MEDICAL WEIGHT LOSS: Obesity: A Strategic Approach

Gail Altschuler, MD

Obesity is a complex, multifaceted medical condition defined as excess body fat. It is chronic and progressive, with an adverse effect on patient health. Early medical intervention offers our most successful approach, yet doctors are often reluctant to discuss weight loss with their patients. Doctors are busy and may not fully understand the positive difference weight loss can make in a patient’s health. In addition, they are often concerned about making their patients uncomfortable by discussing their weight--yet it must be just as frustrating to add medications for hypertension, diabetes, hyperlipidemia or osteoarthritis while knowing that weight loss can treat the causes rather than the symptoms of these conditions. Weight reductions of as little as 10% can make a significant difference.

Only 45% of obese patients have been told to lose weight by a health professional, but those who have been told are almost four times more likely to try losing weight.[1] Patients want their physicians to give dietary advice, help them set realistic weight-loss goals and offer exercise recommendations. Good ways to start conversations about weight loss include:

• Would it be all right if we discussed your weight?
• Are you concerned about your weight?
• I’m concerned about your weight because I believe it’s causing health problems.

Patients prefer words and phrases such as weight, unhealthy weight, excess weight and unhealthy BMI to describe their condition. On the other hand, they are offended by obese, fat and large size.

Preventing obesity is far easier than reversing it. The best time to intervene is when a patient is 10 or 20 pounds overweight, when small adjustments can make a big difference. These adjustments can include environmental controls, substitutions, planning and support.

Environmental controls and substitutions can make a huge difference. Patients have been conditioned to eat sugar, fat and salt, and they regularly come across foods with high levels of these elements. Environmental control requires eliminating these tempting or “trigger” foods at home and at work, identifying good-tasting healthy foods, and keeping these healthy foods readily available. One way to keep healthy foods available is to prepare a pot of something tasty on the weekend for lunches or a quick meal during the week. Another substitution option is to keep high-protein, low-calorie snacks handy at all times.

For planning, patients should take time to consider what they will need throughout the day and how they will handle challenging situations as they arise. You can support these patients by reminding them that they deserve to have safe work and home environments that meet their needs. Such support extends to your own office, where you can supply seats, gowns and blood-pressure cuffs that are large enough for overweight patients. You can also regularly measure waist circumference and BMI, and make them part of routine vital signs. In addition, you can offer handouts with diet and exercise recommendations, and arrange for monthly visits to support and encourage continued progress.

When a patient has significant weight gain and/or medical or social problems that are impacted by their weight, and they have not responded to your initial efforts, there are multiple resources available. Physician-supervised weight-loss programs, for example, can be the next step in the treatment continuum. The National Weight Control Registry has found that 55% of people who successfully lose weight do so with the help of a program.[2]

A bariatrician (obesity specialist) can provide the support, accountability and attention needed to achieve sustained weight loss. Bariatricians have extensive training in factors causing and contributing to obesity, along with the experience to address these complex issues. A successful bariatric program sees weight loss as the beginning of a healthy lifestyle, not as an end in and of itself.

At The Altschuler Center, where I serve as medical director, we view losing weight as a three-stage process: weight loss, transition and maintenance. During the initial consultation, we explore the patient’s needs and expectations and recommend a program. We also request appropriate lab and EKG; we’re looking for medications or medical conditions that might impact weight. Throughout the appointment, we answer questions, set expectations and, most important, establish a commitment. This initial visit sets the stage for successful, long-term weight loss. Generally, our patients leave with a clear picture of how they can achieve their weight-loss goals.

For the weight-loss phase of our program, I find that a low-calorie, low-carbohydrate approach works for most patients. This approach promotes burning fat and building muscle, and it controls hunger. Once a patient’s usual pattern is interrupted and weight-loss momentum is achieved, I address the emotional and cultural challenges that often lead to weight gain.

During weekly visits, patients report their accomplishments, challenges and any medical issues they’ve experienced. I discuss progress and build skills needed to maintain healthy weight. Results from the week are reviewed, adjustments made, challenges discussed. Plans are then laid for the following week.

One approach I frequently use is called partial meal replacement. Patients are encouraged to eat two healthy meals a day and use protein replacements for between-meal snacks. Protein meal replacements provide a convenient, portion-controlled, nutritionally sound replacement for tempting high-calorie foods. Using these replacements allows patients to keep the calories down while maintaining metabolic balance and controlling hunger. An average weekly weight loss is 2-3 pounds, which is healthy and sustainable. Healthy meals, during this initial weight-loss phase, can include restaurant and family meals when an appropriate approach is included.

