Obesity Management in Primary Care Changing the Status Quo

Despite their high prevalence, obesity and obesity-related diseases are underdiagnosed and undertreated by family physicians.¹ Possible barriers to changing the status quo of obesity management include concern that patients are uncomfortable with a more proactive approach, questions about the safety and efficacy of obesity management drugs, office visits that are too short, incomplete physician education, lack of reimbursement, and a powerful “obesogenic environment” in the United States.²

Two articles in this issue of JFP address the management of obesity in primary care.^3,4 Potter and colleagues³ describe what some primary care patients want from their physicians with respect to weight management. The authors’ data indicate that overweight and obese patients want more help with weight management than they are currently getting from their physicians. There were no important differences between lean, overweight, or obese patients in their strong preferences for exercise or dietary recommendations; interest in weight loss products or pills was much lower. Patients also wanted help setting realistic weight goals. Physicians should remember that even a 10% decrease in weight would produce medically important decreases in blood pressure, blood lipids, or blood glucose.⁵

In the second article, Smith and coworkers⁴ document the 12-month effectiveness and safety of sibutramine therapy. Their placebo-controlled trial suggests that otherwise healthy overweight or moderately obese patients can achieve a 5% decrease in body weight, on average, within 6 months with brief dietary counseling and 10 mg sibutramine per day.

The weight loss effects of sibutramine must be balanced against the cost of the drug ($108 per month) and possible adverse health effects (increased heart rates, ventricular ectopic beats, or epileptic seizures). Because the long-term (2-year to 5-year) health effects of sibutramine are not known, a cautious family physician may wish to delay prescribing this drug until more information is available. Also, an over-reliance on pharmacologic therapy could undercut efforts to encourage more physical activity and dietary change.⁶

What can a motivated family physician do to change the obesity status quo in primary care? A first step would be to use the patient’s height and weight to determine the body mass index (BMI) at each visit.* Elevated BMI could be added to the chronic problem list and could be integrated into assessment and plans with other chronic conditions. Physicians could use educational material available through the American Heart Association web site (www.americanheart.org) or Shape Up America (www.shapeup.org) and supplement this advice with referrals to Weight Watchers or other local exercise and weight loss programs as needed. An evidence-based guideline for primary care physicians is available for free from the National Institutes of Health (www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.htm). These office-based measures may not be as effective as long-term cognitive-behavioral counseling with adjunctive pharmacologic therapy, but they address patient concerns, build on familiar principles and practices of chronic disease care, acknowledge real world time and resource constraints, and are safe.⁷