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CME/CE

NOVEMER 2007

Helping Patients to Avoid Obesity

Sandra A. Carson, MD

Many patients (and physicians) may feel that a few extra pounds are no cause for concern. However, preventing obesity is a matter of “nipping it in the bud”—and the earlier the better before it becomes a mortal disease.

Continuing Medical Education

GOAL

To help health care professionals educate women at risk for obesity before they develop a serious weight problem.

OBJECTIVES

To explore several parameters for defining overweight and obesity in women.
To review the advantages and disadvantages of various weight-loss drugs in women.
To recommend behavioral strategies to help patients recognize and change their eating habits.

ACCREDITATION

This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of Albert Einstein College of Medicine and Quadrant HealthCom Inc. Albert Einstein College of Medicine is accredited by the ACCME to provide continuing medical education for physicians.
This activity has been peer reviewed and approved by Brian Cohen, MD, professor of clinical OB/GYN, Albert Einstein College of Medicine. Review date: October 2007. It is designed for OB/GYNs, primary care physicians, and nurse practitioners.
Albert Einstein College of Medicine designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
Participants who answer 70% or more of the questions correctly will obtain credit. To earn credit, see the instructions on page 57 and mail your answers according to the instructions on page 58.

CONFLICT OF INTEREST STATEMENT

The “Conflict of Interest Disclosure Policy” of Albert Einstein College of Medicine requires that authors participating in any CME activity disclose to the audience any relationship(s) with a pharmaceutical or equipment company. Any author whose disclosed relationships prove to create a conflict of interest, with regard to their contribution to the activity, will not be permitted to present.
The Albert Einstein College of Medicine also requires that faculty participating in any CME activity disclose to the audience when discussing any unlabeled or investigational use of any commercial product, or device, not yet approved for use in the United States.1
Dr Carson reports that she is on the Speakers Bureau of Columbia Laboratories, Inc; Serono Pharmaceuticals; and Ferring Pharmaceuticals. All disclosures reported by the author present no conflict of interest to this article. The author reports no discussion of off-label use. Dr Cohen reports no conflict of interest.

Obesity is the second leading cause of preventable death in the United States.1 To help patients fight this deadly condition, physicians must:

Understand the role of the body mass index (BMI) in defining obesity
Appreciate the risks of obesity in women with regard to health and reproduction
Counsel patients on appropriate diet and lifestyle to promote weight loss
Know the principles of diet, exercise, and behavioral reinforcement for successful weight loss.

Obesity poses significant health risks (Table 1). It decreases longevity and increases the risk of cardiovascular disease, skeletal disease, and diabetes mellitus. It is more prevalent in some ethnic groups, but in general the whole US population is becoming overweight. Some basic strategies can be utilized in all patients who wish to lose weight. Care begins with a thorough history and physical examination (Tables 2 and 3), and then concentrates on education and an individualized treatment plan.

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TABLE 1. Health Risks/ Consequences of Obesity

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TABLE 2. History to Detect Causes and Extent of Weight Problems

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TABLE 3. Physical Examination

DIAGNOSIS

Obesity can be defined using several “yardsticks,” all of which can help patients to understand the problem. Women are obese if they meet the following criteria:

Body fat exceeding 35%
BMI exceeding 30
Weight more than 30% above ideal weight.

In the physician’s office obesity is best determined by using one of the latter two criteria. Measuring the patient’s percentage of body fat may not always be feasible in the physician’s office, but can be accomplished by weight and height measurements at home. The BMI is calculated using the patient’s weight and height: kg/m2, or lb/in2 x 703. A BMI of 25 to 30 is considered overweight in women, but no significant health risks are incurred until the BMI reaches 27. A BMI of 30 to 35 is considered obese, while morbid obesity is defined as a BMI exceeding 35 (Table 4). Obesity is also defined as 30% above ideal body weight, which can be calculated as 105 lb for the first 5 ft of height, plus an additional 5 lb for every inch over 5 ft.

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TABLE 4. Interpreting Body Mass Index

Fat distribution can also influence a patient’s health risks. For example, patients whose fat is primarily in the abdominal area—as opposed to the buttocks, hips, or breasts—have an increased chance of morbidity and mortality as their weight increases. A 22-lb weight gain after age 18 years increases the risk of coronary events in women, and when that fat is centrally distributed the risk increases even more. Central obesity can be determined by measuring a woman’s waist-to-hip ratio. If it exceeds 0.8 or the waist alone is greater than 35 inches, she has an increased risk of coronary heart disease, hypertension, and mortality.

