Management of Obesity

 

Treatment Guidelines

Although there is agreement about the health risks of overweight and obesity, there is less agreement about their management. Some have argued against treating obesity because of the difficulty in maintaining long-term weight loss, and because of the potentially negative consequences of weight cycling, a pattern frequently seen in obese individuals. Others argue that the potential hazards of treatment do not outweigh the known hazards of being obese.

The treatment guidelines provided are based on the most thorough examination of the scientific evidence reported to date on the effectiveness of various treatment strategies available for weight loss and weight maintenance.

Tailor Treatment to the Needs of the Patient

Standard treatment approaches for overweight and obesity must be tailored to the needs of various patients or patient groups. Large individual variation exists within any social or cultural group; furthermore, substantial overlap occurs among subcultures within the larger society. There is, therefore, no “cookbook” or standardized set of rules to optimize weight reduction with a given type of patient. However, obesity treatment programs that are culturally sensitive and incorporate a patient’s characteristics must do the following:

• Adapt the setting and staffing for the program.
• Understand how the obesity treatment program integrates into other aspects of the patient’s health care and self-care.
• Expect and allow modifications to a program based on a patient’s response and preferences.

Attitudes, Beliefs, and Histories.

In the patient-provider interaction, individual histories, attitudes, and beliefs may affect both parties.

The diagnosis of obesity is rarely new or news for the patient. Except for patients with very recent weight gain, the patient brings into the consulting room a history of dealing with a frustrating, troubling, and visible problem.

Obese people are often the recipients of scorn and discrimination from strangers and, sometimes, hurtful comments from previous health care professionals.

The patient with obesity may be understandably defensive about the problem.

Be careful to communicate a nonjudgmental attitude that distinguishes between the weight problem and the patient with the problem. Ask about the patient’s weight history and how obesity has affected his or her life. Express your concerns about the health risks associated with obesity, and how obesity is affecting the patient.

Similarly, most providers have had some frustrating experiences in dealing with patients with weight problems. Appropriate respect for the difficulty of long-term weight control may mutate into a reflexive sense of futility. When efforts to help patients lose weight are unsuccessful, the provider may be disappointed and may blame the patient for the failure, seeing obese people as uniquely noncompliant and difficult. Providers too may feel some anti-fat prejudice.

Objectively examine your own attitudes and beliefs about obesity and obese people.  Remember, obesity is a chronic disease, like diabetes or hypertension.

In a sense, patients are struggling against their own body’s coordinated effort to stop them from losing weight.

Compliance with most long-term treatment regimens that require behavior change is poor. Expectations should be realistic regarding the ease, amount, speed, and permanence of weight change.

Partnership with the Patient

The patient must be an active partner in the consultation and must participate in setting goals for behavior change. It is the patient who must make the changes to achieve weight loss; the patient already has goals concerning weight loss and how to achieve it.  These goals may be different from those the provider would select.

The provider can be a source of general information, perspective, support, and some measure of guidance but cannot cause the patient to meet goals that he or she does not endorse.

When weight is first brought up, ask what the patient’s weight goals are. You may indicate that the patient’s weight goals are more ambitious than necessary for health improvement, but acknowledge that the patient may have many other reasons for selecting a different goal.

Distinguish between the long-term result of weight loss and the short-term behavior changes (diet, activity, etc.) that are the means to that end.

Emphasize that the patient will judge which specific goals to attempt and that your review of goal attainment is meant to evaluate the plan, not the patient. Also, emphasize that the most important thing the patient can do is to keep return appointments, even if goals have not been met.

Set Achievable Goals

Setting goals should be a collaborative activity. From all the available dietary and physical activity changes that might be made, a small number should be selected on the basis of their likely impact on weight and health, the patient’s current status, and the patient’s willingness and ability to implement them. Once goals are selected, an action plan can be devised to implement change.

