Obesity in adults: a clinical practice guideline

Obesity is a complex chronic disease in which abnormal or excess body fat (adiposity) impairs health, increases the risk of long-term medical complications and reduces lifespan.1 Epidemiologic studies define obesity using the body mass index (BMI; weight/height2), which can stratify obesity-related health risks at the population level. Obesity is operationally defined as a BMI exceeding 30 kg/m2 and is subclassified into class 1 (30­34.9), class 2 (35­39.9) and class 3 (≥ 40). At the population level, health complications from excess body fat increase as BMI increases.2 At the individual level, complications occur because of excess adiposity, location and distribution of adiposity and many other factors, including environmental, genetic, biologic and socioeconomic factors.

Obesity management and indigenous peoples

Exploring obesity within the context of multiple co-occurring health, socioeconomic, environmental and cultural factors, and situating these within policy/jurisdictional structures specific to Indigenous populations (e.g., federal versus provincial health funding), can facilitate emerging opportunities for obesity management. These contexts highlight a tension that providers must navigate, between drivers of obesity embedded in social- and system-level inequities and protective factors that promote healing through relationships and culturally contextualized approaches to care. Healthcare professionals should consider the following contextual factors when providing obesity care for Indigenous peoples: Structural inequities (i.e., social and systemic in origin) are embedded in health, education, social services and other systems, and they maintain social disadvantage for a large segment of the Indigenous population. These inequities influence food security, for example, through lower wages perpetuated by inaccessible education and high food costs in urban and remote areas, or through limited access to activity-based resources at individual and community levels. Indigenous people have experienced systemic disadvantage throughout their lifespan and those of their family members, producing a cumulative effect on obesity. In Indigenous contexts, obesity is therefore deeply affected by responses to pervasive stressors, as individuals navigate social and systemic barriers to meeting their goals. Overwhelming stress from social (e.g., discrimination) and systemic exclusion (e.g., poor or absent primary healthcare) can disempower Indigenous people in maintaining healthy behaviours. Patients may appear to be resistant to healthcare recommendations, where together with healthcare providers they may come to feel fatalistic toward their capacity to address obesity. Healthcare professionals often interpret such patient incongruity with recommendations in a deficit lens, labeling it as patient non-compliance or non-adherence. This non-concordance, or seeming apathy, may actually be a sense of paralysis in the face of overwhelming stress. Exploration of the patient's social reality can open opportunities for contextualized approaches to obesity management. Reflection on assumptions about seeming apathy may contextualize patient motivations, where deep exploration of one's own perceptions, attitudes and behaviours toward Indigenous patients may uncover anti-Indigenous sentiment implicit in healthcare practices or systems. Validation of a patient's experiences of inequity can empower both patients and providers to identify steps to address social factors that influence health behaviours. Culture and relationships facilitate learning of complex knowledge. The interaction of obesity with co-occurring structural factors represents complex knowledge that is critical for patients to gain deep understanding of their health. Non-Indigenous healthcare providers may have ways of knowing and doing that are inconsistent with Indigenous patient perspectives on health knowledge and how it should be exchanged. Obesity management in this context requires a longitudinal, relationship-centred approach that engages and explores interactions with co-existing factors to build both knowledge and trust, in a manner aligned with Indigenous principles for communication. Connection: When patients connect with healthcare providers around their co-occurring health needs, there are complex linkages between wider structures and their health. The therapeutic relationship may be critically supportive when knowledge is delivered in a relevant way and makes sense to the patient. Trust-building: Healing of the therapeutic relationship is itself fundamental to engaging and supporting patients within contexts of multi-generational trauma to explore complex intersections in relation to health and health behaviour change. Differing worldviews: Western concepts of healthy behaviours related to obesity management, including preferences for body size, activity and food, may be dis­cordant with Indigenous perspectives. Patients may not identify with provider perspectives, and providers must not assume that patients share provider worldviews or principles around how to communicate health knowl­edge. Discordant perspectives may involve a distinct sense of locus of control, self-efficacy and modes for speaking about the pathways into and out of obesity. An Indigenous approach to knowledge exchange in­cludes contextualizing knowledge within the world of the patient and employing a narrative-based and indi­rect approach to sharing knowledge.

