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)

Children/Youth
• Normal - BMI < 85th percentile
• Overweight- BMI > 85th percentile
• Obese > 95th percentile
Adults
• 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: female: ≥ 80 cm male ≥ 94 cm
High risk: female: ≥ 88 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 Adults Inactive: no appreciable exercise

Moderately increased heart rate
Inactive <30 min/day <30 min/day
active: e.g.: walking.
Moderately active 30-90 min/day 30-60 min/day
Very active: e.g.: Running, cycling,
Very active >90 min/day >60 min/day swimming lengths

BRITISH
COLUMBIA
MEDICAL
ASSOCIATION
Ministry of Health
RECOMMENDATION 4 Using the questions below, determine and record diet quality/dietary
habits

1. Do you usually eat breakfast?

2. Do you usually* eat 5 or more servings of fruit and vegetables/day
3. Do you usually* choose whole grain products?
4. Do you usually* choose low fat or reduced fat alternatives at home and when eating out?
5. 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 Adult
Depression Hypertension
Asthma Type 2 diabetes
Being bullied Arthritis
Learning difficulties Depression
Type 2 diabetes

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 Brit-
ish 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 regard-
ing 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 over-
weight 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 fund-
ing 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 E-mail: hlth.guidelines@gov.bc.ca

Fax: (250) 952-1417 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)

AGE BOYS GIRLS

(yrs) Overweight Obese Overweight Obese

6 17.6 19.8 17.3 19.7

7 17.9 20.6 17.8 20.5
8 18.4 21.6 18.4 21.6
9 19.1 22.8 19.1 22.8
10 19.8 24.0 19.9 24.1
11 20.6 25.1 20.7 25.4
12 21.2 26.0 21.7 26.7
13 21.9 26.8 22.6 27.8
14 22.6 27.3 23.3 28.6
15 23.3 28.3 23.9 29.1
16 23.9 28.9 24.4 29.4
17 24.5 29.4 24.7 29.7
18 25.0 30.0 25.0 30.0

Appendix 2 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
 Appendix 3

Body Mass Index (BMI) Chart (Adults)

Weight
45 48 50 52 55 57 59 61 64 66 68 70 73 75 77 80 82 84 86 89 91 93 95 98 100 Kg
100 105 110 115 120 125 130 135 140 145 150 155 160 165 170 175 180 185 190 195 200 205 210 215 220 Lbs
Height 5’0” 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 152 Height
(ft/in) (cm)
5’1” 19 20 21 22 23 24 25 26 26 27 28 29 30 31 32 32 34 35 36 37 38 39 40 41 42 155
5’2” 18 19 20 21 22 23 24 25 26 27 27 28 29 30 31 32 33 33 34 36 37 38 39 40 42 157
5’3” 18 19 19 20 21 22 23 24 25 26 27 27 28 29 30 31 32 33 34 35 35 36 37 38 39 160
5’4” 17 18 19 20 21 21 22 23 24 25 26 27 27 28 29 30 31 32 33 33 34 35 36 37 38 163
5’5” 17 17 18 19 20 21 22 22 23 24 25 26 27 27 28 29 30 31 32 32 33 34 35 36 37 165
5’6” 16 17 18 19 19 20 21 22 23 23 24 25 26 27 27 28 29 31 32 32 33 34 35 36 37 168
5’7” 16 16 17 18 19 20 20 21 22 23 23 24 25 26 27 27 28 29 30 31 31 32 33 34 34 170

8
5’8” 15 16 17 17 18 19 20 21 21 22 23 24 24 25 26 27 27 28 29 30 30 31 32 33 33 173
5’9” 15 16 16 17 18 18 19 20 21 21 22 23 24 24 25 26 27 27 28 29 30 30 31 32 32 175
5’10” 14 15 16 17 17 18 19 19 20 21 22 22 23 24 24 25 26 27 27 28 29 29 30 31 32 178
5’11” 14 15 15 16 17 17 18 19 20 20 21 22 22 23 24 24 25 26 26 27 28 29 29 30 31 180
6’0” 14 14 15 16 16 17 18 18 19 20 20 21 22 22 23 24 24 25 26 26 27 28 28 29 30 183
6’1” 13 14 15 15 16 16 17 18 18 19 20 20 21 22 22 23 24 24 25 26 26 27 28 28 29 185
6’2” 13 13 14 15 15 16 17 17 18 19 19 20 21 21 22 22 23 24 24 25 26 26 27 28 28 188