Certain medications are associated with increased weight gain—especially tricyclic antidepressants, phenothiazines, glucocorticoids, cyproheptadine, progestin, lithium, and testosterone. However, estrogen therapy does not increase the risk of weight gain. In fact, patients who use hormone therapy for menopausal symptoms are less likely to have abdominal fat distribution than nonusers.

Even moderate weight loss can confer significant health benefits; this is an important concept in setting reasonable goals. In fact, when the BMI exceeds 27 a patient’s health risks begin to decrease after she loses only 10% of her initial weight. For example, the life of a patient who weighs 250 lb will be prolonged by 3 to 4 months for every kg she loses. A goal of losing 25 lb to gain this benefit is much easier to achieve than a loss of 100 lb to reach her ideal body weight.

Central Obesity

The waist-to-hip ratio should be < 0.8 in women, but waist circumference is an equally acceptable indicator. The tape measure should be placed horizontally at the level of the iliac crest and the measurement taken at the end of a normal expiration. In women a circumference > 35 inches elevates risk one category above that associated with body mass index alone.

PREVENTING OBESITY

Preventing obesity is easier than losing weight, and the physician can begin prevention when the problem is in its early stages. When a patient presents for her annual examination, it is important to obtain her weight and waist measurement. If her weight increases by more than 10 lb in 1 year or her waist measurement by more than 2 inches, the physician should advise her to begin a weight-loss diet and exercise program. She should receive counseling about decreasing caloric intake, increasing caloric output, and modifying her behavior.

Again, one of the keys is to set attainable goals. It is not easy to lose weight; an appropriate rate of weight loss is 1 to 2 lb/wk, with the goal of losing 10% to 15% of the current body weight. The patient should understand that this is a health issue and not a matter of appearance, and that weekly or monthly contact with the physician will increase her chances of success.

A patient’s caloric requirements depend on her weight and her activities. A patient who is relatively inactive requires about 13 kcal/lb to maintain her weight, whereas one with a moderate activity level requires about 15 kcal/lb, and one who is very active needs 17 kcal/lb. As 3,500 kcal is equal to 1 lb of fat, a patient needs 500 kcal/d less to lose 1 lb/wk. For example, a 150-lb woman who is relatively sedentary needs 1,950 kcal/d to maintain her weight. If she eats 1,450 kcal/d, this will result in a 500-kcal/d deficit, and at the end of 1 week this deficit will reach 3,500 kcal—allowing her to lose 1 lb (Table 5).

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TABLE 5. Calculating Calorie Reduction for Weight Loss

There is an endless variety of weight-loss diets. Some of the most popular include the low-fat diet (20 g/d of fat), the high-carbohydrate diet (minimal amounts of fat and protein), and—probably the most well known—the high-protein (Atkins) diet (predominantly consume fat and protein, with 20 g/d of carbohydrates). Studies show that all of these are basically low-calorie diets, and that patients who adhere to the diet that best suits them will succeed. Many of these diets do not conform to the principles of good nutrition, but in the patient who must lose weight nutrition is not the sole consideration. The physician can help the patient choose the most appropriate diet for her by inquiring about her food preferences and recommending the regimen that best accommodates them.

Medication

Patients occasionally need the help of an anorectic agent (Table 6).2,3 Probably the most popular are the neurotransmitter reuptake inhibitors (eg, sibutramine). Noradrenergic stimulants will also decrease appetite (eg, diethylpropion and mazindol). Amphetamines are not indicated for weight control.

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TABLE 6. Drug Therapy for Obesity*

The most commonly prescribed anorectic agent is probably sibutramine. Studies show that sibutramine, 10 mg/d, resulted in 60% of subjects ultimately losing more than 5% of their body weight—provided they lost at least 4 lb in the initial 4 weeks. By contrast, 80% of subjects who failed to lose 4 lb in the first month ultimately lost less than 5% of their initial weight. Thus, anorectic agents are best prescribed on a trial basis; if the patient does not lose weight within the first month, the drug may be discontinued based on the risk/benefit ratio.

Another agent, the lipase inhibitor, orlistat can decrease a patient’s intake by interfering with fat absorption from the bowel. The patient should be instructed to take 120 mg before each meal, and make sure that she consumes less than 30% of her calories from fat. Consuming more than the recommended amount of fat can result in significant cramping and diarrhea sufficient to interfere with daily activities, and the patient may experience fecal incontinence as well. This drug also interferes with the absorption of fat-soluble vitamins, so the patient should take a multivitamin more than 2 hours before or after consuming the orlistat. A 60-mg dose is available OTC.

