Stages of Care
Physicians are doing a relatively good job of identifying and working with severely obese patients with comorbid conditions, but mildly overweight patients remain a missed opportunity, Dr. Kushner said.
“Everyone who is substantially obese was at one time a little bit overweight,” Dr. Frank observed. He urged physicians to do more to identify and help patients “who have an early or mild form of the disease.”
“Primary care physicians must treat obesity in an aggressive manner,” Dr. Vash said, highlighting the relationships between obesity, diabetes, and hypertension. “If you don't deal aggressively with obesity, obesity will chew up and maim your patient.”
Diet and physical activity remain the mainstay of weight-control programs, but pharmacotherapy also has a place, said Daniel H. Bessesen, M.D., of the University of Colorado, Denver.
Medication may not help people shed as much weight as they want or need to lose, but it can boost weight loss by about 5%. The is similar to what can be achieved with behavior modification. Pharmacotherapy and behavioral interventions together can be more effective than either strategy by itself, Dr. Bessesen said.
Yet many physicians refuse to prescribe weight-loss medications. Dr. Bessesen summed up their reasons: The drugs don't work for everyone, they cost too much, and they have side effects. Yet the same can be said of many widely used blood pressure drugs, and diets have side effects, too.
“Our mindset is completely different with other health problems. I think you have to ask yourself, why is that?” he said.
More weight-loss drugs “are coming down the pipe in the next 10 years,” he added. “This is going to be a bigger issue in the future.”
Dr. Schumacher suggested that clinicians prepare patients for weight gain, so they won't be too embarrassed or frustrated to come back. “You need to remind them that they will lapse, and that's not a personal flaw. That's life, and you will be with them if they lapse.”
Gary D. Foster, Ph.D., said low-carbohydrate diets produce greater weight loss at 6 months than low-calorie, low-fat diets. The few studies to evaluate low-carbohydrate diets have reported remarkably consistent short-term results, he said, noting, however, that weight loss at one 1 year was the same as for low-fat regimens.
Dr. Foster, a psychologist and obesity researcher at the University of Pennsylvania in Philadelphia, urged patience when patients do gain back weight. “The patient needs to know we are going to be treating him in a nonjudgmental way,” he said, recommending the clinician assume the reason is “lack of planning or skills, rather than a lack of motivation.”
Figure out what got in the way of adherence, then come up with a plan for how the patient will deal with the same situation in the future, he advised.