|
 
 |
| PRACTICAL APPROACH |
|
| Year : 2014 | Volume
: 2
| Issue : 2 | Page : 68-71 |
|
Managing obese patient: Using the Five A's approach
Bandar Abdullah Al Asmari
Department of Family Medicine, General Directorate of Aseer Health Affairs, Saudi Arabia
| Date of Web Publication | 18-Dec-2014 |
Correspondence Address:
Bandar Abdullah Al Asmari
Department of Family Medicine, Aseer Region
Saudi Arabia
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/2347-2618.147347
Five A's technique was first used for smoking cessation. Later on this approach was practiced by health professional to manage obese patients. The objective of this paper is to demonstrate how to manage obese patient by using five A's approach based on clinical scenario. Keywords: Approach, obesity, practical
How to cite this article:
Al Asmari BA. Managing obese patient: Using the Five A's approach. Saudi J Obesity 2014;2:68-71 |
| Background | |  |
Five A's technique (Ask, Agree, Assess, Advise, and Assist) was first used to smokers in order to help them regarding smoking cessation. [1] This approach was found to be simple, easy to use, and cost-effective. [2] Later on, this approach was practiced by health professionals to manage obese patient. [3],[4],[5]
Objective
The objective of this paper is to demonstrate how to manage obese patient using Five A's approach step by step based on the clinical scenario.
| Clinical scenario | | |
Mr. Ali is a 30-year-old Saudi male married who attended family medicine clinic for the annual checkup. Initial nurse assessment showed that his weight and height were 90 kg and 167 cm respectively, and his body mass index (BMI) was 32 kg/m 2 .
At the beginning of the consultation, family physician (FP) should welcome and greet Mr. Ali for his attendance and his interest to have an annual checkup. FP should explore Ali's idea and concern regarding his health status, including weight (Ask).
At this stage, FP should ask Mr. Ali about his opinion and satisfaction with his weight using open-ended question (What do you think about your weight? Normal, overweight, or obese?). FP should listen to Ali and give him time to respond to this question. Reaction of FP would depend on Ali's response. In the case of that Mr. Ali was unaware about his weight status, doctor should use BMI chart to show him his weight status (Assess). In the case that Ali was aware of his weight status (obesity), FP should (Ask) about willingness to reduce his weight.
Mr. Ali thanked his doctor and told him that he is not happy with his weight but today, he is busy and should go home. FP asked Mr. Ali regarding giving him an appointment within 1-2 weeks (Arrange). Ali responded "that is a good idea" and he agreed to come back to discuss his weight with FP.
After 2 weeks Mr. Ali came to the clinic for follow-up.
At this visit, FP welcomed Mr. Ali and appreciated his compliance with appointment stating that this indicated good attitude to reduce weight. FP conducted an initial assessment which included:
- History of weight gain (duration, onset, progress)
- Past trial to reduce weight including methods, success, failure, barriers
- Social history including smoking and mood status
- Drug history including drug use and abuse
- Complete dietary history (number of meals, contents, fast food, fruit, soft drink, sweets, cakes, fatty diet)
- History of physical activity (type, frequency, duration, barriers)
- Assessment for risk factors of coronary heart diseases
- Clinical assessment to look for secondary causes of obesity such as hypothyroidism and Cushing syndrome
- Assess vital sign and measured waist circumference for (visceral obesity)
- Basic investigations (blood glucose, lipid profile, and liver function test).
History taking showed that Mr. Ali suffers from progressive weight gain since 3 years, eating unbalanced diet rich in fat and carbohydrate with sedentary life, he is not smoker or drug abuser, there is no family history of obesity or diabetes but his mother has hypertension.
Physical examination revealed the following: BMI = 32 kg/m 2 , blood pressure = 135/80 mmHg, hip circumference was 104 cm. Rest of clinical examination was normal.
Family physician informed Mr. Ali that the initial assessment was within normal except weight status which showed obesity grade-1 as calculated using formula and BMI chart and hip circumference. FP told Mr. Ali that his weight gain was most likely due to over-eating and lack of physical activity. FP discussed with Mr. Ali the magnitude and danger of obesity, which is known risk factor for many serious health problems such as diabetes, hypertension, heart diseases, joint diseases, dyslipidemia and tumors and unless managed it may cause many problems for him.
Mr. Ali Agreed that obesity is serious health problem, and he stated that his weight gain resulted from eating unbalanced diet and his sedentary life as he did not remember the last physical activity practiced by him.
Family physician told Mr. Ali that he had about 23 extra kg which should be lost. Mr. Ali responded to his doctor "How can I reduce this huge amount of my weight?"
Family physician thanked Mr. Ali for his important question and reassured him that "if there is will there is way" and started to discuss with him how he can help Mr. Ali to get rid of this excess weight (Assistance).
Family physician Assessed Mr. Ali's willingness to lose weight in order to ensure that Mr. Ali is ready for change. "Mr. Ali can you tell to which extent you are ready to lose weight?"