After considering the recommended dietary and physical activity guidelines, the patient should be encouraged to select two or three goals that he or she is willing and able to take on. If the patient does not select an area that appears in need of change, inquire about the perceived costs and benefits of that achievement, without presenting it as mandatory. (“One thing that seems very important for most patients is physical activity. What are your thoughts about increasing your activity level?”) Assess the patient’s perceived ability to meet a specific goal. (“On a scale from 1 to 10, how confident are you that you can meet this goal?”)

Effective goals are specific, attainable, and forgiving. Thus, “exercise more” would become “walk for 30 minutes, 3 days a week, for now.”

Shaping is a behavioral technique that involves selecting a series of short-term goals that get closer and closer to the ultimate goal (e.g., an initial reduction of fat intake from 40 percent of calories to 35 percent of calories and later to 30 percent). Once the patient has selected a goal, address briefly what has to be done to achieve it. (“What are the best days for you to take your walks? What time of day is best for you? What arrangements will you need to make for child care?”) Provide the patient with a written behavioral “prescription” listing the selected goals.

Cultivate the Partnership

Follow up visits are occasions for monitoring health and weight status and for monitoring responses to any medication regimens. They also provide the opportunity to assess progress toward the goals selected at the previous visit, to provide support and additional information, and to establish goals for the next visit. Imperfect goal attainment is often the norm. Focus on the positive changes, and adopt a problem-solving approach toward the shortfalls. This is achieved by communicating that the goal, not the patient, is at issue.

While in the waiting room, the patient can write down the outcomes of the previous goals, effects of the various aspects of the treatment program (diet, activity, medication), items to discuss with you, and possible targets for new goals.

In the consultation, a matter-of-degree approach can be communicated by questions such as “How many days a week were you able to walk?” rather than “Did you meet your walking goal?” Successes should receive positive attention and praise. If the patient has not successfully met a desired goal, emphasize the extent to which he or she approached the goal. (“So even though you weren’t able to walk 4 days each week, you did get out there at least twice a week.”)

Acknowledge the challenging nature of weight control by adopting problem-solving responses to goals that are not fully met.  Emphasize that examining the circumstances of unmet goals can lead to new and more effective strategies. (“What do you think interfered with your walking plans on the days you didn’t walk?”)

Emphasize that weight control is a journey, not a destination, and that some missteps are inevitable opportunities to learn how to be more successful.

Set goals for the next visit in collaboration with the patient. These goals should be based on the outcome of the previous goals, consideration of the patient-selected targets, and assessment of the patient’s status. If a previous goal was missed by a wide margin, it may be useful to lower the goal somewhat.

Modify Patient Behaviors

Proven behavior modification techniques can be used to assist patients in weight control. Some can be communicated readily in person or via written materials.

Goals may include the use of one or more of these techniques.

Self-monitoring refers to observing and recording some aspect of behavior, such as caloric intake, exercise sessions, medication usage, etc., or an outcome of these behaviors, such as changes in body weight. Self-monitoring of a behavior usually changes the behavior in the desired direction and can produce real-time records for your review. Some patients find that specific self-monitoring forms make it easier, while others prefer to use their own recording system.

Recording dietary intake (food choices, amounts, times), although seen as a chore by some patients, is a very useful application of self-monitoring.

Although some patients prefer daily weighing and others do better with less frequent steps on the scale, regular self-monitoring of weight is crucial for long-term maintenance.

Rewards can be used to encourage attainment of behavioral goals, especially those that have been difficult to reach. An effective reward is something that is desirable, timely, and contingent on meeting the goal. Patient administered rewards may be tangible (e.g., a movie, music CD, or payment toward buying a more costly item) or intangible (e.g., an afternoon off work or an hour of quiet time away from family). Numerous small rewards, delivered for meeting smaller goals, are preferable to bigger rewards that require a long, difficult effort.

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Stimulus control changes involve learning what social or environmental cues seem to encourage undesired eating and then modifying those cues. For example, a patient may learn from reflection or from self-monitoring records that he or she is more likely to overeat while watching television, or whenever treats are on display by the office coffeepot, or when around a certain friend. The resulting strategies may be to sever the association of eating from the cue (do not eat while watching television), avoid or eliminate the cue (leave the coffee room immediately after pouring coffee), or change the circumstances surrounding the cue (plan to meet with the friend in a setting where food is not available). In general, visible and accessible food items are often cues for unplanned eating.