Educating for Equity Care Framework: Addressing social barriers of Indigenous patients with type 2 diabetes.

OBJECTIVE: To present a clinical framework for addressing critical social elements for Indigenous patients with type 2 diabetes. SOURCES OF INFORMATION: The Educating for Equity (E4E) Care Framework was developed through a rigorous analysis of qualitative research that included the perspectives of Indigenous patients (n = 32), physicians (n = 28), and Indigenous health curriculum developers (n = 5) across Canada. A national advisory group of Indigenous health experts, educators, leaders, physicians, and community members provided feedback on integrating analysis from primary research into recommendations for physicians. Systematic literature reviews were conducted and a nominal group technique process helped forge research team consensus around the framework's themes and recommendations. MAIN MESSAGE: For Indigenous patients with type 2 diabetes, social factors arising from the legacy of colonization are often barriers to improved diabetes outcomes, while culture is often not recognized as a facilitator in diabetes management. Structural competency in balance with cultural safety should be central to the clinical process when negotiating diabetes management with Indigenous patients. The E4E Care Framework presented in this article provides recommendations to navigate this terrain. CONCLUSION: A focus on social and cultural elements is fundamental to effective diabetes care among Indigenous patients. The E4E Care Framework is a resource that can help clinicians improve Indigenous patients' capacity for change in a way that acknowledges the social factors that affect the increasing diabetes rates, while using a cultural lens to facilitate improved outcomes.

Cadre de soins fondé sur l'éducation pour l'équité: Éliminer les obstacles sociaux des patients autochtones vivant avec le diabète de type 2.

OBJECTIF: Présenter un cadre clinique afin de prendre en considération les éléments sociaux critiques pour les patients autochtones atteints de diabète de type 2. SOURCES DE L'INFORMATION: Le Cadre de soins fondé sur l'éducation pour l'équité (Educating for Equity [E4E] Care Framework) a été produit à la suite de l'analyse rigoureuse d'une recherche qualitative portant sur les points de vue de patients autochtones (n = 32), de médecins (n = 28) et d'élaborateurs de cursus en santé autochtone (n = 5) dans toutes les régions du Canada. Un groupe consultatif national formé d'experts en santé autochtone, d'enseignants, de dirigeants, de médecins et de membres de la collectivité a exprimé des commentaires sur une analyse intégrant la recherche primaire dans les recommandations à l'intention des médecins. Des revues systématiques de la documentation ont été effectuées, et la technique du groupe nominal a servi à en arriver à un consensus de l'équipe de recherche sur les thèmes et les recommandations du cadre. MESSAGE PRINCIPAL: Pour les patients autochtones atteints du diabète de type 2, les facteurs sociaux découlant des séquelles de la colonisation sont souvent des obstacles à l'amélioration des issues du diabète, et la culture n'est souvent pas reconnue comme une facilitatrice dans la gestion du diabète. Il est essentiel que le processus clinique unisse la compétence structurelle en juste équilibre avec la sécurité culturelle dans la négociation de la gestion du diabète avec des patients autochtones. Le Cadre de soins fondé sur l'éducation pour l'équité présenté dans cet article propose des recommandations pour naviguer dans ces eaux. CONCLUSION: Il est fondamental de mettre l'accent sur les éléments sociaux et culturels pour offrir des soins du diabète efficaces aux patients autochtones. Le Cadre de soins fondé sur l'éducation pour l'équité est une ressource qui peut aider les cliniciens à améliorer la capacité des patients autochtones à apporter des changements d'une façon qui reconnaît les facteurs sociaux qui influencent les taux croissants de diabète, tout en ayant une perspective culturelle pour favoriser de meilleurs résultats.

Educating for Indigenous Health Equity: An International Consensus Statement.

