BY PEGGY PECK
Obesity is a chronic, relapsing disease that requires chronic treatment -- that's a long-haul message that family physicians need to deliver to their patients, said Raul Zimmerman, M.D., co-director of the Halifax Medical Center Weight Management Program, Daytona Beach, Fla.
Moreover, obesity is fast becoming a major health problem for Americans of all ages and incomes, he explained during his Oct. 1 Assembly lecture, "Obesity: Battling an Epidemic." FPs, said Zimmerman, "don't need a national nutrition summit or a call to action or a special issue of JAMA to tell us obesity is a problem -- because as family physicians, we see it daily in our offices and sometimes in our homes. Obesity is not an occult problem."
But many FPs don't even try to treat obesity, Zimmerman said. For example, he said few physicians "tell the patient that he or she needs to lose weight," even though that is an effective first step in behavioral modification. This reluctance is understandable, Zimmerman said, because treatment is "expensive, time consuming and often frustrating."
Best treatment approach
What, then, is the best approach to treatment? Zimmerman said a simple, consistent approach works best for office-based management of obesity.
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First, identify and risk-stratify patients. "Remember that the problem is not just weight, but also fat and the location of the fat," he said. A muscle-bound body builder who weighs 260 pounds is not in the same risk category as an office worker who weighs 260 pounds. So a simple tool for stratifying fat risk is a measuring tape: Waist measurements of 35 inches in women and 40 inches in men are risk factors for cardiovascular disease and diabetes. "Each of us should go into the examining room with a tape measure," he said.
Risk also increases as body mass index increases -- 18.5 to 24.9 is a "normal" BMI, 25 to 29.9 is overweight, 30.0 to 39.9 is considered obese and more than 40 is considered extremely obese, Zimmerman explained.
When treating children, "use the CDC BMI for age tables and remember that among children, both age and gender are factors in determining BMI," he said.
Start small
In terms of weight loss, Zimmerman said he prefers to start small because small weight loss can yield big health benefits.
Given that one pound equals about 3,500 calories, cutting back by 500 calories a day should translate into a weight loss of a pound a week. But rather than starting out by counting calories, he recommended:
He also urged behavioral changes such as "getting up from the table immediately" to avoid seconds. If these changes don't achieve the desired goal, "it's time to count calories" and weigh food, he said.
And while these approaches address "energy in," Zimmerman said a daily exercise program can balance the "energy out" side of the equation.
If more is needed
Diet and exercise will not, however, be sufficient for all patients. A logical next step is pharmacologic therapy in selected patients. Two drugs -- sibutramine and orlistat -- are currently available. Although there have been no head-to-head studies of these drugs, Zimmerman said, "my observation is that they are about equally effective; both are associated with about a 10-pound weight loss at six months."
Finally, some patients should be considered for surgical treatment, Zimmerman said. For patients who don't succeed with lifestyle modification and pharmacologic therapy, surgery may be a good option and can even reduce the likelihood of comorbidities such as type 2 diabetes and hypertension.
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Copyright © 2003 by
American Academy of Family Physicians.