Impact Obesity v1 Module 2 Overview of Obesity Medicine
Contents Overview of Obesity Medicine...... 3 Introduction...... 4 Obesity Prevalence...... 5 Central Adiposity Diagnosis...... 5 Quiz: Diagnosis...... 7 Obesity-Related Comorbidities...... 7 Obesity and Mortality...... 9 Weight Loss Is Possible...... 10 Weight Loss Improves Health...... 11 Quiz: Ms. Castillo's Health Outcomes...... 12 Successful Treatment...... 13 Quiz: Effectiveness of Interventions...... 14 Motivating Patients...... 15 Focus: Raising Patient Awareness...... 15 Evoke Patient Motivation...... 16 Eliciting Stage of Change, Confidence, and Importance...... 17 Quiz: Motivating Ms. Castillo...... 17 Initial Weight-Loss Goals...... 18 Problematic Dietary Patterns...... 19 The Sugar Problem...... 22 Poll: What diets do you suggest for weight-loss to your patients?...... 23 Effective Dietary Changes...... 24 Calorie Reduction for Weight Loss...... 25 Changing Dietary Habits...... 26 GUIDELINES FOR CHANGING DIETARY HABITS FOR WEIGHT LOSS...... 26 Changing Portion Size...... 27 Quiz: Mr. Smith's Dietary Changes...... 28 Physical Activity and Weight...... 29
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Activity Guidelines for Health and Weight Maintenance...... 29 Quiz: Physical Activity Recommendations...... 30 Referrals for Support...... 31 Counselors and Dietitians...... 31 Weight-Loss Programs...... 32 Quiz: Mr. Smith - Referral for Behavioral Support...... 33 Adjunctive Treatments...... 34 Pharmacotherapy...... 35 FDA Approved Pharmacotherapy...... 35 Quiz: Pharmacotherapy for Mr. Smith?...... 37 Bariatric Surgery...... 38 Primary Care Role in Surgery...... 38 Types Of Bariatric Surgery...... 39 Quiz: Which Treatment?...... 39 Weight Management Clinical Protocol: History and Evaluation...... 40 Weight Management Clinical Protocol: Treatment and Referral...... 41 Module Summary...... 43 Resources available through this module:...... 44 References used in this module:...... 45
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OVERVIEW OF OBESITY MEDICINE
Goal: To provide an overview of clinical assessment, diagnosis, treatment, and referral skills for managing adult overweight and obesity. To meet the training needs of providers who only have limited time for training or who have little background in this subject. After completing this module participants will be able to: • Recommend a comprehensive, evidence-based weight management strategy for patients having weight problems
• Use a motivational counseling style with patients who are overweight or obese to encourage the lifestyle changes required for weight management
• Identify patients for whom weight-loss programs or counseling, prescription weight-loss medications, or bariatric surgery are appropriate adjunctive treatments to diet and exercise Professional Practice Gaps Evidence-based practice guidelines recommend screening all patients for weight problems and classifying or diagnosing them as overweight or obese (Jensen et al., 2013). Guidelines also recommend that treatment include reduced energy diet and increased physical activity for all patients, plus additional treatments for patients with relatively higher body mass or weight-related comorbidities (Jensen et al., 2013; Apovian et al., 2015). Additional treatments recommend include behavioral supports, pharmacotherapy, and bariatric surgery. Despite these recommendations, primary care physicians and other primary care clinicians do not consistently assess, diagnose, counsel, or advise patients who are overweight or obese (Loureiro et al., 2006; Simkin-Silverman et al., 2008; Smith et al., 2011). Specifically, weight and height data needed to assess for obesity using BMI is lacking in roughly 50% of medical records and the majority of obese patients are not told that they are overweight or obese by a physician (STOP, 2010; Bardia et al., 2007). Additionally, physicians frequently report a lack of training and competence in weight management (Dietz et al., 2015; Jay et al., 2009; Forman-Hoffman et al., 2006; STOP, 2010). In our needs analysis (N=25), only 52% of physicians reported that they had adequate training to manage obesity and overweight conditions in their patients (Tanner, 2011). Of the physicians surveyed, 84% reported that they needed training to counsel patients on proper diet recommendations (Tanner, 2011). Furthermore, 80% of providers surveyed reported that they need additional training in classifying obesity in order to determine the need for surgical interventions and 88% of these providers reported needing further training in the use of pharmacotherapy in weight management. In another survey of obesity experts (n= 7), 86% believed that primary care providers need more training in what diet to recommend to patients (Tanner, 2011).
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INTRODUCTION
The Obesity Epidemic Is Still Growing – What Can Be Done? Treating obesity successfully takes time. Time pressures and emphasis on short-term outcomes that are common in health care are in conflict. Other weight management challenges for clinicians include:
• Physiological adaptations perpetuating chronic obesity. • The patient's living environment often supports poor food choices and overeating. • Many people feel discomfort with this topic. In light of these challenges, being prepared to offer the most effective, evidence-based brief counseling, treatments, and referrals for obesity is critical. Impact Obesity has this focus. How Can Patients Struggling With Obesity Be Helped? MS. CASTILLO
Ms. Castillo was diagnosed with Class I obesity and central adiposity during a physical. How can you assess and help her improve her diet? MR. SMITH
He thinks he's "up a few pounds", but his BMI is in the obese range. How can you raise his awareness, building an alliance rather than offending him? OUTLINE OF THE OVERVIEW TO OBESITY MEDICINE MODULE This module provides an overview of the of the Impact Obesity activity, which presents current practice in obesity treatment and management. This module is intended for those who need fundamentals before studying obesity medicine in more detail or who do not intend to take the other modules in ImpactObesity.com. The focus of this module is:
• The extent of the obesity epidemic and how the prevalence of overweight and obesity can affect your practice and your patients' health. • The evidence that providers can make a difference through comprehensive weight management and that your patients' health will improve as a result. • A brief introduction to what is included in comprehensive weight management.
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OBESITY PREVALENCE
The Trends
FYI: Many graphs in this program can be expanded by clicking. OBESITY The prevalence of obesity in the U.S. rose steadily from:
• 13% in the 1970s, to • 34.9% in 2011-2012 (Fryar et al., 2014). Obesity prevalence is currently 37.7% in the U.S. (women 40%) and highlights a worsening weight condition in the country (Flegal et al., 2016). The severity of obesity is also increasing. The percentage of people who have extremely severe or "morbid" obesity (BMI ≥ 40.0 kg/m2) has increased from 2.8% of the population in 1990 to 6.4% in 2012. Note: This is one criterion for considering bariatric surgery. OVERWEIGHT The percentage of the population that is overweight but not obese (BMI 25.0–29.9 kg/m2) has remained fairly steady at around 33 to 34% for the past 40 years (Fryar et al., 2014). The current prevalence of overweight is 33.6%. The percentage of people who are either overweight or obese is currently around 71% of adults and is increasing.
CENTRAL ADIPOSITY DIAGNOSIS According to her record, Ms. Castillo's waist circumference has never been measured in this clinic. How important is this measurement? What is the best approach to obtain it?
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Measuring waist circumference is an objective approach to diagnosing central adiposity, which helps identify patients at increased risk for certain obesity-related comorbidities. Central adiposity is:
• Associated with greater risk for heart disease, stroke, and type 2 diabetes mellitus (Jensen et al., 2014). This increased risk is seen even with normal BMI. • Better at predicting certain risks than BMI. For example, waist circumference is approximately twice as effective as BMI at predicting future coronary heart disease (Jensen, 2007). Waist measurement is as important as calculating a BMI – both need to be done to get a better estimate of patients' metabolic risk. Criteria for Central Adiposity: Assessed through waist circumference measurements
• ≥ 40 inches (102 cm) men • ≥ 34.5 inches (88 cm) women (Jensen, 2007)
(Source: NHLBI) Recommended Frequency for Measuring Waist Circumference: Waist circumference should be updated at annual visits and more often in patients who are overweight or obese (Jensen et al., 2013). Procedure: How to Measure Waist Circumference 1. With the patient standing, place the tape measure around the abdomen, at the level of the top of the iliac crests. 2. Have the patient breathe out normally. 3. Take the measurement at the end of the exhale. 4. Be sure that the tape is parallel to the floor and fits snugly, without compressing the skin. (DHHS, 2005) PRACTICE TIP Measuring waist circumference can be completed in primary care without complicated equipment and can be delegated to staff.
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QUIZ: DIAGNOSIS MS. CASTILLO'S waist circumference was measured just above her hipbones and recorded at the end of her exhale. Her waist measurement was found to be 37 inches. Question: The following can be concluded based on Ms. Castillo's waist measurement: (Check all that apply) 1. A diagnosis of obesity • Feedback: Incorrect. Someone with a high waist circumference (central adiposity) may not necessarily have a diagnosis of overweight or obesity. 2. A diagnosis of central adiposity • Feedback: Correct! The cut point for diagnosing a woman with central adiposity is ≥ 34.5 inches (88 cm). 3. Increased risk for heart disease • Feedback: Correct! Elevated waist circumference (over 34.5 inches in women) is associated with an increased risk for heart disease. Also, waist measurements are twice as effective as BMI at predicting future coronary heart disease 4. Increased risk for type 2 diabetes • Feedback: Correct! Elevated waist circumference (over 34.5 inches in women) is associated with an increased risk for type 2 diabetes.
