Weight loss strategies that

really Work .
With your guidance, sustained weight loss is possible— even for the severely obese. Th ese tips
and tools will help.

PRACTICE RECOMMENDATIONS › Calculate body mass index and diagnose obesity to increase the
likelihood that obese patients will take steps to lose weight. B › Prescribe a low-calorie diet for at least 6
months to help patients achieve a weight loss of at least 5% to 10%; prescribe physical activity for
weight loss and weight maintenance. A › Review the benefits and risks of bariatric surgery with patients
who are severely obese, and provide a referral, when appropriate. A Strength of recommendation (SOR)
Good-quality patient-oriented evidence Inconsistent or limited-quality patient-oriented evidence
Consensus, usual practice, opinion, disease-oriented evidence, case series

 Adopting weight loss strategies needn’t be too time-consuming; evidence suggests that
physicians can provide basic counseling about healthy behaviors in fewer than 5 minutes.
 National Weight Control Registry: Lessons from “successful losers” J. Graham
Thomas, PhD, NWCR co-investigator

I t’ s not only obese patients who are resistant to weight loss strategies. Many physicians contribute to
the gap between current practice and optimal management of adult obesity, as well. Th ere are a
number of reasons for this—a dearth of knowledge, time, and reimbursement among them.1,2 What’s
more, physicians are often pessimistic about how much headway patients can make in their weight loss
efforts. That’s not surprising, given that the average weight loss achieved in well-controlled clinical trials
tends to be modest and the recidivism rate is extremely high.3 Yet these same trials are cause for
optimism, with substantial subsets of patients often achieving clinically meaningful long-term weight
loss. The National Weight Control Registry, a long-term prospective study of “successful losers,” is
another hopeful indicator: The registry includes approximately 6000 individuals who have lost, on
average, more than 70 lb, and kept it off for an average of 6 years.4 (Listen to the audio cast at

click here to find out how.) Weight loss does not have to be huge to be clinically significant.
Even a modest loss (5%-10% of total body weight) can have major health benefits. There’s much you can
do to help. Evidence suggests that patients are considerably more likely to lose weight when they are
advised to do so and supported by their primary care physician.5-9 Because there is no way to predict
which approach will be most effective for which patient, family physicians (FPs) should offer a variety of
evidence-based treatments, including dietary change, increased physical activity, medication for
selected patients, and surgery for severely obese adults (TABLE 1). In 2009, the National Committee on
Quality Assurance added body mass index (BMI) to the list of effectiveness-of care measures that health
plans and physicians are rated on.10 Th at addition, coupled with a recent study indicating that obesity
accounts for more than 9% of annual health care expenditures,11 highlights the growing recognition
that obesity should be considered a medical condition—not just a risk factor

2 weight loss tools that can jump-start your efforts Physicians

often cite time as a key reason for not providing weight loss counseling. But physician knowledge—
actually, lack of knowledge—may be a bigger barrier. In 1 recent study, 44% of physicians said they did
not feel qualified to treat obesity.12 In another, 72% of primary care physicians surveyed said that no
one in their practice was trained to deal with weight-related issues.13 As the focus on obesity grows,
clinical weight management tools are increasingly available. Two excellent examples are the California
Medical Association Foundation’s Obesity Provider Toolkit (www.
thecmafoundation.org/projects/obesity Adopting weight loss strategies needn’t be too time-consuming;
evidence suggests that physicians can provide basic counseling about healthy behaviors in fewer than 5
minutes. IMAGE © JOE GORMAN Project.aspx) and the clinical tools from North Carolina’s Eat Smart,
Move More program (www.eatsmartmovemorenc.com/ ESMM Plan/ESMMPlan.html). You can
download a toolkit, review the strategies described, and adopt those you think would be most effective
in your practice. Doing so needn’t be especially time-consuming; evidence suggests you can provide
basic counseling about healthy behaviors in fewer than 5 minutes.14 ❚ Review guidelines. The National
Heart, Lung, and Blood Institute issued the first evidence-based guidelines for the treatment of adult
obesity in 1998.15 Many other groups— the US Preventive Services Task Force (USPSTF),16 the
American Dietetic Association,17 and the American College of Physicians,18 among them—have
followed suit, with guidelines addressing practical weight loss interventions and treatment related to
specific co morbidities. The organizations all recommend using BMI to diagnose and classify obesity,
assessing readiness to change, and setting realistic goals (TABLE 2)

 TABLE 1 BMI, health risks, and weight loss: Which intervention for which patients?15

Disease risk

BMI, kg/m2 (weight status) Normal waist measurement Elevated waist measurement

25-29.9 (overweight) Increased high

30-39.9 (obese) 30-34.9: High 35-39.9: Very high very high

≥40 (extremely obese) Extremely high extremely high

Intervention

Diet and physical activity Medication Surgery

25-26.9: Yes, for patients with 25-26.9: NA 27-29.9: NA

Co morbidities 27-29.9: Yes for patients with co morbidities 30-34.9: Yes, 35-39.

