Commit No Nuisance

Instruct the Patient to Lose Weight

Self-Care for ObesityObesity medicine physician Ethan Lazarus explained to healthcare professionals in Philadelphia Friday how little he needed to know about treating obesity when recently renewing his board certification in Family Medicine. When necessary, “instruct the patient to lose weight.” That was it.

It’s a low bar to clear. But such instructions don’t work out too well. In a 2002 clinical review published by JAMA, Brian Haynes and colleagues compared medication compliance to weight loss and noted:

Compliance with instructions to lose weight or stop smoking is substantially lower, with long-term success rates less than 10%.

As Lazarus explained, treating obesity involves a bit more than instructing a patient to lose weight. Giving weight loss a try is something that has occurred to most every person living with obesity – many times over. Simply telling people to lose weight has little effect. But that’s all that most people get from an interaction with their primary care provider. So the next step for many people is to try one of the many weight loss schemes that make up a multibillion dollar industry. Most of them have no evidence for a lasting benefit.

Evidence-Based Care for ObesityEvidence-based obesity care offers considerably better outcomes. When self-care has not been enough, professionally-guided intensive behavioral therapy (IBT) can provide better results. For many people, this may mean referral to a qualified diabetes prevention program. Registered dietitians, clinical psychologists, and fitness professionals are also helpful.

Lazarus explained practical approaches to medications for obesity management, often considered the next step in obesity care. Many people with obesity already take medicines that affect their weight. Though primary care providers don’t often use anti-obesity medicines, those same providers commonly prescribe drugs that can cause weight gain.

So the first step is simply paying attention to the weight-promoting effects of medicines a person is already taking. In many cases, smarter prescribing can produce meaningful weight loss. In addition, five anti-obesity medications can help manage obesity. For the most part, healthcare professionals who specialize in obesity care are the ones who prescribe these medications: obesity medicine physicians, endocrinologists, and other health professionals with training and experience in obesity care.

As reported recently, all five of these options can produces good long-term outcomes if the therapy is carefully individualized.

The next step in evidence based care – surgical treatment – is often described as a last resort. That description misleads people terribly. Obesity is a chronic disease. Until we have genuine cures, it will require lifelong management. Even though surgical care for obesity – gastric bypass, gastric sleeve, and other procedures – is quite effective, it’s not the end of the road. People need to understand that weight regain can happen and that post-surgical care can provide tools for managing it.

That’s why post-surgical care is an essential part of the picture. Obesity is a chronic disease that most often progresses without treatment. People need access to the full range of options for keeping it under control.

Simply instructing the patient to lose weight is woefully inadequate.

Click here for the evidence-based obesity treatment guidelines and here for obesity pharmacotherapy guidelines. Click here for obesity surgery guidelines and recommendations.

Commit No Nuisance, photograph © James Cridland / flickr

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June 26, 2016