Overweight, Obesity And Physical Inactivity

Overweight, Obesity and Physical Inactivity Scope The prevalence of overweight, obesity and physical inactivity has been increasing in all ages and is a major contributor to chronic diseases, including diabetes, hypertension, cardiovascular disease (CVD) and kidney disease. Family physicians are encouraged to discuss and provide brief advice to all patients regarding the importance of a healthy active lifestyle (when an opportunity is available and appropriate). Learning new behaviour around eating and exercise is like learning a new language-it takes time (up to 4 years or more), practice, and requires ongoing support and encouragement from a hopeful, empathetic and informed care provider. RECOMMENDATION 1

Physicians are encouraged to measure and document health indicators

Height, weight, body-mass index (BMI), waist circumference, physical activity level, and eating behaviour should be measured and documented in people of all ages, as appropriate, when they are seen by the physician for other reasons. RECOMMENDATION 2

Determine and record body mass index (BMI), using tools attached to this guideline. (see Appendix 1, 3, 4,5,6) Adults

Children/Youth • • •

• •

Normal - BMI < 85th percentile Overweight- BMI > 85th percentile Obese > 95th percentile

•

BMI ≥25 overweight BMI >27 overweight and increased risk of hypertension, diabetes and CVD BMI ≥ 30 obese, higher risk of complications

Adult Waist Circumference Increased risk: High risk:

female: ≥ 80 cm female: ≥ 88 cm

male ≥ 94 cm male ≥ 102 cm

A rapid increase in BMI over a short period of time should prompt review of the nutritional and physical activity situation of the subject. RECOMMENDATION 3

Activity level – determine and record Children/youth

Inactive Moderately active Very active

<30 min/day 30-90 min/day >90 min/day

Adults <30 min/day 30-60 min/day >60 min/day

BRITISH COLUMBIA MEDICAL ASSOCIATION

Inactive: Moderately active: Very active:

Ministry of Health

no appreciable exercise increased heart rate e.g.: walking. e.g.: Running, cycling, swimming lengths

RECOMMENDATION 4 1. 2. 3. 4. 5.

Using the questions below, determine and record diet quality/dietary habits

Do you usually eat breakfast? Do you usually* eat 5 or more servings of fruit and vegetables/day Do you usually* choose whole grain products? Do you usually* choose low fat or reduced fat alternatives at home and when eating out? How many boxes, cups or cans of fruit juice or pop do you usually drink per day? What do you drink when you are thirsty?

More than one “no” answer and more than one serving of sweetened beverage per day indicates the need for nutritional advice from the physician or referral to a registered dietitian or Dial-A-Dietitian (1 800 667-3438) *indicate to the patient that “usually” means 5 or more days of the week, most weeks. RECOMMENDATION 5

Assess factors that may influence weight, activity level and risk levels

1. Ask about family history of overweight, diabetes, high cholesterol, heart disease, hypertension and kidney disease 2. Consider associated health conditions: Children/youth Depression Asthma Being bullied Learning difficulties Type 2 diabetes

Adult Hypertension Type 2 diabetes Arthritis Depression

3. Assess social conditions • • • • •

poverty unemployment/employment issues education level workplace and home stresses current or previous abuse

4. Further diagnostic assessment should be individualized based on risk factors and family history. Extensive laboratory assessment of overweight, obese and physically inactive patients in the absence of obvious risk factors or physical findings is rarely fruitful. RECOMMENDATION 6

Adults: Assess each individual’s readiness for change. Tailor interventions and support to their current situation (See Appendix 2)

1. Educate adults about the risks of excess weight and the benefits of moderate weight loss and increased activity. Reinforce the message that even modest weight loss and increased activity can confer significant health benefits. Increases in physical activity in a stable, overweight person likely confer greater health advantages than diet in a physically inactive person. 2

OVERWEIGHT, OBESITY 2AND PHYSICAL INACTIVITY

2. Assess readiness to change: Ask the following questions: • Are you considering trying to lose weight or increase activity? • Are you currently trying to lose weight or increase activity? • Would you like some information to help you? 3. Help the patient who is ready to change to set realistic goals: • Emphasize gradual change in lifestyle over time • Recommend increased physical activity (e.g. walking 30 minutes/day) • Recommend some level of caloric restriction • Provide self-help materials • Praise success See Appendix 2 for detailed explanation of stages of change Physicians are encouraged to provide brief lifestyle advice during the management of other conditions whenever an opportunity is available and appropriate. RECOMMENDATION 7

