The new obesity guidelines – updated for the first time in 15 years – are geared to primary care providers (PCPs) and offer an algorithm for managing obesity.
The protocol for the management of overweight and obese adults is among four updated guidelines commissioned by the National Heart Lung and Blood Institute, and developed by the American Heart Association and the American College of Cardiology to identify at-risk patients and prescribe appropriate interventions. The timing coincides with the American Medical Association’s recent classification of obesity as a “disease.”
To guide weight management decision-making, an algorithm focuses on the identification of patients with excess body weight and those at risk for obesity-related health problems.
Most information is straightforward:
• Patients with a BMI of 30 or higher are considered obese and need treatment.
• Patients with a BMI 25 to 30 are considered overweight and should be treated if they have additional risk factors, such as an elevated waist circumference of 35 inches or more for women, or 40 inches or more for men.
However, even though research soundly shows the higher the BMI, the greater the risk for cardiovascular disease, diabetes, and cancer, the question about the use of BMI as a screening tool has drawn debate.
Healthcare providers agree that every 5 to 10 percent of total body weight lost is a milestone that reaps health benefits. But with so many diet programs available – the guideline committee reviewed 17 different plans and concurred that as long as there’s a negative energy flow, and the intake of calories is reduced daily to 1,000 or less, it should work – determining the right one, and the amount of weight that’s safe to lose over the course of weeks and months, has also been the center of controversy.
The diet, guidelines say, should be a component of a comprehensive lifestyle intervention including physical activity and behavioral changes, delivered by a trained counselor. The guidelines suggest that patients meet with the interventionist 14 times in the first 6-month period.
Donna Ryan, MD, co-chair of the guideline committee and a professor emeritus at Pennington Biomedical Research Center in Louisiana, admitted the current approach is for PCPs to simply tell patients to lose weight but “they don’t really engage in helping patients achieve weight loss, either through referral or providing counseling or prescribing. They’ve been reluctant … but that’s changing.”
What’s not addressed: the reason why some patients make adjustments to lead a healthier lifestyle, but still cannot successfully reach a more optimal weight for their body frame.
“It’s not as simple as telling a patient, ‘you need to lose weight,’” said Gus Vickery, MD, a North Carolina family medicine physician. “Sometimes, it takes some investigating to determine the source. It might be thyroid issues, or a combination of medical problems. Unfortunately, we (PCPs) stay so busy … it’s helpful when patients come prepared. It’s OK for a patient to say, ‘I can’t lose weight and I don’t know why. It doesn’t always seem to be a matter of willpower.’”
After Vickery talked to a colleague about the colleague’s doctor-supervised weight loss clinic focusing on a well-rounded, low-calorie, low-carbohydrate food plan, he ditched his own in-house program and began referring patients there. One couple, patients of Vickery, lost a combined 140 pounds in less than a year. Other patients returned to Vickery tens of pounds thinner – and much healthier.
“My colleague,” said Vickery, “does the heavy lifting; I monitor the results.”
The impetus for the proactive movement of PCPs may be practice for the future, when they may be accountable for patients who haven’t made sincere efforts to lose weight to get healthier. Patients could eventually be penalized by insurers for not taking documented action to achieve a healthier weight.
“I could see (insurers) really increasing people's premiums if they don’t follow certain preventive measures in the future,” said urologist Stan Sujka, MD, a partner of Orlando Urology Associates in Central Florida. “Unfortunately, we’re becoming a society of regulations. A lot of people don't seem to want take personal responsibility for their well-being.”
Recently, to set an example for patients and to improve his health, Sujka dropped 36 pounds in nine months with the assistance of a diet app on his smart phone, a practice he encourages patients to follow as a first course of action for losing excess weight.
“Your smart phone can serve as your personal coach to shed those unwanted pounds,” he said. “It’s easy, free, and studies show it works.”
The two most popular free apps are “Lose It” and “My Fitness Pal,” which allows patients to meet pre-set calorie and exercise goals.
Sujka’s partner, Albert Ong, MD, gave him a kickstart on the new lifestyle modification by downloading the “Lose It” app on Sujka’s smart phone and programming it to lose one pound per week. Sujka is now very close to his college weight goal of 200 pounds.
“Since losing weight, a lot of my patients have asked, ‘how did you do it?’ After explaining to them about using their (smart) phones to lose weight, many of them have come back to the office and told me their doctors for years have been telling them to lose weight but have never told them how,” explained Sujka. “They’ve told me they’ve found the app simple and effective. As a result, I wrote up the principle of using your smart phone to lose weight. A lot of patients appear more excited about losing weight than the effects of Viagra or Cialis!”
Overall, the guidelines don’t focus on specific obesity medications. Only orlistat (Alli or Xenical) was available during the committee review process. Since then, the FDA has approved new diet drugs – lorcaserin (Belviq) and phentermine/topiramate (Qnexa) – that are recommended for use as “an intensification approach.”
Bariatric surgery for weight loss was the fifth and final recommendation “when other interventions fail.”
