rest of their lives and have other addictions
  • There is increasing evidence for treating all addictions together, otherwise people move through one after another44.

Some people are either in a binge episode or are restricting everything too much. Lack of any supports/strategies/replacement foods may put them at risk of switching between the two modes of eating, in a ‘boom and bust’ manner. Aiming for nutritious diets that are sustainable is very important.

Some people are like alcoholics – a chocolate biscuit may set off a binge. If this is the case then these known addictive items have to be omitted except for rare, externally controlled time’s e.g. chocolate - controlled amounts on few socially sanctioned holidays’ e.g. religious holidays, seasonal festivals, birthdays.

Addictions have to have rules. There is no reasoning or logic in this part of the brain. Once addictive items are started again people tend to return to old habits. Most people learn this the hard way, and that’s good. The clinician puts the responsibility back to the person but offers support and interest in how they are managing.

If someone has gone on a binge, then help them with their rules, and prepare them for ‘cessation’ of those items (only truly addictive items – can include bread, rice etc.) and replacement options e.g. high nutrient dried fruit to replace lollies, and help with insight to keep these foods out of sight.

The timing of cessation of this food is difficult to predict – see if you can help the person get everything as ready as possible. Sometimes a quit date can be made but trying to wait for a ‘motivational high’ is the way with many people. Many addicts say they have to get to rock bottom, before they change, but if people are given the expectation that someday they will know the right time, and they will be ready, that gives them hope and confidence that they can become empowered. Lastly, although there has been an enormous amount of study on how to predict which individuals will do well, no-one is good at predicting which individual will do this when – extend your ‘hope and confidence’ to all.