The 5A’s of Obesity Management

If you listened to our new podcast from the “Is Obesity A Disease?” debate, you will have heard a brief discussion of the “5 A’s of Obesity Management”, a new project developed by the Canadian Obesity Network.  The 5 A’s are based on previous “5 A’s” initiatives focusing on smoking cessation and increasing physical activity, and are built around 5 core principles of obesity management:

Obesity is a Chronic Condition: Obesity is a chronic and often progressive condition not unlike diabetes or hypertension. Successful obesity management requires realistic and sustainable treatment strategies. Short-term “quick-fix” solutions focusing on maximizing weight loss are generally unsustainable and therefore associated with high rates of weight regain.

Obesity Management is About Improving Health and Well-being, and not Simply Reducing Numbers on the Scale: The success of obesity management should be measured in improvements in health and well-being rather than in the amount of weight lost. For many patients, even modest reductions in body weight can lead to significant improvements in health and well-being.

Early Intervention Means Addressing Root Causes and Removing Roadblocks: Successful obesity management requires identifying and addressing both the ‘root causes’ of weight gain as well as the barriers to weight management. Weight gain may result from a reduction in metabolic rate, overeating, or reduced physical activity secondary to biological, psychological or socioeconomic factors. Many of these factors also pose significant barriers to weight management.

Success is Different for Every Individual: Patients vary considerably in their readiness and capacity for weight management. ‘Success’ can be defined as better quality-of-life, greater self-esteem, higher energy levels, improved overall health, prevention of further weight gain, modest (5%) weight loss, or maintenance of the patient’s ‘best’ weight.

A Patient’s ‘Best’ Weight May Never be an ‘Ideal’ Weight: An ‘ideal’ weight or BMI is not a realistic goal for many patients with obesity, and setting unachievable targets simply sets up patients for failure. Instead, help patients set weight targets based on the ‘best’ weight they can sustain while still enjoying their life and reaping the beneits of improved health.

The A’s themselves are as follows:

  1. Ask for permission to discuss weight and explore readiness for change.
  2. Assess obesity related health risk and potential “root causes” of weight gain.
  3. Advise on obesity risks, discuss benefits treatment options.
  4. Agree on realistic weight-loss expectations and on a SMART plan to achieve behavioral goals.
  5. Assist in addressing drivers and barriers, offer education and resources, refer to provider, and arrange follow-up.

Not being a practitioner myself, I’m curious to hear what people think of the program (and also interested to hear what people who self-identify as HAES followers think of it).   You can find out more about the program at Dr Arya Sharma’s blog here.


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20 Responses to The 5A’s of Obesity Management

  1. Ray says:

    I agree with what you are saying, but there is no denying that the scales motivate patients more than health improvement. If we use this to our advantage the we can educate them and show the improvements as we go. Another thing they respond well to is medication reductions!

    • No denying? What evidence beyond anecdotal do you have for this? Are you looking at short-term or long-term? How long on the long-term?

      It’s my understanding from Linda Bacon’s work that when they focused on health behaviors rather than on weight, that people were more likely to maintain those health behaviors long-term, with the associated improvements in metabolic health.

  2. Nora says:

    I don’t feel especially motivated by the number on the scale, though I did for many years. After nearly 40 years of gaining more than I ever lost, just looking at a scale fills me with despair and panic.

    On the other hand, I’m highly motivated to exercise every day and eat a sensible amount of nutritious food, just because the benefits are immediate and obvious: I feel better, I sleep better, and I am happier. I have more energy and I get more done.

    While my weight remains high, my blood pressure, lipid profile, triglycerides, and glucose levels are the envy of many of my much slimmer friends.

  3. Nora says:

    The five core principles above seem very sound to me; the 5 As, however, seem a little more specifically focused on weight loss as opposed to health optimization. I suppose that would depend on the prior experience of the patient as well as the practitioner’s willingness/ability to integrate “best weight” and “reasonable goals” into a treatment plan.

  4. Linda Fair says:

    I find this approach very encouraging. The diet mentality is the gateway to eating disorders and anything that asserts that weight loss is the ONLY way to health and happiness is a big part of the problem. Becoming realistic in a hopeful way about Health at every size seems to me to be the right path.

