Counseling for Obesity: Weighing in on What Works and What Doesn't

Approaching patients who are overweight or obese requires sensitivity and a supportive approach.

Obesity is epidemic and is the number one cause for poor health and premature death. The Centers for Disease Control and Prevention estimates that 66% of adults are overweight and 35.7% are obese. By 2015, researchers predict that 75% of adults will be overweight and 41% will be obese.^1,2 Overweight and obesity are defined using body mass index (BMI) (see Table 1³ ).

Comorbidities

Fat cells produce inflammatory adipokines, resulting in chronic low-grade inflammatory responses that increase risk for life-threatening conditions including^2,4-7:

• Diabetes, high blood pressure, coronary artery disease, high cholesterol, elevated triglycerides, osteoarthritis. 80% of obese individuals suffer from 1 or more of these conditions.
• Endometrial, breast, and colon cancer
• Liver and gallbladder disease
• Sleep apnea, respiratory disease
• Gout, degenerative cartilage, bone disease
• Reproductive health complications
• Benign prostatic hyperplasia
• Urinary incontinence
• Gastroesophageal reflux disease

Fad Diets

In any given year, there is at least 1 diet plan on the best seller list, promising dramatic weight loss. The Atkins, Slim Fast, Sugar-Busters, Glycemic Index, Weight Watchers, the Zone, and South Beach diets have all attracted millions of followers. Some plans eliminate entire food groups (eg, no carbohydrates); others require individuals to purchase meals or snack bars. Do these diets work? The short answer is “yes”—providing that patients are willing to adhere to these diets for prolonged periods.⁸

Patients following these diets lose an average of 13 pounds; however, 50% regain the weight, partly because long-term adherence is problematic.⁸

Fad diets often carry significant risks, including vitamin and mineral deficiencies and increased risk for cancer, fractures, and renal impairment. Overall, low calorie diets are more effective than low-fat diets. Meal replacement diets tend to offer greater weight loss than calorie-controlled diets with normal food.⁹ Differences, however, are short-term; at 12-month follow-up, all diets result in comparable weight loss. Diets that are accompanied by counseling tend to produce the most weight loss.⁹

Counseling

Up to 25% of patients are confused regarding diet information. 10 Weight counseling by primary care physicians is often lacking, leaving counseling to other health professionals.¹¹ Effective counseling begins with patient education on several topics, including the effectiveness of popular diets (see Table 2 ^7,9 ).

The focus of counseling is 2-fold: initial weight loss and sustained weight loss. Sustained weight loss is especially problematic—up to 95% of patients regain their weight within 5 years.¹⁰ Some patients may be puzzled by the fact that they are eating less, but are not losing weight. This occurs when the brain senses reduced intake and attempts to compensate by decreasing energy expenditure.²

Counseling should address unrealistic patient expectations. Emphasize that even a small weight loss can have significant results; a 5% weight loss, for example, reduces type 2 diabetes risk by 60%.^9,12 Encourage patients to seek counseling. Patients engaged in cognitive behavioral therapy along with diet and exercise lose an additional 10.8 pounds compared with patients adhering only to diet and exercise.⁹ Up to one-third of obese patients achieve long-term weight loss when interventions include diet, drugs, and counseling.¹²

Pharmacotherapy

Pharmacotherapy is recommended for patients with failed attempts either at weight loss or at sustaining the loss.² FDA-approved agents include phentermine, diethylpropion, orlistat, and sibutramine. Additionally, fluoxetine, topiramate, bupropion, and metformin are used off-label. Some practitioners use combination therapy (eg, topiramate/phentermine). All agents achieve some level of weight loss, but are considered adjunct support for diet and exercise.²

Patients often skip breakfast, mistakenly believing this facilitates weight loss. The National Weight Control Registry (www.nwcr.ws) tracks patients who have successfully sustained weight loss and identified 4 key trends: 78% eat breakfast; 75% weigh themselves at least weekly; 62% watch less than 10 hours of television per week; and 90% exercise an average of 1 hour a day.¹⁴

Internet-Based Interventions

Most online programs charge a monthly fee, often requiring users to purchase prepackaged meals or snacks. Some provide online support and counseling with an emphasis on realistic goal setting, self-monitoring, and patient education. Evidence suggests some of these programs are successful, although data are limited regarding longterm sustained weight loss.

