Traversing the Chasm: Overcoming the Challenges of Obesity Management in Primary Care
Learning Objectives • Discuss the benefits of weight loss with persons who are candidates for medical management of obesity • Discuss weight loss goals and treatment options with people who are candidates for medical management of obesity • Describe the indications, administration, and potential adverse events associated with anti-obesity medications • Examine approaches for addressing obstacles and adjusting therapy in the long-term management of obesity 2
Obesity Is a Chronic Medical Condition Associated With a Number of Comorbidities US FDA: 1 “…a chronic relapsing health risk defined by excess body fat.” Metabolic 2-5 : • Prediabetes, T2DM, asthma, gallstones, infertility, fatty liver • Cancers : endometrial, kidney, ovarian, breast, colorectal • Cardiovascular diseases: stroke, dyslipidemia, hypertension, coronary artery disease, heart failure Mechanical 2,3,6 : Incontinence, osteoarthritis, sleep apnea, chronic back pain Mental health 2,7,8 : Depression, anxiety, bipolar disorder, agoraphobia FDA = US Food and Drug Administration. 1. US FDA. www.fda.gov/media/71252/download; 2. Sharma AM. Obes Rev. 2010;11:808-809; 3. Guh DP, et al . BMC Public Health. 2009;9:88; 4. Church TS, et al. Gastroenterology. 2006;130:2023-2030; 5. Hosler AS. Prev Chronic Dis. 2009;6:A48; 6. Li C, et al. Prev Med. 2010;51:18-23; 7. 3 Luppino FS, et al. Arch Gen Psychiatry. 2010;67:220-229; 8. Simon GE, et al. Arch Gen Psychiatry. 2006;63:824-830.
A Diagnosis of Obesity Improves Outcomes for the Patient Obesity is underdiagnosed in the US 1,2 A diagnosis of obesity or discussion about “I can help you” weight by an HCP is associated with 2-4 : Weight loss advice from Increased likelihood of weight loss providers increases a patient’s attempts (OR, 2.42) 3 weight loss efforts by 3.5 to 3.8 times 5,6 Increased likelihood of actual weight loss (OR, 2.70) 3 HCP = healthcare provider; OR = odds ratio. 1. Kaplan LM, et al. Obesity . 2018;26:61-69; 2. Post RE, et al. JAMA Int Med . 2011;171:316-321; 3. Singh S, et al. Am Heart J . 2011;160:934-942; 4. Pool AC, et al. Obes Res Clin Pract . 2014;8:e131-e139; 5. Jackson SE, et al. BMJ Open . 2013;3:e003693; 6. Rose SA, et al. Int J Obes (Lond). 4 2013;37:118-128.
Case Study: Introducing Tasha • Tasha has recently moved to the city and is attending your clinic following a health check-up that raised some worrying results • Current status ‒ Height: 156 cm (61.4 in) ‒ Weight: 68.9 kg (152 lb) ‒ BMI: 28.7 kg/m 2 Age: 26 ‒ WC: 92.5 cm (36.4’’) Ethnicity: African ‒ BP: 156/94 mm Hg American ‒ A1C: 6.1% ‒ FPG: 102.7 mg/dL (5.7 mmol/L) 5 FPG = fasting plasma glucose; WC = waist circumference.
Motivational Interviewing (5As) 1,2 : Start With Asking the Patient Permission to Discuss Weight “Would you be open to discussing your weight today?” If the patient makes it clear that they Weight and obesity are personal do not want to have a discussion and sensitive topics; discussing today, respect the choice and table them could be difficult for the the conversation for a later date 1,3 patient and cause feelings of embarrassment or fear 1,3 Seeking permission to discuss weight encourages a nonjudgmental conversation 1 1. Vallis M, et al. Can Fam Physician. 2013;5:27-31; 2. Bays HE, et al. Obesity Algorithm 2020. https://obesitymedicine.org/obesity-algorithm/; 3. 6 STOP Obesity Alliance. whyweightguide.org/tool-content.php.