OBESITY-RELATED COMORBIDITIES Evaluate for weight-related comorbidities. The metabolic changes associated with obesity as well as the effects of the fat mass bearing down on the body and vital organs result in a large number of comorbid diseases. Early treatment of weight gain before comorbidities develop makes sense because physiologic changes caused by chronic obesity make it difficult to lose weight. (* = most common): *CARDIOVASCULAR
• *Hypertension • *Dyslipidemia • Stroke • Venous varicosities, phlebitis, lower extremity edema RESPIRATORY
• Sleep apnea • Asthma • Respiratory impairment GASTROINTESTINAL
• *Diabetes and Insulin resistance • Fatty liver, steatosis, and steatohepatitis • GERD • Gallbladder disease
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• Incontinence • Gout and hyperuricemia *CERTAIN FORMS OF CANCER
SKIN
• Intertrigo (bacterial and/or fungal) • Acanthosis nigricans • Hirsutism • Risk for cellulitis and carbuncles MUSCULOSKELETAL
• *Osteoarthritis • Low back pain and other pain • Increased risk of chronic pain and injury SURGICAL
• Increased surgical risk and postoperative complications: • Wound infection • Postoperative pneumonia • Deep venous thrombosis • Pulmonary embolism NEUROLOGICAL
• Pseudotumor cerebri (tumor-like neurological symptoms from increased intracranial pressure) REPRODUCTIVE/ENDOCRINE
• Women: • Infertility • Polycystic ovarian syndrome • Early puberty • Hyperestrogenism symptoms including abnormal menses • Hyperandrogenism • Men: • Hypogonadotropic hypogonadism • Sexual dysfunction (Hofstra, 2008; Janniger, 2005; WHO, 2002; ASMBS, 2013; Cary, 2013; Blankfield, 2000; NINDS, 2010; NIDDK, 2014) Psychosocial Comorbidities Psychosocial comorbidities of obesity include the following:
• Psychological disorders • *Binge-eating disorder • *Depression
• Social stigmatization
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• Problems with personal hygiene (WHO, 2002; Tonkin, 1998; Luppino, 2010)
OBESITY AND MORTALITY
Evidence shows that obesity has the following impact on mortality:
MORTALITY RATE INCREASE: Increase of all-cause mortality rates due to diagnoses of moderately severe obesity and worse (≥ BMI=35 kg/m2)(Flegal et al., 2013).
MORTALITY RATE INCREASES AS BMI INCREASES (Whitlock et al., 2009). Increased mortality for specific diseases for every 5 units over 25 kg/m2:
• 41% increase in vascular mortality • 21% increase in diabetes-related mortality • 29% increase in overall mortality
YEARS OF LIFE LOST: Obesity reduces median survival by 2 to 4 years if BMI is 30-35 kg/m2 and by 8 to 10 years if BMI is 40-45 kg/m2 (Whitlock et al., 2009).
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DECREASE IN LONGEVITY: The longer an individual is obese, the greater the impact on their longevity (Fontaine et al., 2003).
GENDER AND MORTALITY: Obesity results in up to 13 years of life lost for men and up to 8 years of life lost for women (Fontaine et al., 2003). Note that elevated percent body fat is associated with increased risk of mortality independent of BMI (Padma, 2016).
WEIGHT LOSS IS POSSIBLE
Obese patients will be more successful at weight loss with treatments that consider that:
• Calorie restriction and chronic obesity both trigger biological adaptations promoting weight retention, which makes weight loss more difficult (Ochner et al., 2015) • The environment most people live in promotes over-consumption of foods and provides many cues to eat (Ochner et al., 2015) • They understand that even a small weight loss can have significant weight loss benefits (Jensen et al., 2014).
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The Evidence Evidence shows that long-term weight loss is possible:
• A review of the literature found that the following in combination result in the most successful weight loss (Jensen et al., 2014): • Any restricted calorie diet • Increased physical activity • Behavioral supports • For some patients with greater severity, adjunctive treatments, such as weight-loss surgery or pharmacotherapy • While there is a high risk of regaining weight that is lost, research has shown that many people can maintain a weight loss. For example: • In patients with type 2 diabetes, the average person lost weight and successfully kept most of it off 10 years later. The patients received diabetes support and education (3.5% weight loss after 10 years) or intensive lifestyle intervention (6% weight loss after 10 years) (Wing et al., 2013). • In another study of individuals who had lost weight through various means, around 20% were successful at long-term weight loss (Wing, 2005). This was defined as losing at least 10% of initial body weight and maintaining the weight loss for at least 1 year • A meta-analysis of weight-loss programs found significant weight loss was achieved with low- carbohydrates and low-fat diets. Low-carbohydrate diets produced greater weight loss at 6 months but comparable weight loss at 12 months (Johnston et al., 2014). • For the calorie-reduction part of weight-loss treatment, there is some evidence for meal replacements being more effective than a food based diet for both weight loss and maintenance in obese adults (Davis et al, 2010). • Adding behavioral supports and/or exercise to weight-loss diets produced further weight loss of 3.23 kg and 0.64 kg respectively at 6 months (Johnston et al., 2014). • Modest increases in weight-loss of around 5% are achieved with FDA-approved weight loss medications (Apovian et al, 2015). The additional weight loss is achieved as long as the medications are used in conjunction with weight-loss diet and increased exercise. Weight loss is maintained as long as the medication is taken. PRACTICE TIP In selecting a weight-loss program, it is important to recommend one to which the individual patient is more likely to adhere.
WEIGHT LOSS IMPROVES HEALTH Obesity treatment should not be delayed while focusing on the treatment of its comorbid conditions. Weight loss is one of the most effective treatments for many comorbidities (Jensen et al., 2014). Additionally, chronic obesity produces self-perpetuating metabolic and physiological changes, which is another reason to not delay treatment (Ochner et al., 2015). Even a modest, intentional weight loss can improve the following conditions:
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• Cardiovascular Disease (Wannamethee, 2005; Jensen et al., 2013) - Improvement with as little as 5% weight loss • Hypertension (Ilane-Parikka et al., 2008; Phelan et al., 2007) • Dyslipidemia (Improved triglycerides, LDL, HDL) and Metabolic Syndrome (Ilane- Parikka et al., 2008; Phelan et al., 2007; NHLBI, 2013) • Type 2 Diabetes Mellitus (Cohen et al., 2012; Mingrone et al., 2012; Schauer et al., 2012) • Non-Alcoholic Fatty Liver Disease (Research shows variable outcomes - Huang et al., 2005)
• Osteoarthritis (Christensen et al., 2007; Fransen, 2004) • Cancer risk and mortality (Adams et al., 2009; Sjöström et al., 2009) • Sleep Apnea (Kuna et al., 2013) • Other: Pancreatitis, cholecystitis, gout, kidney disease, infertility, carpal tunnel syndrome, rheumatoid arthritis, impaired immunity, and low back pain (Rader, 2014)
QUIZ: MS. CASTILLO'S HEALTH OUTCOMES
Patient Name: Gloria Castillo Age: 50 y/o Height: 5' 4" Weight: 195 lbs BMI: 33.5 kg/m2 Waist: 37 inches BP: 130/86 Pulse: 90 Respiration: 18/min Chief Complaint: Routine physical, prompted by family members' cancer diagnoses
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Medical History: Hypertension (controlled with medications), cholecystitis, dyslipidemia. A family history of both parents having obesity, hypertension, dyslipidemia, and cancer (cervical-mother, colon-father). Question: Which of Ms. Castillo's health problems are likely to improve with a modest, intentional weight loss? 1. Hypertension: a reduction in medication use • Feedback: Correct. Weight loss has the potential to reduce the medication dosage she needs to control her hypertension. 2. Dyslipidemia • Feedback: Correct. Weight reduction is likely to improve her dislipidemia. 3. Risk for certain forms of cancer • Feedback: Correct. Obesity increases her risk for certain forms of cancer including breast and colon cancer, and weight loss will lower that risk. 4. Cholecystitis • Feedback: Correct. Weight loss has the potential to improve her cholecystitis, along with her cancer risk and dislipidemia and potentially, a reduction in her antihypertensive medication.
