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Wednesday Jan 14, 2015

Put the Rx Pad Down: Why Meds Aren't the First Step to Weight Loss

"Dr. Gray, I saw a TV commercial for a weight-loss medication. I just need you to prescribe it for me."

We've all heard this type of request. As family physicians, we encounter obesity and weight-related comorbidities every day. Now that the new year -- and patients' subsequent resolutions -- has arrived, I am hitting those issues with full force.

I am used to counseling patients on proper nutrition and the importance of routine exercise regardless of whether obesity is a factor. However, obesity has become an epidemic. In my home state of Nevada, the prevalence of obesity(www.cdc.gov) is greater than 25 percent. No state in the nation has a prevalence of less than 20 percent.

The AMA (with support from the AAFP's delegation to the AMA House of Delegates) definitely focused more attention on the issue when it classified obesity as a disease in 2013, and obesity is now more frequently a part of discussions with patients. But the diet fads that have swept through the nation -- and my office -- can pose an obstacle to counseling, and the discussions are almost comical sometimes.

"What do you mean eating only grapefruit for three weeks isn't healthy? It's fruit," was one of my favorite comments from a patient. I also get questions about the human chorionic gonadotropin (HCG) diet, Atkins and more.

Then there are diet medications. These magical, all-encompassing, easy-to-use drugs require no behavioral change from patients, or so they think. One pill or injection, apparently, will ease our epidemic and therefore the diabetes, hypertension and hyperlipidemia that comes with a poor lifestyle.

But if it were really that easy, millions of Americans wouldn't be struggling to achieve and maintain a healthy weight.

Weight loss was not something I was heavily educated about as a medical student or resident. I learned about nutrients and how our cardiovascular system benefits from good nutrition and aerobic exercise. I learned how to counsel patients about a proper diabetic diet. I did not, however, learn about all the new weight-loss medications being marketed and how to effectively advise patients on weight management. Stages of change certainly apply to this type of counseling, but let's face it: Behavioral changes are tough. That's why many patients find it so hard to quit smoking, for example. At the crux of a majority of weight issues are behaviors that must change.

I have to give patients a litany of reasons why they should make nutrition changes such as eliminating or reducing processed foods, carbohydrates and other unhealthy items. Sometimes, patients who think that change is too difficult turn the discussion to what I eat on a daily basis and how I manage to incorporate exercise into my busy schedule. But I practice what I preach, so that part of the conversation tends to end quickly.

The plethora of weight-loss medications (and the marketing efforts to promote them) has hindered my counseling, which is built on nutrition and exercise. In a society where people often expect what they want when they want it, it can be difficult to convince a patient to slow down and notice that the fine print of the medication label states, "with proper exercise and nutrition."

The FDA recently approved two new weight-loss medications -- including one this week -- so expect more questions from patients.

I offer a compromise to my patients who request medication management for weight loss. I ask them to implement proper lifestyle changes and return to my office in four to six weeks. I counsel them on appropriate food choices and portion sizes, and if I think they require more assistance, I refer them to a nutritionist. We discuss what an appropriate routine exercise regimen would be for them based on their previous exercise habits.

If they return to my office having made a consistent effort to follow my advice, the numbers don't usually lie. At that point, many of my patients can see that their behavioral changes are enough to obtain the healthy lifestyle they desire, and the thought of medication management goes out the window. Other times, some still wish for a boost to what they have achieved, and at that point -- after counseling them about the medication -- I send them on their way with a prescription.

There are many ways to assist patients with weight and nutrition goals. This method works for me in my practice, especially at the start of the new year when patients are making resolutions about their health. How do you deal with requests for weight-loss medications in your practice?

Helen Gray, M.D., is an employed family physician in Reno, Nev., working in a hospital-based setting. She also is adjunct faculty with the University of Nevada School of Medicine. You can follow her on Twitter @helengraymd.

Posted at 12:10PM Jan 14, 2015 by Helen Gray, M.D.

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