Weight loss strategies that really work

The Journal of Family Practice. 2010 July;59(7):378-385

July 1, 2010|The Journal of Family Practice

Kathy Cable, MLS;Kathryn M. Kolasa, PhD, RD, LDN;David N. Collier, MD, PhD

	National Weight Control Registry: Lessons from "successful losers"

With your guidance, sustained weight loss is possible—even for the severely obese. These tips and tools will help.

TABLE 2
Obesity: Key components of evaluation and treatment

Assess	Severity of obesity with calculated BMI, waist circumference, and comorbidities Food intake and physical activity in context of health risks and appropriate dietary approach Medications that affect weight or satiety Readiness to change behavior and stage of change
Advise	Diagnosis of overweight, obese, or severe obesity Caloric deficit needed for weight loss Various types of diets that lead to weight loss and ease of adherence Appropriateness, cost, and effectiveness of meal replacements, dietary supplements, over-the-counter weight aids, medications, surgery Importance of self-monitoring
Agree	If patient is not ready, discuss at another visit If patient is motivated and ready to change, develop treatment plan If patient chooses diet, physical activity, and/or medication, set weight loss goal 10% from baseline If patient is a potential candidate for surgery, review the options
Assist	Provide a diet plan, physical activity guide, and behavior modification guide Provide Web resources based on patient interest and need Identify method for self-monitoring (eg, diary) Review food and activity diary on follow-up. (Reassess if initial goal is not met.)
Arrange	Follow-up appointments to meet patient needs Referral to registered dietitian and/or behavioral specialist for individual counseling/monitoring or weight management class Referral to surgical program Maintenance counseling to prevent relapse or weight regain
BMI, body mass index.

Diagnose obesity without delay

While most patients can report their height and weight with reasonable accuracy, few obese adults consider themselves to be obese.¹⁹ And, although the USPSTF 2009 recommendations call for screening all adults for obesity and introducing behavioral interventions to promote sustained weight loss as needed,²⁰ most obese men and women receive neither a diagnosis nor an obesity management plan.²¹ Yet both are key components of long-term weight control. Physicians should calculate and document the BMI of all adult patients, and routinely diagnose obesity in patients with a BMI ≥30 kg/m² (TABLE 1).

Get the patient’s perspective
In addition to using BMI and waist circumference measures and identifying comorbidities such as diabetes and hypertension, it is important to determine whether the patient is motivated to change. You can start by asking whether he or she has previously been told to lose weight; adults who have received weight control counseling in the past are more likely to be in a greater state of readiness.⁷

Review the patient’s medications. Once you have identified obesity, look for iatrogenic causes—most notably, current use of 1 or more medications that are associated with weight gain or known to affect satiety. If you identify any such drugs, it may be possible to find a suitable alternative (TABLE 3).

Factor in literacy. Patients with low literacy are less likely to fully comprehend the health benefits of weight loss or to report that they are ready to lose weight, as compared with those with higher literacy levels.²² Talking to such patients to determine what will spark their interest and motivation—ie, looking and feeling better, being able to play with children or grandchildren—can help.

Assess the patient’s dietary patterns. This can be done with the Rapid Eating Assessment for Participants (REAP), an office-based tool of adequate reliability and validity for nutrition assessment and counseling that can be administered in a few minutes.²³

FAST TRACK

Receiving weight management advice from a physician is strongly associated with patient efforts to lose weight.

This office-based survey, available at https://bms.brown.edu/nutrition/acrobat/REAP%206.pdf, provides information that can be the basis for an action plan. While there is no direct evidence that having a plan leads to weight loss, receiving advice from a physician is strongly associated with efforts to lose weight.⁶ Be aware that obese individuals may not be as responsive to weight management counseling from a physician as those who are overweight, so they may require more assistance.²¹

TABLE 3
Drugs that promote weight gain—and alternatives to consider^46,52,53

Indication/drug class/medication	Alternatives*
Anticonvulsants/psychotropics Anticonvulsants Valproic acid,^† carbamazepine^†	Topiramate^‡
Antimanic (bipolar) Lithium	Valproic acid,^† carbamazepine^†
Antipsychotics Atypical: Olanzapine, clozapine, risperidone, quetiapine Typical: Chlorpromazine, thiothixene, haloperidol	Ziprasidone Molindone, loxapine
Antidepressants MAOI: Phenelzine Tricyclics: Amitriptyline, imipramine	Tranylcypromine, moclobemide Nortriptyline, protriptyline, desipramine
Antidiabetics Sulfonylureas Glipizide, glyburide	Gliclazide, metformin, acarbose
Antihypertensives Alpha-adrenergic blockers and centrally acting agents Clonidine, guanabenz, methyldopa, prazosin, terazosin Beta-blockers Propranolol Calcium channel blockers Nisoldipine	Guanfacine, doxazosin Acebutolol, atenolol, betaxolol, bisoprolol, labetalol, metoprolol, nadolol, pindolol Amlodipine, diltiazem, felodipine, nicardipine, nifedipine, verapamil
Anti-inflammatories Corticosteroids	NSAIDs, COX inhibitors
COX, cyclooxygenase; MAOI, monoamine oxidase inhibitor; NSAIDs, nonsteroidal anti-inflammatory drugs.
* Table is not meant to imply equal efficacy for all choices for a given indication.
^† Valproic acid and carbamazepine are associated with weight gain, but less than that associated with lithium.
^‡ Topiramate may not be adequate as a single agent.

Set a goal, prescribe a food plan

After discussing possible interventions based on the patient’s BMI and weight status (TABLE 1), set a safe and achievable goal to reduce body weight at a rate of 1 to 2 lb per week for 6 months to achieve an initial weight loss goal of up to 10%. Not only does such a target have proven health benefits,^15,24 but defining success in realistic and achievable terms helps maintain patient motivation.

References

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