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Management: Part I—Behaviour change, diet,
and activity
Alison Avenell, Naveed Sattar and Mike Lean Updated information and services can be found at: References
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ABC of obesity
Management: Part I—Behaviour change, diet, and activity
Alison Avenell, Naveed Sattar, Mike Lean
In the United Kingdom over 22% of the adult population isnow obese, with multiple health problems related to a bodymass index—weight (in kilograms) divided by height (in metres)squared—of 30 or higher. In England the national serviceframeworks for diabetes and coronary heart disease highlightthe importance of helping patients who are obese. Peoplecontinue to gain weight until their 50s and 60s, so 30-40% ofolder people will be obese, with chronic disease, mobilityproblems, and depression aggravated by obesity.
Obesity needs to be managed like any other chronic disease—with empathy and a non-judgmental professionalattitude. Helping people to manage their weight is difficult andcan be discouraging and time consuming for healthprofessionals.
High relapse rates, apparent lack of effectiveness, and lack of training and resources are major obstacles. However, an Achievable weight change (95% confidence intervals) from
increasing evidence base exists for the effective management of meta-analyses of randomised controlled trials in adults
obesity. And resources for health professionals are also nowavailable.
Weight change (kg) at 1-3 years
Resources for health professionals
x www.nationalobesityforum.org.uk (National Obesity Forum) x www.domuk.org (Dietitians in Obesity Management UK) x www.aso.org.uk (Association for the Study of Obesity) x www.nice.org.uk/page.aspx?o = 296567 (draft guidance from National Institute for Health and Clinical Excellence) (accessed 1 For people who are obese, long term low fat diets—together with increased physical activity and strategies to help modify their lifestyle—may prevent type 2 diabetes in those with impaired glucose tolerance and improve the control of hypertension and type 2 diabetes. These health benefits are seen with surprisingly small weight losses—5-10% sustained over a year or more, well within achievable goals for weight loss and despite some weight regain over subsequent years.
General strategies for helping a patient with a weight problem include agreeing an individual, realistic, weight loss goal, such as 5-10% over three to six months. Achieving this goal can help motivate success. Aim for weight loss initially, Data from Avenell et al (see Further Reading box).
followed by a distinct strategy for weight maintenance. Provideongoing support and positive feedback; this can be provided ina group setting.
A careful history can provide useful information for weight Important factors to evaluate in patient’s history
management. Weight, height, body mass index, and waist x Is the weight problem recent or longstanding (for example, since circumference (plus cardiovascular risk factors if indicated) should be documented regularly—changes in strategy can be x Consider the patient’s successful and unsuccessful attempts at used to help to motivate the patient.
losing weight and establish what he or she thinks about them x What is the patient’s attitude to smoking? For example, he or she may not be interested in stopping smoking because they may feel Aims and success criteria
x How does the patient feel about illness and medication? For The emphasis for “obesity treatment” used to be on weight loss.
example, he or she may relate weight gain to inadequate thyroxine But, as identified in the 1996 Scottish Intercollegiate Guidelines replacement, that weight gain is associated with depression Network guideline, weight loss is only one element in weight x Is there a family history of weight problems? Does the patient’s x Does the patient believe that their medical, social, or psychological Weight loss (short term, three to six months) Weight maintenance (long term, more than six months) x What is the patient’s motivation for weight loss or stability? BMJ VOLUME 333 7 OCTOBER 2006
Successful weight management does not necessarily have to For effective weight loss, energy intake must be reduced
mean weight loss. It can also reflect weight maintenance in and physical activity increased
somebody who in the past has gained weight.
In general, the diet and lifestyle strategies to achieve weight For weight maintenance, physical activity is possibly the
loss, weight maintenance, and improved risk factors are the same.
most important element, but evidence from, for
There may be individual variations in responses to individual example, the national weight control register, shows that
the best results come from continued, cognitive,
components—for example, lower fat or lower carbohydrate diets, restriction of energy (especially fat) together with
increased physical activity
Behavioural change
The key elements to successful behavioural change are frequent contact and support. Group counselling does not seem less Concern expressed by patient or health professional regarding weight effective than individual counselling for long term weightchange. Weight loss clubs may be helpful, but evidence is limited. For some people, however, initial individual counsellingmay be needed, and groups may not be beneficial—for example, BMI ≥30 or ≥28 with obesity related disease for men needing support but whose local group comprises mainly women. If possible, immediate family or key friendsshould be involved. Beneficial behavioural changes may have knock-on effects for other members of the family.
