I think most of us would agree that it is much easier to stabilize weight or lose a few pounds then it is to lose several pounds. Excuse the pun, but an ounce of prevention is worth a pound of cure!

Several recent articles from the medical literature have documented that excess weight influences many other chronic illnesses by either causing or compounding illness. Therefore, it is important to be vigilant about your patients’ weights.

How does one handle the whole weight(-y) issue?

What is normal weight vs. obesity? The classification of normal weight, overweight and obesity are described frequently. The classifications are as follows:

* Disease risk for type 2 diabetes, hypertension, CVD, certain forms of cancer, dyslipidemia, stroke, liver, and gallbladder disease, sleep apnea, respiratory problems, osteoarthritis, and gynecological problems.
^† Increased waist circumference can also be a marker for increased risk even in persons of normal weight.¹

Is the visit initial or follow-up?For initial and follow-up visits, patients are usually "vitaled." Often an assistant takes the patient’s blood pressure, heart rate, and weight. Height should be included, without shoes, on the first adult visit so BMI can be calculated.

What is the patient's weight status? During the initial visit history-taking, it is prudent to ask the patient if their weight is stable and what they think a healthy weight is for self. If they are at a comfortable stable weight, then other health concerns and prevention topics can be addressed during the medical history and physical exam.

If they have questions about a "healthy" weight or are concerned about their weight, ask, "How has your weight changed recently or over the years?" This information helps establish a desirable weight range and gives some information to help you and the patient establish weight loss goals when the timing is right. The following factors are helpful when determining a healthy weight:

• Family genetics
• Build/bone structure/musculature
• Patient’s input as to a weight that feels good to them (the weight range in which they feel they have plenty of energy, are eating normally, and generally feeling well)
• A BMI range of 20 to 24.9 and a waist circumference of < 35 inches women and < 40 inches men are also helpful guides

When the above is taken into consideration, do give a healthy weight range and avoid a single weight number.

How can we track weight status? Whether the visit is initial or follow-up, the weight number is often ignored. However, this habit has been called into question as our nation faces an obesity epidemic. To help focus attention on this epidemic, at the very least, a notation could be made on the progress note as the examination begins—did the patient gain (+), lose (-), or stay the same—before examining other systems.

Another option to help follow a person’s weight over time is showing the patient a color coded BMI chart. A positive aspect of the BMI chart is its speed to determine the critical BMI range. The chart simplifies the number crunching. All you do is plot the patient's height and weight on the chart, or better yet have your assistant plot it for you before you see the patient! Click here to see an example of a height based BMI chart.

Are there weight concerns? After weight status is noted and the rest of the medical exam is completed, weight concerns can be addressed in the following ways:

• If the patient’s weight is stable, make a quick suggestion to improve nutrition. A nutrition goal that is rarely reached is to eat more fruits and vegetables (5 a day is the goal, but that is not an easy guideline for most to achieve).
• If the patient’s weight is creeping up in the good or caution zone, advise that some changes need to be made in the patient’s eating and exercise routine to stop the weight increase.
• If the patient’s BMI is > 25, discussing healthy eating and physical activity to prevent weight increase is very important.
• If the patient’s BMI is over 30, this is considered obesity. Intervention and treatment are important, but how do you bring that up?

Many physicians (about 50%²) are hesitant to bring up the subject of weight. By including weight as one of several health parameters that are usually reviewed (i.e., cholesterol and blood pressure, etc.), the physician should decrease the discomfort associated with the subject.² A recent study found that sensitive use of words helps the patient accept the information.³Do not use words such as "obesity" or "fatness" to describe excess weight. Use words such as "weight," "excess weight," or "BMI" instead.

Is the patient ready to change? After the weight issue has been discussed, it is important to assess if the patient is ready to make changes. Ensuring that there are no major life stressors and there is adequate time to devote (15 to 30 minutes per day) to weight loss is important so that the patient does not have another failure. If the patient has enough stress and can't deal with the rigors of weight loss, respect this, and suggest ways to at least keep weight stable. If the patient is ready to make some lifestyle changes to lose weight, then the next step is treatment and intervention, which are discussed in the next Weight Management Treatment.

References

1. NIH, NHLBI Obesity Education Initiative. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. Available online: http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.pdf
2. Wadden TA, Tsai AG. Weight management in primary care: can we talk? Obesity Management. January 2005;1(1):9-14.
3. Wadden TA, Didie E. What’s in a name? patient-preferred terms for describing obesity. Obesity Research. 2003;11:1140-6.