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NP Sam's Research

NP Sam's research looks at how to assess & treat overweight & obese adults in primary care.

  

Sixty percent of Canadian adults are overweight or obese. 1 2 Obesity is now a confirmed risk factor for a group of conditions known as lifestyle disease that include cardiovascular diseases, metabolic diseases, cancers, and mental health conditions. 3 4 5 It is projected that by 2021, the annual direct health care costs associated with obesity in Canada will reach $8.8 billion. 6 


Canadian guidelines on adult obesity task primary care with assessment of overweight and obese adult patients and referral to structured behavioural interventions delivered by interdisciplinary teams. 7  But specific assessment tools and treatment programs are neither recommended nor supplied. 8 9 10 


Traditional nutrition advice, such as the Canada Food Guide, has only seen increases in the incidence, prevalence, and extent of adult obesity over the last forty years. 11 12 13  Recent evidence on weight loss and disease management in adults, points to a whole-foods diet with controlled carbohydrate intake. 14 15 16 17  However, in the absence of specific strategies and tools primary care providers are likely to rely on out-dated interventions and recommendations for dietary change or will not assess and treat adult obesity at all. 18 


To address this practice gap NP Sam focussed on two questions in her research: 


(1) how can NPs & MDs be supported to introduce a conversation about obesity & dietary change into their appointments with patients in primary care? 


(2) what is the best way to deliver a safe, effective, & evidence-based nutrition program that will accomplish sustained weight loss & improved health in overweight or obese adults in the primary care setting? 


In collaboration with Nutrition Coach Shelley Aggett, NP Sam conducted nutrition pilot programs at the Trent Hills Family Health Team (THFHT) over a three-year period. Assessment strategies, program content, and program delivery methods were tested and compared. With the lessons learned from the pilot programs the official THFHT Nutrition Program was launched in January 2018. 


Lessons learned in the pilot programs provided direction for the current THFHT program:

  

  • Prioritizing behavioural change & focusing on gradual habit adjustments resulted in better program participation, effective weight loss, & desired biomarker changes. 
  • A multidisciplinary team approach utilizing both clinicians and nutrition coaches was the best way to shift emphasis from metrics and outcomes to behavioural change & healthy habit development. 
  • Similar to smoking cessation, patients were most receptive to nutrition program referral when an NP or MD discussed weight loss & recommended behavioural change. NP Sam created The Obesity Tool, based on the 5A’s of smoking cessation, to guide providers through brief counselling on obesity & to introduce a conversation about dietary change into appointments. 
  • Individualization in dietary intervention shows evidence for effective & sustainable weight loss. Private consultations allowed tailoring of behavioural change & nutrition planning based on patient choice, medical conditions, goals, & nutrition history.
  • Self-management is enhanced in a more autonomous & individualized version of the nutrition program. Participants were more likely to do their own research and sustain habit change and weight loss when shorter & fewer online presentations were provided and viewed before appointments with the nutrition coach. 
  • It became essential to leverage technology & communicate through social media, e-mail, & online platforms in order to provide timely communication & support to a growing number of participants spread over a large & rural geographical area. 
  • Focussing on behavioural change & monitoring a few key metrics correlates with sustained weight loss & program participation. Fat caliper testing, pictorial documentation, & food tracking did not correlate with better program attendance or behavioural change and may have deterred people from participating in the program. 
  • Similar to smoking cessation, obese patients may need to make habit changes many times before they make a permanent lifestyle transformation. 

Outcome measures demonstrate that this patient-centred individualized model of program delivery results in weight loss, biomarker improvement and subjective measure improvement.


In seven months of program activity the number of all adult patients assessed for obesity increased by 10%. Ninety-five percent of program participants achieved weight loss (average loss 4.3 kg), reduced waist circumference (average loss 4.8 cm), and reduced blood pressure readings.  Serological markers showed decreases in average blood sugar (HbA1C, FBS, fasting insulin), inflammatory markers (ESR, CRP), and cholesterol (LDL, TG). Subjective markers scores for mood, energy, sleep and gastrointestinal function demonstrated improvement in all markers. Six participants were able to reduce or discontinue chronic medications for cholesterol, hypertension, GERD, and hypothyroidism in consultation with the program NP. 


The ultimate goal of NP Sam’s research is to educate primary health care NPs and MDs on assessing and addressing the adult obesity crisis and to inspire teams to deliver adult obesity care and intervention. 


Primary care providers can view The Obesity Tool and program assessment tools on this website on the Primary Care Provider Page. If you would like more information on NP Sam’s research or results please message her @ npsamanthadalby@gmail.com or go to the contact page of this website. 

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Primary Care teams & providers can learn about NP Sam's Nutrition Program and view her Program Assessment & Referral Tools on the Primary Care Provider page. 

