Motivating the Obese Patient

With more than 6 of every 10American men and womenoverweight or obese,¹ incorporatingcounseling on dietary indiscretionand physical inactivity into mosthealth care visits might help stem theapproximately 300,000 deaths that obesitycauses annually.² Yet, how manyhealth care providers actually discussobesity, or help the 85% of patients whodo not exercise enough or are sedentary³take constructive steps towardweight loss? If the constant increase inthe number of overweight Americans isany indication,⁴ few are doing so. In reality,health care professionals advise only34% to 42% of obese adults to loseweight.^5-7

Often, clinicians perceive that patientsfind this issue sensitive and intrusive;become frustrated because many patientscannot or do not lose weight;believe that weight loss is a patientresponsibility; or feel unprepared toaddress nutrition and exercise. With prescription-strength and OTC weight-lossagents now available, pharmacists mayneed to hone their counseling skills withrespect to obesity.

The consequences of obesity?a conditionthat results from a chronic energyintake/energy expenditure imbalance⁸?are well-known. Energy-dense foods andtechnology that makes tasks effortlesshave skewed that balance toward greaterintake and less energy expenditure, creatinga nation of heavier people.⁹ Table 1lists basic facts about obesity that healthcare professionals who counsel overweightor obese patients should know.

Opportunity and MotivationalInterviewing

The pharmacist?s best opportunity tocounsel patients about obesity is whenthey present with conditions known tobe associated with obesity or when theypick up obesity-management drugs.During counseling, pharmacists need tolook for chances to raise the issue ofweight or, if the patient mentions weight,to ease into the subject respectfully andnonjudgmentally.

Sometimes, cloaking counseling ascuriosity allows the patient to elaborate.Asking, ?Just out of curiosity, whatprompted you to consider [or have youconsidered] weight loss?? might start aconversation. It is crucial also to believethat patients are capable of changingtheir behaviors and to listen carefully.¹⁴

Motivational, tolerant interviewing isdesigned to help patients move throughthe stages of change more rapidly than ifthey were left to their own devices. Itprovides support and encouragement. Itdiscourages apathy and uses open-endedquestions to help patients see wherethey are and lead them to where theyneed to be. This confrontation is notargumentative or coercive.¹⁵ Asking,?How do you think your current weightaffects your health?? lets patients verbalizetheir own observations. It recognizesthat the decision to change is thepatient?s.

Resistance is normal. Should patientsassume that an obesity-managementdrug makes exercise optional, they maybe resistant to suggestions concerningexercise. Asking, ?What did the prescribertell you about diet and exercise?? will letthe patient review information. It also willidentify information gaps, presenting anopportunity to provide additional education.¹⁴ Ultimately, motivational interviewingfocuses on building self-efficacy in away that incorporates an individual?sreadiness to make a change.¹⁵Weight-loss Drugs

Weight-loss drugs may sound likemagic, but they should be reserved forpeople with weight-related health problemswho are willing to adhere to ahealthy diet and regular exercise. Thebest candidates for these drugs have thefollowing characteristics:

• Failure with other methods of weightloss
• Body mass index (BMI) >27 and medicalcomplications of obesity, such asdiabetes, high blood pressure, orsleep apnea
• BMI >30¹⁶

Combining medication, calorie restriction,and increased activity can result in aweight loss of 5% to 10% of weight withina year. Although this amount mayseem small, modest weight loss oftendecreases blood pressure, serum lipids,and insulin levels.¹⁶

Counseling the patient who presents aprescription for an obesity-managementdrug should emphasize that these drugsmust be used with a change in eatinghabits and an increase in activity. All currentlyapproved prescription weight-lossdrugs work by suppressing the appetite,except orlistat. Orlistat, a lipase inhibitorthat decreases dietary fat absorption by30%, limits the number of calories availableto the body. Its common side effectsare cramping, diarrhea, flatulence, intestinaldiscomfort, and leakage of oily stool.Alli, the OTC half-strength version of prescriptionorlistat, has been approved bythe FDA.¹⁶

