Page 35 - The SA Journal Diabetes & Vascular Disease Volume 9 No 4 (November 2012)

VOLUME 9 NUMBER 4 • NOVEMBER 2012 177
SA JOURNAL OF DIABETES & VASCULAR DISEASE PREVENTION IN PRACTICE
THE INITIAL CONSULTATION
RIO does not claim to have invented the cure for weight problems, and
cannot guarantee weight loss. Instead, it aims to maximise the chances
of weight loss by bringing together all NHS-approved and evidence-based
methods for weight loss into one primary care-based centre. But many
of the techniques used at RIO can be used by any general practice that
wants to help patients lose weight (Table 3).
As with any consultation, a good history and examination are vital in
formulating the management plan for each patient. An overweight pa-
tient, who has spent 20 years ‘on a diet’, who may have previously seen
a dietitian, accessed commercial or other weight-loss services, will be
managed very differently from a patient who has decided she needs to
lose weight for the first time, and wants to lose 20 kg in three weeks for
a special occasion.
An effective weight management clinic can be run with just a height
measure, some accurate scales and a tape measure. However, at RIO, all
patients are assessed in a dedicated weighing and measuring room. We
use bio-impedance scales, and floor-mounted scales are available for
morbidly obese patients with limited mobility, or wheelchair users.
Bio-impedance scales allow us to dispel patients’ mistaken beliefs
that they are ‘big-boned’, that their weight is ‘all muscle’, or that it is
‘ just fluid’. As patients become more active, we can also show that, even
without actual weight loss, unhealthy visceral fat is being replaced by
denser muscle.
Unless blood tests have been performed recently, they should be taken
to exclude previously undiagnosed metabolic conditions. Every patient
should also receive basic dietary and nutritional advice, as well as life-
style and exercise education, which should be reinforced throughout their
time in the weight management programme. At RIO, patients are triaged
by the Obesity Specialist Nurse (OSN) to assess which, if not all, of our
services are required, and appointments made as appropriate.
EATING FOR WEIGHT LOSS
In any practice, basic nutritional information may be delivered by the
practice nurse, OSN if available, or appropriately qualified healthcare as-
sistants (HCAs). At RIO, it is also delivered by the facilitators of the Cook
& Eat sessions in the on-site kitchen. We have always believed that it is
unlikely to be effective to deliver nutritional information to a patient who
does not know how to cook from raw ingredients.
The OSN has a vital role in explaining the energy-balance equation
(weight loss achieved by less energy intake from food, or more energy
expenditure through physical activity). The most established method of
losing weight is the hypocaloric diet, in which intake is 500–600 kcal
less than the body requires each day. The Harris Benedict or Schofield
equations can estimate how many calories a patient needs to maintain
current weight, but specialist equipment can be purchased to allow more
accurate assessment.
In order to keep things simple for patients, we advise 500 kcal less
each day. We do not advise calorie counting unless this suits the patient,
but instead look for ways in which patients can ‘save’ 500 kcal from
their daily diet. In some patients this can be easy: advice to reduce por-
tion size, to change snacks to lower-calorie alternatives, or to substitute
particular foods in their meals (Table 4).
A daily 500 kcal deficit translates into a weekly 3 500 kcal deficit,
which should result in approximately 500 g weight loss. To the patient,
Table 1. Benefits of a 10 kg weight loss
Mortality 20–25% reduction in total mortality
30–40% reduction in diabetes-related deaths
40–50% reduction in cancer-related deaths
Diabetes Reduced risk of developing diabetes by > 50%
30–50% reduction in fasting glucose
15% reduction in HbA1c
Lipids 10% reduction in total cholesterol
15% reduction in LDL cholesterol
30% reduction in triglycerides
8% increase in HDL cholesterol
Blood pressure 10 mmHg reduction in systolic BP
20 mmHg reduction in diastolic BP
HbA1c = glycosylated haemoglobin; LDL = low-density lipoprotein;
HDL = high-density lipoprotein; BP = blood pressure. Adapted from: Jung R.
Br Med Bull 1997;53:307–21.
Table 2. The multidisciplinary team at the Rotherham Institute for Obesity
• Obesity specialist nurses
• Healthcare assistants with specialist weighing and measuring equipment
• Dietetics input for complex dietary needs
• Group work and cooking skills education in the on-site kitchen
• Talking therapists for psychological and counselling input
• Physical activity specialist with on-site gym facilities
• GP with a specialist interest in obesity for any prescribing issues
• Access to local bariatric surgeons and other secondary care specialists
(if patient meets criteria)
• Pre-operative assessment for adults who may be suitable for surgery
• Triage of children who may be suitable for residential weight management
camps
Table 3. Weight management in primary care
Initial consultation
• Blood pressure
• Weight and height for body mass index
• Waist circumference
• Blood tests: full blood count, HbA1c, thyroid function tests, liver function
tests, lipid profile
• Dietary and nutritional advice to reduce energy intake by 500 kcal/day
• Education on lifestyle and exercise
Follow-up
• Reinforce advice on hypocaloric diet and lifestyle
• Weigh every four weeks and measure waist circumference
• Consider referral for psychological counselling or other ‘talking therapies’
• Refer to exercise therapist/liaise with local gym
• Encourage regular, vigorous exercise as part of the daily routine