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Obesity Management in Primary Care



Family practitioners are busy. Family practitioners have little to no training in obesity management.

Here is what I would consider the bare minimum of obesity management, easily doable in a busy family practice (even with virtually no obesity expertise):

1. DO NOT BLAME, THREATEN, OR PRESSURE YOUR PATIENT!

2. DO NOT SUGGEST OR ENCOURAGE RIDICULOUSLY UNREALISTIC WEIGHT-LOSS TARGETS! (for most patients 5-10% weight loss is realistic, but even that is incredibly hard to keep off).

3. DO educate your patient on the risks of overweight and obesity and that obesity once established is a chronic condition (any treatment that works is essentially lifelong!).

4. DO encourage your patient to eat regularly (especially breakfast!) and keep a food diary. (For most people, the key to not gaining weight is to not get hungry). For emotional/binge eaters it also helps to record the emotions associated with “emotional” eating.

5. DO encourage your patient to develop some understanding and knowledge of caloric content of foods and drink.

6. DO recommend reducing “liquid calories”

7. DO recommend at least 30-60 min of daily physical activity; use a pedometer and record steps in food diary

8. DO offer regular “weigh-ins” (at least once a month)

9. DO NOT stop the above when patient stops losing weight – preventing weight regain needs more effort (AND SUPPORT) than weight loss!

10. DO treat recidivism for what it is – a natural and expected phenomenon of a chronic disease – GO TO step 3

At each visit:

1. Review any changes in lifestyle since last visit

2. Review any changes in eating pattern since last visit and review use of food diary

3. Review intake of “liquid calories”

4. Review emotional eating/snacking

5. Review physical activity and use of pedometer

6. Review weight changes (DO NOT BE JUDGEMENTAL!):

if gaining: re-emphasize considering change

if maintaining: compliment on effort; encourage change; consider meal replacements and/or medication

if losing: compliment, but warn that weight loss is unlikely to continue at present rate, manage expectations (5-10% weight target), focus on health and QoL improvements rather than weight lost

Obviously, this is the bare minimum. If obesity management was really that simple, we would not have an obesity crisis.

AMS
Edmonton, Alberta

8 Comments

  1. Right to the point, very effective steps. I wonder: at what point is it best to involve the help of any or all of the following: a psychologist (for behavior modification), a nutritionist/dietitian, and an excercise physiologist/specialist? Is such a multidisciplinary team approach an absolute necessity? Can a bariatric physician, alone, cover all those aspects? Is it better to involve a multidisciplinary team, if any, from the very beginning? Whenever there are impending signs of a plateau? All along for all individuals (which makes it costly)? Only as an optional service in selected cases? I do not have clear answers to those questions, although I am inclined to think that the answer probably depends on the individual physician’s set-up and capabilities.

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  2. Response to Dr. Hanafy: Ultimately multidisciplinary is a must – especially for any patient even remotely considering bariatric surgery. 40-60% of these patietns will have DSM IV “grade” psychiatric disorders that can prove important impedements to their success, if not handled appropriately. All surgical patients will need medical, dietary, psychological, exercise and perhaps even occupational therapy follow-up.
    Remember, surgery is only a small “technical” piece in a complex, multidimensional, lifelong treatment strategy.
    AMS

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  3. Thank you Dr. Sharma for highlighting this. I agree. Surgery is only a tool, a part of a comprehensive approach. In our surgical program, we have been employing a multidisciplinary team approach (a psychologist, a diatitian, an exercise physiologist) for all our surgical patients, in addition to support groups. Actually my question was about managing the *non-surgical* overweight or obese. At what point along the timeline of management should a multidisciplinary approach be introduced for an individual who is *not* going for surgery? Potentially subjecting 60% of the population in the US to this approach may not be feasible, even though ideal. Thank you.

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  4. Some of the suggestions for obesity management in primary care are good. However the truth of the matter is that unbeknownst to primary care physicians, they are treating thousands of people with disordered eating. Unless physician’s have the training and time to help their patients get to the root of their unhealthy relationship with food and their bodies, (in this era of managed care, I hardly think so!) these patients will continue to present with the same difficulties that will only become compounded over the years. Physicians should make more referrals to mental health workers and registered dieticians who are trained to treat this problem. Perhaps if this is done early enough in the patient’s life, they won’t have to resort to surgery. I have seen patients who have had the surgery and come to see me because they are gaining the weight back.

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  5. @Donna Fellenberg: Agreed on all counts. I can say from my own experience trying to lose weight that I’ve been moderately or highly successful at a number of specific interventions involving behaviour changes and nutritional plans, but without having addressed what I think of as the psychological and emotional precursors to my lifelong disordered eating habits, each of those individual interventions have simply lost their effectiveness as I lost my will to keep up the plans.

    I’m having much more success right now after having engaged in a course of psychotherapy and then engaging in several of the techniques mentioned by Dr. Sharma. And if there’s one bit of insight I feel like I’ve developed so far, it’s that it doesn’t really matter too much what exact diet plan you choose to follow. More important than anything is that a plan of some sort is followed; that regular physical activity is undertaken; that an accurate and honest food diary is kept; that efforts are made to eat regular meals throughout the day and that those meals contain sufficient protein (especially at breakfast); to avoid eating excessively at night; and to engage yourself psychologically to avoid overeating and bingeing in general.

    If I do those things (or a combination thereof), it doesn’t matter if I’m on Atkins, The Zone, or Ornish — the weight starts to come off because my awareness about what and how much I’m eating is increased, and I’m not bingeing in general.

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  6. Are you really suggesting that patients who are maintaining their weight despite making healthy changes (ie: following the plan of action you have described) should be encouraged to take more drastic measures such as relying on meal replacements instead of food and using weight loss meds? Really? Is there not a benefit to simply not gaining further wt. Is taking meal replacements going to be their lifelong treatment as suggested in #3? If not, how is this different than a ‘diet’ which leads to a cycle of yo-yo-ing, further wt gain, and feelings of failure? What about monitoring other health indicators like blood pressure and certain lab work? Are you assuming MD’s are already doing this so it doesn’t need mentioning? Would it not be helpful, especially if the patient is maintaining/plateauing, to be able to congratulate them on any successful changes in lab work/blood pressure despite “only” maintaining their wt? Afterall, aren’t these true measures of health improvement?

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  7. @Patricia: “encouraged to take more drastic measures such as relying on meal replacements instead of food and using weight loss meds?”

    Good points – perhaps not clear from the post – of course weight loss is only indicated when the health problems are really related to excess weight and likely to get better with weight loss: see following post on indications for weight loss: http://www.drsharma.ca/indications-for-obesity-treatment.html

    Of course, as I’ve said before, the success of obesity management should not be measured on a scale.

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  8. Dear Dr. Arya
    I had submitted an abstract in ADA titled “CREW Study (Calcium reduces Weight).” It has been accepted for poster presentation in the next meet. In the mean time Calcium controversy claiming enhanced MI by 30% has been claimed by Ian Reid. Mark Bolland has extended this risk to stroke ans well as Vit D takers as well. Women’s health Initiative, Osteoporosis Australia and Chris Nordin have opposed this claim. Would you kindly offer me your comments

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