Getting patients to stay off the fat track
For most individuals, losing weight—and keeping it off—is difficult. Here is what you can do to help patients meet their fitness goals.
For most patients who need it, weight loss is a team sport and you’re a key teammate. Studies have shown that doctors who spend even 10-15 minutes discussing weight, nutrition, and exercise can motivate patients to complete and sustain a weight-management program.1
Here, then, is a multifaceted, step-by-step approach that combines lifestyle change, behavioral management, and, in some cases, medication that you can use to help at-risk, overweight, and obese patients turn the tide.
Help patients prepare
Begin by assessing the patient’s obesity level and set a goal. Fat distribution is important; central fat deposition and a waist circumference >40 inches in men and >35 inches in women are considered risk factors for a host of disorders. Weight loss of 7%-10% of body weight is achievable and can have a significant, positive impact on a patient’s health. More aggressive goals can be counterproductive since most people will be unable to reach them, get discouraged, and stop trying.
The next step is to teach patients how to self-monitor using a food and exercise diary. A diary will help them become aware of the amount, time, and circumstances of their eating and exercise habits. Daily food diaries are available from the About: Weight Loss Web site (http://weightloss .about.com/cs/ourtoptips/l/blfooddiary [accessed August 15, 2007]).
Patients should also become familiar with the caloric value and nutrient content of common foods. Some may need guidance on how to read food labels and estimate portion size. You may want to develop handouts on these topics or direct patients to printed or online information. A U.S. Department of Agriculture Web site (www.mypyramid.gov) is both informative and helpful.
Offer behavioral techniques
Teach patients strategies to help them control their eating and exercise behavior. Have them decide what foods they will eat, as well as when and where they will eat. They should also think about how fast they are eating, what size each bite should be (smaller is better), and how many times they’ll eat each day. For example, a patient may decide that she will eat only at the dining room table, her office desk, and at a specific coffee shop and that she will eat three meals and two snacks daily.
Shopping for food on a full stomach, laying out exercise clothing to encourage activity, and taking other concrete steps to encourage healthy behavior can also help. Behavioral therapy in a group setting can be highly effective; members often provide valuable mutual support and encouragement.
Instead of making rules about which foods and beverages patients should consume or avoid, encourage them to follow two simple strategies: (1) Stick to a daily calorie goal, and (2) reduce fat intake to <25% of total calories (Table 1).
It’s nearly impossible for a diet of fewer than 1,000-1,200 calories daily to be nutritionally adequate; very-low-calorie diets are likely to fall short in iron, folacin, vitamin B6, and zinc. Patients consuming fewer than 1,100 calories a day should take a daily multivitamin, multimineral tablet. Using formula diets or nutrition bars as meal substitutes once or twice daily for a period of time, particularly initially, can be quite helpful.
Clinicians should counsel patients to consume adequate protein during weight loss to conserve lean body mass. This means they should eat 1.0-1.5 g of protein per kg of ideal body weight daily. Protein sources include meat, poultry, fish, dairy foods, legumes, and nuts. Vegetarian diets must be carefully planned.
Continued use of food diaries will help track progress and spot pitfalls. As patients develop self-monitoring and behavioral skills, it’s important to be encouraging and nonjudgmental, especially when slipups and backsliding occur.
Incorporate movement and (maybe) medication
Inadequate physical activity is an important factor in obesity. Encourage simple lifestyle changes like using stairs instead of elevators, parking at a distance, and walking instead of driving when possible. Programmed activity—biking, gym workouts, swimming—should include a mix of aerobic, flexibility, and strength-training exercises. Sedentary patients should increase their activity slowly and exercise at least three times per day five days per week for at least 10 minutes per session.
For some patients—such as those having extreme difficulty losing weight or maintaining their weight loss—medication can be a helpful addition to treatment. Drugs currently approved for use in the United States include orlistat (Xenical) and sibutramine (Meridia). Orlistat, a GI lipase inhibitor, reduces dietary fat absorption by about 30%. Sibutramine is a serotonin norepinephrine reuptake inhibitor. Because of its effect on norepinephrine, sibutramine has the potential to increase BP and heart rate.
This agent must be used cautiously in overweight prediabetic patients, who have a high incidence of metabolic syndrome and cardiovascular disease.
Don’t be deterred by depression
Though linked to a higher risk of dropping out of weight-loss programs, depressive symptoms have not been shown to inhibit weight loss. Therefore, they should not deter you from initiating a weight-loss program with a patient. Maintaining a lower weight is difficult: Weight loss can depress metabolic rate and result in increased efficiency of lipogenic pathways that enhance re-accretion of fat. Patients who have lost significant weight will need to limit their fat and calorie consumption indefinitely, and all the lifestyle changes learned during the weight-loss period will need to continue, including the exercise program. Having regular contact with a caring clinician can go a long way toward ensuring continued success.
Dr. Pi-Sunyer is professor of medicine at Columbia University College of Physicians and Surgeons and director of the New York Obesity Research Center at St. Luke’s-Roosevelt Hospital in Manhattan.
1. Anderson D, Wadden TA. Treating the obese patient. Arch Fam Med. 1999;8:156-167.