Obesity in Primary Care: Treatment

There is general agreement that, to lose weight and keep the weight off long-term, an improvement on lifestyle factors is a key component. Healthy eating, active lifestyle, good sleeping habits, and optimal strategies to deal with stress and anxiety all are important components of a weight loss program. Keep in mind that because weight loss usually is associated with increased hunger, the use of medications to reduce appetite might be very helpful.

Key Treatment Questions[[{"type":"media","view_mode":"media_crop","fid":"60686","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_6366076661872","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"7671","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 228px; width: 228px; border-width: 0px; border-style: solid; margin: 5px; float: right;","title":" ","typeof":"foaf:Image"}}]]

Following are answers to the questions primary care physicians most often ask about obesity treatment:

• How do I treat a patient with obesity?

As with any other chronic disease, obtaining a detailed medical history is very important. With this information, you can design a specific lifestyle intervention program personalized for each patient. In addition to information regarding the obesity risks and weight loss options, 5 specific areas should receive special attention: nutrition, physical activity, appetite control, quality of sleep, and psycho-emotional stage. Following are some recommendations for nutrition and physical activity.

Nutrition: Obese patients need to improve the quality of their diet. They usually need to reduce calories, but it’s important that they don’t become hungrier. In many physical senses, patients may benefit from a visit with a dietitian.

Reducing the calories the patient is taking in by 30% is a good technique, but it’s not always easy to know how many calories the patient is actually consuming. Maintaining the calorie amount at about 1200 to 1800 daily and just reducing the proportion of fat and carbs is an alternative. To be successful in this area, provide specific information to patients so they can make good choices when shopping, cooking, and eating every day.

Keep in mind the patient’s cultural background, traditions, food availability, time constraints, financial issues, nutritional knowledge, and cooking skills. Follow-up with a knowledgeable team of dietitians will be based on supervising the quantity and quality of meals and the patient’s adherence to a healthy nutritional plan.

According to strong data in the literature, a Mediterranean diet-including poultry, fish, vegetables and fruits, whole grains and beans, olive oil, nuts, and seeds-seems to be the healthiest to follow.

Next: What About Physical Activity?

Physical activity: The routine needs to be personalized and adapted to the medical and physical status of each patient. In many circumstances, an exercise program should be carried out while the patient is seated, including arm exercises. Swimming/aquatic exercises may be helpful if the patient has standing or walking limitations.[[{"type":"media","view_mode":"media_crop","fid":"60688","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_6464642952363","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"7673","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 160px; width: 226px; border-width: 0px; border-style: solid; margin: 5px; float: right;","title":" ","typeof":"foaf:Image"}}]]

Patients need to increase their level of physical activity slowly. Hopefully they can identify a type of activity they enjoy.

Exercise should be prescribed like any other treatment (type, intensity, frequency, time).

For many patients, referral to cardiology would be advisable to obtain clearance to start an exercise program. Patients who have asthma or obstructive sleep apnea should be evaluated by pulmonary medicine. 

A good physical activity program should start slowly and target 2.5 hours per week of moderate physical activity or at least 1.25 hours per week of more vigorous intensity (this aerobic exercise will promote modest weight loss and will prevent weight gain) and resistance exercises that involve major muscle groups 2 or 3 times per week.

Offer patients some general recommendations, such as walking short distances instead of using public transportation, taking stairs instead of an elevator, carrying overnight travel bags instead of using rollers, maintaining an active work environment (eg, standing desks, walking desks), and avoiding prolonged inactivity (taking breaks to stand, walking, and doing some movements). 

Patients who practice exercise on a regular base have the best results in terms of losing weight and maintaining weight loss. Encourage patients to start this change and provide them with proper tools until they can learn to enjoy exercising.

Next: Change the Patient’s Medications?

• Should I change some of the patient’s medications to help him/her lose weight?

A change in a patient’s medical treatment could trigger increased appetite and weight gain. If, for example, the patient has type 2 diabetes and is receiving insulin, sulfonylureas, thiazolidinediones, or meglitinides, we should evaluate whether this is the better medication, even when the patient has an acceptable HbA1c. We should keep in mind that there are other options for treating diabetes that also can help the patient lose weight by decreasing their appetite.

Many antipsychotic and some antidepressant medications are associated with weight gain. This issue may need to be reviewed with your patient’s psychiatrist. Some antidepressants (eg, paroxetine, fluoxetine) are associated with weight gain, but others (eg, wellbutrin and venlafaxine) are more likely to cause weight loss. Antihypertensives (eg, beta-blockers) are more prone to cause weight gain than ACE inhibitors and calcium channel blockers.

The next installment in this special report on obesity in primary care will focus on bariatric surgery and referral.