Mr. Ali responded that he was ready to reduce at least 5 kg during the coming few weeks. FP encouraged Ali's reaction and told him that gaining weight took a long time and also losing weight will take longer time again. Mr. Ali and FP Agreed to lose 500-1,000 g/week and Mr. Ali signed informed consent in this regard.
Family physician gave Mr. Ali brief Advice about the importance of healthy diet and physical activity, asked him to make dietary note for the coming 2 weeks, gave him appointment after two weeks to discuss the results of investigations, and dietary diary.
Two weeks later, Mr. Ali came to his with dietary diary. FP welcomed Mr. Ali and asked him about his performance during the last two weeks. Mr. Ali provided his FP with dietary diary and informed him that he started to reduce most of the diet rich in fat and sweets. FP appreciated Ali's effort and looked at the dietary diary in order to get an idea about the food intake in the past 2 weeks.
Family physician found that he intakes many items rich in calories and fat such as rice, beans, potatoes, full cream milk, chocolate, cola, coffee-milk, dates, but few items from vegetables and fruit groups. In this regard, it was estimated that Mr. Ali consumed >3,500 calories/day while his actual needs based on the level of physical activity is about 2,000 calories/day. As an important step in dietary counseling, FP told Mr. Ali that he should not consume >1,800 calories as the first objective of obesity management is to "maintain his current weight." Second objective of management is to establish the total target of weight loss that should be specific, measurable, attainable, rewarding and timely.
After negotiation, Mr. Ali and his FP agreed on the following executive plan.
Mr. Ali will reduce 10% from his current weight (i.e. 9 kg) during the coming 6 months (about 1.5 kg/month).
In order to achieve the above-mentioned objective doctor advised Mr. Ali to restrict to 1,600 calories/day and he provided Mr. Ali with simple pamphlet (assists) which illustrated the distribution of calories all over the day and the food items that should be utilize. In addition to that, FP advised Mr. Ali to drink a glass of water before all meals, to eat slowly, to grind food completely and to avoid food intake while watching TV or reading journals.
Family physician discussed with Mr. Ali the role of physical activity in general and its effects on all aspects of life. FP informed Mr. Ali that the regular exercise is proved to improve general health, reduce weight and control diabetes and hypertension in addition to sustain positive mental health. Mr. Ali Agreed that physical activity is important, but it is very difficult to him to run or to ride bicycles or to swim as he is busy most of the time. FP responded to Ali's concern and discussed such barriers (assist) which could be overcome. FP reinforced the importance of regular physical activity as one important aspects of Mr. Ali's management and reassured him that he is fit for performing any type of exercise.
Family physician informed Mr. Ali that he could perform any type of physical activity that he prefer as almost all types are very beneficial. After long discussion, Mr. Ali agreed to choose walking at night as an appropriate time. FP appreciated the idea and gave advice regarding frequency, intensity, and duration of physical session, provided Mr. Ali with brochure about physical activity (Assistance). FP advised Mr. Ali to prepare himself and to buy suitable shoes. Physical activity will take 30 min/ night, starting by warming for 10 min and then continue for another 10 min and ended by slowdown for 10 min. He can perform physical activity at garden at home or any other suitable place.
By the end of this consultation that took about 30 min, FP negotiates the appropriate next appointment which agreed upon by both to be after 4 weeks. Mr. Ali thanked his Doctor for his care and promised him to comply with his medical advice. FP, told Mr. Ali that he can call him by phone if he needs any help or face any problem before next appointment (Assist).
After 1-month Mr. Ali came to the clinic with his wife. FP started this consultation by welcoming Mr. Ali and his wife and then asked Mr. Ali about any new complaint, assessed compliance with diet and physical activity since the last visit.
Mr. Ali responded to his doctor stating that I'm very happy as I lost 2 kg, I spent more than 20 h in exercise and I feel that I achieved my objectives of the last visit. However, my compliance to diet was not as good as expected because I attended two social gatherings and eat Kabsa and some cakes.
Family physician appreciated Mr. Ali for this great effort to attain the predetermined objectives and regular exercise and encouraged to continue, he told Mr. Ali that he can participate in social gathering, but he could eat fruits, vegetable, small amount of meat and rice (advise and assist).
While conducting consultation, Ali's wife participated in discussion and told FP that she helped her husband as she made all meals at home, used low fat oil for cooking, and no meals from restaurants, get rid of fatty milk, soft drinks since 4 weeks, not only that but she accompanied her husband during physical activity in order to maintain good health (assistance and social support).
Family physician appreciated this cooperation of couple in order to help each other, he advised Mr. Ali to increase the duration of physical activity to 45 min/day and to continue dietary therapy as prescribed in the last visit, and gave appointment after 8 weeks.
After 2 months Mr. Ali came for follow-up, FP asked Mr. Ali regarding any compliant, assessed weight status, compliance with diet and exercise.
Mr. Ali did not report any complaint or concern, his weight became 84 kg and BMI become (30 kg/m 2 ). Mr. Ali's compliance with diet and physical activity were excellent without any difficulty.