SUCCESSFUL TREATMENT
Providers play a key role in supporting significant patient weight loss through coordinated efforts to ensure delivery of:
• Evidence-based interventions and treatments (Jensen et al., 2013) • Appropriate referrals The Evidence • Behavioral interventions produced more weight loss (1.2 to 4.6 kg) than no interventions in randomized controlled trials conducted in a primary care setting (Wadden et al., 2014). • Increasing the number of weight-loss treatment sessions was associated with greater mean weight loss (Wadden et al., 2014). At least twice per month is best (Jensen et al., 2014). • Treating overweight and early obesity prevents the metabolic adaptations of chronic obesity that make losing weight more difficult (Ochner et al., 2015). The U.S. Preventive Services Task Force concluded from a review of the evidence that physician and other healthcare provider interventions, repeated over time and as a part of intensive
Page 13 of 54 June 14, 2018 Update – Module 2 Overview of Obesity Medicine www.obesity.ClinicalEncounters.com Impact Obesity v1 multi-component behavioral interventions, are effective in supporting weight loss (USPSTF, 2012). Comprehensive, long-term treatment makes a difference. PRACTICE TIP Make a Referral for Regular, Long-Term Behavioral Support Providers can take an active role in making referrals for the recommended behavioral support in weight loss attempts. The behavioral referral may be to:
• a medical or commercial weight-loss program • a support group • one-on-one counseling with a trained interventionist, such as a dietitian A coordinated effort can mean positive outcomes for your patients.
QUIZ: EFFECTIVENESS OF INTERVENTIONS For each potential weight management intervention, select whether there is evidence to support its effectiveness in producing sustained weight loss or not. Make your selection by clicking on each drop down menu: 1. Most fad diets • Feedback: Not Effective. Most fad diets are effective in the short-term, but do not produce sustained weight loss. 2. FDA-approved weight-loss medications without a weight-loss diet • Feedback: Not Effective. FDA-approved weight-loss medications produce a modest increase in weight-loss of around 5% when used in conjunction with a weight-loss diet and exercise (Apovian et al, 2015). They are not effective by themselves. 3. Behavioral interventions in primary care • Feedback. Effective. Behavioral supports produce an average of around 3.2 kg weight loss when added to weight-loss diets (Johnston, 2014). More treatment sessions were associated with greater mean weight loss (Wadden et al., 2014). 4. Restricted calorie diet, increased physical activity, and behavioral supports • Feedback: Most Effective. A combination of any restricted calorie diet or restricted carbohydrate diet, increased physical activity, behavioral supports, and (for some patients with greater severity) adjunctive treatments result in the most successful weight loss (Jensen et al., 2014). Each treatment contributes additional weight loss (Johnston et al, 2014), so this choice, combining the treatments, is the most effective of the ones listed. 5. Low carbohydrate diet • Feedback: Effective. In a major meta-analysis of multiple weight-loss programs, significant weight loss was found to be achieved with low-carbohydrate or low-fat diets (Johnston et al., 2014).
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MOTIVATING PATIENTS Patient education is not enough to facilitate patient weight loss. Patients may also need interventions to help motivate them to take steps toward weight loss or gain confidence that they can succeed. The counseling technique, Motivational Interviewing, can be adapted for brief counseling of patients on their weight problems (Miller & Rollnick, 2012). The four basic steps are: 1. Engaging the patient: It is important to spend time on basic rapport building before bringing up the topic of weight. For example, convey that you care about the patient and are interested in them as a person. Weight is a sensitive topic for many people. When you connect with them, they will be much more responsive. Provider: It's been a while since I've seen you. What's been going on in your life? 2. Focusing: Bring up the topic of their weight. Relating it to their main health concerns is often an affective approach. Next work with the patient to focus on a subtopic, for example, one that they are ready to address or that has particular importance for their health. Provider: I am concerned because your BMI is higher than is healthy. The excess weight is probably contributing to your high blood pressure and cholesterol. Can we talk about that? 3. Evoke/Elicit: Ask them questions to evoke feelings and elicit their thoughts on topics related to their weight. Provider: How does your weight affect your daily life? Provider: What do you think got in the way last time you tried to stay on a weight-loss plan? 4. Plan: Work with the patient to come up with a plan to move toward a lifestyle change promoting healthy weight. Consider the individual patient's history, health, and interests. Provider: What steps would you be willing to take of the possible healthy changes we have been discussing? (Miller & Rollnick, 2012)
FOCUS: RAISING PATIENT AWARENESS
Many patients may not be aware that they are overweight. It may be because:
• They may have gained a few pounds each year without noticing. • They may be in denial of their excess weight, due to weight being an emotionally-charged issue.
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• Some cultural groups are accepting of overweight/obesity, or may even consider it attractive. • Some patients are aware of their excess weight, but not aware of the potential consequences. Poor Awareness of Personal Weight Problem Is Common • On the average, people overestimated their previous weight when asked about past year weight change in one study (Wetmore, 2012). Their estimates would have them gaining less weight than they actually gained. Some subjects even reported a weight loss when they actually had gained weight!
CONCLUSION: On average, self-reports of weight are not accurate and many people are in denial about their weight gain.
• Over half of Americans, especially men, said they do not think they are overweight in 2011- 2013 Gallup polls (Wilke, 2014). However, the reality is that around 2/3 of Americans are overweight or obese (Ng et al., 2014).
CONCLUSION: Many people who are overweight or obese do not realize it. Ideas for Raising Patient Awareness Some ways to help raise patient awareness of weight problems and address denial include:
• Recommend regular home weight checks, at least weekly, and comparisons to a weight range that you recommend. • Recommend paying attention to how clothes fit. • Educate patients who are relatively earlier in the disease process that there is a symptom-free period of obesity-related comorbidities. • Offer empathy and understanding. Tell the truth in a caring way. Do not use shaming tactics. Keep in mind, however, that only a subset of overweight/obese patients are not aware of their weight problem. Many people are well aware of their weight problem and often have already struggled with weight loss for many years.
EVOKE PATIENT MOTIVATION Basic Motivational Topics To Discuss Three quick questions can help you understand where your patient stands with respect to attempting weight loss. Elicit from the patient one or more of the following according to how much time you have: 1. Importance: How important is weight loss to them? 2. Confidence: How confident are they that they can make the necessary lifestyle changes? 3. Readiness: How ready are they to make the changes? PRACTICE TIP Worried that time limitations in your practice will prevent you from implementing motivational interventions? Using even one motivational technique at each appointment can make a difference. Obesity is a chronic condition, so the motivational dialogue could be viewed as a conversation you have over a long period of time.
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ELICITING STAGE OF CHANGE, CONFIDENCE, AND IMPORTANCE Brief interventions for obesity are best approached by identifying the following characteristics of a patient:
• Importance of weight loss to the patient • The patient's readiness to lose weight • The patient's confidence in their ability to succeed in a weight-loss attempt Patients Not Ready for Change Patients who are not ready to change can have interventions that focus on helping them move to the next stage of change by:
• Increasing hope • Building self-confidence • Exploring their personal barriers Even if a patient is not ready to lose weight, changes that will eventually support weight loss can be the current focus. For example, patients could keep a food diary to start becoming aware of eating patterns and motivations. The module, "Motivating Patients to Lose Weight," in this activity further explains how to use motivational interviewing with patients for weight management.
QUIZ: MOTIVATING MS. CASTILLO
Patient Name: Gloria Castillo Age: 50 y/o Height: 5' 4" Weight: 195 lbs BMI: 33.5 kg/m2 Waist: 37 inches BP: 130/86 Pulse: 90 Respiration: 18/min Chief Complaint: Routine physical, prompted by family members' cancer diagnoses Medical History: Hypertension (controlled with medications), cholecystitis, dyslipidemia. A family history of both parents having obesity, hypertension, dyslipidemia, and cancer (cervical-mother, colon-father). Question: What would be a good approach to discussing weight loss with Ms. Castillo? 1. On a scale of 1 to 10, 10 being the highest, how important is making this health change to you? • Feedback: Correct. This is a good approach to determine Ms. Castillo's stage of change. Provider: On a scale of 1 to 10, 10 being the highest, how important is making this health change to you?
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Ms. Castillo: It's very important, a 10.
2. Based on your past experience, how successful do you think you'll be in losing weight this time, on the scale from 1 to 10? • Feedback: Not the best choice. Framing questions in a negative manner by reminding her of past weight-loss failures can decrease the motivation of the patient and harm their overall chances of success. Provider: Based on your past experience, how successful do you think you'll be in losing weight this time, on the scale from 1 to 10? Ms. Castillo: Well, I wasn't successful in the past, so if that's an indicator I guess I'd rank it down to about 3.
3. How confident are you that you can make this important health change, on the scale from 1 to 10? • Feedback: Correct. This is a good way to determine Ms. Castillo's confidence level in making this change. Provider: How confident are you that you can make this important health change, on the scale from 1 to 10? Ms. Castillo: I've tried to make health changes before, but this time feels different. I'd say my confidence is at a 6.
4. It's clear that this change is very important to you and the confidence is there. Are you ready to do this? On a scale of 1 to 10? • Feedback: Correct. This is a good way to determine how important weight loss is for Ms. Castillo. Provider: It's clear that this change is very important to you and the confidence is there. Are you ready to do this? On a scale of 1 to 10? Ms. Castillo: Very much! My readiness is a 9.
