 Sept. 30 - Oct. 2, 2003 |
| ASSEMBLY EDITION • NEW ORLEANS |
 Source: National Health and Nutrition Examination Survey 1999 2000 |
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 lecture yesterday, "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 make an effort to treat obesity, Zimmer-man 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 to treat obesity is understandable, Zimmerman said, since treatment is "expensive, time consuming and often frustrating." About 7 percent of U.S. health care costs are obesity-related, an annual bill that adds up to $51 billion, while another $30 to $40 billion is spent on weight-loss services.
Yet the health benefits of even modest weight loss are undeniable since obesity claims more than 300,000 lives a year. "It surpasses smoking as the leading cause of preventable death," Zimmerman said.
The best approach
What, then, is the best approach to treatment? Zimmerman said a simple, consistent approach works best for office-based management of obesity.
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 BMI 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, he 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.
Since there are about 3,500 calories to a pound, 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.
Add activity
While these approaches address "energy in," he said a daily exercise program can balance the "energy out" side of the equation. Zimmerman noted that people who maintain weight loss "all exercise 60 to 90 minutes a day."
If more is needed
 Few physicians "tell the patient that he or she needs to lose weight," said Raul Zimmerman, M.D. |
Diet and exercise will not, however, be sufficient for all patients. A logical next step is pharmacologic therapy. Zimmerman said that candidates should be either obese with co-morbidities or extremely obese (a BMI of 30 or higher) who have failed lifestyle modification. Two drugs -- sibutramine (Meridia) and orlistat (Xenical) -- 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."
While Zimmerman said some patients will need pharmacologic therapy, he cautioned that many patients will try herbal remedies. Most physicians and many patients are aware of risks associated with supplements that contain ephedra, but Zimmerman pointed out that the active ingredient in ephedra is ephedrine, which is really the problem. "Many supplements are advertising that they are 'ephedra-free', but they still contain ephedrine," he said. "I advise staying away from all herbals until we have more information."
Finally, some patients should be considered for surgical treatment, he said. For patients who fail lifestyle modification and pharmacological therapy, it is a good option. In one study, surgery was associated with an 80 percent reduction in type 2 diabetes and 50 percent reduction in hypertension. "It cures co-morbidities," Zimmerman said.
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