Meeting News

Managing obesity starts with addressing behavioral factors

SAN DIEGO — At the primary care level, physicians should delve into the key behavioral factors that affect weight, including quality of diet, physical activity and sleep, to manage obesity in their patients, according to a presentation at the ACP Internal Medicine Annual Meeting.

There is no specific diet that patients should be following, but the focus should be on incorporating lean protein, whole grains and vegetables into the diet, according to Fatima Cody Stanford, MD, MPH, MPA, professor of medicine and pediatrics at the Harvard Weight Center at Harvard Medical School.

Fatima Cody Stanford
Fatima Cody Standford

“I want patients to do the diet that’s the healthiest that they can do for the longest time,” she said.

With regard to physical activity, clinicians should advise patients to engage in activities that are applicable to them and that they enjoy doing and will want to do consistently for the rest of their lives, she added.

Often patients who suffer from obstructive sleep apnea can achieve significant weight loss just regulating and improving their quality of sleep; therefore, it is essential for physicians to pay close attention to whether or not these patients have daytime hypersomnolence, snoring, morning headaches or gasping or choking for air, Stanford said.

Weight bias in health care

“The most prevalent bias in health care currently is weight bias,” Stanford said. “About 60% of [physicians] exhibit some form of explicit bias.”

Patients with obesity commonly delay seeking care or do not seek care in general because they feel stereotyped, judged or threatened by environmental cues that are in the office, she said. Thus, the patient may avoid care, have stress, mistrust their providers and feel as though they are not in a safe place, she said. In addition, patients who feel weight bias may have poor adherence to medications because they don’t value their provider, which leads to poor communication between the patient and the provider and consequently, poor patient outcomes, she said.

“I really want you to think about that as you are working with patients who struggle with weight,” Stanford urged the audience. “If patients sense that bias, they are not going to achieve beneficial outcomes and they’re going to sense you as a person who’s not going to help them achieve a healthy lifestyle and that’s really going to delay and cause worsening issues.”

Assessing and managing obesity

The initial steps to evaluating patients with obesity are assessing the health status of the patient, measuring height and weight, calculating BMI, determining weight category, assessing and treating CVD risk factors and obesity related comorbidities and assessing weight and lifestyle histories, according to Stanford.

Other steps include examining the patient’s need to lose weight, advising to avoid weight gain and addressing risk factors, assessing readiness to make change and identifying barriers to success, determining weight loss and health goals and intervention strategies and comprehensive lifestyle therapies alone or in conjunction with adjunctive therapies, she noted.

“I will not start medications or send patients to surgery unless I feel like we optimized everything that we can do to address the behavioral factors, including diet quality, physical activity and sleep,” Stanford said. “I’m going to address those factors first and if that is unsuccessful, then we will venture off into other modalities of treatment including pharmacotherapy and/or surgery.”

Stanford noted that clinicians should advise patients to, if possible, discontinue the use of common weight promoting medication categories, including antipsychotics, antidepressants, sleep agents, neuropathic agents, beta-blockers, steroids, insulin and hypoglycemic agents. If patients do not have a critical need for such medications, clinicians should switch patients to a drug that will not promote weight gain, she said.

“If discontinuation of a weight-promoting medication is not feasible, consider the use of anti-obesity pharmacotherapy for weight loss in conjunction with appropriate lifestyle changes,” she said.

Overall, clinicians should track weight loss progress in terms of excess body weight and total body weight at each visit; listen to patient cues about hunger, satiety and side effects to drive weight management; continue to encourage healthy lifestyle behaviors; use weight loss medications only after behavioral changes are not successful; continue medications indefinitely when a patient has a superior response to medication (5-10% of total body weight loss); and advise women of childbearing age about discontinuing medication prior to conception, Stanford concluded. – by Alaina Tedesco

Reference:

Stanford FC. MTP 022: Weighing In on Medical Management of Obesity. Presented at: ACP Internal Medicine Annual Meeting; March 29-April 1, 2017; San Diego.

Disclosure: Stanford reports being a consultant for Novo Nordisk.