INITIAL WEIGHT-LOSS GOALS
How Much and How Fast? How much weight? A modest initial goal of approximately 5 to 10% of current body weight is often recommended to achieve metabolic improvement or reduce cardiovascular risk (Jensen et al., 2013). Improved medical test results can provide an interim reinforcement that helps sustain motivation when weight loss is not yet very evident by physical observation. If Ms. Castillo's goal is to lose 5% of her weight, and she now weighs 195 lbs, she will have a goal to lose approximately 10 lbs. initially. How fast? A moderate pace of 1 to 2 lbs per week is often recommended (Jensen et al., 2013). See, however, the exception for morbid obesity described below.
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If Ms. Castillo loses weight at a rate of 1 lb per week, she will have reached her interim weight-loss goal in 10 weeks, which is a little over two months. After acknowledging the significance of that success, another goal can then be set for further weight loss and even greater health benefits. Rationale for Slow and Steady Weight Loss Reasons for losing weight slowly include the following:
• Rapid weight loss is almost always followed by regain of weight – often more weight than was lost. Weight re-gain is associated with negative mental and physical health consequences. In contrast, slow, steady weight-loss that allows time for integrating new behavior patterns better supports sustained weight loss (Jensen et al., 2013). • Moderate, sustained weight loss can significantly decrease the severity of obesity-related comorbidities. Even a weight loss of 3 to 5% of body weight results in measurable improvements, such as reductions in: • triglycerides • blood glucose • HbA1c • risk for type 2 diabetes
for patients in whom these were elevated (Jensen et al., 2013).
• Losing and maintaining a moderate weight loss is better than losing a larger amount and regaining it. Morbid Obesity Exception to Slow Weight Loss: In the case of very high BMI or morbid obesity, rapid weight loss is often important in order to achieve functioning and reduce medical risk rapidly. These patients may be placed on very low calorie, very low carbohydrate, or protein sparing modified fast diets initially. These diets require nutritional supplementation and medical supervision. Meal replacements or weight loss surgery may be part of this strategy.
PROBLEMATIC DIETARY PATTERNS
Typical American Diet Is Part of the Problem
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The typical American diet is too high in sugars and other carbohydrates and saturated and manufactured trans fats and partially hydrogenated fats, and too low in vegetables and other fiber (USDA, 2015). This diet is inexpensive and convenient, but can lead to obesity, diabetes, cancer, heart disease, and stroke (USDA, 2015). Foods Consumed in Too High Quantities In addition to total calories, the following food groups are consumed in excess, contributing to obesity. Each overweight or obese patient could be interviewed regarding their intake of the following: 1. Sweet beverages and other sweets:
• Added sugar is a major component of the snacks and beverages in the typical diet. Sugary beverages and juices account for 47% and snacks and sweets account for 31% of added sugars (USDA, 2015). • Concentrated sugar: Even 100% fruit juice is problematic, because it contains almost as much sugar as sweetened sodas, about 45.5 vs. 50 grams per liter (Walker et al, 2014). Recommend that patients eat whole fruits, around 2 per day, rather than drink juices. Requirements: There is no physiological need for added sugar or concentrated fruit sugars. 2. Trans and saturated fats:
• Trans fats or partially hydrogenated fats that are manufactured and added to foods should be avoided completely due to health risks; so any consumption is too high. Although trans fats have been reduced in many processed foods, they are still being consumed in harmful quantities (USDA, 2015). The Dietary Guidelines for Americans recommend that patients look for and avoid trans or partially hydrogenated fats in food labels or, more simply, avoid processed foods. • Saturated fats: Saturated fats typically comprise around 11% of energy intake (Wells & Buzby, 2008) and the current USDA recommendation is less than 10 percent of calories per day from
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saturated fats (USDA, 2015). However, the American Heart Association recommends limiting saturated fats to 5 to 6% of total energy for cardiovascular health (AHA, 2014). Some recent research suggests that dairy saturated fats may support weight loss (Rautiainen et al, 2016), reduce risk of diabetes (Yakoob et al, 2016), and reduce cardiovascular risk (Chowdhury, 2014; de Souza RJ, 2015). However, there is some disagreement as to whether people should increase high fat dairy intake: Current Dietary Guidelines do not recommend adding dairy fat to the diet (USDA, 2015). Recommend that patients reduce saturated fats that are found in less healthy foods by not eating less-nutritious snacks or fried foods containing these fats. Requirements: Around 20 to 35% of total calories should come from fats and oils, primarily from the more healthy monounsaturated and polyunsaturated fats (USDA, 2015). Weight loss diets should not dip below 20% fat in order to meet basic nutritional needs and to feel sated. Recommend replacing unhealthy fats with healthy sources, such as nuts, avocados, and seeds and increasing intake of foods with omega 3 fatty acids, such as many fish and leafy green vegetables. 3. Processed foods: The typical diet contains too many processed foods (USDA, 2015). The added sugar, trans fats and partially hydrogenated fats make these foods higher in nutrient-poor calories and cause other health problems. Recommend avoidance or at least careful reading of food labels. Foods Consumed in Too Low Quantities 1. Vegetables: On average, Americans are not getting the recommended 3 cups (or 5 servings per day) for an average, moderately-active adult (USDA, 2015). Vegetables contribute a sense of fullness without adding excessive calories. 2. Whole grains: The typical diet often does not meet the recommended levels for whole grains (USDA, 2015). They also contribute a sense of fullness. Making these recommended dietary changes may also affect gut microflora and food absorption and transit time, which are among areas being researched currently in weight management. PRACTICE TIP Some patients may "know" all this already from watching the news. However, knowing is not "doing." Applying this knowledge is key. Try reviewing the food a patient ate at their last three meals and snacks in light of this information.
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THE SUGAR PROBLEM
The typical American diet includes approximately 22 to 30 teaspoons (352-480 calories*) of added sugar daily (USDA, 2015; Johnson et al., 2009). High sugar consumption contributes to obesity, type 2 diabetes, heart disease, cancer growth, and other chronic disease. For good health, no more than 10 teaspoons (USDA, 2015) of added sugar per day is recommended by the USDA (2015). The American Heart Association recommends even less added sugar: 6 tsp per day for women/9 tsp for men (Johnson, 2009). For weight loss, this amount should be decreased. Sugar-Sweetened Beverages Sodas account for most of the added sugar that comes from sugary beverages (25%), followed by fruit drinks that are not 100% juice (17%) (USDA, 2015). A 20-ounce soda typically contains more than 240 calories, mostly from sugar. When patients drink their calories, they are not likely to feel as full as if they had consumed the same amount of calories from solid foods (Pan & Hu, 2011). People also do not typically compensate for drinking sweet beverages by eating less and so they contribute to weight gain. Sugary drinks include sodas, sports drinks, energy drinks, juices, sweetened teas and coffee drinks. Hidden Sugar Is Common! Many popular food items contain a surprising amount of added sugar, for example:
YOGURT
Yogurt can contain 17-33 grams (4-8 teaspoons) of sugar per 8-ounce serving. (The equivalent of a cup of chocolate ice cream) (Magee, 2014).
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BREAKFAST CEREALS
Many healthy-sounding, popular oat, corn, and bran cereals contain 10-20 grams of sugar (2-5 teaspoons) per cup (Magee, 2014).
PASTA SAUCES
Most pasta sauces have 6-12 grams (1-3 teaspoons) of sugar per half-cup serving. (The equivalent of a chocolate chip cookie) (Magee, 2014).
ENERGY DRINKS
Most contain about 25 grams (about 6 teaspoons) of sugar per 8-ounce serving, in addition to the caffeine (Magee, 2014). 1 teaspoon of sugar = 4 grams of sugar 1 teaspoon of sugar ~ 16 calories
POLL: WHAT DIETS DO YOU SUGGEST FOR WEIGHT- LOSS TO YOUR PATIENTS? Responses: 1. Low Calorie • 19% (51 votes) 2. Low Carbohydrate • 31% (84 votes) 3. Low Fat • 3% (8 votes) 4. High Protein
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• 5% (13 votes) 5. Menu Based, e.g., DASH, Mediterranean (Weight loss versions of these diets) • 30% (80 votes) 6. Meal Replacement Based • 2% (6 votes) 7. Other Dietary Changes • 6% (17 votes) 8. None • 3% (8 votes)
EFFECTIVE DIETARY CHANGES Evidence shows that many types of dietary plans are effective for weight loss, as long as an energy deficit is created (Jensen et al., 2014).
• Calorie reduction is the basic recommendation. However, counting calories may be too laborious for some and is often done inaccurately. Alternative approaches include: • Food substitutions • Portion control • Pre-made meals • Dietary plans with prescribed menus • Technology to keep track of calories and foods eaten • Low carbohydrate diets are more effective than calorie restriction in early weight loss (first 6 months) and in reducing blood sugar (Yamada et al., 2014). A variant in combination with adequate protein, "Ideal Protein", may be more effective at weight loss and improving metabolic disease (Logeman T. et. al., 2014). Very low carbohydrate diets have more medical risks and therefore require medical management, but produce more rapid weight loss. • Lower fat diets also reduce energy intake. This approach might be a good choice for someone who eats exceptionally high levels of fat. A lifelong change to a healthy level of fat (around 20 to 35% of daily energy intake — USDA, 2015) should be the goal, rather than a level lower than is recommended or than a temporary lower level of fat. Too low a level of fats can affect satiety (Kim et al, 2011) and too low a level of polyunsaturated fats appears to increase mortality risk (Wang et al, 2016). Patients on lower-fat diets should:
• Eat enough fats to avoid intolerable hunger • Eat relatively healthy fats, such as monounsaturated fats, polyunsaturated fats, and omega 3 fatty acids. • Be careful about how many and what carbohydrates are added (Harcombe et al., 2015). Add lean proteins and only add carbohydrates that are relatively higher in fiber and nutrient-rich, such as vegetables and beans to replace the fat.
