Strategies for treatment of obesity - Beyond the Guidelines

USA: One of the most challenging aspects of primary care in obese patients is counseling them about weight management. Scott Kahan, National Center for Weight and Wellness, Washington, DC, and JoAnn E. Manson, Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts have a released convenient “ABCDEF” framework, published in the journal JAMA, to guide weight counseling in primary care settings.

A. Ask “permission” before discussing obesity

It may seem awkward to ask patients for permission to discuss a clinical issue, but doing so supports patients’ autonomy and is a respectful and strategic way to broach a sensitive topic. Patients who decline counseling will nonetheless know that they can seek support when they are ready.

Advising patients to “just eat less and exercise more” is unhelpful, especially for patients affected by binge eating disorder, adverse childhood experiences and trauma, medication-induced weight gain, and other common contributors to weight gain. A clinical problem-solving approach should be used, with an eye toward identifying causes and leverage points. Elicit a weight history and explore the patient’s weight trajectory, what has contributed to weight gain, what has or has not worked in the past, and barriers that may get in the way of sustained behavioral changes.

Support motivation by appealing to patients’ interests, values, and preferences. Because current evidence does not define a “best diet,” patients should be counseled on how to strategically decrease energy intake within a dietary pattern that is reasonably appealing and convenient. It remains important to encourage intake of whole foods and minimize ultra-processed foods and added sugars. Helping patients manage expectations is important; whereas achieving a “normal” weight is unrealistic for many patients, sustained weight loss of 5% to 10% is often achievable and improves health. Then, aiming for additional weight loss and positive behavioral changes over time is still an option.

D. Determine health status

Patients should be evaluated for weight-related health conditions (eg, diabetes, hypertension, sleep apnea, osteoarthritis), disability, and impaired quality of life so that intensity of treatment can be aligned with the severity of the disease. Obesity treatment is indicated when a patient’s weight affects health, quality of life, or functioning. In contrast, some excess weight beyond normative levels or societal norms in the absence of adverse health effects does not necessarily demand management beyond preventive monitoring.

According to the USPSTF, current evidence is insufficient to recommend pharmacotherapy in healthy individuals, despite elevated weight. However, when excess weight is complicated by health risks and if a patient does not achieve enough improvement in weight and health with counseling alone, then obesity medications (BMI ≥27) approved by the US Food and Drug Administration (FDA) or bariatric surgery referral (BMI ≥35) should be considered. Medications and surgery lead to more weight loss and health improvements than behavioral counseling alone. In patients with type 2 diabetes mellitus (T2D), obesity medications combined with counseling improves hemoglobin A_1c by 0.5% to 1.6%—as much improvement as with many FDA-approved diabetes medications; for patients at risk of T2D, medications decrease the risk for progression to T2D by as much as 40% to 80% over 2 to 4 years. Bariatric surgery improves numerous comorbidities and decreases mortality.

Obesity will not be solved in a single clinic visit, yet only 24% of 3008 patients in a recent survey reported having a follow-up appointment scheduled after an initial weight loss discussion. Clinicians should offer support and monitor weight and other metrics, such as changes in waist circumference and weight-related risk factors, as well as subjective improvements in energy, mobility, and chronic pain symptoms. Frequent counseling is essential, but clinicians need not provide this alone. When expertise or time demands exceed the clinician’s capacity, referral of patients to other practitioners or services, such as obesity medicine physicians, registered dietitians, behavioral therapists, commercial or community programs, or digital and telehealth programs, should be considered.