Exercise

Adding exercise to a weight-loss diet often makes patients feel better and helps to control their appetite. In some patients, however, increasing activity may also increase appetite. A meta-analysis of almost 500 studies covering 25 years of successful weight loss reveals that in the first 15 weeks of therapy, diet alone resulted in a 24 lb weight loss, exercise alone in a 6 lb weight loss, and a combination of both in a 24 lb weight loss.4 Therefore, to avoid confusion and disappointment patients should understand that while exercise increases lean body mass and may prevent a diet-induced decrease in metabolic rate, it does not increase the rate of weight loss. Exercise is associated with improved cardiovascular function, lipid profile, weight distribution, well-being, and appearance, but it can also result in injury and physical discomfort. Indeed, exercise alone is an inefficient way for women to lose weight. Table 7 shows the calories burned during some common exercise activities. Exercise is essential to avoid or reduce a number of medical risks and maintain/improve emotional health and mental function. However, to lose weight efficiently, it must be combined with decreased caloric intake.5

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TABLE 7. Calories/Hour Expended in Common Physical Activities*

Behavioral Issues

Physicians frequently hear a patient say, “But I really don’t eat very much, and I still can’t lose weight!” There are several reasons why a patient may believe this. First, many patients are not aware of how many calories are in certain foods, and appearances can be deceiving. For example, a small piece of chocolate candy can have 25 kcal, while a “healthy” taco salad with guacamole can have 1,500 kcal. In addition, patients may not be aware of how much they eat between meals; that is, a cracker or a piece of candy may add 50 kcal, and a forkful of chocolate pie can add 60 kcal. Video cameras placed in the kitchen revealed that some dieters consumed approximately 1,000 kcal/d that were not recorded in their food diaries; this was because the patient was either walking around the house or watching television and eating without realizing it.

Another way that patients take in unrecognized calories is by poor portion control. Oftentimes, especially when eating in restaurants, the portions served are far larger than the portions specified on labels or in calorie-counting pamphlets/devices. Thus, 3 cups of pasta may be “counted” as a much smaller volume. In this way, patients can consume more food than they realize.

Finally, patients can fail to lose weight due to periodic binge-eating. After decreasing their calorie intake by 500 to 1,000 kcal/d for 4 or 5 days, they may feel that they deserve a “reward” and overeat during the weekend—erasing the calorie deficit.

Patients can be helped to overcome unconscious intake by keeping a food diary in which they record all of the food they eat, with accurate amounts. Frequent office visits with this diary will help the patient and physician pinpoint where “unconscious calories” are consumed. In addition, enlisting the help of a support group is often vital to weight-loss success.

CONCLUSION

To lose weight, patients must decrease their caloric intake, often with the help of an anorectic agent or lipase blocker. They should also increase their caloric output by adding exercise to a weight-loss diet—if they can control their appetite while doing so. Finally, frequent office visits, behavioral changes, and membership in a support group will maximize their chances of weight loss. Generally, then, the same weight-loss principles apply whether the patient is overweight by 10 lb or by 80 lb. However, the patient who is only mildly overweight should understand that it is far easier to reverse this tendency the sooner—and the younger—she starts, and that she cannot afford to ignore it.

Resources and Websites

American Dietetic Association: 1-800-877-1600 www.eatright.org
American Obesity Association: 1-800-986-2373 www.obesity.org
American Society of Bariatric Physicians: 1-303-779-4833 www.asbp.org
Weight Control Information Network: 1-800-946-8098 win.niddk.nih.gov

Sandra A. Carson, MD, is professor, Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Providence, RI; and director, Division of Reproductive Endocrinology and Infertility, Women and Infants Hospital, Providence, RI.

References

Manson JE, Willett WC, Stampfer MJ, et al. Body weight and mortality among women. N Engl J Med. 1995;333(11):677-685.

Kaya A, Aydin N, Topsever P, et al. Efficacy of sibutramine, orlistat and combination therapy on short-term weight management in obese patients. Biomed Pharmacother. 2004;58(10):582-587.

Lucas CP, Boldrin MN, Reaven GM. Effect of orlistat added to diet (30% of calories from fat) on plasma lipids, glucose, and insulin in obese patients with hypercholesterolemia. Am J Cardiol. 2003;91(8):961-964.

Miller WC, Koceja DM, Hamilton EJ. A meta-analysis of the past 25 years of weight loss research using diet, exercise or diet plus exercise intervention. Int J Obes Relat Metab Disord. 1997;21(10):941-947.

Frost G, Lyons F, Bovill-Taylor C, Carter L, Stuttard J, Dornhorst A. Intensive lifestyle intervention combined with the choice of pharmacotherapy improves weight loss and cardiac risk factors in the obese. J Hum Nutr Diet. 2002;15(4):287-295.