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• Certain other diets, such as the DASH diet (NES, 2013) and the Mediterranean diet (Estruch, 2013), are effective in managing weight-related comorbidities, such as hypertension, cardiovascular disease, and type 2 diabetes. They also decrease all-cause mortality. Each of these diets can be adapted for weight loss by restricting total caloric intake. DID YOU KNOW? An emerging area of research to watch are the gut hormones and bacteria and how they may be modified by diet to impact obesity (Wallis, 2014).
CALORIE REDUCTION FOR WEIGHT LOSS How to Achieve Slow, Steady Weight Loss
The Calculations: 3500 calories equals about a pound of fat. Therefore, losing one pound in a week requires a reduction of 500 kcal/day (500 kcal/day X 7 days = 3500 kcal). A reduction of 500 to 1000 calories per day (kcal/day) would achieve one to two pounds of weight loss per week for most people, if other factors did not come into play*. Around 2 pounds per week is the recommended rate of weight loss recommended by the USDA guidelines (USDA, 2010). However, weight loss approaches for moderate to very obese individuals, such as meal substitutions as part of a medically supervised very low calorie diet, often start with a period of more rapid weight loss. In later modules we will explain some of the complex reasons why a reduction of 3500 calories per week does not continue to produce the expected weight loss. MS. CASTILLO, who wants to lose 1 lb. per week, currently maintains a weight of 195 lbs. by consuming roughly 2200 calories per day. The calculation for Ms. Castillo to lose 1 lb. per week is as follows:
2200 cal. − 500 cal. = 1700 cal. Therefore, to lose one pound per week, Ms. Castillo would need to reduce her daily calorie intake to 1700 cal./day. Possible Recommendations Below is an example of how Ms. Castillo can eliminate 500+ calories from her daily diet by making smarter choices. Current Dietary Choice New Dietary Choice Net Change • 8 oz. fruit low-fat yogurt • 8 oz. plain nonfat yogurt • Lower-fat yogurt
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Current Dietary Choice New Dietary Choice Net Change • ½ cup granola • ½ cup low-fat granola • Lower-fat granola Calories: 540 cal Calories: 320 cal Deficit: −220 cal • 20 oz. regular soda • 20 oz. water • Substituted beverage • candy bar • baked potato chips • Substituted snacks Calories: 465 cal Calories: 120 cal Deficit: −345 cal
Old total: 1005 cal New total: 440 cal Total Change: −565 cal
CHANGING DIETARY HABITS
MR. SMITH When not eating out and enjoying a mug of beer, Mr. Smith often eats processed food snacks and eats few vegetables or fruits. What changes can he make to his regular diet in order to lose weight and improve his overall health at the same time? Effective Dietary Patterns From the perspective that weight loss depends on taking in fewer calories than are expended, a calorie is a calorie. Reducing calories, whether fat, carbohydrate, or protein, will result in weight loss. However, eating patterns are also important. For example, the combinations of food eaten contribute to producing feelings of satiety after consumption. Recommendations The Dietary Guidelines for Americans 2015-2020 (USDA, 2015) recommended that Americans eat in balanced, healthy patterns. Based on a review of dietary patterns that are associated with healthy body weight (lower body fat, waist circumference, BMI), they concluded the following:
GUIDELINES FOR CHANGING DIETARY HABITS FOR WEIGHT LOSS The Dietary Guidelines for Americans 2015-2010 recommendations are as follows: INCREASE CONSUMPTION OF
• Fruits • Vegetables • Whole grains • Unsaturated fats
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MODERATE CONSUMPTION OF
• Alcohol • Dairy Products DECREASE CONSUMPTION OF
• Red meats • Sugar-sweetened foods • Saturated fats • Sodium • Refined grains Weight-Related Reasons to Limit Alcohol Use Mr. Smith and other people trying to lose weight should limit their alcohol intake because:
• Alcohol contains all empty calories (7 calories per gram of pure alcohol) (Stark, 2004). • The intoxicating effects of alcohol predispose people to overeat because of lowered inhibitions. Further, alcohol can slow metabolism, result in hypoglycemia, and impair gastrointestinal absorption of nutrients (Brust, 2010).
CHANGING PORTION SIZE Calorie Reduction Without Counting Calories Reducing portion size is one of several ways you can recommend to patients for reducing energy intake without counting calories. Another is having a low calorie, relatively healthy food instead of a higher calorie food. Portion Sizes Have Increased
In the U.S., average portion sizes have increased dramatically over the last several decades. In the past twenty years, bagels have doubled in size, from 3 inches in diameter (140 calories) to 6 inches in diameter (350 calories). In the same amount of time sodas have tripled in size, from 6.5 ounces (82 calories) to 20 ounces (250 calories) (NHLBI, 2013a). Compare Portion Size to Common Objects Visual Examples Of Single Servings
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Fish or lean meat is A pancake is the size Cheese is the size of Fruit or vegetables is the size of a deck of of one compact disc your thumb (from tip to the size of your fist cards (CD). base) (WebMD, 2014) Keep on hand objects that approximate the size of a single portion, such as a deck of cards or CD, to illustrate your discussion. Tips for Decreasing Portion Size Suggest that, rather than eliminating favorite foods, patients eat smaller portions of them (NHLBI, 2013b).
• Encourage patients to measure their portions and compare them to a standard you help them select. • Using a smaller plate can help reduce portion size. The module, "Dietary Recommendations for Patients and Referral to Dietitians," in this activity describes this in greater detail.
QUIZ: MR. SMITH'S DIETARY CHANGES Patient Name: Martin Smith Age: 55 y/o Height: 5' 4" Weight: 210 lbs BMI: 36.0 Waist: 41 inches BP: 140/90 Pulse: 110 Respiration: 19/min Chief Complaint: Slightly concerned about his weight Medical History: Hypertension (controlled with medications), high cholesterol. Question: Mr. Smith acknowledges frequently enjoying a beer or two. Reducing alcohol consumption can be helpful in reducing weight, because alcohol (Choose all that apply): 1. Improves gastrointestinal absorption of nutrients. • Feedback: Incorrect. Alcohol consumption impairs gastrointestinal absorption of nutrients (Brust, 2010). 2. Contains all empty calories. • Feedback: Correct! Alcohol contains all empty calories (7 calories per gram of pure alcohol and few nutrients) (Stark, 2004). 3. Speeds up metabolism. • Feedback: Incorrect. Alcohol consumption can slow metabolism (Brust, 2010). 4. Can result in hyperglycemia. • Feedback: Incorrect. Excess alcohol consumption can result in hypoglycemia (Brust, 2010).
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PHYSICAL ACTIVITY AND WEIGHT
How much does exercise contribute to weight loss? Exercise indirectly supports weight loss by helping to improve mood and sleep and is critical for maintenance of weight loss. It also has important effects on weight-related comorbidities by reducing the risk of heart disease and increasing glucose sensitivity of peripheral tissue. However, the amount of weight loss from exercise may not be as much as previously thought, because exercise increases hunger and therefore may increase caloric intake. Furthermore, exercise increases muscle mass which, in turn, decreases the percentage of body fat, which, in addition to weight loss, also has health benefits. Overall, however, studies of exercise as a treatment in overweight or obesity lasting 3 months to 12 months have shown evidence that there is some net benefit for exercise in terms of weight loss:
• Physical activity supports weight loss, but the amount is generally small from exercise alone (Shaw et al., 2006, Dachs, 2007). • More frequent and more intense activity is more effective (Wadden, 2006).
ACTIVITY GUIDELINES FOR HEALTH AND WEIGHT MAINTENANCE GUIDELINES FOR PHYSICAL ACTIVITY
For health, adults need at least:
• 150 minutes of moderate-intensity – OR – 75 minutes of vigorous-intensity aerobic activity/week • Muscle-strengthening on 2 or more days/week of all muscle groups (Physical Activity Guidelines for Americans. USDHHS, 2008)
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Most patients need to increase their activity level to meet the above guidelines:
of adults do NOT meet the U.S. recommendations for physical activity of 150 minutes per week (USDHHS, 2010). Recommendations for Reducing Sedentary Behavior Additionally some guidelines recommend as much as 2 hours of general movement (ideally 4 hours) during a sedentary work day (Buckley et al., 2015). Interrupting long sedentary behavior significantly decreased the higher mortality rate compared to those who continued sedentary behavior throughout a workday (Beddhu et al., 2015). As little as 2 minutes of movement per hour made a difference. Sedentary time should be limited; some researchers recommend no more than 2 hours per day of recreational screen time (Tremblay et al, 2011). Recommendations for Activity Within a Weight-Loss Plan Considering their medical condition and current level of conditioning, people who are obese can start with a goal of a small increase in physical activity. They can continue to increase activity incrementally until they at least reach the recommended level. As patients build exercise tolerance, their mobility will improve, allowing them to progress toward a healthy level of physical activity. Encourage a life-long change to follow recommendations for healthy levels of activity. Advise patients that activity is very important for weight-loss maintenance.
