Introduction

The Obesity Epidemic Is Still Growing – What Can Be Done?

Obese and overweight body mass is highly prevalent and affect the health nearly every system in the body. It will therefore be a major part of your clinical practice and affect the health of many of your patients. Treating obesity successfully takes time. Time pressures and emphasis on short-term outcomes that are common in healthcare are in conflict. Weight management challenges include:

• Physiological adaptations perpetuating chronic obesity.
• The patient’s living environment often supports poor food choices and overeating.
• The discomfort that many people feel with this topic.

In light of these challenges, being prepared to offer the most effective, evidence-based, brief counseling, treatments, and referrals for obesity is critical. You can make a difference through comprehensive weight management and your patients’ health will improve as a result.

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Obesity Prevalence

Obesity

The prevalence of obesity among adults was 42.4% in 2017-18 (Hales et al., 2020).

The percentage of individuals who are obese rose steadily to this point from only 13% in the 1970s (Fryar et al., 2014)

The prevalence of severe or “morbid” obesity (BMI ≥ 40.0 kg/m2) has also increased, going from 2.8% of the population in 1990 (Fryar, 2014) to 9.2% in 2017-2018 (Hales et al., 2020).

Overweight

The percentage of the population that is overweight but not obese (BMI 25.0–29.9 kg/m²) has remained fairly steady at around 32 to 34% for the past 18 years (CDCP, 2018). The prevalence of being overweight in 2015-16 was 31.9%.

The percentage of people who are either overweight or obese is over 70% of adults and is increasing.

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Weight Loss Is Possible

Obese patients will be more successful at weight loss with treatments that consider that:

• Calorie restriction and chronic obesity both trigger biological adaptations promoting weight retention, which makes weight loss more difficult (Ochner, Tsai, Kushner, & Wadden, 2015)
• The environment most people live in promotes over-consumption of foods and provides many cues to eat (Ochner et al., 2015)
• They understand that even a small weight loss can have significant weight loss benefits (M. Jensen, Ryan, Apovian, & et al., 2013).

Evidence shows that long-term weight loss is possible:

• A review of the literature found that the following in combination results in the most successful weight loss (M. Jensen et al., 2013):
  • Any restricted calorie diet
  • Increased physical activity
  • Behavioral supports
  • For some patients with greater severity, adjunctive treatments, such as weight-loss surgery or pharmacotherapy
• While there is a high risk of regaining weight that is lost, research has shown that many people can maintain a weight loss. For example:
  • In patients with type 2 diabetes, the average person lost weight and successfully kept most of it off 10 years later after an intensive lifestyle intervention (Wing, Bolin, Brancati, & et al., 2013).
  • 17% of a large population who had ever been overweight or obese reported having experienced a long-term weight loss of at least 10% of their total weight (Kraschnewski et al., 2010).
• Significant weight loss was achieved with both low carbohydrate and low-fat diets(Yannakoulia, Poulimeneas, Mamalaki, & Anastasiou, 2019). Low-carbohydrate diets produced greater weight loss at 6 months but comparable weight loss at 12 months (Johnston, Kanters, Bandayrel, & et al., 2014).
• Meal replacements have some evidence that they are more effective than a whole food-based diet for both weight loss and maintenance in obese adults (Davis et al., 2010; Yannakoulia et al., 2019).
• Adding behavioral supports and/or exercise to weight-loss diets produced further weight loss of 3.23 kg and 0.64 kg respectively at 6 months (Johnston et al., 2014).
• Modest increases in weight-loss of around 5% are achieved with FDA-approved weight loss medications in conjunction with a weight-loss diet and increased exercise (Apovian et al., 2015). Weight loss is maintained as long as the medication is taken and is usually regained when it is stopped.

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Weight Loss Improves Health

Obesity treatment should not be delayed while focusing on the treatment of its comorbid conditions. Weight loss is one of the most effective treatments for many comorbidities that are associated with it(M. D. Jensen et al., 2013). Additionally, chronic obesity produces self-perpetuating metabolic and physiological changes, which is another reason to not delay treatment (Ochner et al., 2015). Even a modest, intentional weight loss can improve cardiovascular disease and many other conditions(Koliaki, Liatis, & Kokkinos, 2019).

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Treatment Is Often Successful

Providers play a key role in supporting significant patient weight loss through coordinated efforts to ensure delivery of:

• Evidence-based interventions and treatments (M. D. Jensen et al., 2013)
• Appropriate referrals

Primary care providers can use the long-term relationship to an advantage by performing a step in the intervention at one appointment, and then following up and completing another step at the next appointment.