The determinants of health inequities between Indigenous and non-Indigenous populations include factors amenable to medical education's influence-for example, the competence of the medical workforce to provide effective and equitable care to Indigenous populations. Medical education institutions have an important role to play in eliminating these inequities. However, there is evidence that medical education is not adequately fulfilling this role and, in fact, may be complicit in perpetuating inequities.This article seeks to examine the factors underpinning medical education's role in Indigenous health inequity, to inform interventions to address these factors. The authors developed a consensus statement that synthesizes evidence from research, evaluation, and the collective experience of an international research collaboration including experts in Indigenous medical education. The statement describes foundational processes that limit Indigenous health development in medical education and articulates key principles that can be applied at multiple levels to advance Indigenous health equity.The authors recognize colonization, racism, and privilege as fundamental determinants of Indigenous health that are also deeply embedded in Western medical education. To contribute effectively to Indigenous health development, medical education institutions must engage in decolonization processes and address racism and privilege at curricular and institutional levels. Indigenous health curricula must be formalized and comprehensive, and must be consistently reinforced in all educational environments. Institutions' responsibilities extend to advocacy for health system and broader societal reform to reduce and eliminate health inequities. These activities must be adequately resourced and underpinned by investment in infrastructure and Indigenous leadership.

Impacts of Educating for Equity Workshop on Addressing Social Barriers of Type 2 Diabetes With Indigenous Patients.

INTRODUCTION: Health education about Indigenous populations in Canada (First Nations, Inuit, and Métis people) is one approach to enable health services to mitigate health disparities faced by Indigenous peoples related to a history of colonization and ongoing social inequities. This evaluation of a continuing medical education workshop, to enhance family physicians' clinical approach by including social and cultural dimensions within diabetes management, was conducted to determine whether participation in the workshop improved self-reported knowledge, skills, and confidence in working with Indigenous patients with type 2 diabetes. METHODS: The workshop, developed from rigorous national research with Indigenous patients, diabetes care physicians, and Indigenous health medical educators, was attended by 32 family physicians serving Indigenous populations on three sites in Northern Ontario. A same-day evaluation survey assessed participants' satisfaction with workshop content and delivery. Preworkshop and postworkshop surveys consisting of 5-point Likert and open-ended questions were administered 1 week before and 3 month after the workshop. Descriptive statistics and t test were performed to analyze Likert scale questions; thematic analysis was used to elicit and cluster themes from open-ended responses. RESULTS: Participants reported high satisfaction with all aspects of the workshop. Reporting improved understanding of socioeconomic (P = .002), psychosocial, and cultural factors (P = .001), participants also described adapting their clinical approach to more actively incorporating social and cultural factors and focusing on patient-centered care. DISCUSSION: The workshop was effective in shifting physician's self-reported knowledge, attitudes, and skills resulting in clinical approach modifications within social, psychosocial, and cultural domains for their Indigenous patients with diabetes.

Exploring Canadian Physicians' Experiences With Type 2 Diabetes Care for Adult Indigenous Patients.

OBJECTIVES: The perspectives of physicians caring for Indigenous patients with diabetes offer important insights into the provision of health-care services. The purpose of this study was to describe Canadian physicians' perspectives on diabetes care of Indigenous patients, a preliminary step in developing a continuing medical education intervention described elsewhere. METHODS: Through in-depth semistructured interviews, Canadian family physicians and specialists with sizeable proportions of Indigenous clientele shared their experiences of working with Indigenous patients who have type 2 diabetes. Recruitment involved a purposive and convenience sampling strategy, identifying participants through existing research and the professional relationships of team members in the provinces of British Columbia, Alberta and Ontario. Participants addressed their understanding of factors contributing to the disease, approaches to care and recommendations for medical education. The research team framed a thematic analysis through a collaborative, decolonizing lens. RESULTS: The participants (n=28) included 3 Indigenous physicians, 21 non-Indigenous physicians and 4 non-Indigenous diabetes specialists. They practised in urban, reserve and rural adjacent-to-reserve contexts in 5 Canadian provinces. The physicians constructed a socially framed understanding of the complex contexts influencing Indigenous patients with diabetes in tension with structural barriers to providing diabetes care. As a result, physicians adapted care focusing on social factors and conditions that take into account the multigenerational impacts of colonization and the current social contexts of Indigenous peoples in Canada. CONCLUSIONS: Adaptations in diabetes care by physicians grounded in the historical, social and cultural contexts of their Indigenous patients offer opportunities for improving care quality, but policy and health system supports and structural competency are needed.

Health care experiences of Indigenous people living with type 2 diabetes in Canada.

