Obesity Management in Family Practice
Obese patients who receive counseling and weight management from physicians are significantly more likely to undertake weight management programs than those who do not. Obesity treatment guidelines and materials are available from various health organizations. A comprehensive weight management program must include dietary adjustments, increased physical activity, and behavioral modification. Nutritional modifications should take into account the diet's energy content, composition, and suitability for the individual patient.
The physical activity component should be safe and practical, including aerobic activity, strength training, and increased daily lifestyle activities. Various behavioral strategies enable the patient to make lifestyle changes that will promote weight loss and management.
Adjunct therapies may serve to support lifestyle modifications in severe or resistant cases of obesity. Models for multidisciplinary care vary depending on whether they are designed for an individual medical practice or as part of the health care services of a larger facility.
Lifestyle changes for healthy weight management must be permanently incorporated into a patient's daily lifestyle to reduce obesity and its associated health risks. Such intervention is necessary if the growing epidemic of obesity is to be slowed and reversed. Physicians are seeing, and are likely to continue to see, increasing numbers of overweight and obese patients in their practices, as the obesity epidemic spreads at rates typically seen for communicable diseases 1. The prevalence and severity of obesity affects both men and women and virtually all ethnic groups.
Childhood and adolescent obesity also continues to escalate rapidly 7 8. An ever growing body of research and clinical experience presents strong evidence that obesity is a chronic disease, a primary medical condition that is progressive, relapsing, and usually lasts many years It is also associated with increased use of health care and increased lost days of work 12 As a chronic disease, obesity acts as a primary underlying cause of multiple comorbid conditions and their associated risk factors 3 14 15 These comorbidities include coronary heart disease CHD , hypertension, dyslipidemia, type 2 diabetes, and other conditions listed in Table 1.
In addition, such comorbidities tend to cluster in obese individuals 17 18 19 Because obesity affects such a large percentage of the population and poses consequential health risks, it is important that physicians treat obesity and counsel healthy weightmaintenance within the primary care setting.
Such treatment, however, is not commonly implemented 21 22 23 , despite evidence that physician counseling and management of obesity treatment can be very effective in helping obese patients undertake and sustain weight management programs 24 25 26 The occurrence of obesity is influenced by a complex interaction of genetic, environmental, and behavioral factors. Therefore, a multidisciplinary treatment program that enables the physician to draw on the resources of specialists in nutrition, exercise, and behavior modification and that works with the obese patient as an actively involved member of the team, provides the most flexible, individualized, and effective strategy.
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Such a multidisciplinary approach can increase the physician's ability to bring this chronic disease under control 28 Obesity is clinically defined as the excess accumulation of body fat. As a practical assessment of relative adiposity, BMI used in conjunction with waist circumference provides an accepted clinical method 1 2. Individuals with BMIs of These values were categorized on the basis of increases in morbidity and mortality associated with various levels of BMI. BMI does not distinguish lean mass from fat mass, it does not reflect the distribution of body fat, and it may not accurately reflect total body fat in all individuals, particularly in those who are very muscular, have very high bone density, or are elderly.
Thyroid, Obesity And Weight Loss
Measuring waist circumference, which is correlated strongly with abdominal fat visceral adiposity , provides a useful indicator of increased medical risk 3 14 18 Assessing the vital signs of BMI and waist circumference during each office visit, or at least at each regular checkup, can provide the physician with an excellent but simple and inexpensive method for patient evaluation and education The enormous burden of disease associated with obesity 14 16 constitutes a powerful reason for physician concern and intervention to improve the health of patients. This finding, which offers motivation for obese patients to exercise or increase activity, needs additional research.
In addition to the independent medical conditions listed in Table 1 , obese individuals are more likely to experience risk factor clustering, as shown by data from the Framingham Offspring Study 17 This evidence provides the basis for the treatment guidelines recommended by the National Institutes of Health 3 , which are summarized in Table 3. After weight stabilization following the first 6 months of treatment and after a careful evaluation, the physician may recommend that some individuals attempt additional weight loss to achieve desired health goals.
Despite the clear evidence of the adverse health risks of obesity and the expanding obesity epidemic, obesity treatment is not commonly practiced in the primary care setting. Additional studies indicate even lower figures These statistics represent missed opportunities for physicians to counsel their patients not only about the health risks of obesity, but about the health benefits of increased fitness and weight loss and management.
