Obesity Management in Primary Health Care

......................................................................................................................................................................

Abdulrazak Abyad

A. Abyad, MD, MPH, MBA, AGSF, AFCHSE
CEO Abyad Medical Center
Chairman, Middle-East Academy for Medicine of Aging http://www.meama.com
President, Middle East Association on Age & Alzheimer's http://www.me-jaa.com/meaaa.htm
Coordinator, Middle-East Primary Care Research Network http://www.mejfm.com/mepcrn.htm
Coordinator, Middle-East Network on Aging http://www.me-jaa.com/menar-index.htm
Editor, Middle-East Journal of Family Medicine http://www.mejfm.com
Editor, Middle-East Journal of Age & Aging http://www.me-jaa.com
Editor, Middle-East Journal of Nursing http://www.me-jn.com
Associate Editor, Middle East Journal of Internal Medicine http://www.me-jim.com


Correspondence:
Abyad Medical Center http://www.amclb.com
Azmi Street , Abdo Center, POBox 618
Tripoli-Lebanon
Tel & Fax : 961-6-443684
Mobile : 961-3-201901
Email: aabyad@cyberia.net.lb

Obesity is a key public health problem across the world. It is a persistent state that is multi-factorial in origin, intricate to treat, and is a key contributor to multiple diseases including heart disease, type II diabetes, hypertension, stroke and some cancers. Simple solutions are improbable knowing the multifaceted interaction between the copious accessibility of energy dense food, the yet decreasing demand for energy expenditure in the modern world, and the effect of our genetic make up (1, 2). Many physicians do not tackle the question of overweight and obesity with their patients who fulfill the criteria for obesity or overweight, or with persons that are at risk of becoming obese (3,4).

Systemic management of overweight and obesity is the key for successful approach. It is important to pinpoint patients who would benefit from nutritional counseling, since the behaviors that increase a patient's risk for related morbidity and mortality are seldom what bring a patient to the office. A detailed physical activity and nutrition history is a critical step in helping overweight and obese patients identify and implement healthier behaviors. Primary care physicians should follow the steps below:

Ask Is the patient ready to make a change?

As frequently as is appropriate, family physicians should ask every patient who is at risk for overweight whether he or she is willing to make one or more health behavior changes.

Advise
There is at least value in simply notifying a patient that his or her BMI is harmful. For patients who express an interest in making one or more changes, advice about nutrition and physical activity must be clear, exact and geared tailored to the patient's lifestyle, experience and capabilities.

Assess BMI
The first step in assessing the overweight of the patient is calculating the BMI. BMI is similar to blood pressure as a vital sign. It must be used to establish health risks and to direct discussion with patients about health behavior changes.

A BMI of 25.0 to 29.9 kg per m2 is defined as overweight; a BMI of 30.0 kg per m2 or more is defined as obesity.

Waist Circumference
Waist circumference, is an significant independent risk factor for cardiovascular disease, type 2 diabetes, dyslipidemia and hypertension (5,6). The waist measurement must be taken around the smallest area below the rib cage and above the umbilicus.

Waist circumference measurements greater than 40 inches (102 cm) in men or 35 inches (89 cm) in women indicate an increased risk of obesity-related comorbidities.

Metabolic Syndrome
The metabolic syndrome consist of five criteria, three of which must be present to make the diagnosis (7,8).

Table 1 lists these criteria.

Telling a patient that he or she has the metabolic syndrome may create a precious counseling chance.

Table 1: NCEP ATP III Diagnostic Factors for the Metabolic Syndrome*

There is little support from prospective studies revealing that weight loss by obese individuals ameliorate long-term morbidity and mortality, strong evidence insinuates that obesity is linked to increased morbidity and mortality and that weight loss in obese persons reduces important disease risk factors (9,10).

In adults, elevated disease risk increases separately with increasing BMI and excess abdominal fat.
Cardiovascular and other obesity-related disease risks increase markedly when BMI exceeds 25.0 kg per m2. Overall mortality starts to increase with BMI levels greater than 25 kg per m2 and increases most considerably as BMI levels surpass 30 kg per m2. Waist circumference measurements greater than 40 inches (102 cm) in men and 35 inches (89 cm) in women also point to an increased risk of obesity-related comorbidities (9).

There is discord concerning whether the known dangers of being obese cause a greater health risk than the possible hazards of treatment(9,11,12). It is preferable to treat patients with a BMI of 25.0 to 29.9 kg per m2 or a high waist circumference, and two or more risk factors. Treatment is also preferable for patients with a BMI of 30 or more kg per m2 regardless of risk factors. Successful management embraces dietary therapy, physical activity, behavior therapy, pharmacotherapy and amalgamation of these methods ( 9). Drugs must be used as a part of a comprehensive plan. Currently, an appetite suppressant, sibutramine (Meridia), and a lipase inhibitor, orlistat (Xenical), are labeled by the U.S. Food and Drug Administration for long-term use and may be helpful in the treatment of suitable high-risk patients.

