Case Study: Morbidly obese

by Alison French Dietitian Centre for Obesity Research Luton and Dunstable Hospital

Alison French has been a dietitian for many years and has worked in obesity and eating disorders for more than 10 years. She believes a behaviour change approach is vital to success within this group.

Dietetic management of a morbidly obese woman Rachel A (dob 27/7/1965) was referred in October 2008 by her GP. She has Type 2 diabetes and osteo arthritis (OA) in both knees that restricts walking. She weighs 145kg. She is 5’2” tall and her Body Mass Index (BMI) is 55.9 kg/m2. She set her own goals – more care with portion sizes and fewer Rachel first attended in January 2009. She saw the medical doctor, who confirmed her medical history and current medication (see Box 1). He discussed the importance of increasing her physical activity. Together they agreed she would walk for five minutes a day and would increase this as it became easier. She then came to see me and I used an assessment sheet to discuss her weight history, previous attempts at losing weight and goals of weight loss. My style is ‘client centred’ (1), incorporating ‘motivational interviewing’ (2) tools, so the discussion was guided by me, but led by Rachel.

Rachel had been overweight from childhood. She had lost weight with a commercial club before her wedding in 1993. She then gained more weight with each pregnancy. Rachel wanted to lose weight for several reasons (see Box 2). These we recorded for future reference. Rachel’s typical day was busy, looking after her children, her husband and her sick mother who lived nearby. She often did not eat a ‘proper meal’ until the evening and she grabbed snacks such as crisps, chocolate and biscuits to keep her going. We agreed that this was not great and she asked for help.

Rachel and I looked at the DOM UK leaflet Time to Lose Weight? (3). This outlines some basic principles of weight management.

Rachel was not keen on keeping a food diary and I agreed with her. I did wonder if a notebook, bought specifically, could be useful so that she could write her goals into it. Rachel agreed that she needed to eat regular meals and together we used a problem-solving approach to find a way of including breakfast. We came up with a few ideas and she decided a breakfast bar, for quickness and ease was the best. We also thought about lunch and Rachel was surprised when I suggested a commercial sandwich, as she thought that they were all ‘fattening’. We discussed this and she agreed to try. February 2009

Rachel weighed 142kg, a loss of 3kg. She was disappointed. I took time to discuss realistic expectations with her. She was amazed to hear that this is considered excellent weight loss in just four weeks.

Rachel reported that she was walking more and while initially difficult, her knees now felt better and she walked for 15 minutes a day. She enjoyed her daily walk.

I asked about her meals, and she was delighted with both the breakfast bar and the lunchtime sandwich. She had also read ahead in the leaflet and was eating a lot more fruit. Like many people, she knew this made sense, but had just found it hard to actually do.

I congratulated Rachel on her progress and for the changes made. • For the children

We set goals for next month, related to planning ahead. Rachel went away clutching her ‘me notebook’, as she called it and smiling broadly. March 2009

Rachel was confident that she had lost weight. She now weighed 136kg and was wearing a skirt she had not worn for three years. She reported that she had more energy and was sleeping better. She was have to really watch what she was eating – just be sensible. Her blood sugars were now 7 or 8 when they had previously been over 10 mmol/l. We discussed how these changes needed to be permanent and she said that maybe for the first time ever she was realising this. We agreed that this was a hard thing to understand.

We set goals to continue to walk every day, to plan ahead and also to ensure that Rachel drank enough fluid. She complained of headaches and on questioning, she was only drinking two to three cups a day. I explained about the importance of drinking enough and she agreed to increase her intake. May 2009

Rachel was despondent, her mum was worse and this caused a lot of worry and extra work. Her eating became erratic again and her weight had only dropped 2kg to 134kg. We talked about how to prioritise and to sometimes rely on ‘fast foods’ or precooked meals stored in the freezer. This emphasised the need to plan, which Rachel agreed she had let slip. We reviewed overall progress and she felt that the weight loss so far was worth it. July 2009

Mum was better and Rachel was back on track. She was planning meals, walking every day, drinking enough and was delighted. She was disappointed with only 3kg loss to 131kg in the eight weeks since we had last met. We talked about these lifestyle changes being good for her overall general health and that the weight loss was a bonus. Rachel liked this definition and wrote it in her book.

She wanted more help with a healthy diet, so I gave another DOM UK leaflet, Eating Healthily and Being More Active(4) and we discussed the Eatwell plate. September 2009 132kg – but Rachel remembered our previous discussion and was philosophical. She told me that she felt so much better than she did last year, that she did not mind the gain. She knew she was healthier. She said it really helped to talk about her eating and weight without being judged. between-meal snacks. November 2009 130kg and back on track. Rachel knows the changes she has made are permanent.

Medical History and Medication • Three pregnancies – 1995, 1997 and 1999 • Osteo arthritis in knees - diagnosed 2004 Ibuprofen prn • Diabetes Mellitus Type 2 – diagnosed 2008 Metformin 500mg bd

Reasons to lose weight walking 20 minutes most days and she liked the fact that she didn’t

• To wear nicer clothes • To have more confidence • To improve health, especially now the diabetes has set in

References 1 Motivational Interviewing Preparing People to Change Addictive Behaviour WM Miller & Stephen Rollnick Pub: The Guildford Press ISBN: 0-89862-469-X 2 Patient-Centered Medicine Transforming the Clinical Method Stewart, Brown, Weston, McWhinney, McWilliams, Freeman. Pub: Sage ISBN: 0-8039-5689-4 3 Time to Lose Weight’ DOM UK available from SnDRI 4 Eating Healthily and Being More Active’ Dom UK available from SnDRI