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Clinical Guidelines for Managing Obesity

Clinical Guidelines for Managing Obesity

According to published data, nearly 155 million adults in the United States are classified as being either overweight (having a BMI of 25 to 29.9 kg/m2) or obese (having a BMI of 30 kg/m2 or higher). “Health-care providers are on the front line of the obesity epidemic,” explains Donna H. Ryan, MD. “Greater efforts are needed to identify patients who need to lose weight for cardiovascular reasons. As clinicians, we’re in a prime position to direct successful weight loss efforts.” According to Dr. Ryan, behaviors around food and physical activity and getting patients the help they need to change these behaviors are paramount to weight loss. “Losing weight is a complex issue that goes beyond a person’s willpower,” she says. “We need to do more than simply advise obese and overweight patients to lose weight. We need to be actively involved to help patients reach a healthier body weight, and that’s not necessarily a so-called ‘normal’ body weight.” Helpful Guidance In 2013, the American Heart Association, American College of Cardiology, and Obesity Society released comprehensive treatment recommendations to help healthcare providers tailor weight loss treatments to adults who are overweight or obese. The guidelines address five specific areas of obesity, including:   1)   The identification of who needs to lose weight.   2)   How much weight patients should lose.   3)   Diets to consider for weight loss.   4)   Expected weight loss with lifestyle interventions.   5) Patients who should be considered for bariatric surgery. According to the guidelines, healthcare providers should calculate BMI at annual visits or more frequently and use BMI and waist circumference (WC) cutpoints to identify...
Physician Rapport With Obese Patients

Physician Rapport With Obese Patients

Recent studies suggest that obese patients may be vulnerable to poorer physician–patient communication because some doctors may hold negative attitudes toward these individuals. “Prior studies have shown that some physicians have less respect for their obese patients, viewing them as being lazy or unmotivated,” explains Kimberly A. Gudzune, MD, MPH. “These negative attitudes may come across during patient encounters.” Yet, no studies had previously assessed whether patient obesity altered physician–patient interactions with regard to biomedical and psychosocial dialogue and rapport building. In a study published in Obesity, Dr. Gudzune and colleagues sought to address this research gap by analyzing audio recordings of visits by 208 patients with high blood pressure who saw 39 primary care physicians (PCPs). Empathy Matters According to the study, patient weight did not appear to play a role in the quantity of physicians’ medical questions and advice, counseling, or treatment regimen discussions. However, PCPs built significantly less emotional rapport with their obese patients than with those who were normal weight. PCPs were more likely to show empathy, concern, and understanding with patients of normal weight by using words and phrases that reassured and legitimized patients’ feelings, regardless of the medical topic being discussed.   The findings raise concern about how these low levels of emotional rapport may impact obese patients, according to Dr. Gudzune. “This may weaken the physician–patient relationship,” she says. “It may also reduce the likelihood that patients will adhere to their doctor’s recommendations and may decrease the effectiveness of behavior-change counseling, which are vital elements to helping obese patients lose weight and improve health.” Building an Alliance Patients usually resent feeling that they are...
Substance & Alcohol Use After Weight Loss Surgery

Substance & Alcohol Use After Weight Loss Surgery

Weight loss surgery (WLS) has been an effective treatment for many patients with clinically severe obesity and comorbid medical con­ditions. Despite its merits, WLS requires major lifestyle changes for potential candidates, and many patients may not be adequately prepared to make such changes. Studies have suggested that substance and alcohol abuse is more common among patients undergoing WLS, but this research has been limited by the lack of preoperative baseline data as well as longitudinal data. The symptom substitution theory states that eliminating a particular symptom without treating the underlying cause will lead to the development of a substitute symptom. Under this theory, it’s possible that the risk of substance use may rise after WLS; while the surgery helps eliminate excessive eating, it doesn’t address any potential underlying psychopathology. Since drugs, alcohol, and other substances trigger responses in the brain similar to that of food, it’s possible that they can serve as a food substitute in the WLS population. A Closer Look At Substance Use After Weight Loss Surgery My colleagues and I had a study published in JAMA Surgery that examined the likelihood of WLS patients to develop substance use—specifically alcohol, cigarettes, and recreational drugs—after their operation. We analyzed 155 patients undergoing WLS—100 who underwent laparoscopic Roux-en-Y gastric bypass (RYGB) surgery and 55 who received laparoscopic adjustable gastric band (AGB) surgery. Participants undergoing either RYGB or AGB surgery reported significant increases in the frequency of substance use—using a composite of drug use, alcohol use, and cigarette smoking—when assessed 2 years after surgery. Notably, patients in the RYGB group reported a significantly higher frequency of alcohol use at 2...
Can Financial Incentives for Patients Induce Weight Loss?

Can Financial Incentives for Patients Induce Weight Loss?

Several studies have suggested that financial incentives appear to help overweight and obese patients continue to participate in weight-loss programs longer and lose more weight than counterparts who do not receive such incentives. However, when financial incentives are removed, patients tend to regain the weight they had lost. “People are hard-wired to make choices that provide immediate gratification, even if it’s known that they will regret those choices in the long term,” says Steven L. Driver, MD, MPH. “The same is true when people are motivated to make healthy decisions.” Testing a Financial Incentive Approach At the American College of Cardiology’s 2013 annual meeting, Dr. Driver and colleagues presented data from a study that investigated whether providing continuous financial incentives for 1 year would encourage participants to achieve and maintain weight loss. “We hypothesized that financial incentives would help participants stick with the healthy behaviors they know they should practice more often,” Dr. Driver says. “This could therefore help them achieve sustainable weight loss.” For the study, 100 patients between the ages of 18 and 63 with a BMI of 30 kg/m2 to 39.9 kg/m2 were randomized to education with or without financial incentives or to education plus a structured behavior modification plan with or without financial incentives. “All participants were given a weight loss goal of 4 lbs per month, which was adjusted based on the previous months’ weight,” explains Dr. Driver. Participants in the incentive arms could earn $10 for attending monthly weigh-ins. An additional $20 could be earned by those who met their goal weight for the month. However, those who failed to meet their goal...

New Weapons in the War on Obesity

Just when you think you’ve seen everything, along comes the AspireAssist. This device, not yet FDA-approved, consists of a tube implanted in the stomach, which leads to a port that is exposed on the surface of the abdomen. Now, I’m not making this up. You can eat whatever you want. Then 20 minutes after your meal, you attach a pump to the port and siphon and lavage the contents of your stomach into a bucket or basin, I guess. The manufacturer says that this will remove about a third of what is eaten leading to weight loss if done after every meal. It doesn’t tell you how to gracefully dispose of the contents of the stomach, especially if you are dining at say, McDonald’s. The only research on this product is in the form of a poster that was shown at a meeting of the Obesity Society in October of 2011. It was a randomized prospective trial of 11 patients who received the device plus “lifestyle intervention” compared with seven patients who had only “lifestyle intervention.” It was funded by the maker of the device. Ten subjects completed a year with the device vs only four who stuck with the lifestyle intervention. Baseline characteristics were similar for the two groups. Percent weight loss and absolute weight loss were significantly greater in the device group. The average 1-year weight loss was 20 kg. However, 10/11 patients had pain more than 4 weeks after surgery, and irritation and bleeding at the stoma occurred in about half the patients. Two had infections at the site. Constipation occurred in six patients and anemia...
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