PRACTICE RECOMMENDATIONS
• Calculate body mass index and diagnose obesity to increase the likelihood that obese patients will take steps to lose weight. B
• Prescribe a low-calorie diet for at least 6 months to help patients achieve a weight loss of at least 5% to 10%; prescribe physical activity for weight loss and weight maintenance. A
• Review the benefits and risks of bariatric surgery with patients who are severely obese, and provide a referral, when appropriate. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
It’s not only obese patients who are resistant to weight loss strategies. Many physicians contribute to the gap between current practice and optimal management of adult obesity, as well. There are a number of reasons for this—a dearth of knowledge, time, and reimbursement among them.1,2
What’s more, physicians are often pessimistic about how much headway patients can make in their weight loss efforts. That’s not surprising, given that the average weight loss achieved in well-controlled clinical trials tends to be modest and the recidivism rate is extremely high.3 Yet these same trials are cause for optimism, with substantial subsets of patients often achieving clinically meaningful long-term weight loss. The National Weight Control Registry, a long-term prospective study of “successful losers,” is another hopeful indicator: The registry includes approximately 6000 individuals who have lost, on average, more than 70 lb, and kept it off for an average of 6 years.4 (Listen to the audiocast at jfponline.com to find out how.)
Weight loss does not have to be huge to be clinically significant. Even a modest loss (5%-10% of total body weight) can have major health benefits. There’s much you can do to help.
Evidence suggests that patients are considerably more likely to lose weight when they are advised to do so and supported by their primary care physician.5-9 Because there is no way to predict which approach will be most effective for which patient, family physicians (FPs) should offer a variety of evidence-based treatments, including dietary change, increased physical activity, medication for selected patients, and surgery for severely obese adults (TABLE 1).
In 2009, the National Committee on Quality Assurance added body mass index (BMI) to the list of effectiveness-of-care measures that health plans and physicians are rated on.10 That addition, coupled with a recent study indicating that obesity accounts for more than 9% of annual health care expenditures,11 highlights the growing recognition that obesity should be considered a medical condition—not just a risk factor. While patients are increasingly likely to have a weight management insurance benefit that reimburses physicians and dietitians for multiple visits, many health plans still do not cover weight-related treatment. FPs can help by advocating for such coverage—and by taking steps to help patients win the battle against obesity.
TABLE 1
BMI, health risks, and weight loss: Which intervention for which patients?15
| Disease risk | Intervention | ||||
|---|---|---|---|---|---|
| BMI, kg/m2 (weight status) | Normal waist measurement | Elevated waist measurement | Diet and physical activity | Medication | Surgery |
| 25-29.9 (overweight) | Increased | High | 25-26.9: Yes, for patients with comorbidities 27-29.9: Yes | 25-26.9: NA 27-29.9: Yes, for patients with comorbidities | NA |
| 30-39.9 (obese) | 30-34.9: High 35-39.9: Very high | Very high | Yes | Yes | 30-34.9: Yes, for patients with comorbidities 35-39.9: Yes |
| ≥40 (extremely obese) | Extremely high | Extremely high | Yes | Yes | Yes |
| BMI, body mass index; NA, not appropriate. | |||||
2 weight loss tools that can jump-start your efforts
Physicians often cite time as a key reason for not providing weight loss counseling. But physician knowledge—actually, lack of knowledge—may be a bigger barrier. In 1 recent study, 44% of physicians said they did not feel qualified to treat obesity.12 In another, 72% of primary care physicians surveyed said that no one in their practice was trained to deal with weight-related issues.13
As the focus on obesity grows, clinical weight management tools are increasingly available. Two excellent examples are the California Medical Association Foundation’s Obesity Provider Toolkit (www.thecmafoundation.org/projects/obesityProject.aspx) and the clinical tools from North Carolina’s Eat Smart, Move More program (www.eatsmartmovemorenc.com/ESMMPlan/ESMMPlan.html). You can download a toolkit, review the strategies described, and adopt those you think would be most effective in your practice. Doing so needn’t be especially time-consuming; evidence suggests you can provide basic counseling about healthy behaviors in fewer than 5 minutes.14
Review guidelines. The National Heart, Lung, and Blood Institute issued the first evidence-based guidelines for the treatment of adult obesity in 1998.15 Many other groups—the US Preventive Services Task Force (USPSTF),16 the American Dietetic Association,17 and the American College of Physicians,18 among them—have followed suit, with guidelines addressing practical weight loss interventions and treatment related to specific comorbidities. The organizations all recommend using BMI to diagnose and classify obesity, assessing readiness to change, and setting realistic goals (TABLE 2).