Medications can help control appetite when needed, either when a patient is getting started or to help with a plateau. Obesity is a medical condition with serious health consequences and should be treated with all the tools available to ensure the best result.

Transition is an oft-overlooked but critical stage. Too often, people conclude that once they have lost weight they are home free.

For the transition phase of our program, patients continue enjoying healthy meals with family and friends and the flexibility to eat in restaurants while simultaneously building the skills to cook, shop and prepare their meals. They are expanding their skills, practicing new strategies and beginning to master the skills needed for long term success. These skills are the foundation for a healthy life.

During this phase, I work to transform the patient’s relationship to food, their weight and their life. My goal is to challenge and change. It is naive to imagine that someone losing weight can return to previous ways of thinking about food and exercise.

For the maintenance phase, I tell patients it takes as much work to keep weight off as it does to lose it. It’s a different set of skills. Years of repetition and practice are required for these new skills to become automatic. I teach the skills and strategies needed to manage their weight no matter what the outside circumstances. I challenge the notion that a diet is something they do for a while and put up on a shelf when it’s inconvenient.

Maintenance is discussed beginning with the first visit. Many people view dieting as a temporary inconvenience, and up to 85% who lose a significant amount of weight are likely to gain that weight back. Successful patients wake up each morning and ask themselves, “How am I going to beat those statistics?” According to the National Weight Control Registry, people who lose weight and keep it off have the following characteristics:

• 78% eat breakfast every day.
• 75% weigh themselves at least once a week.
• 62% watch less than 10 hours of TV per week.
• 90% exercise, on average, about one hour per day.

One successful maintenance strategy is self-monitoring, such as wearing fitted clothing and weighing at least once a week; I advise three or more weighings per week. Managing weight without weighing oneself is like sailing across the ocean without a compass. It’s the information that lets us know if what we’re doing is working.

Another successful strategy is the notion that “Five pounds is an emergency.” Patients need to take immediate action if they regain five pounds. Managing weight within this narrow range makes maintenance easier. The body is designed to keep us from wasting away, and the forces to eat and store can be very powerful.

Bariatric surgery is recommended for people with a BMI of 40 or greater and for people with a BMI of 35 with comorbid conditions. Recently recommendations have been adjusted to include lap-band surgery for people with BMI of 30 or greater and comorbid conditions. Bear in mind that men with a BMI greater than 40, ages 25-34, have a 12-fold increase in overall mortality. Furthermore, obesity is one of the only modifiable risk factors for cardiovascular disease--the No. 1 killer of women.

Bariatric surgery does work. It can resolve many illnesses and return a person to good health in a relatively short time. Not everyone is willing or interested in surgery, however. My job is to educate patients in the range of available treatments, enabling them to choose the approach best suited to their needs. In general, when someone has had multiple failed attempts at weight loss and their health and quality of life are markedly diminished by their weight, I encourage them to attend a support group and go for a consultation.

After bariatric surgery, patients need significant follow-up care. Surgical patients initially experience rapid weight loss, but they must use the first one or two years to establish healthy routines. If not, they risk regaining the lost weight. I also screen for depression, addiction and abuse in these patients, which can often trigger overeating. Surgery cannot treat the real needs in these cases.

Conventional weight loss-skills apply to surgery patients as well, including sleep and stress management, dietary interventions, low-calorie diets, physical activity, eating at home, psychological interventions when needed, and anti-obesity medications. They also need to be checked for nutritional deficiencies, per post-surgery protocols.

In conclusion, physicians should be the first responders to the American obesity epidemic. Obesity affects over 30% of patients seen, and there are direct connections between illness and overweight. Understanding obesity’s impact and the benefits of intervention is a beginning. Fortunately, this epidemic can be addressed through early recognition and a systematic approach. Not every patient needs physician oversight, but in cases where oversight is indicated, it can mean the difference between success and failure.

---

Dr. Altschuler, a bariatric physician, is medical director of The Altschuler Center for Weight Loss & Wellness in Novato and Greenbrae.

Email: drgail@marinweightloss.com

References

1. Smith AW, et al, “U.S. primary care physicians’ diet, physical activity and weight-related care of adult patients, Am J Prev Med, 41:33-42 (2011).

2. Klem ML, et al, “A descriptive study of individuals successful at long-term maintenance of substantial weight loss,” Am J Clin Nutrition, 66:239-246 (1997).