• The most effective weight loss management is a restricted calorie diet, increased physical activity, and behavioral supports(M. Jensen et al., 2013). Some patients with more severe obesity do better with adjunctive pharmacological or surgical treatments added.
• Behavioral interventions produced more weight loss (1.2 to 4.6 kg) than no interventions in randomized controlled trials conducted in a primary care setting (Wadden, Butryn, & Hong, 2014).
• Increasing the number of weight-loss treatment sessions was associated with greater mean weight loss (Wadden et al., 2014). At least twice per month is best (M. Jensen et al., 2013).
• Treating overweight and early obesity prevents the metabolic adaptations of chronic obesity that make losing weight more difficult (Ochner et al., 2015).

The U.S. Preventive Services Task Force concluded from a review of the evidence that physician and other health care provider interventions, repeated over time and as a part of intensive multi-component behavioral interventions, are effective in supporting weight loss (U.S. Preventive Services Task Force, 2012). A coordinated effort with other health care providers and institutions can mean positive outcomes for your patients.

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Evaluating Patient Body Mass

Providers play a key role in supporting significant patient weight loss through coordinated efforts to ensure delivery of:

• Evidence-based interventions and treatments (M. D. Jensen et al., 2013)
• Appropriate referrals

Primary care providers can use the long-term relationship to an advantage by performing a step in the intervention at one appointment, and then following up and completing another step at the next appointment.

• The most effective weight loss management is a restricted calorie diet, increased physical activity, and behavioral supports(M. Jensen et al., 2013). Some patients with more severe obesity do better with adjunctive pharmacological or surgical treatments added.
• Behavioral interventions produced more weight loss (1.2 to 4.6 kg) than no interventions in randomized controlled trials conducted in a primary care setting (Wadden, Butryn, & Hong, 2014).
• Increasing the number of weight-loss treatment sessions was associated with greater mean weight loss (Wadden et al., 2014). At least twice per month is best (M. Jensen et al., 2013).
• Treating overweight and early obesity prevents the metabolic adaptations of chronic obesity that make losing weight more difficult (Ochner et al., 2015).

The U.S. Preventive Services Task Force concluded from a review of the evidence that physician and other health care provider interventions, repeated over time and as a part of intensive multi-component behavioral interventions, are effective in supporting weight loss (U.S. Preventive Services Task Force, 2012). A coordinated effort with other health care providers and institutions can mean positive outcomes for your patients.

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Taking a Weight History and Starting a Dialogue

A thorough weight history will enable you to provide more targeted treatment. Weight histories often include the following components:

• Current weight and body mass status and past changes. History of weight changes. Year of maximum and minimum weight.
• Past attempts to lose weight, types of weight-loss treatments attempted, and the corresponding difficulties and results
• Eating patterns and cravings that might need to be addressed

Raising Patient Awareness

While many people are well aware of their weight problem and often have already struggled with weight loss for many years, some patients are not aware that they are overweight, that they gained weight, or that there are health consequences. They may have gained a few pounds each year without noticing or may be in denial(Wetmore & Mokdad, 2012).Self-reports of weight are often inaccurate (Wilke, 2014).

Some ways to help raise patient awareness of weight problems and address denial include recommending regular home weight checks, at least weekly, and comparisons to a recommended weight range. Offer empathy and understanding. Tell the truth in a caring way. Do not use shaming tactics.

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Assessing Body Mass

Body Mass Index (BMI) is still the standard used to measure body mass and determine excess weight and treatment. It measures body mass in terms of kilograms per meter squared (kg/m²) and is calculated based on patient height and weight.

Assess weight and body mass index in kg/m² (BMI) annually, and more often during the weight management and maintenance stages. (Garvey et al., 2016; M. D. Jensen et al., 2013).

BMI Calculations

The BMI formula is 703 x (weight in pounds)/(height in inches)².

Diagnosis and Classification of Obesity

• BMI ≥25 kg/m^{2 –} Overweight
• BMI ≥30 kg/m^{2 –} Obesity

Further breakdown of obesity involves three classes (Gonzalez-Casanova et al., 2013):

• BMI 30 – 34.9 kg/m² – Class I Obesity
• BMI 35 – 39.9 kg/m² – Class II Obesity (severe)
• BMI >40 – Class III Obesity (morbid)

AMA Policy Calls to Diagnose, Treat, and Prevent Obesity

Previously, obesity was often viewed as a lifestyle choice, a lack of patient willpower, or a condition rather than an illness (Basulto, 2013). In 2013, the AMA adopted a policy that obesity is “a disease requiring a range of medical interventions” (American Medical Association, 2013). The policy was adopted “to advance obesity treatment and prevention.” The policy is not legally binding for insurance companies (Basulto, 2013).

Making a separate, official diagnosis of “obesity” and inclusion in the patient’s problem list supports the development of a weight management plan.