QUIZ: PHYSICAL ACTIVITY RECOMMENDATIONS The USDHHS guidelines for physical activity of 150 minutes per week of moderately intense activity – OR – 75 minutes per week of intense activity: 1. Produce significant weight loss in people who are obese. • Feedback: Incorrect. The USDHHS guidelines described are the level recommended for all people for optimal health. Physical activity alone without diet change actually results in just a small weight loss. This much exercise or more is important for maintenance of weight loss. Exercise also reduces risk of cardiovascular disease and improves glucose sensitivity, and thus improves several weight-related comorbidities. 2. Provide a healthy guideline for intentional physical activity (exercise) for all individuals. • Feedback: Correct. The USDHHS guidelines described are the level of intentional physical activity recommended for all people for optimal health. 3. Both of the above. • Feedback: Incorrect. The USDHHS guidelines described are the level recommended for all people for optimal health. Physical activity alone without diet change actually results in just a small weight loss. This much exercise or more is important for maintenance of weight loss. Exercise also reduces risk of cardiovascular disease,
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improves glucose sensitivity, improves mood, and improves sleep and thus improves several weight-related comorbidities.
REFERRALS FOR SUPPORT Patients who are at least moderately overweight (BMI ≥ 27) or more, or have had past attempts at weight loss that failed, should have behavioral supports to achieve weight loss. Consider a referral to a counselor or weight-loss program according to the following guidelines: GUIDELINES FOR WEIGHT-LOSS BEHAVIORAL SUPPORTS • Prescribe on-site, high-intensity (i.e., ≥14 sessions in 6 mo) comprehensive weight-loss interventions provided in individual or group sessions by a trained interventionist. – and/or – Select a weight loss program that helps participants adhere to a lower-calorie diet and increased physical activity, also at high intensity (i.e., ≥14 sessions in 6 mo). • Prescribe face-to-face instead of electronically delivered (via internet or telephone) interventions when possible, because face-to-face interventions result in greater weight loss, on average. (Jensen et al., 2014) Note that single visits to a dietitian are not sufficient. The evidence strongly suggests that low to moderate lifestyle interventions by primary care practices alone are also not sufficient, on average (Jensen et al., 2014). Consider referral to a physician specializing in Obesity Medicine, especially when first line treatments have been unsuccessful or there are significant comorbidities/limitations or severe obesity. For a current list of American Board of Obesity Medicine Diplomates, see abom.org. PRACTICE TIP Physicians or designated staff can provide behavioral support in weight loss or make a referral for this purpose (e.g., a registered dietitian or a cognitive behavioral therapist or comprehensive weight- loss program).
COUNSELORS AND DIETITIANS A basic understanding of what happens in counseling for weight loss can help you prepare patients to accept a referral. Additionally, you might be able to apply some of the techniques used in counseling with your patients. Behavioral Interventions and Cognitive Behavioral Therapy
Behavioral and cognitive behavioral therapy (CBT) can add to the effectiveness of weight loss efforts when part of a multi-component treatment (ADA, 2009). They are more effective than patient education.
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In behavioral therapy, simple behavior changes or use of tools leading to weight loss are taught and rewarded. CBT teaches patients to change their thinking, which in turn supports a change in mood and behaviors leading to weight loss. EVIDENCE
Research on behavioral and CBT counseling for weight loss has found that:
• Counseling is most effective when it is long term, lasting around 6 months (Jensen et al., 2014). • Counseling interventions are most effective when they include a variety of components (ADA, 2009). Potential components include keeping a food diary, problem-solving, or finding alternative ways for coping other than over-eating. Dietitians Patients can work with a registered dietitian (RD) to tailor a healthy eating plan to their preferences (ADA, 2014). Research supports the effectiveness of working with an RD; in one study, subjects receiving counseling with an RD were twice as likely to have significant weight loss (Bradley, 2013). RD services can be billed as a Medicare annual wellness visit, intensive behavioral therapy for obesity, or Medical Nutrition Therapy. The latter is reimbursable in the treatment of chronic conditions, including overweight/obesity and many of its comorbidities (Jortberg, 2013).
WEIGHT-LOSS PROGRAMS Weight-loss programs are important for providing additional structure and support for people trying to achieve their weight-loss goals. Typically, anyone who is at least moderately overweight (BMI of at least 27) would likely do better with a weight-loss program than dietary or physical activity change alone. Long-term (6 months) involvement with a behavioral support is a critical component of effective weight-loss treatment (Jensen et al., 2014). Medical Center Programs Many hospitals and medical centers offer long-term (spanning weeks), intensive weight-loss programs that vary in their intensity and level of involvement. In addition to the basic diet, exercise, and counseling support, many of these programs involve bariatric surgery. Another type of program involves very low-calorie meal replacements along with a comprehensive weight-loss program and medical evaluation. Commercial Programs Some commercial-based programs may be appropriate intervention options, as long as there is peer- reviewed, published evidence of their safety and efficacy (Jensen et al., 2014). The approach of these programs varies, ranging from meal replacements to prescribed diets. Most weight-loss programs provide some form of social support. The rate of weight loss recommended also varies, from a long and slow approach to rapid weight loss. Programs with rapid weight loss often involve very low calorie diets, typically with meal replacements (requires medical supervision).
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One commercial program (Weight Watchers) was found to be more effective than self-help in a research trial (Johnston et al., 2013). More research is needed on the effectiveness of these groups. Although weight-loss programs can be costly, several commercial weight-loss programs can now be claimed as deductible medical expenses for tax purposes when prescribed as treatment.
QUIZ: MR. SMITH - REFERRAL FOR BEHAVIORAL SUPPORT
Patient Name: Martin Smith Age: 55 y/o Height: 5' 4" Weight: 210 lbs BMI: 36.0 Waist: 41 inches BP: 140/90 Pulse: 110 Respiration: 19/min Chief Complaint: Slightly concerned about his weight Medical History: Hypertension (controlled with medications), high cholesterol. Question: Having counseled Mr. Smith on diet and exercise, his provider is ready to make a referral for behavioral supports. Which of the following is the *minimum* intervention that will be effective, according to the evidence? (Assume that every choice applies evidence-based type support for following diet and exercise recommendations for weight-loss.) 1. At least one session with a dietitian. • Feedback: Incorrect. A dietitian referral is a good choice in order to provide behavioral support. However, it needs to be intensive, that is, at least twice per month for at least 6 months. 2. A medical weight loss program with meal substitutes that includes six support group sessions of one hour each. • Feedback: Incorrect. A medical weight loss program with meal substitutes may be a good choice for him and the six support group sessions are probably better than nothing, however, the minimum effective support is intensive, which means at least twice per month for at least 6 months. 3. Private cognitive behavioral counseling focused on weight loss for six sessions. • Feedback: Incorrect. Private cognitive behavioral counseling focused on weight loss and six sessions are probably better than nothing, however, the minimum effective support is intensive, which means at least twice per month for at least 6 months. 4. A weight-loss support group run by a licensed clinical social worker specializing in weight loss, meeting every week for 6 months. • Feedback: Correct. A weight loss support group run by a licensed clinical social worker specializing in weight loss meets the requirements for an effective weight loss support, as do all of the above approaches, as long as they apply evidence-based supports for
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following diet and exercise. However, only this choice is correct, because it is intensive enough, that is, it meets at least twice per month and for 6 months.
ADJUNCTIVE TREATMENTS
Adjuncts to Weight Loss Treatments For patients with relatively higher body mass, especially with weight-related comorbidities, adjunctive treatments of pharmacotherapy or bariatric surgery are effective in supporting weight-loss efforts (Jensen et al., 2014). Weight loss management guidelines indicate the following BMI cutoffs for recommending these treatments: Cut points for Adjunctive Treatments
Pharmacological treatment Consider when BMI is ≥ 30 kg/m2 (or ≥ 27 with weight-related comorbidity)
Bariatric Surgery Consider when BMI is ≥ 40 kg/m2 (or ≥ 35 with weight-related comorbidity) (According to AHA/ACC/TOS guidelines - Jensen et al., 2014) How Many Patients Need Pharmacotherapy or Surgery? Following the obesity management guidelines for when to add adjunctive treatments (Jensen et al., 2013) and considering current rates of obesity (Yang & Colditz, 2015): 2 • Around 36% of U.S. adults meet the cut point of (BMI ≥30 kg/m ) for weight- loss pharmacotherapy. This number would be increased by the percentage of overweight patients, who have a BMI over 27 and a significant comorbidity. 2 • 6% of U.S. adults are candidates for bariatric surgery by virtue of having a (BMI ≥40 kg/m ). This number would be increased by the percentage of obese patients, who have a BMI of 35 to 40 along with a significant comorbidity. PRACTICE TIP Adjunctive treatments do not replace lifelong and comprehensive lifestyle change. Dietary and physical activity lifestyle change is needed. The lifestyle change still needs to be supported through a structured weight-loss program or other behavioral support and continued medical follow-up.
