Two recent randomized trials were helpful in determining some key factors in weight loss success. Interestingly, the study found that weight loss was associated with reduced calories and dietary adherence, not diet type, improvement in cardiac risk factors were associated with weight loss, not dietary approach.^1,2 The authors recommended more research determining how to match individuals with eating plans that best suit their food preferences, lifestyle and medical condition. What a relief, we can be patient specific and do not have to choose the “best” diet!

The screening Tidbit discussed the importance of screening weight to identify those at risk for developing obesity. This Tidbit will focus primarily on the nutritional treatment of weight management. To simplify this process, four patient types will be discussed:

PATIENT TYPE A—Weight gain potential (BMI<24.9)
Prevention oriented – It is hard to tell who, in this group, will develop an unhealthy weight. It is very important to stress healthy eating and activity at routine visits. All patients need reassurance that bodies come in all sizes and shapes and that they can be healthy, despite their build, if they develop positive eating habits and keep active.³

PATIENT TYPE B—Active weight gain (BMI 25-29.9)
Gaining weight rapidly but has a BMI less than 30 with no health risks.

PATIENT TYPE C—Obesity with Health Risks (BMI 30-<34.9)

PATIENT TYPE D—Morbid Obesity (BMI>35)
This patient type will not be discussed in this Tidbit. See reference 4 for more information on gastric bypass surgery

Dealing with your patients

Whether treating patients for weight gain prevention or weight loss, it is helpful to employ time-management techniques. Before you spend much time counseling a patient, encourage one specific appointment with you to assess their lifestyle. At that visit, it is helpful if the patient brings in a completed food intake record and/or a food frequency table. Click here for a food intake record. If one specific assessment visit is impossible, the list below focuses on the most common lifestyle weight management problems, which can be addressed, one by one, at subsequent visits. If the patient follows through with a special appointment and keeps records, you are better able to evaluate readiness to commit to weight loss. The records they bring in will be a big time saver when you are evaluating eating patterns and deciding how to make positive changes.

Dealing with Patient Types A and B in the office can be efficacious. The process requires time, training and interest to provide weight management strategies, support and follow-up. If you cannot do this treatment in-house, you can refer the patient to a registered dietitian, whose training advocates personalized eating and activity plans. Another option is a community weight loss program. It is very important to match the patient to a program in which the eating approach and philosophy best reflects their preferences and needs. Support found in community weight loss programs can be very important for some patients.

How to give weight management suggestions

Keeping successful dietary adherence in mind, one approach for patients who make a specific appointment is to have them look over their eating records or food frequency tables with you while you determine potential behavior change goals. Otherwise ask questions that elicit the following information:

Consistency of eating times
If meals are often skipped, the patient may not feel as well as if they were eating about every 4 to 6 hours while awake. Why? Because blood sugar drops about 4 to 6 hours after eating during the awake cycle, and causes hypoglycemic like symptoms. Regular eating times will alleviate those symptoms. Encourage patients to eat every 4 to 6 hours while awake, and remind them that skipping meals is a setup for overeating when the opportunity presents itself!

Frequency of dining out
Does the person eat out frequently at buffets or fast food restaurants? Many choices available at these types of eateries are high in calories due to cooking methods and serving sizes.

• Suggest asking food establishment for their “Nutrition Facts” to make better choices.
• Suggest eating out less often and instead preparing her/his own healthy meals.
• Explain how and where calories are often hidden.
• At buffets, suggest getting only one level plateful instead of many heaping plates of food.

Excessive snacking
Does the patient’s lifestyle reflect excessive snacking? Sometimes suggesting lower calorie substitutions will help with weight loss, but that often does not address the real problem which is eating when not physically hungry. Suggest folks do one of the following:

• Only eat at designated times. It is helpful to set up specific eating times with your patient; or
• Only eat when physically hungry. Before eating anything, tell your patient to ask him/herself, “Am I physically hungry?”

If excessive snacking persists, this patient may be using food as a stress manager. Referral to a therapist who specializes in cognitive behavioral therapy will often alleviate the stress-food connection.

Food choice preference
Does food choice reflect a preference toward protein, starch or fat?

Protein Orientation

• Suggest satisfying servings of lean meats that are prepared with little or no added fat.
• Limit high fat protein products like whole milk, whole milk cheeses, fatty cuts of meat and fried foods.
• Emphasize the importance of fruits and vegetables for health and satiety.