Family physician congratulated Mr. Ali as he lost 6 kg within 3 months that indicated the personal positive effort of Mr. Ali to achieve the targeted weight loss that agreed on in the second visit.
Mr. Ali asked his FP to help him to lose more weight by prescribing some pill as he was advised by his friend.
Family physician welcomed this idea and explored more regarding the pill. Mr. Ali told him that his friend told him about this drug and he got more information through internet (ORLISTAT), but he did not use it yet because he did not like to use any medication unless prescribed by his doctor.
Family physician informed Mr. Ali that this pill could be useful for obesity in some situations particularly if no response to nonpharmacological therapy or if there is morbid obesity or comorbidity such as diabetes or hypertension. Mr. Ali asked his Doctor could you prescribe this pill for me? FP told him that his weight is reducing by diet therapy and exercise and his condition is not absolute indication for this drug now and he can prescribe it later on if his weight does not reach the target after 1-year.
Mr. Ali agreed to continue nonpharmacological therapy and to attend for follow-up after 3 months.
After 3 months, Mr. Ali attended clinic for follow-up. During this visit, there was no complaint, compliance with diet and physical activity were good. Weight reduced to 82 kg and his BMI becomes (29.3 kg/m 2 ). FP told Mr. Ali that his weight is improving as a result of his compliance with medical advice and his weight status now is in the overweight status (using BMI chart) and if he continues his weight will come back to the normal. Mr. Ali showed his happiness and told his FP that he feels better, and he increased his physical activity to 1 h/day and he never eats cakes and soft drink. FP encouraged Mr. Ali to continue as this behavior will sustain good health and prevent chronic diseases. FP gave Mr. Ali appointment after 4 months and asked for blood glucose and lipid profile.
After 4 months Mr. Ali attended clinic with laboratory results. His FP welcome him and conducted comprehensive (Assessment).
Mr. Ali told his FP, that he was well, without compliant, compliance with medical advice was excellent, weight was 79 kg, BMI = 28 kg/m 2 ). Blood glucose was 85 mg/dL, total cholesterol was 175 mg/dL and triglyceride was 142 mg/dL.
Family physician informed Mr. Ali that he is doing well, his laboratory investigations were within normal and his weight target is about to achieve as he lost about 11 kg during the last 12 months and he needs to lose more 10 kg during the coming 9 month in order to return back to his ideal body weight. FP gave Mr. Ali appointment after 4 months (Arrange).
Four months later, Mr. Ali came to his FP for follow-up. FP assessed Mr. Ali and he found that there was no complaint, compliance with medical advice was satisfactory, weight was reduced by 4 kg since the last visit (75 kg), and BMI was 26.8 kg/m 2 (Assessment). At this moment FP congratulates Mr. Ali again as he is almost near the target weight that they planned to achieve >1-year ago. FP reinforced the importance of compliance with medical advices (Assistance) and gave him an appointment after 4 months (Arrange).
Four months later, Mr. Ali attended to his FP for follow-up. Assessment revealed that Mr. Ali was in good health status, weight was 71 kg and BMI was 25.3 kg/m 2 , compliance with diet and physical activity were excellent. FP informed Mr. Ali that he is doing fine and his body weight return back to near normal but he needs to comply with recommended dietary therapy and physical activity as many patients will regain weight and relapse if they do not follow such medical advices. FP informed Mr. Ali to come regularly each 6 months or if he needs any help in the future.
| Conclusion | | |
Using 5 A's approach is practical and useful patient-centered tool to help the obese patient to reduce their weight. At each visit, 5 A's could be used taking in consideration patient's idea, concern, and expectation.
| References | | |
| 1. | Fiore MC, Jaén CR, Baker TB, Bailey WC, Benowitz NL, Curry SJ, et al. Treating Tobacco Use and Dependence: 2008 Update. Washington, DC: US Department of Health and Human Services; 2008. Available from: http://www.ahrq. gov/clinic/tobacco/treating_tobacco_use08.pdf. [Last accessed 2012 Nov 27]  |
| 2. | Melvin CL, Dolan-Mullen P, Windsor RA, Whiteside HP Jr, Goldenberg RL. Recommended cessation counselling for pregnant women who smoke: A review of the evidence. Tob Control 2000;9 Suppl 3:III80-4. |
| 3. | Alexander SC, Cox ME, Boling Turer CL, Lyna P, Østbye T, Tulsky JA, et al. Do the five A′s work when physicians counsel about weight loss? Fam Med 2011;43:179-84. |
| 4. | Jay M, Gillespie C, Schlair S, Sherman S, Kalet A. Physicians′ use of the 5As in counseling obese patients: is the quality of counseling associated with patients′ motivation and intention to lose weight? BMC Health Serv Res 2010;10:159. |
| 5. | Freedhoff Y, Sharma AM. Best Weight: A Practical Guide to Office-Based Obesity Management. Edmonton, AB: Canadian Obesity Network; 2010. |
|
Search Pubmed for