Dietary behavior changes can make it easier to eat less without feeling deprived. An important change is to slow the rate of eating to allow satiety signals to begin to develop before the end of the meal. Another tactic is to use smaller plates so that moderate portions do not appear meager.  Changing the scheduling of eating can be helpful for patients who skip or delay meals, then overeat later.

Focus on What Matters

Improvement of the patient’s health is the goal of obesity treatment.

Monitoring progress is a continuous process of motivational importance to the patient and provider. Simple, clear records of body weight, relevant risk factors, other health parameters, and goal attainment should be kept.

Use simple charts or graphs to summarize changes in weight and the associated risk factors that were present initially or suggested by the patient’s family history. For example, for a patient presenting with a BMI of 33, hypertension, and a family history of type 2 diabetes, a chart might include successive measures of weight, BMI, waist circumference, blood pressure, and fasting blood glucose. Copy these records for the patient.

The initial goal of weight loss therapy for overweight patients is a reduction in body weight of about 10 percent. If this target is achieved, consideration may be given to further weight loss. In general, patients will wish to lose more than 10 percent of body weight; they will need to be counseled about the appropriateness of this initial goal.  Further weight loss can be considered after this initial goal is achieved and maintained for 6 months.

The rationale for the initial 10-percent goal is that a moderate weight loss of this magnitude can significantly decrease the severity of obesity associated risk factors. It is better to maintain a moderate weight loss over a prolonged period than to regain weight from a marked weight loss. The latter is counterproductive in terms of time, cost, and self-esteem.

Rate of Weight Loss

A reasonable time to achieve a 10-percent reduction in body weight is 6 months of therapy. To achieve a significant loss of weight, an energy deficit must be created and maintained.

Weight should be lost at a rate of 1 to 2 pounds per week, based on a caloric deficit between 500 and 1,000 kcal/day. After 6 months, theoretically, this caloric deficit should result in a loss of between 26 and 52 pounds.  However, the average weight loss actually observed over this time is between 20 and 25 pounds. A greater rate of weight loss does not yield a better result at the end of 1 year.³⁷

It is difficult for most patients to continue to lose weight after 6 months because of changes in resting metabolic rates and problems with adherence to treatment strategies.  Because energy requirements decrease as weight is decreased, diet and physical activity goals need to be revised so that an energy deficit is created at the lower weight, allowing the patient to continue to lose weight.

To achieve additional weight loss, the patient must further decrease calories and/or increase physical activity. Many studies show that rapid weight reduction is almost always followed by gain of the lost weight. Moreover, with rapid weight reduction, there is an increased risk for gallstones and, possibly, electrolyte abnormalities.

Weight Maintenance at a Lower Weight

Once the goals of weight loss have been successfully achieved, maintenance of a lower body weight becomes the major challenge. In the past, obtaining the goal of weight loss was considered the end of weight loss therapy. Unfortunately, once patients are dismissed from clinical therapy, they frequently regain the lost weight.

After 6 months of weight loss, the rate at which the weight is lost usually declines, then plateaus.  The practitioner and patient should recognize that, at this point, weight maintenance, the second phase of the weight loss effort, should take priority. Successful weight maintenance is defined as a regain of weight that is less than 6.6 pounds (3 kg) in 2 years and a sustained reduction in waist circumference of at least 1.6 inches (4 cm). If a patient wishes to lose more weight after a period of weight maintenance, the procedure for weight loss, outlined above, can be repeated.

After a patient has achieved the targeted weight loss, the combined modalities of therapy (dietary therapy, physical activity, and behavior therapy) must be continued indefinitely; otherwise, excess weight will likely be regained.

Numerous strategies are available for motivating the patient; all of these require that the practitioner continue to communicate frequently with the patient. Long-term monitoring and encouragement can be accomplished in several ways: by regular clinic visits, at group meetings, or via telephone or e-mail. The longer the weight maintenance phase can be sustained, the better the prospects for long-term success in weight reduction.