Kathryn M. Kolasa, PhD, RD, LDN Departments of Family Medicine and Pediatrics at East Carolina University, Greenville, NC kolasaka@ecu.edu
Kathy Cable, MLS Brody School of Medicine at East Carolina University, Greenville, NC
David N. Collier, MD, PhD Pediatrics at East Carolina University, Greenville, NC
Dr. Kolasa reported that she serves on a nutrition advisory committee to Burger King International. Dr. Collier and Ms. Cable reported no potential conflicts of interest relevant to this article.
TABLE 2 Obesity: Key components of evaluation and treatment
Assess
Severity of obesity with calculated BMI, waist circumference, and comorbidities
Food intake and physical activity in context of health risks and appropriate dietary approach
Medications that affect weight or satiety
Readiness to change behavior and stage of change
Advise
Diagnosis of overweight, obese, or severe obesity
Caloric deficit needed for weight loss
Various types of diets that lead to weight loss and ease of adherence
Appropriateness, cost, and effectiveness of meal replacements, dietary supplements, over-the-counter weight aids, medications, surgery
Importance of self-monitoring
Agree
If patient is not ready, discuss at another visit
If patient is motivated and ready to change, develop treatment plan
If patient chooses diet, physical activity, and/or medication, set weight loss goal 10% from baseline
If patient is a potential candidate for surgery, review the options
Assist
Provide a diet plan, physical activity guide, and behavior modification guide
Provide Web resources based on patient interest and need
Identify method for self-monitoring (eg, diary)
Review food and activity diary on follow-up. (Reassess if initial goal is not met.)
Arrange
Follow-up appointments to meet patient needs
Referral to registered dietitian and/or behavioral specialist for individual counseling/monitoring or weight management class
Referral to surgical program
Maintenance counseling to prevent relapse or weight regain
BMI, body mass index.
Diagnose obesity without delay
While most patients can report their height and weight with reasonable accuracy, few obese adults consider themselves to be obese.19 And, although the USPSTF 2009 recommendations call for screening all adults for obesity and introducing behavioral interventions to promote sustained weight loss as needed,20 most obese men and women receive neither a diagnosis nor an obesity management plan.21 Yet both are key components of long-term weight control. Physicians should calculate and document the BMI of all adult patients, and routinely diagnose obesity in patients with a BMI ≥30 kg/m2 (TABLE 1).
Get the patient’s perspective In addition to using BMI and waist circumference measures and identifying comorbidities such as diabetes and hypertension, it is important to determine whether the patient is motivated to change. You can start by asking whether he or she has previously been told to lose weight; adults who have received weight control counseling in the past are more likely to be in a greater state of readiness.7
Review the patient’s medications. Once you have identified obesity, look for iatrogenic causes—most notably, current use of 1 or more medications that are associated with weight gain or known to affect satiety. If you identify any such drugs, it may be possible to find a suitable alternative (TABLE 3).
Factor in literacy. Patients with low literacy are less likely to fully comprehend the health benefits of weight loss or to report that they are ready to lose weight, as compared with those with higher literacy levels.22 Talking to such patients to determine what will spark their interest and motivation—ie, looking and feeling better, being able to play with children or grandchildren—can help.
Assess the patient’s dietary patterns. This can be done with the Rapid Eating Assessment for Participants (REAP), an office-based tool of adequate reliability and validity for nutrition assessment and counseling that can be administered in a few minutes.23
FAST TRACK
Receiving weight management advice from a physician is strongly associated with patient efforts to lose weight.
This office-based survey, available at http://bms.brown.edu/nutrition/acrobat/REAP%206.pdf, provides information that can be the basis for an action plan. While there is no direct evidence that having a plan leads to weight loss, receiving advice from a physician is strongly associated with efforts to lose weight.6 Be aware that obese individuals may not be as responsive to weight management counseling from a physician as those who are overweight, so they may require more assistance.21
TABLE 3 Drugs that promote weight gain—and alternatives to consider46,52,53
* Table is not meant to imply equal efficacy for all choices for a given indication.
† Valproic acid and carbamazepine are associated with weight gain, but less than that associated with lithium.
‡ Topiramate may not be adequate as a single agent.
Set a goal, prescribe a food plan
After discussing possible interventions based on the patient’s BMI and weight status (TABLE 1), set a safe and achievable goal to reduce body weight at a rate of 1 to 2 lb per week for 6 months to achieve an initial weight loss goal of up to 10%. Not only does such a target have proven health benefits,15,24 but defining success in realistic and achievable terms helps maintain patient motivation.