Yes _

yes _

Diagnose obesity without delay While most patients can report their height and weight with
reasonable accuracy, few obese adults consider themselves to be obese.19 And, although the USPSTF
2009 recommendations call for screening all adults for obesity and introducing behavioral interventions
to promote sustained weight loss as needed,20 most obese men and women receive neither a diagnosis
nor an obesity management plan.21 Yet both are key components of long-term weight control.
Physicians should calculate and document the BMI of all adult patients, and routinely diagnose obesity
in patients with a BMI ≥30 kg/m2 (TABLE 1). Get the patient’s perspective In addition to using BMI and
waist circumference measures and identifying co morbidities such as diabetes and hypertension, it is
important to determine whether the patient is motivated to change. You can start by asking whether he
or she has previously been told to lose weight; adults who have received weight control counseling in
the past are more likely to be in a greater state of readiness.7

❚ Review the patient’s medications. Once you have identified obesity, look for iatrogenic causes—most
notably, current use of 1 or more medications that are associated with weight gain or known to affect
satiety. If you identify any such drugs, it may be possible to find a suitable alternative (TABLE 3).

❚ Factor in literacy. Patients with low literacy are less likely to fully comprehend the health benefits of
weight loss or to report that they are ready to lose weight, as compared with those with higher literacy
levels.22 Talking to such patients to determine what will spark their interest and motivation—ie, looking
and feeling better, being able to play with children or grandchildren— can help.

❚ Assess the patient’s dietary patterns. This can be done with the Rapid Eating Assessment for
Participants (REAP), an office based tool of adequate reliability and validity for nutrition assessment and
counseling that can be administered in a few minutes.23 This office-based survey, available at
http://bms.brown.edu/nutrition/acrobat/ REAP%206.pdf, provides information that can be the basis for
an action plan. While there is no direct evidence that having a plan leads to weight loss, receiving advice
from a physician is strongly associated with efforts to lose weight.6 Be aware that obese individuals may
not be as responsive to weight management counseling from a physician as those who are overweight,
so they may require more assistance.21

 Set a goal, prescribe a food plan After discussing possible interventions based on the patient’s
BMI and weight status (TABLE 1), set a safe and achievable goal to reduce body weight at a rate
of 1 to 2 lb per week for 6 months to achieve an initial weight loss goal of up to 10%. Not only
does such a target have proven health benefits,15,24 but defining success in realistic and
achievable terms helps maintain patient motivation. Although no single dietary approach has
been found to have a metabolic advantage or be most likely to support long-term weight
maintenance,15,25-28 energy balance is central. It is critical to induce a negative energy
balance—with a deficit of 250 to 500 calories per day to achieve a weight loss of 0.5 to 2 lb per
week. Which diet is best? Diets emphasizing varying contents of carbohydrate, fat, and protein
have generally been found to be equally successful in promoting clinically meaningful weight
loss and maintenance over the course of 2 years, although some studies have found specific
approaches to encourage initial weight loss.26 Because different strategies have proven helpful
to various patients, your best bet is to analyze the patient’s eating pattern and prescribe the diet
he or she is most likely to adhere to for at least 6 months. ❚ If the patient has co morbidities,
choose the diet expected to have the greatest impact—a low- glycolic diet for an obese patient
with diabetes, for example, and the Dietary Approaches to Stop Hypertension (DASH) food plan
for a patient with hypertension.27 For premenopausal women, diets low in carbohydrates have
been found to facilitate weight loss without negative health consequences.25 Offer specific—
and actionable—strategies Most clinically obese patients (63%, according to 1 study) do not
receive weight loss counseling from their primary care physician. Often, they are told to lose
weight, but not given advice on how to do so. Providing specific strategies can help patients stay
motivated. One set of specific weight-loss messages comes from the Centers for Disease Control
and Prevention (CDC)’s Research to Practice Series.29 Patients are advised to: • limit eating
away from home
 • select healthy options when eating out • eat more fruits and vegetables • avoid large portion
sizes • eat low energy-dense foods (ie, foods that are high in micronutrients but low in calories
per gram). The CDC also encourages new moms to breastfeed. In addition to helping the women
themselves control their weight, breastfed infants appear to be more likely to maintain a normal
body weight—an important consideration as overweight children are more likely than children
of normal weight to become overweight adults.30 (To learn more about pediatric obesity, see
“How best to help kids lose weight” on page 386.) The “5-3-2-1-almost none” plan offers
additional advice. Every day, patients should: • Eat ≥5 servings of fruits and vegetables • Have 3
structured meals (including breakfast) • Limit TV/video game use to ≤2 hours • Engage in ≥1
hour of moderate to vigorous physical activity • Limit sugar-sweetened drinks to almost none.31
❚ Encourage patients to keep a diary. Suggesting that patients track their food and beverage
intake, as well as their physical activity, is another helpful strategy, as self-monitoring creates a
sense of accountability and awareness. Patients are likely to need ongoing encouragement to do
 so, however, because record keeping typically declines with time.32,33 Prescribe physical
activity, and sleep Physical activity guidelines vary for active adults, older adults, and those with
disabilities. To attain health benefits, however, the general recommendation is for ≥150 minutes
of moderate-intensity physical activity per week, plus muscle strengthening activities at least
twice a week.33,34 Help patients identify strategies that will improve adherence, such as
wearing a pedometer to gauge miles walked per day or working out with a buddy.34 ❚ Sleep
duration, too, may affect weight. Although there is insufficient evidence to support the idea that
sleep is an independent risk factor for obesity,35 it appears that those who sleep too much (9-
10 hours

 Drugs that promote weight gain—and alternatives to consider click here

 Drugs that promote weight gain—and alternatives to consider click here