Children and youth-assessment and management

Assessment and management will require: • the involvement of parents or care-givers where possible and may require formal nutritional counseling by a registered dietitian and or pediatric referral • an understanding and sensitive approach to assessment of potential eating disorders With growing children and youth, the goals may be weight maintenance and increased activity while normal linear growth occurs. RECOMMENDATION 8

Drugs/popular diets/surgical treatment (adults)

1. Pharmacological treatments are of limited benefit and have frequent side effects. The long term benefits are unknown. There may be limited use of one agent in adolescence. 2. Popular diets are becoming extremely prevalent and controversial. Evidence shows that over the long term, their efficacy is due to caloric deficit (energy in and out) and duration. Diets that are restrictive in particular food groups offer no long-term benefit and impose considerable risk of micronutrient deficiencies. 3. The surgical treatment of obesity involves risks and complications. Patients should only consider surgery if their BMI is greater than 40 or if it is greater than 35 and there is a related condition such as hypertension, type 2 diabetes or cardiovascular disease. 4. Very frequent “weigh-in” sessions (for example, weekly visits) have shown no long term benefits. Rationale Obesity in adults is indicated by a body-mass index (BMI) of 30 or more. About 33% of adult Canadians had a BMI greater than 25 (overweight) and 14.9% had a BMI of >30 in 20031. The British Columbia Nutrition Survey showed that 56% of British Columbians are overweight or obese2. The prevalence of obesity in both children and adults has been increasing in BC and throughout Canada in children, adolescents and adults 2,3,4. Obesity is a major risk factor for hypertension, type 2 diabetes, dyslipidemia, gallbladder disease, cancer and cardiovascular disease 5. Physicians and patients have requested a coherent reproducible approach to medical assistance in the management of obesity and inactivity. Recommendations for screening and intervention for obesity have recently been developed by the American College of Family Physicians5. The recommendations 3

OVERWEIGHT, OBESITY AND PHYSICAL INACTIVITY

focus on using BMI as an indicator of obesity and advice regarding weight loss, increased physical activity and the risk of more serious diseases. Efforts to reduce calorie and fat intake have been shown to cause weight loss, particularly if they are applied together with a physical exercise program. The American Academy of Pediatrics has provided some recommendations for the prevention of pediatric overweight and obesity6 . The Canadian Pediatric Society, the College of Family Physicians, Dietitians of Canada and the Community Health Nurses Association have prepared a summary regarding the use of growth charts in Canadian infants and children 7. Although therapeutic options remain to be optimized, behavioural approaches that involve the child and family have demonstrated success. The recommendations suggest as a guideline that children and adolescents should be considered overweight if they are between the 85th and 95th percentiles using Centers for Disease Control (CDC) growth charts8,9. Obesity in children and youth is a BMI for age of greater than the 95th percentile. Physicians can use clinical judgment to address overweight and obesity in children and adolescents and to advise them about the benefits of weight loss, increased physical activity and increased risk of complications. Recent evidence indicates that adult BMI of between 25 and 30 is not associated with increased mortality. Attempts at intervention should focus on more overweight ≥ 27 with comorbidities such as hypertension or diabetes and obese patients, particularly those with comorbidities10. References 1. Statistics Canada Health Indicators. June 2004. 2. British Columbia Ministry of Health Services. British Columbia Nutrition Survey. Report on Physical Activity and Body Weight. March 2004. 3. Katzmaryk PT. The Canadian obesity epidemic, 1985-1998. CMAJ 2002;166:1039-1040. 4. Tremblay MS and Willms JD 2000. Secular trends in the body mass index of Canadian children CMAJ 2000;163:1429-33. 5. McTigue KM, Harris R, Hemphill B et al. Screening and intervention for obesity in adults: Summary of the evidence for the US Preventive Services Task Force. Ann Intern Med 2003;139:933-949. 6. American Academy of Pediatrics. prevention of pediatric overweight and obesity. Pediatrics 2003;112: 424-430. 7. Canadian Paediatric Society. Use of growth charts for assessing and monitoring growth in Canadian infants and children: Executive summary. Paediatr Child Health 2004;9:171-173. 8. Centres for Disease Control 2005. http://www.cdc.gov/nchs/about/major/nhanes/

growthcharts/charts.htm 9. Cole TJ, Bellizzi MC, Flegal KM and WH Dietz. Establishing a standard definition for child overweight and obesity worldwide: international survey. BMJ 2000;320:1-6. 10. Flegal KM, Graubard BI, Williamson DF and MH Gail. Excess deaths associated with underweight, overweight and obesity. JAMA 2005;293:1861-67.