Pharmacotherapy is used in patients with a BMI of 30 or more kg per m2 and no associated obesity-related risk factors or diseases, or patients with a BMI of 27 or more kg per m2 with associated obesity-related risk factors or diseases (i.e., hypertension, dyslipidemia, coronary heart disease, type 2 diabetes [formerly noninsulin-dependent diabetes] and sleep apnea).

Surgery may be entertained for difficult cases where the patients do not respond to medical treatment because such individuals are at high risk for the comorbidities associated with obesity. Surgical treatment of clinically severe obesity normally is done to restrict caloric intake (e.g., vertical banded gastroplasty) or to combine caloric restriction with some degree of malabsorption (e.g., Roux-en-Y gastric bypass, biliopancreatic bypass).

Currently children normally eat more calories than they burn up in physical activity. This discrepancy results from several recent alterations at home, school, and neighborhood environments. The Institute of Medicine (IOM) study, Food Marketing to Children and Youth: Threat or Opportunity (13) gives a scary report of how this influences children's health. Food marketing, the IOM says, deliberately targets children who are too young to differentiate advertising from genuineness and leads them to eat high-calorie, low-nutrient "junk" foods; companies succeed so well in this endeavor that business-as-usual must not be allowed to persist.
The IOM report gives enough evidence to maintain extra policy actions. Restrictions or bans on the use of cartoon characters, celebrity endorsements, health claims on food packages, stealth marketing, and marketing in schools, along with federal actions that promote media literacy, better school meals, and consumption of fruits and vegetables.

In the pediatric patients clinical evaluation must include determination of the BMI percentile (for age and sex) and vigilant assessment to pinpoint potential complications of obesity such as hypertension, dyslipidemias, orthopedic disorders, sleep disorders, gallbladder disease and insulin resistance (14). Treatment must be considered in children with a BMI higher than the 85th percentile and complications of obesity, or a BMI higher than the 95th percentile with or without complications.

1. Centre for Reviews and Dissemination. The prevention and treatment of obesity. Eff Health Care 1997;3(2).

2. National Heart, Lung, and Blood Institute. Clinical guidelines on the identification, evaluation and treatment of overweight and obesity in adults. Bethesda, MD: National Heart, Lung, and Blood Institute, 1998. Available at ww.nhlbi.nih.gov/guidelines/obesity/ob_home.htm

3. Stafford RS, Farhat JH, Misra B, Schoenfeld DA. National patterns of physician activities related to obesity management. Arch Fam Med 2000;9:631-8.

4. Potter MB, Vu JD, Croughan-Minihane M. Weight management: what patients want from their primary care physicians. J Fam Pract 2001;50:513-8.

5. Chan JM, Rimm EB, Colditz GA, Stampfer MJ, Willett WC. Obesity, fat distribution, and weight gain as risk factors for clinical diabetes in men. Diabetes Care 1994;17:961-9.

6. Kuczmarski RJ, Carrol MD, Flegal KM, Troiano RP. Varying body mass index cutoff points to describe overweight prevalence among US adults: NHANES III (1988 to 1994). Obes Res 1997;5:542-8.

7. Expert Panel on Detection, Evaluation, and Treatment of High Blood
Cholesterol in Adults. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Adult Treatment Panel III. Bethesda, Md.: National Institutes of Health; 2001. NIH Publication No. 01-3670.

8. Expert Panel on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: evidence report. Bethesda, Md.: National Heart, Lung, and Blood Institute Obesity Education Initiative; 1998. NIH Publication No. 98-4083.

9. National Institutes of Health, National Heart, Lung, and Blood Institute. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults--the evidence report. Obes Res 1998;6(suppl 2):51S-209S [Published erratum appears in Obes Res 1998:6:464]. Retrieved September 2000 from: http://www.nhlbi.nih.gov/ guidelines/obesity/ob_home.htm.

10. U.S. Preventive Services Task Force. Screening for obesity. In: Guide to clinical preventive services. 2d ed. Baltimore, Md.: Williams & Wilkins, 1996:219-29.

11. Thomas PR. Weighing the options: criteria for evaluating weight-management programs. Committee to Develop Criteria for Evaluating the Outcomes of Approaches to Prevent and Treat Obesity, Institute of Medicine. Washington, D.C.: National Academy Press, 1995.

12. Pi-Sunyer FX. Short-term medical benefits and adverse effects of weight loss. Ann Intern Med 1993;119:722-6.

13. McGinnis JM, Gootman JA, Kraak VI, eds. Food marketing to children and youth: threat or opportunity? Washington, D.C.: National Academies Press, 2006.

14. Koplan JP, Liverman CT, Kraak VI, eds. Preventing childhood obesity: health in the balance. Washington, D.C.: National Academies Press, 2005.