Weight loss plans move through various stages: precontemplation, contemplation, preparation, action, maintenance, and often relapse. Patients need help to make plans with achievable goals—unrealistically high goals for Provide health promotion information and reasons for change weight loss lead to disappointment. The goals can be reviewedover time, with a graded approach to changing habits.
Commonly used techniques, such as self monitoring, Review readiness to change at follow-up appointments identifying internal triggers for eating, and creation of copingstrategies, can help with behaviour change. There is evidence If patient not ready for change provide option for patient to come back and join programme at own request that these techniques aid weight loss and maintenance. Theyhave been incorporated into a successful model for weight Refer to local obesity management programme management in primary care in the UK—the Counterweightprogramme. This programme achieved weight loss results A possible pathway for starting weight management to provide support
similar to those achieved by the Diabetes Prevention Program appropriate to the stage. Adapted from Counterweight programme (see
Group (see Further Reading box) for those who completed the Further Reading box)
Prompts or reminders can be used to help to build better habits. A lapse presents an important opportunity to plan howto deal with the experience next time. Rewards should be Examples of commonly used behaviour modification
planned, and evidence of benefit—in terms of reduction in techniques
cardiovascular risk factors or in changes in clothing size—can be Behavioural
helpful. It is important to help to build self esteem and avoid approach
Techniques
criticism. A diary of food intake and physical activity can Daily diary (time of eating, type and amount of food, prompt discussion about situations that led to a particular thoughts and feelings, physical activity); personalised behaviour, so that strategies can be planned.
5-10% weight loss targets; weight monitoring charts Web based resources are available for patients, and a Haynes Patient to identify and record external and internal manual (Banks I. HGV man manual. Yeovil: Haynes, 2005) has triggers for eating; negotiate goals (for example, if eats been produced specifically to help men to lose weight.
when worried or stressed, to make list of alternative,relaxing activities) Negotiate goals (such as avoid watching television or Web based resources for patients to help with weight control
Realistic weight loss expectations of 5-10% discussed x www.realslimmers.com (online food retailer and diet club) at first appointment; achievable dietary and activity x www.eating4health.co.uk (organisation of state registered dietitians goals set in collaboration with patient; patient encouraged to challenge self defeating thoughts with positive thoughts; patient discouraged from using x www.whi.org.uk (Walking the Way to Health Initiative—aims to get words such as “always” and “never” more people walking in their own communities) Patient learns how to read food labels; patient learns x www.weightlossresources.co.uk (gives tips and programmes for Patient encouraged to plan in advance how to prevent x www.toast-uk.org (The Obesity Awareness and Solutions lapses; management of cravings discussed; patient Trust—campaigning charity offering a help and information line via encouraged to generate list of coping strategies for phone or email; online chat rooms and forum facilities) BMJ VOLUME 333 7 OCTOBER 2006
Dietitians with skills in weight management can give advice andsupport to general practices, including information for patients.
Diets partly work by imposing a regular regimen. Regular mealtimes, and the need for breakfast, are important. People whoskip meals early in the day often more than make up for thislater in the day. Shift workers have particular problems, so it isimportant to help the patient make his or her own plan.
Snacking or grazing is best discouraged, but low energy snacks must be available when snacking is unavoidable.
Reducing portion sizes, using portion controlled foods(including meal replacements) and limiting the size of platesused may all be helpful. Patients should be advised to avoidhaving tempting, high energy foods at home, to shop when theyare not hungry, and to use a shopping list.
A diary of food intake is a useful starting point for making Some patients may find that alcohol accounts for a much larger energy
intake than they expected. Alcohol can also encourage some people to eat
changes. This may be particularly useful for patients who claim to be unable to lose weight despite eating virtually nothing. Adiary may help them to see that they eat more than theythought and is useful for looking at triggers to overeating.