Historically, a number of factors may have contributed to physician reluctance to treat obesity. These impediments include a view of obesity as simply willful misconduct by obese individuals 28 46 ; an overwhelmingly large number of obese patients 4 5 6 ; a general lack of physician training and background in nutrition, exercise science, and obesity management 47 48 49 50 ; and lack of reimbursement for obesity treatment Additionally, a common view held both within the medical and public communities is that obesity is more of a cosmetic concern than a health concern.
However, abundant evidence and guidelines from national and international organizations emphasize the importance of acknowledging obesity as a chronic disease with serious health consequences, thus, requiring treatment 2 3 14 38 Routine contact with patients provides repeated opportunities for intervention, and obese patients who are advised by their physicians to lose weight are significantly more likely to attempt weight loss than those who do not receive such advice 24 53 Based on such findings and the seriousness of the health risks of obesity, national organizations, including the American Heart Association and American Dietetic Association, are urging physicians and other health care professionals to take a larger role in obesity treatment and weight management 2 3 14 15 38 A multidisciplinary approach to obesity treatment allows the primary care physician to take advantage of his or her influence with the patient to offer various approaches to weight management that can be individualized for the patient; involve the patient in developing the treatment plan; take into account patient preference, lifestyle, and social situation; and make available counseling, resources, and support in various aspects of treatment, including dietary therapy, activity therapy, and behavior therapy Models for multidisciplinary care may vary depending on whether they are designed for an individual medical practice or are set within the structure and health care services of a larger facility 11 28 56 Models designed for a large facility may include an interactive team made up of health care professionals from various disciplines who are physically located within the facility.
In cases in which the physician or patient does not have access to all of the team members, the physician may play a role in implementing some or all facets of the multidisciplinary care. Strategies for implementing these various levels of multidisciplinary approaches are discussed in the following sections.
In all models, the primary care physician provides the primary medical assessment and medical management of the patient and serves in motivating the patient to start and stay with treatment 24 26 Even if the physician does not use a team approach, it is still possible to implement multidisciplinary treatment to support more positive patient involvement and outcomes. An increasing number of resources, such as those developed and made available in print and online by the National Institutes of Health 58 and such organizations as the American Dietetic Association and American Heart Association, can aid the busy physician in patient education, in reinforcing weight management guidelines with the patient, and in supporting the patient in daily efforts for weight loss or maintenance.
These guidelines set forth some basic practical steps that a physician may use to establish effective and efficient obesity treatment. As an essential first step, the medical assessment of the patient serves to determine the severity and consequences of obesity. This assessment includes taking baseline measurements of BMI and waist circumference, taking the patient's weight and health history, and performing a physical examination to detect possible complicating conditions or comorbidities.
Recommended questions and tests for the assessment are summarized in Table 4 3 15 58 The medical evaluation and patient attitude and readiness revealed by assessment can help the physician and patient, working together with the multidisciplinary care team, to shape the appropriate dietary, physical activity, and behavioral goals and activities of the obesity treatment plan.
If indicated, due to the severity of the obesity or comorbidities in a given patient, this primary plan may be supported as appropriate by medication or surgery, but these components should not considered as alternatives or substitutes 3 Tailoring the plan to the specific needs, goals, responses, and preferences of the individual patient is imperative to developing a weight management plan. This underscores the importance of active patient involvement and feedback within the multidisciplinary team A standard multidisciplinary strategy must be flexible enough to be individualized so that it can be integrated into the patient's everyday life in a positive way 3 Planning appropriate diets and nutritional modifications for weight loss and weight management should take into account the diet's energy content, composition, and suitability for the individual patient.
Key recommendations for each of these aspects are presented in Table 5 3 58 Representative dietary education topics are listed in Table 6 3 58 The National Institutes of Health, the American Dietetic Association, and other organizations provide materials, checklists, guidelines, menus, and recipes to assist in such patient education 3 38 Patients should be encouraged to maintain daily records of food and beverage intake, because this increases awareness of consumption and promotes dietary adherence. It is important for the nutrition and physical activity plans to be integrated to ensure appropriate rates of weight loss, because the total energy deficit should derive from both decreased energy intake and increased energy expenditure.
Estimated energy intake for weight loss diets may be set at kcal for women and kcal for men. However, these levels may vary in individuals based on patient size, body composition, activity level, tolerance, and preferences. Diets that involve complete or intermittent fasting or intakes below kcal daily are not recommended 3 Dietary composition should be geared toward decreasing risks for chronic diseases, particularly cardiovascular diseases. Accordingly, as shown in Table 5 , the diet should be relatively low in fat, saturated fat, cholesterol, and sodium, whereas high in both soluble and insoluble fiber.