BACKGROUND: Indigenous social determinants of health, including the ongoing impacts of colonization, contribute to increased rates of chronic disease and a health equity gap for Indigenous people. We sought to examine the health care experiences of Indigenous people with type 2 diabetes to understand how such determinants are embodied and enacted during clinical encounters. METHODS: Sequential focus groups and interviews were conducted in 5 Indigenous communities. Focus groups occurred over 5 sessions at 4 sites; 3 participants were interviewed at a 5th site. Participants self-identified as Indigenous, were more than 18 years of age, lived with type 2 diabetes, had received care from the same physician for the previous 12 months and spoke English. We used a phenomenological thematic analysis framework to categorize diabetes experiences. RESULTS: Patient experiences clustered into 4 themes: the colonial legacy of health care; the perpetuation of inequalities; structural barriers to care; and the role of the health care relationship in mitigating harm. There was consistency across the diverse sites concerning the root causes of mistrust of health care systems. INTERPRETATION: Patients' interactions and engagement with diabetes care were influenced by personal and collective historical experiences with health care providers and contemporary exposures to culturally unsafe health care. These experiences led to nondisclosure during health care interactions. Our findings show that health care relationships are central to addressing the ongoing colonial dynamics in Indigenous health care and have a role in mitigating past harms.

One program, multiple training sites: does site of family medicine training influence professional practice location?

INTRODUCTION: Numerous strategies have been suggested to increase recruitment of family physicians to rural communities and smaller regional centers. One approach has been to implement distributed postgraduate education programs where trainees spend substantial time in such communities. The purpose of the current study was to compare the eventual practice location of family physicians who undertook their postgraduate training through a single university but who were based in either metropolitan or distributed, non-metropolitan communities. METHODS: Since 1998, the Department of Family Practice at the University of British Columbia in Canada has conducted an annual survey of its residents at 2, 5, and 10 years after completion of training. The authors received Ethics Board approval to use this anonymized data to identify personal and educational factors that predict future practice location. RESULTS: The overall response rate was 45%. At 2 years (N=222), residents trained in distributed sites were 15 times more likely to enter practice in rural communities, small towns and regional centers than those who trained in metropolitan teaching centers. This was even more predictive for retention in non-urban practice sites. Among the subgroup of physicians who remained in a single practice location for more than a year preceding the survey, those who trained in smaller sites were 36 times more likely to choose a rural or regional practice setting. While the vast majority of those trained in metropolitan sites chose an urban practice location, a subgroup of those with some rural upbringing were more likely to practice in rural or regional settings. Trainees from distributed sites considered themselves more prepared for practice regardless of ultimate practice location. CONCLUSIONS: Participation in a distributed postgraduate family medicine training site is an important predictor of a non-urban practice location. This effect persists for 10 years after completion of training and is independent of other predictors of non-urban practice including gender, rural upbringing, and rural undergraduate training. It is hypothesized that this is due not only to a curriculum that supports preparedness for this type of practice but also to opportunities to develop personal and professional roots in these communities.

Help bring back the celebration of life: a community-based participatory study of rural Aboriginal women's maternity experiences and outcomes.

BACKGROUND: Despite clear evidence regarding how social determinants of health and structural inequities shape health, Aboriginal women's birth outcomes are not adequately understood as arising from the historical, economic and social circumstances of their lives. The purpose of this study was to understand rural Aboriginal women's experiences of maternity care and factors shaping those experiences. METHODS: Aboriginal women from the Nuxalk, Haida and 'Namgis First Nations and academics from the University of British Columbia in nursing, medicine and counselling psychology used ethnographic methods within a participatory action research framework. We interviewed over 100 women, and involved additional community members through interviews and community meetings. Data were analyzed within each community and across communities. RESULTS: Most participants described distressing experiences during pregnancy and birthing as they grappled with diminishing local maternity care choices, racism and challenging economic circumstances. Rural Aboriginal women's birthing experiences are shaped by the intersections among rural circumstances, the effects of historical and ongoing colonization, and concurrent efforts toward self-determination and more vibrant cultures and communities. CONCLUSION: Women's experiences and birth outcomes could be significantly improved if health care providers learned about and accounted for Aboriginal people's varied encounters with historical and ongoing colonization that unequivocally shapes health and health care. Practitioners who better understand Aboriginal women's birth outcomes in context can better care in every interaction, particularly by enhancing women's power, choice, and control over their experiences. Efforts to improve maternity care that account for the social and historical production of health inequities are crucial.

