WEIGHT MANAGEMENT: GOALS SET BY CLINICSIt is absolutely essential that, from the outset, the patient and the clinician share the realistic expectations of what weight loss might be achieved. One specialist clinic asked female patients how much weight they expected to lose. The average response was 37% of their total body weight. They said they would consider a 25% bodyweight loss as satisfactory, would be reluctant to accept 17% and would be disappointed with only 10%. It is therefore quite common that at initial presentation the first appointment turns into disappointment, as the patient is helped to recognize more realistic goals. Of course, it is possible for patients to lose much more than 10% body weight, even as much as 40-50%, but this is uncommon and the vast majority of patients should reasonably expect to be able to lose and maintain 10% of their body weight.The medical benefits of this 10% weight loss should be emphasized to the patient (and the clinician!) and should help promote acceptance. The concept of attempting to return the patients to their ‘ideal weight’ is outdated and should be unceremoniously dumped. The use of ‘ideal weight’ as a target is highly likely to lead to unrealistic and unachievable weight loss goals and ultimate failure. It is important that, from the outset, the initial aim of the weight management programme should be stressed to be modest weight loss followed by weight maintenance.For the majority of obese adults a weight loss goal of 10% over a period of 3-6 months is achievable. This could be achieved by losing 0.5-1 kg per week on average. This would lead, on average, to weight loss of anywhere between 5 and 20 kg and would require a kcal deficit of 500-600 kcal to be achieved daily.Many patients will express disappointment at this projected rate of weight loss, describing it as ‘too slow’. This needs to be addressed at the outset, perhaps by encouraging them to consider that as weight gain has occurred over a prolonged period, weight loss should also be a gradual process. Even at a rate of weight loss of 1-2 lb per week, weight reduction will be much more rapid than the original gain. Additionally, it is recognized that those who lose weight rapidly are more likely to regain afterwards. In arriving at agreed weight loss goals with the patient, the following measures of progress should also be discussed:- appropriate weight loss- avoiding subsequent weight regain- management of other risk factors- improvements in mental and emotional well-being.*66/312/5*

What is this client asking for? Why does he or she want that? With personal issues such as health, fitness and appearance the client’s expression of his or her needs can easily be distorted by anxiety.

The woman in the above example who wishes to get a satisfying relationship by losing fat is unlikely to give this initially as her reason for seeking help. If she is partially aware of and embarrassed about her insecurities, she may deny this even if you ask directly about it. You need to take some care in considering what the initial request for help really represents.

What are his or her strengths and weaknesses? Consider what the client is and is not capable of achieving. Sometimes you can teach the skills and knowledge required. Sometimes the client already has these, so they can be left out of the program. Sometimes you can refer them to someone else who can offer better help or modify your approach accordingly.

What are the probable consequences of this client successfully losing fat? Of staying the same? You should consider whether the gains that can be reasonably expected would be a worthwhile return on the effort and cost involved. You should specifically take into account potential unwanted effects, particularly if the fat loss efforts are unsuccessful. This should include some thought about how the client and other important people in her life are likely to respond to the client losing fat and how they would respond if she regained it. The responses will not always be entirely positive.

What is this client’s history of obesity management? How have these past efforts affected them? Most clients have already made many efforts to lose fat. This history of efforts to lose fat makes up a powerful set of learning experiences that shape what clients expect of you and of themselves. Unless there is good reason to expect a different outcome, it may be unethical to repeat things that have been unhelpful in the past. It is almost certainly unethical to re-expose the client to something that has already been found to be harmful.

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