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PHARMACOTHERAPY When to Consider Pharmacotherapy for Weight Loss In addition to the requirement to be obese (BMI ≥30) or moderately overweight (BMI ≥27) with a weight-related comorbidity, the patient should have the following characteristic to consider weight-loss pharmacotherapy:
• Willing to take the medication in addition to a reduced-calorie diet and increased exercise • Has a realistic understanding of potential weight loss with medication • Has been unable to lose weight despite serious attempts at diet, exercise, and behavioral changes • Not pregnant or breastfeeding (Jensen et al., 2013) Other Considerations Note that:
• Side effects are often experienced. • The mean weight-loss is fairly low and very low if the medication is stopped. However, while weight-loss medications only lead to a small weight reduction, the reduction can benefit health, especially cardiovascular risk factors and serum glucose. (Jensen et al., 2013). Pharmacotherapy is considered effective if weight loss of ≥ 5% of body weight is achieved by 3 months and it is well tolerated, it can be continued (Aprovian et al., 2015). If not, it should be discontinued. Payor coverage of weight-loss pharmacotherapy is highly variable, and patients may need to pay out of pocket for many of the current available agents.
FDA APPROVED PHARMACOTHERAPY The medications currently approved by the FDA for weight loss and their mechanisms of action are the following:
• Orlistat: Lipase inhibitor • Lorcaserin: Serotonin receptor agonist • Phentermine plus topiramate: Combination anorectic / anticonvulsant • Bupropion / naltrexone: Combination dopamine blocker plus opioid antagonist • Liraglutide: Glucagon-like peptide-1 agonist The module on the "Biology Underlying Obesity and FDA-Approved Weight-Loss Medications" in this program describes these medications and their risks and benefits in greater detail. Binge Eating Disorder In addition to counseling, binge eating disorder, which is fairly common among obese individuals (Myers, 2014), has been shown to respond to several medications: lisdexamfetamine, second
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• Lisdexamfetamine - Amphetamine
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QUIZ: PHARMACOTHERAPY FOR MR. SMITH?
Patient Name: Martin Smith Age: 55 y/o Height: 5' 4" Weight: 210 lbs BMI: 36.0 Waist: 40 inches BP: 140/90 Pulse: 110 Respiration: 19/min Chief Complaint: Slightly concerned about his weight Medical History: Hypertension, high cholesterol. Question: Mr. Smith wants to consider pharmacotherapy to help him lose weight. He has not yet attempted diet, exercise, or therapy for an extended period of time. Is he a good candidate for this type of treatment?
1. Yes, he meets enough criteria to consider pharmacotherapy as long as he also engages in a comprehensive weight loss plan that includes dietary change, exercise, and counseling/support. • Feedback: Correct. One of the considerations for using pharmacotherapy in weight loss is that the patient has been unable to lose weight despite serious attempts at diet, exercise, and behavioral changes and support and Mr. Smith does not meet this criteria. However, even though Mr. Smith has not yet attempted weight reduction through a comprehensive weight loss attempt, because of his comorbidities and high BMI, it might be beneficial to include pharmacotherapy in his treatment. 2. No, he has not yet explored all the options available for weight loss • Feedback: Partially correct. One of the considerations for using pharmacotherapy in weight loss is that the patient has been unable to lose weight despite serious attempts at diet, exercise, and behavioral changes. Since Mr. Smith has not yet attempted this, it would be beneficial if this route were taken prior to pharmacotherapy. However, if prescribing the medication gave him the boost he needs to see some weight loss in response to his efforts, it might be beneficial. 3. Try him on some pharmacotherapy alone to see if that helps him lose some weight. • Feedback: Incorrect. Pharmacotherapy for weight loss should only be used together with a comprehensive plan that includes dietary change, exercise, and behavioral changes and support.
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BARIATRIC SURGERY Benefits of Bariatric Surgery
Many people seek weight-loss surgery for the effects of improved appearance and physical functioning. However, other significant health benefits are achieved.
• Improved Weight-Related Comorbidities: The vast majority of common medical problems attributable to obesity are improved or resolved after weight-loss surgery, including: • Hypertension • Asthma • Peripheral Edema • Dyslipidemia • GERD • Sleep Apnea • Type 2 diabetes • Osteoarthritis • Stress Incontinence (Adams et al., 2010; Buchwald, 2004)
• Reduced Mortality: Reductions of 29% to 40% in long-term mortality rates have been reported post-surgically in comparison to matched controls not receiving surgery (Sjostrom, 2007; Adams 2007). Mortality from cancer and type 2 diabetes are particularly lowered.
• High Weight-Loss Success Rate if "success" is defined as losing a little over half of one's excess weight. The most common forms of weight-loss surgery on average produce 40% to 80% of excess weight lost at 1 to 2 years post-surgery (ASMBS, 2014, Callery, 2008). In years 2 to 4, there is typically a slow regain of weight to an average loss of 65% of the original excess weight (Callery, 2008). PRIMARY CARE ROLE IN SURGERY
Primary care providers play a vital role in:
• Identifying potential candidates for bariatric surgery. • Helping patients make informed choices about whether to follow the referral. • Providing post-surgical follow-up care of the bariatric patient, especially long-term. • Providing long-term follow-up care. Comprehensive care is essential for these patients long- term in order to achieve successful outcomes. Although follow-up with the bariatric surgeon is recommended, the reality is that many patients turn to primary care for follow-up treatment (Schneider, 2011). Providers need an understanding of how to follow patients post-surgically. It is essential to provide support for successful weight loss and to recognize and treat complications.
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PRACTICE TIP Weight-loss surgery increases, rather than decreases, the attention that the patient must focus on their diet and exercise – these changes must be lifelong. The success of weight-loss surgery is dependent on a careful, appropriate and regular lifestyle modification plan.
TYPES OF BARIATRIC SURGERY The types of bariatric surgery vary in terms of patient motivation and BMI required, amount of weight loss, amount of malabsorption, and risk of complications (Tucker, 2013; Fiore, 2013; Mechanick et al., 2013). These factors should all be discussed with patients. Laparoscopic surgeries are now far more common than open gastric bypass (Livingston, 2010). The procedures in order from most risk and side effects to least and from most weight loss to least weight loss are:
• BilioPancreatic Diversion (BPD)/Duodenal Switch (DS) or “long limb” Gastric Bypass - Restrictive + Bypass • Roux-En-Y Gastric Bypass - Restrictive + Bypass — Most weight loss and most risk • Vertical (Sleeve) Gastrectomy - Restrictive • Adjustable Gastric Band (Realize® and Lap-Band®) - Restrictive • Weight Loss Devices - Several devices have also been FDA-approved (FDA 2015, 2016): An implanted vagal blocking device, a gastric balloon temporarily inserted in the stomach, and a surgically implanted tube that is used to drain stomach contents. Weight-loss surgery is discussed in greater detail in our module on this topic, "Weight-Loss Surgery: Candidates, Concerns, and Long-Term Care." Review: BMI Criteria for Bariatric Surgery
• BMI ≥40 • BMI ≥35 with a significant weight-related comorbidity (Jensen et al, 2014; Tucker, 2013)
QUIZ: WHICH TREATMENT? Match the following patient with the treatment recommended by guidelines in addition to a calorie restricted diet and increased exercise. Make your selection by clicking on each drop down menu: Reference: 1. Deborah Stein - BMI 28, no comorbidities • Weight-Loss Programs or Counseling. According to guidelines, she is overweight and above the threshold of BMI=27 at which weight-loss group or counseling would be recommended (Jensen et al., 2014). 2. Jean Smith - BMI=30, hypertension and dyslipidemia • Weight-Loss Programs or Counseling, Weight-Loss Pharmacotherapy. According to guidelines she is above the threshold for pharmacotherapy of BMI=27 with weight- related comorbidities, BMI=30, even without weight-related comorbidities (Jensen et
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al., 2014). She is also above the threshold of BMI=27 for a weight-loss group or counseling. 3. John Dillinger - BMI+38, hypertension, dyslipidemia, and type 2 diabetes • Weight-Loss Programs or Counseling, Weight-Loss Pharmacotherapy, Bariatric Surgery. According to guidelines he is above the threshold for bariatric surgery of BMI=35 when there is a significant weight-related comorbidity. He also is above the threshold for the other treatments as well (Jensen et al., 2014). 4. Sally Roth - BMI=26, no comorbidities • None. Weight-loss diet and increased exercise is sufficient. According to guidelines, she is just overweight but below the threshold of BMI=27 at which weight-loss group or counseling would be recommended (Jensen et al., 2014). However, if she has struggled with diet and exercise and failed, a weight-loss support group or counseling would be indicated.