Awareness of do-not-resuscitate orders: what do patients know and want?

OBJECTIVE: To assess outpatient understanding of and previous experiences with do-not-resuscitate (DNR) orders and to gauge patient preferences with respect to DNR discussions. DESIGN: Cross-sectional, self-administered survey. SETTING: Four urban primary care physician offices in Vancouver, BC. PARTICIPANTS: A total of 429 consecutive patients 40 years of age and older presenting for routine primary care between March and May 2009. MAIN OUTCOME MEASURES: Awareness of, knowledge about, and experiences with DNR decisions; when, where, and with whom patients wished to discuss DNR decisions; and differences in responses by sex, age, and ethnicity, assessed using χ² tests of independence. RESULTS: The response rate was 90%, with 386 of 429 patients completing the surveys. Most (84%) respondents had heard of the terms do not resuscitate or DNR. Eighty-six percent chose family physicians as among the people they most preferred to discuss DNR decisions with; 56% believed that initial DNR discussions should occur while they were healthy; and 46% thought the discussion should take place in the office setting. Of those who were previously aware of DNR orders, 70% had contemplated DNR for their own care, with those older than 60 years more likely to have done so (P = .02); however, only 8% of respondents who were aware of DNR orders had ever discussed the subject with a health care provider. Few patients (16%) found this topic stressful. CONCLUSION: Most respondents were well informed about the meaning of DNR, thought DNR discussions should take place when patients were still healthy, preferred to discuss DNR decisions with family physicians, and did not consider the topic stressful. Yet few respondents reported having had a conversation about DNR decisions with any health care provider. Disparity between patient preferences and experiences suggests that family physicians can and should initiate DNR discussions with younger and healthier patients.

The birthing experiences of rural Aboriginal women in context: implications for nursing.

It has been established that the birthing experiences and outcomes of rural women are shaped by poverty, isolation, limited economic opportunities, and diminishing maternity services. We lack research into how these dynamics are compounded by intersecting forms of oppression faced by Aboriginal women, to impact on their birthing experiences and outcomes. The findings of this study of rural Aboriginal maternity care in 4 communities in British Columbia show how diminishing local birthing choices and women's struggles to exert power, choice, and control are influenced by centuries of colonization. The research questions focus on rural Aboriginal women's experiences of birthing and maternity care in this neocolonial context and their desire for supportive birthing environments. A community-based participatory and ethnographic design was employed. Individual interviews, focus groups, and participant observation were the primary data sources. Although the women's experiences in each community were shaped by distinct histories and traditions, economics, politics, and geographies, the impacts of colonization and medical paternalism and the struggle for control of women's bodies during birth intersect, placing additional stress on women. The implications for nurses of accounting for the intersecting dynamics that shape Aboriginal women's experiences and birth outcomes are discussed.

Three-year follow-up study of women who participated in a cervical cancer screening intervention while in prison.

OBJECTIVE: This study describes rescreening following a prison cervical cancer screening intervention: the numbers of women who received rescreening during the three-year follow-up period; their timing of rescreening in relationship to intervention follow-up recommendations; and socio-demographic factors associated with rescreening. METHODS: Socio-demographic information was collected from Corrections Branch records. Clinical and risk factor information was obtained by a self-administered questionnaire. Pap screening histories were collected from Cervical Cancer Screening Program (CCSP) client records using the client ID number for Pap smears taken during the intervention period, during the three-year follow-up period, and during the 30-month period preceding the intervention period. Results were entered in Excel and responses summarized with frequency tables; bivariate analysis of categoric variables was done using chi-square tests of independence. RESULTS: During the three-year follow-up period, only 28 (21%) of 138 women who participated in a prison cervical cancer screening intervention were rescreened within 6 months of the recommendation received at intervention Pap test. Women with fewer than 5 multiple names (aliases) were more likely to be rescreened (p = 0.02). Educational level approached statistical significance (p = 0.05), with women with least education receiving highest rescreening. There was no relationship between rescreening and ethnicity, injection drug use, having borne children and current methadone treatment. CONCLUSION: Only 50% of women who participated in a specifically designed prison screening intervention were rescreened during the subsequent three years. Further work is needed to design, implement and evaluate follow-up initiatives of community cervical cancer screening programs for women who are at higher risk of developing cervical dysplasia.