  5. Your last post had the quote from Dr. Sharma suggesting obesity should be defined as “a condition in which excess body fat threatens or affects health,” rather than as a number on the BMI scale. Are we starting with that definition or with the BMI number before we even start looking at the 5 points of obesity management and the 5A?

    If we’re still starting with BMI, then we’ve got a more positive approach built on an intrinsically flawed measure.

    • Travis says:

      Good question. Dr Sharma is the Scientific Director and primary force behind the Canadian Obesity Network (the group that created the 5As), so I assume that it is referring to the definition he espoused in the debate and in his recent blog post, rather than the traditional definition of a BMI > 30.

  6. Dee says:

    I see unhealthy weight as a result and would like to see efforts to define and treat causes. By doing this, we realize the issues, pressures, and diseases contribute to unhealthy weight that is a symptom not a disease.
    The more we label results as disease, forcing people to wear a label everywhere they go, the greater the (however well-meaning) dis-service to them.
    I believe the key is to understand how an unhealthy lifestyle, dysfunctional reasoning, lack of good health information or diagnosis leads to unhealthy weight.
    I certainly agree with your approach, it may sound overly picky or arguing semantics but I think the words we use are important to the people who are affected. If we have to use labels, then to be fair, many of us should be called “common-weighted’ or ordinary.

    • Travis says:

      I believe the key is to understand how an unhealthy lifestyle, dysfunctional reasoning, lack of good health information or diagnosis leads to unhealthy weight.

      With due respect, I don’t think that many people develop obesity as a result of “dysfunctional reasoning”. In the debate earlier this week, this was one of the key reasons why Dr Sharma argued that obesity should be medicalized – to do away with the view that obesity is simply a lifestyle problem or lack of willpower, rather than a complex physiological process.

  7. Nora says:

    I’ll repeat here and expand on what I said in the other thread: I’d really like to see some effort to reach those who are not fat, who wouldn’t even qualify for intervention if BMI or visual weight cues are what initiates the conversation. When they get to be my age (let’s say around 50), they’ve never had to “watch their weight,” have never been active, have no idea that the junk they eat is maybe harmful, but suddenly they show up with high blood pressure, high cholesterol, or other -sometimes much worse — signs that all is not well.

    Maybe if they’d learned 20 years previously that exercise and eating well are not just obesity interventions, they wouldn’t be in that predicament, or they would be less resistant to incorporating healthier practices in their lives.

    Its my belief that Health at Every Size isn’t just for us fat people.

    • Travis says:

      From my (admittedly limited) understanding of HAES, I think most proponents of that approach would agree with you.

  8. Pingback: BBC News – Global weight gain more damaging than rising numbers « Ye Olde Soapbox

  9. WRG says:

    I am fundamentally uncomfortable with the idea that being obese (BMI of 30 or over) is necessarily “a chronic and often progressive condition not unlike diabetes or hypertension”. In other words, a condition to be avoided or cured.

    Yes, there are lots of people with conditions that are correlated (not caused by, because we just don’t know) with a higher body weight, but we also know that these same conditions may be found in people with low or average body weights as defined by the BMI. There are also many people who are metabolically healthy, though their BMI is 30 or above.

    As long as we take the default stance that fat = unhealthy, we’re going to be in a whole lot of trouble. First, this belief implicitly sends us on a road much traveled but woefully unhelpful: getting people to lose weight. Ninety-five percent of those who lose weight gain it back and indeed often end up fatter than where they started out. We can scream and shout about lifestyle, mind-set change, turning your life around and all it gets us is a world that’s fatter and fatter. Some fat people eat “badly”, so do some slim people. Some fat people are addicted to food, so are some slim people. But fat people fundamentally are not that different from average weight people. To maintain a lower weight, however, we must lead superhuman lives, obsessing about every morsel of food that passes our lips, exercising significantly more than our average weight brethern and never, ever letting our guards down. Our bodies will fight to the end to return to what is normal for us: being fat. Not being unhealthy, just being fat.

    Being unhealthy is a whole different issue and that is one that we actually know a lot about remediating: moderate exercise, five times a week and a balanced diet made up of mostly fresh, unprocessed (or minimally processed) foods are generally good for your health. These habits won’t help you to lose weight, unless perhaps your diet consists of drinking 2 litres of Coke a day and eating Doritos (and of course, that’s what many people–aided and abetted by the media–think we fat people do all day, every day), but they’ll probably help you become much healthier. For that matter, 30 minutes a day of mindful meditation can have an amazing effect on your health, but that won’t make you any slimmer either.