New diets appear in the media and on the bookshelves all the time and it can be difficult to counter this barrage.
Key principles for a successful diet
Consistent evidence shows that a long term, low fat diet x Include a variety of foods from the main food groups produces long term weight loss and beneficial changes in lipids, blood glucose, glycaemic control, and blood pressure. Typically, x Reduce the proportion of fat, particularly saturated fat such a diet would have a deficit of 500-600 kcal/day below the x Partially replace saturated fat with monounsaturated fat (such as current requirement for energy balance, leading to a weight olive oil) or omega 3 polyunsaturated fats reduction of 0.5 kg a week. A low fat diet can be consistent with x Increase intake of fruit and vegetables to at least five portions a day x Ensure that meals include wholegrain and high fibre foods, and providing low glycaemic index foods, as in diets that focus on eating foods with a low glycaemic index. Such a diet provides the best chance for a long term change to healthy eating habits, with protection against chronic diseases such as cancer and x Follow a structured meal plan that starts with breakfast heart disease. Low energy meal replacements may be helpfulfor some patients, but palatability can be a problem.
Very low energy diets may produce better initial weight loss—which might improve motivation—but long term, theweight loss achieved in this way is rarely any greater than the Beans on toast, fruit, and porridge are all useful
loss achieved with low fat diets. Rapid weight loss may standbys for low energy meal replacements—and they
occasionally be required, however (for example, to allow surgery are all easily available and tasty
Low carbohydrate, Atkins-type diets (diets that focus on eating mostly protein, with small amounts of carbohydrate) areeffective in the short term but less so after a few months. Shortterm side effects include headache, constipation, halitosis fromketosis, and fatigue. Longer term effects on disease risks havebeen little studied for these diets. Low carbohydrate diets lead todeterioration of some parts of the lipid profile—for example,low density lipoprotein cholesterol—but improvements in highdensity lipoprotein cholesterol, triglycerides, and glycaemiccontrol. Short term use is unlikely to be harmful and can be astarting point for the otherwise poorly motivated patient.
Physical activity
Patients should be encouraged to reduce their inactivity ratherthan “do more exercise,” which for some people may have Concerns have been raised that diets focusing long term on eating mostly
negative connotations of team sports and “going to the gym.” protein with small amounts of carbohydrate may increase the risk of
Weight loss and long term weight maintenance will be osteoporosis and kidney stones (above)
improved if activity levels can be increased. Step counters maybe useful to set daily targets, but their value is unclear. As well asits effect on weight loss, increased physical activity hasadditional benefits for cardiovascular risk factors, insulin Keeping physically active helps people to curb excess
resistance, and depression and also limits the loss of lean tissue appetite and avoid situations that prompt eating
BMJ VOLUME 333 7 OCTOBER 2006
Patients who have previously been inactive must decide and Department of Health recommendations on physical activity
plan for themselves how to incorporate more physical activity for adults*
into their current lifestyle—for example, less sitting and morestanding, less television, walking some of the way to work, x Thirty minutes of at least moderate activity on at least five days a gardening, and cycling. Walking initiatives in the patient’s area x For many people, 45-60 minutes of moderate activity a day may be may be useful (www.whi.org.uk). Patients may think that they have to go to exercise classes, but this may be unrealistic for x People who have been obese and have managed to lose weight may their current activity levels and lifestyle. Other people may need to do 60-90 minutes of activity daily to maintain weight loss x Recommended levels of activity may be obtained in one session or enjoy attending organised classes and the peer support this as bouts of activity of 10 minutes or more provides. Recording physical activity in a diary can be used in x The activity can be “lifestyle” activity (such as walking, cycling, much the same way as a diet diary. Patients may find it difficult climbing stairs, hoovering, mowing lawn), structured exercise, or to attain the levels of moderate activity recommended initially, but this should be the long term goal. Although the *www.dh.gov.uk/assetRoot/04/08/09/88/04080988.pdf (accessed 1 Aug 2006) Department of Health’s recommended goals for physicalactivity clearly reduce the risk of cardiovascular disease forpeople who are overweight and obese, they are not sufficient tocounteract all the ill effects of obesity.