 

SAN DIEGO — At the primary care level, physicians should delve into the key behavioral factors that affect weight, including quality of diet, physical activity and sleep, to manage obesity in their patients, according to a presentation at the ACP Internal Medicine Annual Meeting.

There is no specific diet that patients should be following, but the focus should be on incorporating lean protein, whole grains and vegetables into the diet, according to Fatima Cody Stanford, MD, MPH, MPA, professor of medicine and pediatrics at the Harvard Weight Center at Harvard Medical School.

Fatima Cody Stanford
Fatima Cody Standford

“I want patients to do the diet that’s the healthiest that they can do for the longest time,” she said.

With regard to physical activity, clinicians should advise patients to engage in activities that are applicable to them and that they enjoy doing and will want to do consistently for the rest of their lives, she added.

Often patients who suffer from obstructive sleep apnea can achieve significant weight loss just regulating and improving their quality of sleep; therefore, it is essential for physicians to pay close attention to whether or not these patients have daytime hypersomnolence, snoring, morning headaches or gasping or choking for air, Stanford said.

Weight bias in health care

“The most prevalent bias in health care currently is weight bias,” Stanford said. “About 60% of [physicians] exhibit some form of explicit bias.”

Patients with obesity commonly delay seeking care or do not seek care in general because they feel stereotyped, judged or threatened by environmental cues that are in the office, she said. Thus, the patient may avoid care, have stress, mistrust their providers and feel as though they are not in a safe place, she said. In addition, patients who feel weight bias may have poor adherence to medications because they don’t value their provider, which leads to poor communication between the patient and the provider and consequently, poor patient outcomes, she said.

“I really want you to think about that as you are working with patients who struggle with weight,” Stanford urged the audience. “If patients sense that bias, they are not going to achieve beneficial outcomes and they’re going to sense you as a person who’s not going to help them achieve a healthy lifestyle and that’s really going to delay and cause worsening issues.”

Assessing and managing obesity

The initial steps to evaluating patients with obesity are assessing the health status of the patient, measuring height and weight, calculating BMI, determining weight category, assessing and treating CVD risk factors and obesity related comorbidities and assessing weight and lifestyle histories, according to Stanford.

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Other steps include examining the patient’s need to lose weight, advising to avoid weight gain and addressing risk factors, assessing readiness to make change and identifying barriers to success, determining weight loss and health goals and intervention strategies and comprehensive lifestyle therapies alone or in conjunction with adjunctive therapies, she noted.

“I will not start medications or send patients to surgery unless I feel like we optimized everything that we can do to address the behavioral factors, including diet quality, physical activity and sleep,” Stanford said. “I’m going to address those factors first and if that is unsuccessful, then we will venture off into other modalities of treatment including pharmacotherapy and/or surgery.”

Stanford noted that clinicians should advise patients to, if possible, discontinue the use of common weight promoting medication categories, including antipsychotics, antidepressants, sleep agents, neuropathic agents, beta-blockers, steroids, insulin and hypoglycemic agents. If patients do not have a critical need for such medications, clinicians should switch patients to a drug that will not promote weight gain, she said.

“If discontinuation of a weight-promoting medication is not feasible, consider the use of anti-obesity pharmacotherapy for weight loss in conjunction with appropriate lifestyle changes,” she said.

Overall, clinicians should track weight loss progress in terms of excess body weight and total body weight at each visit; listen to patient cues about hunger, satiety and side effects to drive weight management; continue to encourage healthy lifestyle behaviors; use weight loss medications only after behavioral changes are not successful; continue medications indefinitely when a patient has a superior response to medication (5-10% of total body weight loss); and advise women of childbearing age about discontinuing medication prior to conception, Stanford concluded. – by Alaina Tedesco

Reference:

Stanford FC. MTP 022: Weighing In on Medical Management of Obesity. Presented at: ACP Internal Medicine Annual Meeting; March 29-April 1, 2017; San Diego.

Disclosure: Stanford reports being a consultant for Novo Nordisk.

 

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