4

OVERWEIGHT, OBESITY 4AND PHYSICAL INACTIVITY

Sponsors This guideline was developed by the Guidelines and Protocols Advisory Committee, approved by the British Columbia Medical Association and adopted by the Medical Services Commission. Partial funding for this guideline was provided by the Health Canada Primary Health Care Transition Fund. Effective Date: September 1, 2005 This guideline is based on the scientific evidence at the time of the effective date.

Guidelines and Protocols Advisory Committee 1515 Blanshard Street 2-3 Victoria BC V8W 3C8 Phone: (250) 952-1347 Fax: (250) 952-1417

E-mail: [email protected] Web site: www.healthservices.gov.bc.ca/msp/protoguides

The principles of the Guidelines and Protocols Advisory Committee are: • to encourage appropriate responses to common medical situations • to recommend actions that are sufficient and efficient, neither excessive nor deficient • to permit exceptions when justified by clinical circumstances.

G&P2005-098

5

OVERWEIGHT, OBESITY AND PHYSICAL INACTIVITY

Appendix 1 International BMI (kg/m2) by age and sex (overweight > 85th percentile and obese >95th percentile9)

Appendix 2

AGE (yrs)

Overweight

Obese

Overweight

6 7 8 9 10 11 12 13 14 15 16 17 18

17.6 17.9 18.4 19.1 19.8 20.6 21.2 21.9 22.6 23.3 23.9 24.5 25.0

19.8 20.6 21.6 22.8 24.0 25.1 26.0 26.8 27.3 28.3 28.9 29.4 30.0

17.3 17.8 18.4 19.1 19.9 20.7 21.7 22.6 23.3 23.9 24.4 24.7 25.0

GIRLS

BOYS

Obese

19.7 20.5 21.6 22.8 24.1 25.4 26.7 27.8 28.6 29.1 29.4 29.7 30.0

Stages of Change

PRE-CONTEMPLATION • Person may be unaware of health consequences of increased weight or inadequate activity. May be resistant due to past failures. • Provide non-judgemental information and advice on health consequences of increased weight or inadequate activity • Tools: Provide patient resources for reducing sedentary activity, increasing activity level and healthy eating using one-page handouts and brief advice. Dialogue:

I am concerned about your weight. Losing some weight could really help you feel better and help your health. Would you like to read some information about why reducing your weight or increasing your activity level is important to your health?

CONTEMPLATION • Person is aware of problem, but not yet ready to change their behaviour/lifestyle • Provide encouragement, positive support, and focus on health consequences of excess weight/inactivity. • Tools: share examples of people who have successfully increased activity/lost weight. Encourage self-evaluation focussing on the pros and cons of changing. Dialogue:

Let’s consider the benefits of weight loss and what you might need to do.

6

OVERWEIGHT, OBESITY 6AND PHYSICAL INACTIVITY

PREPARATION • The person is ready to change but is uncertain how to get started • Provide support and encouragement, offer information, options and referrals as necessary. Emphasize the success of gradual incremental change. • Tools: Provide appropriate resource information. Assist in negotiating a plan and setting realistic goals and timelines. Dialogue:

What two changes do you feel you could you make in your eating habits/activities this week to start you in the right direction?

ACTION • Person feels empowered to reach goals, and is actively learning or trying new behaviors. • Engagement strategy: develop and discuss strategies to increase activity improve eating habits, affirm positive changes and encourage modifications to behaviour and lifestyle. • Tools: identify community-based and professional programs that will provide support for ‘lifestyle’ changes. Assist individual to develop a relapse prevention plan. Encourage them to exercise with a partner or join a group with similar goals. Dialogue:

It’s great to see you making such positive changes. How are you feeling? Have you run into any problems or difficulties? What did you do about that?

RELAPSE • Person feels discouraged and helpless, doesn’t feel they have been successful • Engagement strategy: Acknowledge the difficulties of real change over time, provide hopeful empathic support, and encourage them to try again. Emphasize again the need for gradual sustained change over the long term. • Tools: Support with problem solving, identifying realistic goals. Dialogue:

What were the positive changes you tried? What were the tough things to manage? Every time you make an effort to improve your nutrition and activity you learn some new things that will help you next time.

MAINTENANCE • Person has made positive lifestyle changes; life skill development and support systems are refined. • Engagement strategies: continue with relapse prevention strategies, provide objectivity and perspective on accomplishments at time of despair or plateau, discuss and normalize life challenges. • Tools: acknowledge successes, continue to offer support and encouragement and problem solving help. Normalize the difficulties in maintaining weight loss and activity levels in the context of aging, busy lives, school and family demands. Dialogue:

Tell me how you manage to continue your healthy eating/exercise when you are ill/busy/stressed/tired? What helps you stay on track?