Starch/SugarOrientation

• Suggest decreasing low nutrient density starches and sugars like sugared beverages (yes, even fruit and sports drinks), candy, and snack foods like chips, pretzels, crackers and the like.
• Watch starch portion sizes. Limit starch portions to 1 to 3 per meal.
• Give serving size examples. Our “normal” servings have grown to “super-sizing”!

High Fat or Saturated Fat Orientation

• Moderation with fat is key. I like the phrase “use very lightly,” because some people have falsely bought the notion that all fat is BAD, and try to eat a diet too low in fat which can actually cause weight problems!
• For health reasons, it is important to minimize saturated fat in the diet (see Tidbit on LDL reduction for more information). Patients should eat lower fat dairy and red meat. Discuss the use of healthy margarines and oils vs. stick margarines, butter and shortening.
• Cut back on “add-ons” and “add-ins,” eat fried food less frequently, and learn to read food labels for fat content (see Tidbit on food labels for more information). Click here for a handout on the “Fat Hit List."

Physical activity level and preference
It is important to stress that:

• Moderate activity is key to health and weight maintenance. Matching activity with patient preference is very important.
• Increasing activities of daily living is a very powerful tool to encourage weight loss. Daily activities conducted in an active way versus a sedentary way can increase calorie consumption by the equivalent of two pounds per month. Click here for an activity chart download.

Patient Type C who have a BMI of 30 or greater usually have at least 50 pounds to lose. The seriousness of their weight’s health impact and the commitment it will take to get to a healthy weight needs to be emphasized. However, research indicates that even a weight loss of 10% of body weight can make a significant contribution to health.^4-7 Keeping the patient motivated for the long term is the biggest hurdle. These patients will need the following to lose weight and maintain the weight loss over time:

• A supportive health care team.
• A food plan that will fit into their life-style.
• An activity plan that the patient can live with.
• An on-going support group.
• A supportive social/family system.
• Sufficient time available to use for weight management and added activity—about 15 to 30 minutes per day.5
• Patience with weight loss patterns of as little as one to two pounds per week.

The focus on weight loss will need to last at least 6 months, with lifelong behavioral changes to maintain the loss. Interestingly enough, the behavior change gurus have found that it takes at least 6 months for a new behavior to become habit.

It is important to evaluate what you can offer the patient whose BMI is greater than 30 because of the commitment it takes to support that kind of weight loss. At the very least, the primary care provider needs to encourage and support patients’ weight loss efforts as they visit with their other health concerns. Advising these patients as to the available treatment options, resources needed and their availability in the community is important if the obesity epidemic is to be adequately addressed.

Except for surgical interventions in the treatment of morbid obesity,⁶ the effectiveness of various treatment approaches in the prevention and treatment of obesity have not been adequately studied.⁷ Treatment is complex and requires much individualization. Motivation on a long-term basis is perhaps the most difficult aspect of weight loss programs. Despite the fact that much research is needed to validate various programs, there is no excuse to do nothing while the obesity epidemic continues to grow...and grow...and grow!

Thanks to Cynthia Kennedy, MS, RD, and Donna Roberts, MD, for help with this Tidbit.

References

1. Dansinger ML, Gleason JA, Griffith JL, Selker HP, Schaefer EJ. Comparison of the Adkins, Ornish, Weight Watchers, and Zone diets for weight loss and heart disease risk reduction: a randomized trial. JAMA. 2005;293(1):43-53.

2. Sacks FM, Bray GA, Carey VJ, Smith SR, et.al. "Comparison of Weight Loss Diets with Different Compositions of Fat, Protein, and Carbohydrates." NEJM, 2009, 360 (9): 859-873.

3. Kater,K. Real Kids Come In All Sizes. NY: Broadway Books, 2004.

4. National Heart, Lung and Blood Institute. The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. Available at http://www.nhlbi.nih.gov/guidelines/obesity/prctgd_b.pdf

5. Wadden TA, Tsai AG. Weight management in primary care: can we talk? Obes Manage. 2005;1:9-14.

6. Sheperd TM. Bariatric surgery in context. J Fam Pract. 2005;S3:3-9.

7. Glenny A-M, O’Meara S, Melville A, Sheldon TA, Wilson C. The treatment and prevention of obesity: a systematic review of the literature. Int J Obes. 1997; 21:715-37.