Further reading and resources
Helping someone to change their behaviour to prevent or x Avenell A, Broom J, Brown TJ, Poobalan A, Aucott L, Stearns SC, et reduce obesity requires a flexible approach tailored to that al. Systematic review of the long-term effects and economic individual, with encouragement when, inevitably, setbacks occur.
consequences of treatments for obesity and implications for healthimprovement. Health Technol Assess 2004;8(21).
The authors thank Karen Allan for reviewing a previous draft of thearticle. The cycling photograph is published with permission from Dennis x Costain L, Croker H. Helping individuals to help themselves. Proc MacDonald/Alamy. The illustration of a drinking party is Heurigen Party,Vienna by Rudolf Klingsbogl, published with permission from Vienna’s x Diabetes Prevention Program Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Musical Sites (1927). The photograph of the kidney stone is published with permission from Stephen J Kraemer/SPL.
x National Obesity Forum. Managing obesity in primary care Alison Avenell is a Chief Scientist Office career scientist at the Health Services Research Unit, School of Medicine, at the University of x Obesity training courses for primary care (from www.domuk.org) x Prochaska JO, DiClemente CC, Norcross JC. In search of how people change: applications to addictive behaviours. Am Psychol The ABC of Obesity is edited by Naveed Sattar ([email protected]), professor of metabolic medicine, and x Scottish Intercollegiate Guidelines Network. Obesity in Scotland: Mike Lean, professor of nutrition, University of Glasgow. The series integrating prevention with weight management.
will be published as a book by Blackwell Publishing in early 2007.
www.sign.ac.uk/pdf/sign8.pdf (accessed 12 Jul 2006).
x Counterweight Project Team. A new evidence-based model for Competing interests: In the past five years, Alison Avenell has received one weight management in primary care: the Counterweight fee for speaking from Roche Products UK, the manufacturer of orlistat.
programme. J Hum Nutr Diet 2004;17:191-208.
For series editors’ competing interests, see the first article in this series.
Several grateful patients
In 1958 I served my national service as the sole anaesthetist in central table engrossed in a game of pontoon, which the British the British military hospital at Kluang, Malaya. In this region had taught the communists. Most of the British soldiers were groups referred to as “communist terrorists” had frequent young national servicemen who were looking forward to skirmishes with British patrols. The wounded British were treated returning to Britain. They held no animosity towards these new at our hospital, whereas the wounded terrorists were taken to the arrivals. The communists became well behaved, polite, and civilian hospital in Kluang, but most were killed by knife attack on cooperative patients, appreciative of the care and trust shown to Shortly after my arrival the British authorities extended a When these patients were ready for discharge and told they goodwill gesture to the civilian hospital by offering army medical could go they were unbelieving. They stated that they would be specialist services for their problem cases. Complying with this rearmed and ordered to fight again, and, after all our kindness, they did not want to fight us. We commented that we had ethical After the next skirmish we treated the wounded British and responsibilities for their treatment while in our care, but what admitted them to our acute surgical ward. We then received our they did after leaving hospital was their own choice.
first referrals from the civilian hospital—five wounded After our care of these first patients we noticed a progressive communists. All required general anaesthetics. They were decrease in hostilities. We continued to treat diminishing uncommunicative, resentful, and only reluctantly accepted numbers of wounded, and hostile activity ceased within three treatment. Postoperative care was only available in our single months of this first event. Our care and treatment of enemy acute surgical ward, so, with some misgivings, the surgeon and I wounded produced grateful patients. This, and the knowledge sent them to the same ward as the British soldiers, but for review that the British intended to withdraw once hostilities ceased, resulted, I believe, in aggression ending earlier than expected inthis region.
The commanding officer, horrified at the non-segregation, hurried to the ward the next day, expecting the worst. Instead, he Duncan I Campbell retired anaesthetist, Sydney, Australia found all those who could leave their beds seated around the BMJ VOLUME 333 7 OCTOBER 2006

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