Consumption of fruits, vegetables, whole grains, lean sources of protein, and water should be encouraged, with emphasis on balance and moderation. Diets that promote extreme restriction or high intakes of any macronutrient or food should be avoided. Ample intake of vitamins and minerals must be ensured.
Women, particularly those of reproductive age, may require iron and calcium supplementation. Endurance activity of at least moderate intensity also substantially lowers the patient's risk of developing CHD and many other comorbidities of obesity and helps control these diseases when they are already present 3 34 Based on the findings of the patient assessment, the physical activity component of the obesity treatment plan should include aerobic activity the primary component , strength resistance training, and increased daily lifestyle activities 3 When planning or prescribing exercise for the overweight or obese patient, the physician should consider the safety and accessibility of the activity as well as the patient's motivation and personal preference 3 Any recommended activity program for obese individuals should include the components of intensity, duration, and frequency recommended for healthy adults by the American College of Sports Medicine 66 , with the modifications and considerations as presented in Table 7.
On the basis of extensive clinical experience and research, walking is recommended as the safest, most convenient, and most effective physical activity for the majority of overweight adults. The physician may wish to encourage patient compliance by providing specific walking program guidelines, such as those provided in the appendix of the National Institutes of Health Practical Guidelines A number of behavioral factors may influence an individual's obesity and success in undertaking and sustaining a weight management program.
Table 8 provides some additional resources that physicians and the care team may use to support patients in weight loss and management 3 25 58 In general, contact should be fairly frequent at the beginning of the program every 1 to 4 weeks but may taper off after 6 months or so A patient who has medical conditions that affect the weight management program may require more frequent visits based on the physician's clinical judgment. Recommendations of FPs are summarized in Table 5. They include utilization of the media for the parents and community education to empower the schools and teachers, to focus the primary healthcare system on preventive medicine, to improve the integration between primary and secondary healthcare system, to reduce the number of patients per physician and their workload.
They need to watch on the screen that obesity is not normal. Family and education are important. At this point, the responsibility of the schools and the teachers are much more important than the families and even more than us. Using a mixed-methods approach, FPs opinions about their role in the management of CO in primary care setting were evaluated. Most FPs agreed that they have a role in managing CO. However, only two thirds of FPs recommended this for children aged 5—15 years. The most reported barriers in the management of CO were lack of time and the fact that in Turkey FHCs are not being utilized for the care of children aged 5—15 years.
Obesity: Assessment and management in primary care. Am Fam Physician. Secondary prevention of overweight in primary school children: what place for general practice? Med J Aust. The results of the qualitative part of the study showed that there might be two reasons behind this opinion of FPs. Second, due to the lack of technical i.
Lack of integration or coordination between primary and secondary healthcare has been mentioned as a problem of primary healthcare in previous studies [ 11 Turner KM , Shield JPH , Salisbury C. Health system review. Health Syst Transit. Eur J Gen Pract.
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Lack of knowledge regarding management of CO was also reported in this study as a barrier among FPs. This lack may indicate a need of effective training of FPs in the management of CO. However, a lack of standardized guidelines was mentioned by only a few FPs in our study; although this has been reported as an important problem in other studies [ 11 Turner KM , Shield JPH , Salisbury C.
Health policy analysis for prevention and control of cardiovascular diseases and diabetes mellitus in Turkey. Int J Public Health. Childhood obesity: how do Australian general practitioners feel about managing this growing health problem? Aust J Prim Health.
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For instance, in Turkey there are no incentives for better performance such as CO management. However, payment cut off occurs if FPs cannot reach specific targets. Lack of time and an excess workload of FPs were reported in both quantitative and qualitative parts of our study. Changes in primary care provision in Turkey: A comparison of and Health Policy. Another critical issue related to problems of PHC in Turkey that fails the role of primary care in the management of CO was that FHCs were not being utilized for child monitoring after school age. Leeds: The Information Centre, : General practice views of managing childhood obesity in primary care: a qualitative analysis.
JRSM Open. Diagnosis and management of childhood obesity: A survey of general practitioners in South West Sydney. Although we found a similar result in our study, FPs have given the maximum priority in the management of CO to the parents Childhood obesity: Do parents recognize this health risk? Obes Res. PLoS One.
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BMJ Open. Parental influence on childhood obesity: A review. Myers S , Vargas Z.
Parental perceptions of the preschool obese child. Pediatr Nurs. Weighing children; parents agree, but GPs conflicted. Arch Dis Child.