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Endnotes

1. Canadian Obesity Network. (2017b). Report card on access to obesity treatment for adults in Canada 2017.  Edmonton, AB: Canadian Obesity Network Inc. Retrieved from http://www.obesitynetwork.ca/files/FULLREPORTfinalENG.pdf

2. Statistics Canada. (2016). Body mass index, overweight or obese, self-reported, adult, by age group and sex (percent). Ottawa, ON: Government of Canada. Retrieved from https://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/health81b-eng.htm

3. Canadian Medical Association. (2012). CMA brief to the House of Commons Standing Committee on Health: Health promotion and disease prevention. Retrieved from https://www.cma.ca/Assets/assets-library/document/en/advocacy/Haggie-HC-Health-Promotion-Disease-Prevention-Feb2012_en.pdf.

4. Public Health Agency of Canada (PHAC). (2017). Healthy living can prevent disease. Ottawa, ON: Public Health Agency of Canada. Retrieved from http://www.canada.ca/en/public-health/services/chronic-diseases/healthy-living-prevent-disease.html

5. Sarris, J., Logan, A., Akbaraly, T., Amminger, G.P., Balanza-Martinez, V., Freeman, M., …Jacka, F. (2015). Nutritional medicine as mainstream in psychiatry. The Lancet, 2(3), 271-274. Retrieved from http://www.sciencedirect.com/science/article/pii/S2215036614000510

6. Canadian Obesity Network. (2017b). Report card on access to obesity treatment for adults in Canada 2017.  Edmonton, AB: Canadian Obesity Network Inc. Retrieved from http://www.obesitynetwork.ca/files/FULLREPORTfinalENG.pdf

7. Brauer, P., Gorber, S.C., Shaw, E., Singh, H., Bell, N., Shane, A....Tonelli, M. (2015). CMAJ guidelines: Recommendations for prevention of weight gain and use of behavioural and pharmacologic interventions to manage overweight and obesity in adults in primary care. Ottawa, ON: Canadian Task Force on Preventive Health Care & Canadian Medical Association. Retrieved from http://www.cmaj.ca/content/early/2015/01/26/cmaj.140887.full.pdf.

8. Brauer, P., Gorber, S.C., Shaw, E., Singh, H., Bell, N., Shane, A....Tonelli, M. (2015). CMAJ guidelines: Recommendations for prevention of weight gain and use of behavioural and pharmacologic interventions to manage overweight and obesity in adults in primary care. Ottawa, ON: Canadian Task Force on Preventive Health Care & Canadian Medical Association. Retrieved from http://www.cmaj.ca/content/early/2015/01/26/cmaj.140887.full.pdf.

9. Canadian Obesity Network. (2017b). Report card on access to obesity treatment for adults in Canada 2017.  Edmonton, AB: Canadian Obesity Network Inc. Retrieved from http://www.obesitynetwork.ca/files/FULLREPORTfinalENG.pdf

10. Vallis, M., Piccinini-Vallis, H., Sharma, A.M., & Freedhoff, Y. (2013). Modified 5 A’s: Minimal intervention for obesity counselling in primary care. Canadian Family Physician, 59, 27-31.

11. Canadian Obesity Network. (2017b). Report card on access to obesity treatment for adults in Canada 2017.  Edmonton, AB: Canadian Obesity Network Inc. Retrieved from http://www.obesitynetwork.ca/files/FULLREPORTfinalENG.pdf

12. Jessri, M., & L’Abbe, M. (2015). The time for an updated Canadian food guide has arrived. Journal of Applied Physiology, Nutrition, and Metabolism, 40, 854-857. 

13.  Public Health Agency of Canada (PHAC). (2011). Obesity in Canada: A joint report from the public health agency of Canada and the Canadian Institute for Health Information. Retrieved from https://secure.cihi.ca/free_products/Obesity_in_canada_2011_en.pdfCalihan, 2018 

14. Eenfeldt, A. (2011). Randomized controlled trials showing significantly more weight loss with low carb diets. On Weight Loss and LC: Time to Stop Denying the Science retrieved from https://www.dietdoctor.com/weight-loss-time-to-stop-denying-the-science   

15. Heart & Stroke Foundation of Canada. (2017). Lifestyle risk factors. Retrieved from http://www.heartandstroke.ca/heart/risk-and-prevention/lifestyle-risk-factors  

16. Kirk, S., Penney, T.L., McHugh, T., & Sharma, A.M. (2012). Effective weight management practice: A review of the lifestyle intervention evidence. International Journal of Obesity, 36, 178-185.

17. Lee, J.J, Tung, Y.C., Tai, K.P., Cheng, S.J., Ang, S.B., & Tan, N.C. (2017). Do primary care physicians use the 5As in counselling obese patients? A qualitative study. Proceedings of Singapore Healthcare, 26(3), 144-149.