    Certainly compared to a lot of the crap going on out there– trying to make chihuahas into Newfoundlanders, rose bushes into sequoias and naturally heavy people into sylphs– the Obesity Network is onto to some interesting ideas. But I’m putting my money on HAES and standing firm against all those magic diets that are nothing but a way for the likes of Weight Watchers and Jenny Craig to make trillions of dollars on the backs of desperate people.

    • Travis says:

      I should have made this more clear in the post, but Dr Sharma (the man behind CON) is as against BMI-based obesity definitions as you are. At our debate in Ottawa he argued for a new definition based on “a condition in which excess body fat threatens or affects health”. Which could arise at a BMI of 45 or a BMI of 21, depending on where that fat is stored. I’m not 100% positive, but I’m assuming that the 5As are focused on this definition of obesity, rather than someone who simply has a BMI above 30.

      I think the core principles and 5As are pretty much in sync with what you’re advocating – more focus on health, way less focus on BMI. Especially if we’re using the non-BMI definition of obesity,

      • WRG says:

        I get what you’re saying Travis. Honestly, compared to virtually everything coming out of the media and the medical world, the Obesity Network seems like a beacon of hope and sanity.

        But I still can’t shake the feeling that there’s still an uncomfortable “push and pull” between seeing “excess” (whatever that means…) fat as a fundamental sign of disease and seeing it as just another variation on the human condition.

        I think that it is essential to rip the focus away from weight loss and put it on health, be it through (and I’m starting to sound like a broken record, but bear with me) moderate, regular exercise; eating fundamentally good food (rather than dieting); stress reduction; psychotherapy (though only when warranted–we’ve just got to give up on the erroneous idea that most fat people are all bingeing to cover up deep psychological wounds); putting a stop to the media circus around the OBESITY EPIDEMIC: RUN FOR YOUR LIVES! message; etc.

        The discussion continues…

        • Travis says:

          But regardless of body weight, we do know that having a lot of visceral fat (or liver fat), can cause ill health. And that the best way to deal with that is to reduce that fat depot. Conversely, sometimes people suffering some sort of ill health as a result of their excess fat already do all of the healthy behaviours in the world. What to do for either of these situations?

          On this issue I think that the 5As might do more to put the focus back on health.

          • WRG says:

            Bringing us back to that intractable question: how to maintain weight loss? If you’ve never been there, with all due respect, you have no idea of how virtually impossible it is.

            I have been reading both HAES blogs and weight loss blogs for a few years now and I am truly saddened to see that the majority of even that miniscule handful of successful losers seems to be in a constant, losing (pardon the pun) battle to keep the pounds off.

            Harping on weight loss–when we know that it just doesn’t work for 95% of people–is not going to make anyone healthier. Why aren’t we devoting more time to studying the effect of moderate exercise and healthy (though not restricted) eating on the health of fat people? We’re not. We’re so stuck on FAT that we can’t imagine studying healthy fat people to understand why they’re healthy.

            When you find a way to make fat people lose weight and become like naturally average-weight people, I’ll personally hand you the Nobel Prize and take out a mortgage on my house to contribute to the prize money. Until then, I want to know how to live the healthiest life I can at the weight my body agrees to live at, not a weight that my body will fight tooth and nail to increase.

            • Violet in Twilight says:

              I think the fallacy here is: fat loss = weight loss.

              Someone can lose fat mass without any significant weight loss. AFAIK, the good news is that visceral fat loss happens before subcutaneous fat loss.

            • Violet in Twilight says:

              Also, please do read ‘EOSS’ by Dr. Sharma and others.

              It does recognize healthy fat people.

    • Violet in Twilight says:

      Perhaps you can look up “Skinny fat” people who are at the same risk for Diabetes. This condition is common in South Asians whose BMI is low but have fat layer around abdomen leading to all sorts of chronic conditions. So, here location of body fat IS a problem, not necessarily BMI.

      Unfortunately, “fat” became a colloquial use for BMI instead of “body fat”.