One study, however, reported sustained weight loss for up to 52 weeks.^7,13,15,16 Consumers must evaluate these programs with healthy skepticism; numerous fraudulent sites exist. Refer patients who are considering online programs to www.consumersearch .com, which evaluates several online programs, including consumer satisfaction.

Bariatric Surgery

Bariatric surgery is recommended for the 5% classified as morbidly obese (BMI >40). Results can be dramatic—one meta-analysis found average weight loss is 61%, type 2 diabetes completely resolved in 76.8%, hypertension resolved in 62%, hyperlipidemia improved in 70%, and obstructive sleep apnea resolved in 86%.¹⁷ Patients considering bariatric surgery must be counseled on the surgery’s risk and be told that up to 25% of patients require a second operation within 5 years.⁵

Final Thought

When it comes to sustained weight loss, the most effective strategy has been and continues to be diet and exercise!

Dr. Zanni is a psychologist and health-systems consultant based in Alexandria, Virginia.

References

1. Centers for Disease Control and Prevention. U.S. obesity trends. www.cdc.gov/obesity/data/trends.html. Accessed April 3, 2012.

2. Fujioka K, Apovian C, Hill J. The evolution of obesity therapies: new applications for existing drugs. Medscape website. www.medscape.org/viewarticle/722366. Accessed April 3, 2012.

3. Centers for Disease Control and Prevention. Body mass index. www.cdc.gov/healthyweight/assessing/bmi/. Accessed April 20, 2012.

4. Centers for Disease Control and Prevention. Halting the epidemic by making health easier at a glance 2011. www.cdc.gov/chronicdisease/resources/publications/AAG/obesity.htm. Accessed April 3, 2012.

5. National Business Group on Health. Evidence statement: obesity (screening and counseling). www.businessgrouphealth.org/benefitstopics/topics/purchasers/condition_specific/evidencestatements/obesity_es.pdf). Accessed April 5, 2012.

6. Moyad MA. Fad diets and obesity--part I: measuring weight in a clinical setting. Urol Nurs. 2004;24:114-119.

7. ConsumerSearch. Weight loss programs: full report, online weight-loss programs. www.consumersearch.com/weight-loss-programs/review. Accessed April 5, 2011.

8. Truby H, Baic S, deLooy A, et al. Randomised controlled trial of four commercial weight loss programmes in the UK: initial findings from the BBC “diet trials.” BMJ. 2006;332:1309-1314.

9. Clifton PM. Dietary treatment for obesity. Nat Clin Pract Gastroenterol Hepatol. 2008;5:672-681.

10. Freedman M. Fad diets. The Gale Encyclopedia of Diets. Longe J, ed. Detroit: Gale; 2008.

11. Neale T. Obesity: weight counseling by PCPs found lacking. MedPage Today. www.medpagetoday.com/MeetingCoverage/OBESITY/28867. Published October 4, 2011.

12. Wadden TA, Volger S, Sarwer DB, et al. A two-year randomized trial of obesity treatment in primary care practice. N Engl J Med. 2011;365:1969-1979.

13. Krukowski RA, West DS, Harvey-Berino J. Recent advances in internet-delivered, evidence-based weight control programs for adults. J Diabetes Sci Technol. 2009;3:184-189.

14. The National Weight Control Registry. NWCR facts. www.nwcr.ws. Accessed April 5, 2012.

15. Collins CE, Morgan PJ, Jones P, et al. Evaluation of a commercial web-based weight loss and weight loss maintenance program in overweight and obese adults: a randomized controlled trial. BMC Public Health. 2010;10:669.

16. Neve M, Morgan PJ, Collins CE. Weight change in a commercial web-based weight loss program and its association with website use: cohort study. J Med Internet Res. 2011;13:e83.

17. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292(14):1724-1737.