OVERWEIGHT, OBESITY 8AND PHYSICAL INACTIVITY

6’3” 12 13 14 14 15 16 16 17 17 18 19 19 20 21 21 22 22 23 24 24 25 26 26 27 27 191
6’4” 12 13 13 14 15 15 16 16 17 18 18 19 19 20 21 21 22 23 23 24 24 25 26 26 27 193
BMI < 18 = underweight 18.5 to 24 = healthy weight ≥ 25 = overweight ≥ 27= increasing risk of hypertension, type 2 diabetes ≥ 30 obese

Note: Consider muscle mass when evaluating BMI

 BODY MASS INDEX TABLE (Children and Youth ) >6 yrs
kg 20 21 22 23 24 25 26 27 28 29 30 31 32 33 kg
Mass
lbs 44 46 48 51 53 55 57 59 62 64 66 68 71 73 lbs
29 39 72
Appendix 4

31 34 35 37 39 40 77
33 30 31 33 34 36 37 39 40 82
35 26 28 29 30 32 33 34 36 37 38 40 87
37 24 25 26 27 28 30 31 32 33 34 35 37 38 39 92
39 21 22 23 24 26 27 28 29 30 31 32 33 34 35 97
41 19 20 21 22 23 24 25 26 27 28 29 30 31 32 102
43 17 18 19 20 21 22 23 24 24 25 26 27 28 29 107
45 16 17 18 18 19 20 21 22 22 23 24 25 26 26 112
Height (cm)

47 15 15 16 17 18 18 19 20 20 21 22 23 23 24 117

Height (inches)
49 13 14 15 15 16 17 17 18 19 19 20 21 21 22 122
51 12 13 14 14 15 16 16 17 17 18 19 19 20 20 127
53 11 12 13 13 14 14 15 15 16 17 17 18 18 19 132
11 11 12 12 13 13 14 14 15 15 16 17 17 18

9
55 137
57 10 10 11 11 12 12 13 13 14 14 15 15 16 16 142
59 9 10 10 11 11 12 12 12 13 13 14 14 15 15 147

kg 34 35 36 37 38 39 40 41 42 43 44 45 46 47 kg
Mass
lbs 75 77 79 82 84 86 88 90 93 95 97 99 101 103.4 lbs

OVERWEIGHT, OBESITY AND PHYSICAL INACTIVITY

37 40 92
39 36 37 38 39 40 41 97
41 33 34 35 36 37 37 38 39 40 102
43 30 31 31 32 33 34 35 36 37 38 38 39 40 107
45 27 28 29 29 30 31 32 33 33 34 35 36 37 37 112
47 25 26 26 27 28 28 29 30 31 31 32 33 34 34 117
49 23 24 24 25 26 26 27 28 28 29 30 30 31 32 122
Height (cm)

51 21 22 22 23 24 24 25 25 26 27 27 28 29 29 127

Height (inches)
53 20 20 21 21 22 22 23 24 24 25 25 26 26 27 132
55 18 19 19 20 20 21 21 22 22 23 23 24 25 25 137
57 17 17 18 18 19 19 20 20 21 21 22 22 23 23 142
59 16 16 17 17 18 18 19 19 19 20 20 21 21 22 147
Appendix 5

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10
OVERWEIGHT, OBESITY10
AND PHYSICAL INACTIVITY
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11
OVERWEIGHT, OBESITY AND PHYSICAL INACTIVITY
 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. Eat a healthy breakfast
2. Eat 5 or more servings of fruit and vegetables per day
3. Choose whole grain products
4. Choose low fat or reduced fat alternatives at home and when eating out
5. Reduce boxes, cups or cans of fruit juice or pop to no more than 1 per day.
6. 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 lb
Weight 50 kg: moderate walk (30 min/day) 5 11
(110 lb) brisk walk (30 min/day) 6.2 14
Weight 70 kg: moderate walk (30 min/day) 7 16
(155 lb) brisk walk (30 min/day) 8.75 20
Resources
BC HealthGuide OnLine has a world of health information just a click away, through the award-
winning 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.