Tackling Obesity in a Super-size Culture

Twenty years ago a cheeseburger was 330 calories. Today an average cheeseburger is 590 calories. The extreme change in portion size is just one of many elements discussed today, June 17, at the Pri-Med NY 2010 meeting’s Obesity Management Session.

Among the most common health issues facing the nation is obesity, but there are steps that can be taken to educate patients and successful treatment options to begin controlling the epidemic, according to speakers at the session.

In her presentation, “Primary Care Approach to Obesity, Jane S. Sillman, MD, outlined the necessary steps in screening for obesity, presented successful ways of motivating patients, discussed essential lifestyle changes, possible drug treatments, and evaluated the effectiveness of baratric surgery.

Sillman is an assistant professor of Medicine and Deputy Director of Current Clinical Issues in Primary Care at Harvard Medical School.

Silliman highlighted some of the key factors in helping patients lose weight, including providing intensive counseling, establishing and raising a patient’s level of confidence and personal strength, modifying to a diet in less calories, and regular exercise.

A physician will have to be aware of the patient’s concerns, she said, if he or she wants to be effective. To do so, he or she may use “motivational interviewing,” a patient-centered method for increasing motivation to change. Motivational interviewing helps the patient explore and resolve ambivalence, she said. This method requires that a physician express empathy, develop discrepancy, roll with resistance, and express confidence that a patient can change, she said.

Assessing a patient’s level of motivation can be done by asking him or her to rate their level of motivation on a scale from one to 10. If the person provides a low answer, the physician should try to ask a question that will invoke reflection. she said. For example, if he or she says the number three, Sillman said a physician could ask why a three and not a one, or “what it would take to change him or her from a three to a seven.”

“You are there to be that caring, believing coach, to support your patient,” she said.

In setting goals, Sillman said it was important to make sure the patient sets up realistic goals that he or she can achieve within a given time frame. In terms of diet, Sillman pointed out that recent research suggests all caloric restrictive diets seem to work.

While drug therapy may be a success for many patients, Sillman said those with a BMI greater than 30, or those with a BMI greater than 27 and with two cardiac risk factors/obesity-related comorbidities are the best candidates for this kind of treatment.

For bariatric surgery, Sillman said patients with a BMI greater than 40 or those greater than 35 with comorbid conditions are better candidates for the surgery.

In her presentation, titled “Evidence-Based Nutrition Counseling Strategies in Weight Management,” Wahida Karmally, MD, discussed the current prevalence of obesity and overweight patients and applied evidence-based tools for the assessment and treatment of both.

Karmally, director of nutrition at the Irving Institute for clinical and Translational Research, Columbia University, also discussed the current research evaluating the efficacy of leading popular diets and counseling skill in weight management.

To kick of her presentation, Karmally presented a chart demonstrating the fact that as of 2007-2008 the average BMI for women age 20 and older was 33.9; for men age 20 and older it was 32.2.

According to clinical guidelines, the goals of weight loss are to “reduce body weight in the short term, maintain a lower body weight for the long term, and prevent further weight gain,” she said. The care of overweight or obese patients requires two steps: assessment and management, she said.

The most successful way to do so is to combine weight loss and weight maintenance therapy that includes changes to diet, physical activity, and behavior therapy. The program should last at least six months until the weight loss goals are achieved, she said. Afterwards, a weight maintenance program should be put in place. The more contact a patient has with his or her practitioner, the better the outcome may be, she said.

Making the process even more difficult are the large portion sizes offered today, Karmally said. This is why meal replacement in the form of liquid meals, meal bars, etc. may be key, she said. Substituting one or two daily meals or snacks with these alternatives may be effective.

Improving nutrition education and having patients read nutrition labels, etc, has been shown to be helpful and should also be encouraged, she said. In terms of drug therapy, Karmally said it’s important to let the patients know that it is not the sole solution to the problem.

The third presenter, Dorothy Ferraro’s presentation, titled “Essentials for Bariatric Surgery for Primary Clinicians,” primarily focused on defining obesity and trends, and determining the best candidates for bariatric surgery as well as discussing emerging procedures and technologies in that field.

Ferraro, MS, APN-CS, is the assistant clinical professor of nursing, Columbia University.

Obesity is one of the major causes preventable death and with 34% of US adults age 20 or older obese, it’s an issue that must be addresses, Ferraro said.

Ferraro highlighted current trends, including the dramatic increase in obesity over the last 20 years (51% higher prevalence in African Americans, and 21% in Hispanics.) Additionally, 12 to 17% of all children are obese and 1 in 7 low-income pre-school aged child is obese, she noted.

Bariatric Surgery as an option for adults has several benefits when diet and exercise seem to be ineffective in morbidly obese, she said. Though there is much misinformation out there on the subject, she said.

“The risks are no greater than those for gall bladder surgery,” she said.

Patients are able to lose 65% of their excess weight and maintain that loss over time, generally, she said. The option should primarily be considered for patients with a BMI of 40 or more, or a BMI of 35 with a life-threatening comorbid condition. The patients should also have a long-standing history of obesity, five years or more and he or she must be willing to make lifelong changes, she said.

Before the surgery, it is important to educate the patient, she said. The physician should also make sure to administer a psychological and dietary evaluation, and offer support group participation opportunities.

While there are a few bariatric surgical options, Ferraro recommends adjustable gastric banding, noting that it “provides the quickest recovery” and “low malnutrition risk.” According to the research, following the surgery, patients with adjustable gastric banding experience 40 to 60% excess weight loss over two or more years.

Ferraro said it is important for the clinicians to assist monitoring the patient after surgery, checking for comorbid conditions, proper medication management, nutritional status, and to encourage the patient to make lifestyle changes.