7

OVERWEIGHT, OBESITY AND PHYSICAL INACTIVITY

OVERWEIGHT, OBESITY 8AND PHYSICAL INACTIVITY

8

17 16 16 15 15 15 14 14 13

16 16 15 15 14 14 13 13 13

15 15 14 14 14 13 13 12 12

17 17 17 16 16 15 15 14 14

52 115 22 22 21 20 20 19 19 18

BMI < 18 = underweight

Height 5’0” (ft/in) 5’1” 5’2” 5’3” 5’4” 5’5” 5’6” 5’7” 5’8” 5’9” 5’10” 5’11” 6’0” 6’1” 6’2” 6’3” 6’4”

50 110 21 21 20 19 19 18 18 17

45 48 100 105 19 20 19 20 18 19 18 19 17 18 17 17 16 17 16 16 19 18 18 17 17 16 16 16 15

57 125 24 24 23 22 21 21 20 20 20 19 19 18 18 17 17 16 16

59 130 25 25 24 23 22 22 21 20 21 20 19 19 18 18 17 17 16

61 135 26 26 25 24 23 22 22 21 22 21 21 20 20 19 19 18 18

66 145 28 27 27 26 25 24 23 23 23 22 22 21 20 20 19 19 18

68 150 29 28 27 27 26 25 24 23 24 24 23 22 22 21 21 20 19

73 160 31 30 29 28 27 27 26 25 25 24 24 23 22 22 21 21 20

75 165 32 31 30 29 28 27 27 26 26 25 24 24 23 22 22 21 21

27 26 25 24 24 23 22 22 21

77 80 170 175 33 34 32 32 31 32 30 31 29 30 28 29 27 28 27 27 27 27 26 25 24 24 23 22 22

82 180 35 34 33 32 31 30 29 28 28 27 27 26 25 24 24 23 23

29 28 27 26 26 25 24 24 23

30 29 28 27 26 26 25 24 24

84 86 89 185 190 195 36 37 38 35 36 37 33 34 36 33 34 35 32 33 33 31 32 32 31 32 32 29 30 31 30 30 29 28 27 26 26 25 24

91 200 39 38 37 35 34 33 33 31

31 30 29 29 28 27 26 26 25

32 31 30 29 28 28 27 26 26

93 95 205 210 40 41 39 40 38 39 36 37 35 36 34 35 34 35 32 33

≥ 27= increasing risk of hypertension, type 2 diabetes ≥ 30 obese

24 23 22 22 21 20 20 19 19

70 155 30 29 28 27 27 26 25 24

≥ 25 = overweight

21 21 20 20 19 18 18 17 17

64 140 27 26 26 25 24 23 23 22

Note: Consider muscle mass when evaluating BMI

18.5 to 24 = healthy weight

18 18 17 17 16 16 15 15 15

55 120 23 23 22 21 21 20 19 19

Body Mass Index (BMI) Chart (Adults) Weight

33 32 31 30 29 28 28 27 26

98 215 42 41 40 38 37 36 36 34

100 220 43 152 42 155 42 157 39 160 38 163 37 165 37 168 34 170 33 173 32 175 32 178 31 180 30 183 29 185 28 188 27 191 27 193

Kg Lbs Height (cm)

Appendix 3

Mass

Height (inches)