Evaluation of a cervical cancer screening intervention for prison inmates.

BACKGROUND: Female prison inmates are underscreened and are at higher risk of cervical cancer. The impact of a nurse-led Pap screening intervention was examined, which included information sessions and Pap testing clinics. METHOD: Pap screening rates for 650 inmates at the Burnaby Correctional Centre for Women were compared both before and during the 20-week intervention period. These rates were determined by record linkage of Correction Branch inmate records and Cervical Cancer Screening Program patient records. Associations between socio-demographic factors and Pap screening rates were also examined. RESULTS: A higher proportion of inmates was screened during the intervention period (26.9%) than during the preintervention period (21.0%) (although the difference was not statistically significant (p=0.06)). Very short-stay inmates were less frequently screened in the preceding two years before the intervention. Inmates with no high school education and longer lengths of incarceration were significantly more likely to receive Pap testing during the intervention period as compared to the preintervention period. CONCLUSION: The nurse-led intervention resulted in a modest improvement in the proportion of inmates receiving Pap screening. Unfortunately, the benefit of the nurse clinician did not reach, to a greater extent, inmates who had not been previously screened or who were inadequately screened. There is need for further work to target this hardest-to-reach group.

A physician peer support writing group.

BACKGROUND AND OBJECTIVES: Barriers to publication can be overcome through a peer support writing group in an academic department of family practice. This study describes the experience and outcomes of a writing group in a family practice department. METHODS: A writing group was established to provide collaboration in identifying potential research and/or writing projects, to assist individual faculty to complete unfinished work for submission, to match journals appropriate to the individual group member's work, and to provide peer support for faculty members through attention to group process. Resource materials included instructions for authors for various journals and writing support literature. Minutes were taken at each meeting, and the manuscripts presented were tracked. Individual publication records in CVs and citations in Index Medicus were used to generate pre-group and post-group publication records for group participants and nonparticipants. RESULTS: The writing group met 23 times in 36 months. Attendance ranged from 3 to 10 participants. Fifty writing projects were discussed, and 12 of the discussed manuscripts were published in indexed journals. The seven most frequent attendees increased their publications as first author from one publication over the 3 years prior to the writing group to 10 publications over the first 3 years of the writing group. Comparison of the attendees' publication records with nonparticipant members of the department demonstrated an increase in publication success for participants. CONCLUSIONS: A peer support writing group, emphasizing group process and respectful collaboration, has increased the publication frequency of faculty in a Canadian department of family practice.

The Haida Gwaii Diabetes Project: planned response activity outcomes.

A 1992 chart review in the Haida Village of Skidegate, Haida Gwaii/Queen Charlotte Islands, Canada, revealed that 17% of the unscreened population aged 35 or over have been diagnosed with diabetes. The Haida Gwaii Diabetes Project was designed to develop a culturally sensitive community-based participatory action approach to the management of noninsulin-dependent diabetes (NIDDM). Phase One included obtaining community support, conducting a chart review, holding clinics to measure biophysical indicators, conducting focus groups, and planning response activities with the communities. A list of activities was developed, based on the focus group results. In addition, the project team developed a set of operating principles that ensured and reinforced collaboration. Phase Two included implementing and monitoring planned response activities, and holding exit clinics. The best attended activities were trials of traditional herbal medicine and traditional diet, and an exercise programme. While participation levels were not high enough for causal conclusions, a significant decrease in total cholesterol (0.45; P = 0.005) and rise in HDL (-0.097; P = 0.05) was found for participants for whom paired values were available. Diabetes intervention research in First Nations settings involves small numbers of participants, making it difficult to quantitatively assess outcomes. To increase participation it is advisable to open activities to the whole community, to tie planned activities into other scheduled community events, and to share findings concerning managing illnesses of acculturation with other communities.