Sibutramine increases the levels ofcertain neurotransmitters to reduceappetite. Hypertension and increasedheart rate are possible side effects, sosibutramine is contraindicated in patientswith uncontrolled hypertension, ahistory of heart disease, congestive heartfailure, irregular heartbeat, or stroke.Other common side effects includeheadache, dry mouth, constipation, andinsomnia.¹⁶

The older obesity-management drugswere approved based on very short-term,limited data. Phendimetrazine, methamphetamine,and phentermine should notbe used by people with heart disease,hypertension, hyperthyroidism, or glaucoma.These drugs are approved for short-termuse only. They have potential forphysical dependence or addiction.¹⁶

Pharmacists also should rememberthat some prescription drugs are associatedwith weight gain. Table 2 lists severalof these drugs. In the event that apatient taking 1 of these drugs complainsof weight gain or difficulty losing weight,nutritional counseling can help. Additionally,consultation with the prescriberabout possible alternatives might be inorder, especially if the weight gain is contributingto nonadherence.¹⁷

End NotePatients who struggle with theirweight need considerable support andguidance. If weight control were just simplemathematics (calories in < caloriesused), everyone would be thin. Pharmacistsshould get serious about counselingpatients who are overweight or obeseand should develop an armamentariumof tools patients can use. Two good toolsare as follows:

• The diet and exercise tracker athttp://myfooddiary.com that, for asmall monthly fee, tracks calories inand calories expended, providesguidance about salt intake, usesgraphics to help dieters modify theireating behaviors, and offers onlinesupport
• The National Institute of Diabetesand Digestive and Kidney Diseases?Weight Control Information Network,located at http://win.niddk.nih.gov/publications/index.htm, a free sitewith information to address mostdieters? questions.

References

1. Mokdad AH, Serdula MK, Dietz WH, Bowman BA, Marks JS, Koplan JP. The spread of the obesity epidemic in the United States, 1991-1998. JAMA. 1999;282:1519-1522.

2. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA. 1993;270:2207-2212.

3. Physical activity and health: a report of the Surgeon General. Atlanta, Ga.: US Dept of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 1996.

4. Prevalence of overweight among adolescents?United States, 1988-91. MMWR Morb Mortal Wkly Rep. 1994;43:818-821.

5. Galuska DA, Will JC, Serdula MK, Ford ES. Are health care professionals advising obese patients to lose weight? JAMA. 1999;282:1576-1578.

6. Stafford RS, Farhat JH, Misra B, Schoenfeld DA. National patterns of physician activities related to obesity management. Arch Fam Med. 2000;9:631-638.

7. Wee CC, McCarthy EP, Davis RB, Phillips RS. Physician counseling about exercise. JAMA. 1999;282:1583-1588.

8. National Institutes of Health Technology Assessment Conference Statement: methods for voluntary weight loss and control, March 30-April 1, 1992. Nutr Rev. 1992;50:340-345.

9. Hill JO, Melanson EL. Overview of the determinants of overweight and obesity: current evidence and research issues. Med Sci Sports Exerc. 1999;31(11 suppl):S515-S21.

10. King AC, Tribble DL. The role of exercise in weight regulation in nonathletes. Sports Med.1991;11:331-349.

11. Garrow JS, Summerbell CD. Meta-analysis: effect of exercise, with or without dieting, on the body composition of overweight subjects. Eur J Clin Nutr. 1995;49:1-10.

12. Prochaska JO. Strong and weak principles for progressing from precontemplation to action on the basis of twelve problem behaviors. Health Psychol. 1994;13:47-51.

13. National Heart, Lung and Blood Institute. NHLBI Obesity Education Initiative. Available at: www.nhlbi.nih.gov/about/oei/index.htm. Accessed July 28, 2007.

14. Mengel MB, Holleman WL, Fields SA. Fundamentals of Clinical Practice. 2nd ed. New York, NY: Kluwer Academic Publishers; 2002.

15. Miller W, Rollnick S. Motivational Interviewing. New York, NY: Guilford Press; 2002.

16. Bray GA, Ryan DH. Drug treatment of the overweight patient. Gastroenterology. 2007;132:2239-2252.

17. Leslie WS, Hankey CR, Lean ME. Weight gain as an adverse effect of some commonly prescribed drugs: a systematic review. QJM. 2007;100:395-404.