Mass

OVERWEIGHT, OBESITY AND PHYSICAL INACTIVITY

9

18

17

16

55

57

59

33

41

20

36

39

53

40

37

21

75

lbs

51

34

kg

23

9

59

49

10

57

25

11

55

47

11

53

27

12

51

45

13

49

30

15

47

43

16

45

24

37

17

26

35

43

30

33

19

34

31

41

39

29

21

44

lbs

39

20

kg

16

17

19

20

22

24

26

28

31

34

37

77

35

10

10

11

12

13

14

15

17

18

20

22

25

28

31

35

46

21

17

18

19

21

22

24

26

29

31

35

38

79

36

10

11

12

13

14

15

16

18

19

21

23

26

29

33

37

48

22

17

18

20

21

23

25

27

29

32

36

39

82

37

11

11

12

13

14

15

17

18

20

22

24

27

30

34

39

51

23

18

19

20

22

24

26

28

30

33

37

40

84

38

11

12

13

14

15

16

18

19

21

23

26

28

32

36

40

53

24

18

19

21

22

24

26

28

31

34

37

41

86

39

12

12

13

14

16

17

18

20

22

24

27

30

33

37

55

25

19

20

21

23

25

27

29

32

35

38

88

40

12

13

14

15

16

17

19

21

23

25

28

31

34

39

57

26

19

20

22

24

25

28

30

33

36

39

90

41

12

13

14

15

17

18

20

22

24

26

29

32

36

40

59

27

19

21

22

24

26

28

31

33

37

40

93

42

13

14

15

16

17

19

20

22

24

27

30

33

37

62

28

20

21

23

25

27

29

31

34

38

95

43

13

14

15

17

18

19

21

23

25

28

31

34

38

64

29

20

22

23

25

27

30

32

35

38

97

44

14

15

16

17

19

20

22

24

26

29

32

35

40

66

30

21

22

24

26

28

30

33

36

39

99

45

14

15

17

18

19

21

23

25

27

30

33

37

68

31

21

23

25

26

29

31

34

37

40

101

46

15

16

17

18

20

21

23

26

28

31

34

38

71

32

22

23

25

27

29

32

34

37

103.4

47

15

16

18

19

20

22

24

26

29

32

35

39

73

33

147

142

137

132

127

122

117

112

107

102

97

92

lbs

kg

147

142

137

132

127

122

117

112

107

102

97

92

87

82

77

72

lbs

kg

Height (cm)

Height (inches)

BODY MASS INDEX TABLE (Children and Youth ) >6 yrs Appendix 4

Height (cm)

Appendix 5

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OVERWEIGHT, OBESITY AND PHYSICAL INACTIVITY

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Healthy Active Living A GUIDE FOR PATIENTS Increasing physical activity and reducing body fat around the waist decreases the risk of hypertension, diabetes, heart disease, stroke and kidney failure. For example, increased activity of more than 2.5 hours of walking per week reduces the risk of heart disease by 40%. The benefit was seen for all ages, in different ethnic groups and regardless of whether a person was normal or overweight. Diet 1. 2. 3. 4. 5. 6.

Eat a healthy breakfast Eat 5 or more servings of fruit and vegetables per day Choose whole grain products Choose low fat or reduced fat alternatives at home and when eating out Reduce boxes, cups or cans of fruit juice or pop to no more than 1 per day. Choose water when thirsty

Recommended activity level • Children and youth 30-90 minutes per day • Adults 30 minutes per day

Tips to increase activity level Children and Youth • increase the amount of time currently spent being physically active by at least 30 minutes more per day • decrease the time spent watching TV, playing computer games and surfing the Internet by at least 30 minutes less per day

Adults • • • •

Create a new morning exercise routine with 10 minutes of exercise Park the car 10 minutes walking distance from work or shopping area Go for a bike ride Do a physical activity routine in front of the TV Expected yearly weight loss with additional activity kg Weight 50 kg: (110 lb) Weight 70 kg: (155 lb)

moderate walk brisk walk moderate walk brisk walk

(30 min/day) (30 min/day) (30 min/day) (30 min/day)

5 6.2 7 8.75

lb 11 14 16 20

Resources BC HealthGuide OnLine has a world of health information just a click away, through the awardwinning Healthwise Knowledgebase®. Over 2500 detailed symptom and condition-based topics are available, including topic overviews, check your symptoms, when to see a doctor, home treatments, and tips and tools for healthy living. Information specific to B.C. is also available, including the BC HealthFiles. Web site: http://www.bchealthguide.org Chronic Disease Self-Management Program A patient education program offered in communities throughout British Columbia that teaches practical skills in managing chronic health problems. Toll-free in B.C.: 1 866-902-3767 Canadian Health Network Canadian Health Network is Canada’s national health information network. Start your search here for health information developed by leading Canadian health organizations and international health information providers. Web site: http://www.Canadian-health-network.ca

Government-listed Health-Related Internet Resources This page provides links to other health-related Internet sites. These information resources have been selected by the Health and Human Services Library to serve the information needs of government staff and stakeholders.

Diet and Nutrition Dial-A-Dietitian is a free nutrition information line for B.C. residents. It specializes in easy-to-use nutrition information for self-care, based on current scientific sources. Dietitians provide brief nutrition consultation by phone. This is an excellent source of information about special diets for people with chronic illnesses, such as diabetes and cardiovascular atherosclerotic disease. Toll-free in B.C.: 1 800 667-3438 Greater Vancouver: 604 732-9191

Exercise Canada’s Physical Activity Web site: www.paguide.com Health Canada’s online guide is designed to help you make wise choices about physical activity that will improve your health, help prevent disease, and allow you to get the most out of life. If you think your congestive heart failure might prevent you from becoming more active, check out the Physical Activity Readiness Questionnaire. Call 1 888 334-9769 for a free activity guide.