WEIGHT MANAGEMENT CLINICAL PROTOCOL: HISTORY AND EVALUATION Protocol Steps: These icons, found throughout this activity, mark clinical protocol steps to follow for patient weight management. The full list of all protocol steps to follow for weight management is presented below. Weight Management Protocol Assess Body Mass
• Assess weight and body mass index (BMI) • Assess waist circumference and classify "abdominal obesity" (≥ 40 inches men; ≥35 inches women). • Assess body composition. [Optional] 2 2 • Diagnose overweight (BMI≥25 kg/m ) and obesity (BMI≥30 kg/m ). • Classify severe (Class III obesity) (BMI≥40) or higher. The assessment of body mass is repeated at regular intervals (annually for people of normal weight, each appointment for active weight loss, monthly for early maintenance, graduated to every 6 months). The following protocol steps are for patients with a diagnosis of overweight (BMI≥25 kg/m2) or obesity (BMI≥30 kg/m2). These steps comprise a long-term protocol that is implemented over multiple patient visits, and continues as long as there is a weight problem. The maintenance protocol steps continue indefinitely. Medical Evaluations
• Complete a weight-focused medical history. • Evaluate for weight-related comorbidities. • Evaluate medications for weight-gain effects • Assess mobility for weight-related limitations. • Evaluate medical fitness for physical activity and discuss any restrictions.
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• Evaluate for medical conditions that could contribute to excess weight, including sleep disorders and eating disorders. • Evaluate for psychological disorders contributing to weight gain • Ideally, patients with symptoms of sleep apnea would be evaluated in a sleep study with polysomnography. Lifestyle Evaluations
• Complete diet screening. • Assess physical activity. • Assess sedentary behavior. • Evaluate for problematic eating patterns. • Evaluate for stressors contributing to excess weight.
WEIGHT MANAGEMENT CLINICAL PROTOCOL: TREATMENT AND REFERRAL Protocol Steps: These icons, found throughout this activity, mark clinical protocol steps to follow for patient weight management. The full list of all protocol steps to follow for weight management is presented below. Weight Management Protocol Brief Counseling Interventions Provide personalized brief interventions at each office visit for another problem or schedule periodic visits for this purpose. Maintain a checklist and follow up on each intervention at the next office visit.
• Assess stage of change and confidence in ability to lose weight. • Explain the potential health risks associated with elevated body mass. • Discuss and provide education regarding restricting energy intake for weight loss. • Discuss and provide education regarding healthy diet • Educate on physical activity benefits and recommendations. • Discuss problematic eating patterns. • Elicit and discuss personal barriers to weight loss, followed by brainstorming solutions. • Facilitate behavioral change goal setting. Treatment
• Set a short-term (around 6 months) weight-loss goal (5-10% of body weight, 1-2 lbs per week) while emphasizing the importance of long-term change. • Prescribe a weight-loss diet that reduces calories. • Prescribe a change in physical activity that supports weight loss and weight loss maintenance. Recommend: • At least the 150 minutes of at least moderate physical activity per week that is recommended for all individuals, and more for weight maintenance. • Reductions in sedentary time to no more than 2 hours at a time without a break of at least several minutes with some physical activity and further reductions in sedentary time to support further weight loss.
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• Recommend changes in eating patterns that will support weight loss and help stop weight gain. • For patients having excess abdominal fat, recommend they do at least the level of physical activity recommended for all people and eat a healthy diet; recommend a weight-loss diet if they have excess weight. Monitor and treat metabolic syndrome as needed. • Weight loss is an important treatment for sleep apnea in patients who are overweight or obese. • Discuss the option of prescribing medications to support comprehensive weight loss program if patient meets the following cut points: • Obese patients with BMI ≥30. • Overweight patients with a BMI ≥27 and at least one comorbidity, such as hypertension, dyslipidemia, diabetes mellitus type 2, or obstructive sleep apnea. (Jensen et al., 2014; Apovian et al., 2015) • Weigh risks vs. benefits of changing medications that promote weight gain and prescribe new medications as indicated. • Treat weight-related comorbidities with weight loss in addition to other treatments. • Treat psychological disorders contributing to weight gain (depression and anxiety, binge eating, and night eating) • Provide treatment for sleep disorders or refer for treatment when necessary. • Anticipate weight loss plateau and adjust treatment intensity. • Plan for transition from pharmacological treatment, very low-calorie diets, or meal replacements to a long-term weight-loss/weight-maintenance program. Referrals
• Recommend a weight-loss program and/or counseling by a qualified professional. Guidelines recommend prescribing a structured, comprehensive weight-loss program that supports the lifestyle change needed, for: • Patients who are moderately overweight (BMI ≥27). • Patients who are overweight (BMI 25-27), have one or more comorbidity, or for whom routine diet and exercise have not worked. (Jensen et al., 2014) • Discuss option of bariatric surgery as part of a comprehensive weight-loss program. Guidelines recommend referral for evaluation for bariatric surgery if: • Patient has a BMI ≥40, regardless of other medical conditions. • Patient has a BMI≥35 plus one or more significant obesity-related conditions AND: • Is motivated to lose weight. • Has not responded with sufficient weight loss to previous behavioral treatments with or without pharmacotherpy. (Jensen et al., 2014) • Discuss option of very low-calorie diet and/or meal replacements as the first phase of treatment; prescribe or refer as indicated. • Consider referral to a physician specializing in Obesity Medicine, especially when first line treatments have been unsuccessful or there are significant comorbidities/limitations or severe obesity. For a current list of American Board of Obesity Medicine Diplomates, see abom.org.
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Maintenance
• Adjust caloric intake and/or physical activity level recommendations as needed to maintain new weight. • Schedule maintenance visits after weight loss: Repeat body mass assessment in office visits during maintenance at intervals of 1 month initially, graduating to every 6 months. • Recommend continued participation in a weight-loss program, similar to the one recommended during weight loss, for at least a year (Jensen et al., 2014). • Increase treatment intensity when stopping pharmacological treatment. • Follow patients post bariatric surgery and evaluate for compliance with diet and recommended supplements and for any complications.
MODULE SUMMARY
Prevalence and Trends of Obesity and Overweight
The prevalence of obesity in the U.S. has risen steadily in the past 40 years from 13% in the 1970s, to 34.9% in 2011-2012 (Fryar et al., 2014). The prevalence of overweight has remained steady at around 33%-34% for the past 40 years. The majority of the population are either overweight or obese: 33.6% are overweight and 34.9% are obese. Diseases and Conditions Linked to Obesity Obesity is linked with diminished life expectancy and is a risk factor for most major causes of death. The following are common examples of conditions and diseases comorbid with obesity:
• Cardiovascular Disease • Type 2 Diabetes Mellitus/Prediabetes • Hypertension • Dyslipidemia • Sleep apnea • Osteoarthritis and other physical functioning problems • Gall bladder disease • Cancer Treatment and Weight Loss Intentional weight loss, even a modest amount, improves most of the common comorbid illnesses listed above. Just a 5% weight loss is associated with:
• Blood pressure reduction • Triglycerides reduction • LDL reduction
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• HDL increased (NHLBI, 2013) Motivating Patients The counseling technique, Motivational Interviewing, can be adapted for brief counseling in a clinical setting. The four basic steps include: 1. Engaging the patient and building rapport. 2. Focusing on a specific health goal. 3. Evoke/Elicit the patients thoughts and feelings. 4. Plan collaboratively so that the patient achieves this goal.
RESOURCES AVAILABLE THROUGH THIS MODULE:
• 2015-2020 Dietary Guidelines. Appendix 3. USDA Food Patterns: Healthy U.S.-Style Eating Pattern Edit This is the third appendix in the Dietary Guidelines for Americans 2015-2020. The US Department of Health and Human Services and the US Department of Agriculture developed this set of guidelines outlining recommended amounts of food from each food group at different calorie levels. • 2015-2020 Dietary Guidelines Appendix 2. Estimated Calorie Needs per Day, by Age, Sex, and Physical Activity LevelEdit This is the second appendix of the Dietary Guidelines for Americans 2015-2020 8th edition. The US Department of Health and Human Services and the US Department of Agriculture developed this list of recommended caloric intake for Americans based on age, sex and activity level. • Find a Registered DietitianEdit The Find an RD online referral service allows you to search a national database of qualified food and nutrition practitioners for the exclusive purpose of finding a Registered Dietitian who is right for you (no solicitations, please). • Motivational InterviewingEdit This web page is dedicated to motivational interviewing training. It contains links to a variety of articles, addressing all areas of MI from brief overviews to history, philosophy, principles, working with resistance, interaction techniques, and strategies. The site has a library, training information, and special populations information. • NIDDK Bariatric Surgery for Severe ObesityEdit This puplication contains information on bariatric surgery for adults/youth, normal digestive processes, types of surgery, medical costs, and research
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REFERENCES USED IN THIS MODULE:
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