December 2000 • Volume 6 Number 12
Teamwork essential to control this chronic problem
BY CINDY McCANSE
A Big, Bold and Beautiful class exercises at St. Joseph Health Center in Kansas City, Mo.
You can't walk into a bookstore these days without seeing shelf upon shelf of books touting the latest "sure-fire" weight-loss diet.
With more than half of all American adults defined as overweight and nearly a quarter as clinically obese, it's easy to see why consumers spend upwards of $30 billion each year on commercial weight-loss products.
The results are often disappointing.
Successful strategies to lose weight and maintain weight loss require a comprehensive, often multidisciplinary approach that combines patient lifestyle modifications with skillful and sensitive medical care, says Sharon Stubbs, M.D., of the family medicine department at the University Hospitals of Cleveland. Stubbs works with overweight and obese patients in the primary care setting.
"Most obese patients want to lose weight," says Stubbs. "If they have a doctor who wants to help them, they're very excited."
Other team members may include a nutritionist or dietitian to provide dietary counseling; mental health professionals who can deal with associated psychosocial problems, if present; and knowledgeable nursing and office staff to track patients and ensure follow-up.
Take a weight history
Management begins with a thorough history. A childhood weight history is essential, as are questions regarding current food consumption and physical activity patterns.
It's also important to ask patients about weight-loss methods they've used and to review all prescription and over-the-counter medications they are taking.
Don't forget to ask about alternative agents, too, says Stubbs. Some of these compounds exacerbate weight problems and can interfere with any pharmacologic therapy instituted.
Weight-loss Drugs
- Appetite suppressants
- Noradrenergic
- Dextroamphetamine
- Phenylpropanolamine*
(Acutrim, Dexatrim)- Phentermine (Ionamin)
- Serotonergic
- Fenfluramine/
dexfenfluramine
(Redux; withdrawn, 1997)- Sibutramine (Meridia)
- Thermogenic agents
- Ephedrine
- Digestive inhibitors
- *Orlistat (Xenical)
- Hormonal manipulation
- Cholecystokinin
- Neuropeptide Y
- Leptin
*On Nov. 6, the FDA said it would seek removal of phenylpropanolamine from all prescription and over-the-counter products containing the drug, based on study results showing that PPA was associated with an increased risk of hemorrhagic stroke in women ages 18 to 49.
Along with a complete physical exam, laboratory testing should focus on determining serum levels of cholesterol and other lipids and assessing blood glucose and insulin levels.
Design a treatment plan based on the results of these investigations, Stubbs advises. Goals of treatment should be to lose more than 2 kg the first month and more than 5 percent of baseline over three to six months. That loss, she adds, should be maintainable.
Dietary and physical activity modifications are the mainstays of therapy. Obese patients should limit fat intake to no more than 20 percent to 25 percent of total calories consumed. Providing specific education about preparing healthy, good-tasting foods goes a long way toward encouraging compliance.
"I don't recommend cutting out any particular food group because it makes it hard to stick to and, nutritionally, it's not sound," says Angela Miller, M.D., also with the family medicine department at the University Hospitals of Cleveland, where she teams up with Stubbs in providing obesity care.
Kick the couch
Becoming more physically active is the toughest part of treatment for many patients, says Miller.
"I find that for my patients, the hardest thing to do is to get them to move," she warns. "They'll change their eating habits, but they just don't want to get up off the couch."
The key, she adds, is to set realistic exercise goals and give positive feedback for even modest gains in physical activity.
Some patients may require pharmacologic therapy to achieve basic weight-loss goals. Typically, clinically obese patients who fail to lose weight despite adherence to dietary and exercise recommendations and those with certain health problems may be started on a drug regimen in concert with behavioral measures.
Drugs to treat obesity fall into four categories. (See box at left.)
When all else fails
What about surgery? Consider it only for morbidly obese patients -- and only if all else fails, advises Miller. Morbidly obese patients are those whose body mass index (weight [kg] divided by height [m] squared) is greater than 40, or those with a BMI greater than 35 and other health risks.
Procedures now recommended include vertical banded gastroplasty and Roux-en-Y gastric bypass. These newer procedures have advantages over the traditional jejunoileal bypass. Other procedures, including laparascopic techniques, are being studied and show promise for the future.
FP Report is published by the AAFP News Department.
Copyright © 2000 by American Academy of Family Physicians.
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