Motivational Interviewing: Assess the Stage and Class of the Obesity BMI classification 1 kg/m 2 Stage 4: End stage ≤18.5 Underweight Stage 3: End-organ Normal weight 18.6-24.9 damage Stage 2: Established Overweight 25.0-29.0 comorbidity Obesity class I 30.0-34.9 Stage 1: Preclinical risk factors Obesity class II 35.0-39.9 Stage 0: No apparent ≥40 risk factors Obesity class III WHO = World Health Organization. 1. WHO. www.who.int/dietphysicalactivity/childhood_what/en/; 2. EOSS Staging tool. www.drsharma.ca/wp-content/uploads/edmonton-obesity- staging-system-staging-tool.pdf. 7
Motivational Interviewing: Assess the Stage and Class of the Obesity BMI classification 1 kg/m 2 Stage 4: End stage ≤18.5 Underweight Stage 3: End-organ damage Normal weight 18.6-24.9 Stage 2: Established Overweight 25.0-29.0 comorbidity Obesity class I 30.0-34.9 Stage 1: Preclinical risk Tasha is overweight according to the WHO classification system, factors with a BMI of 28.3 kg/m 2 Obesity class II 35.0-39.9 Stage 0: No apparent However, she has stage 2 obesity per the Edmonton Obesity ≥40 risk factors Obesity class III Staging System because she has established hypertension WHO = World Health Organization. 1. WHO. www.who.int/dietphysicalactivity/childhood_what/en/; 2. EOSS Staging tool. www.drsharma.ca/wp-content/uploads/edmonton-obesity- staging-system-staging-tool.pdf. 8
Motivational Interviewing: Assess Drivers, Complications and Barriers, and Readiness for Change “Have you experienced problems in any of the following “Are you interested in taking some domains, which could contribute to weight management?” steps to lose weight?” Mechanical Mental Health If the patient is ready to make a change: None reported Feels low/isolated • Ask about previous weight loss efforts following move to new and what has worked in the past city; husband frequently Metabolic • Determine the level of support the away for work, leaving her Hypertension patient desires from you to care for young child Prediabetes Reports eating out of boredom during Missed periods If the patient is not ready to make a change: evenings/weekends Reports concern about her • Work to address barriers to readiness, Recently started a newly diagnosed health such as existing health conditions stressful new office job problems • Invite the patient to let you know when they are ready Monetary: Well educated; insurance will cover medical therapy for obesity if needed 9
Motivational Interviewing: Advise That Small Amounts of Weight Loss Can Lead to Meaningful Health Improvements • Weight loss required for therapeutic benefits (%) 1,2 0 5 10 15 10 to 15% Diabetes (prevention) 3 to 10% Diabetes (remission) 5 to >15% Hypertension 3% to >15% Dyslipidemia 3% to >15% 5% to 10% Hyperglycemia 10% weight loss can NAFLD 10% improve quality of Sleep apnea 10% life, and this Osteoarthritis 5% to 10% improvement is Stress incontinence 5% to 10% maintained even if GERD (males) 10% some weight is GERD (females) 5% to 10% regained 3 PCOS 5% to 15% GERD = gastroesophageal reflux disease; NAFLD = nonalcoholic fatty liver disease; PCOS = polycystic ovary syndrome. 1. Cefalu WT, et al. Diabetes Care . 2015;38:1567-1582; 2. Lean MJ, et al. Lancet . 2018;391:541-551; 3. Blissmer B, et al. Health Qual Life Outcomes . 2006;4:43. 10
Why Is Modest Weight Loss Beneficial? 10% weight loss = 30% VAT Loss Increased Risk Lowered Risk Deterioration Lipid profile Improvement VAT VAT Impaired Insulin sensitivity Improved Blood insulin After Abdominal weight obesity, loss, Blood glucose increased reduced WC WC Risk markers for thrombosis Inflammatory markers Impaired Endothelial function Improved SCAT = subcutaneous adipose tissue; VAT = visceral adipose tissue. 11 Adapted from: Després J, et al. Br Med J . 2001;322:716-720.
Motivational Interviewing: Agree on a Weight Loss Target and Approach • Weight loss goals 1-4 Think Beyond the Scale! 6 ─ Good initial goal: 5% to 10% within 6 months Health improvement (eg, BP), ─ Complications? More aggressive approach? ability to do more, less pain, ─ Reassess therapy when health goal is met better sleep, better diet, etc ─ Greater losses yield greater benefits • Goal-setting tips 5 ─ SMART (Specific, Measurable, Attainable, Relevant to you, Time limited) ─ Short and long term ─ Expect setbacks ─ Reassess and adjust 1. Garvey WT, et al. Endocr Pract . 2016;22:842-884; 2. Apovian CM, et al. J Clin Endocrinol Metab . 2015;100:342-362; 3. Jensen MD, et al. Obesity . 2014;22(suppl 2):S1-S410; 4. Bays HE, et al. Obesity Algorithm 2020. https://obesitymedicine.org/obesity-algorithm/; 5. Mayo Clinic. https://www.mayoclinic.org/healthy-lifestyle/weight-loss/in-depth/weight-loss/art-20048224; 6. Dietitians Association of Australia. 12 https://daa.asn.au/smart-eating-for-you/smart-eating-fast-facts/weight-management/weight-loss-goals-other-than-the-scales/.
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