Diagnoses

Diagnoses relevant for obesity include

E66.9	Obesity, unspecified
E66.01	Morbid (severe) Obesity due to excess calories
E66.3	Overweight
E65	Localized Adiposity

(National Center for Health Statistics, 2018)

Limitations of Body Mass Index

While BMI is effective for a quick assessment of body mass, which helps guide weight management, it does have a number of limitations:

• Overestimates the body fat of a muscular person (Sharma & Kushner, 2009).
• Underestimates the body fat of a person with little muscle mass (such as an older person) or a very short person, under 5 feet tall (Sharma & Kushner, 2009).
• Does not analyze body composition; therefore, it does not distinguish fat mass from lean body mass (the combined weight of the internal organs, bones, muscles, water, ligaments, tendons, and essential fat in bone marrow, CNS, and organs) (Nimptsch, Konigorski, & Pischon, 2019).

Percent Body Fat

Most research uses BMI rather than percent body fat to assess body mass, probably because of the relative convenience of BMI. Percentage body fat can be measured via measured via dual-energy x-ray absorptiometry (DXA)

Acceptable body fat percentages are:

• Women 25 to 31%
• Men 18 to 24%

(American Council on Exercise, 2015)

Obesity Is a Disease

Obesity is increasingly being considered a disease, in and of itself, separate from its comorbid conditions (Ochner et al., 2015). Obesity is one of the most common chronic illnesses, leading to premature death for many individuals (World Health Organization, 2011). Clinicians will be better prepared to treat patients with weight problems if they understand the following biological mechanisms by which obesity contributes to comorbid disease and perpetuates itself:

1. Fat Mass Effects: The fat mass itself infiltrates and surrounds organs and bears down on the body, resulting in fat mass diseases, such as congestive heart failure, hypoventilation syndrome, and problems of musculoskeletal functioning.
2. Metabolic Effects: The metabolic consequences of obesity involve changes that lead to:
   • Comorbid conditions, such as type 2 diabetes mellitus and cardiovascular disease.
   • Resistance to weight loss and chronic physiological changes that help perpetuate obesity and contribute to easier weight regain. The metabolic changes to the body from chronic obesity often persist, even after weight loss (Ochner et al., 2015).
3. Inflammatory Effects: Obesity worsens chronic inflammatory processes beyond the load-bearing effects of weight. It produces a low-grade, chronic inflammatory state in metabolic tissues in response to excess nutrients and energy (Gregor & Hotamisligil, 2011). Tissues affected include fat, liver, muscle, pancreas, and brain. This inflammation contributes to insulin resistance and metabolic dysfunction. This inflammation may contribute to fibromyalgia, rheumatoid arthritis, lupus, psoriasis, pain, and many other conditions.

Impact of High Body Mass

Higher BMI correlates with increased morbidity and mortality. This underscores the need for obesity prevention and intensive treatment of patients who are obese or overweight.

• Elevated BMI correlates with higher risk for cardiovascular disease (especially heart disease and stroke), diabetes, musculoskeletal disorders (especially osteoarthritis), and some forms of cancer (e.g., endometrial, breast, colon)(Nimptsch et al., 2019).
• For every 1-point increase in their BMI, women had a 12% lower chance of surviving to age 70 in “good health” (Sun, Townsend, & Okereke, 2009).

Because of its increasing resistance to treatment in chronic obesity and its complications, some experts recommend treatment of obesity sooner in the course of the illness, that is, at a lower BMI (Ochner et al., 2015). The rationale is to prevent the metabolic changes of chronic obesity that make weight loss and maintenance more difficult to sustain.

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Measuring Central Adiposity

Waist circumference should be assessed annually and “abdominal obesity” (≥ 40 inches men; ≥35 inches women) should be recorded for patients having a BMI of 35 or less (M. D. Jensen et al., 2013). At a BMI over 35 kg/m², there is no advantage over BMI in correlations with metabolic disease (Bays, Seger, Primack, & et al., 2017). Waist measurement for patients whose body mass is normal to mildly obese, is as important as calculating a BMI – both need to be done to assess a patients’ metabolic risk. An increased waist circumference is better than BMI at predicting future coronary heart disease(Nimptsch et al., 2019).

An unhealthy amount of fat around the waist is associated with a greater risk of heart disease, stroke, and type 2 diabetes (M. D. Jensen et al., 2013; Nimptsch et al., 2019). This effect is seen even when BMI is within the normal range. Excess abdominal fat in normal weight or slender individuals carries significant health risk (Sahakyan & Somers, 2015).

Measuring the waist at a BMI or 35 or higher may be useful as an indication of severity and for tracking treatment progress.

Waist Measurement in Practice

The waist circumference measurements that indicate central adiposity and therefore, greater risk of metabolic disease are:(International Diabetes Federation, 2006).

U.S. Europids	Waist circumference in cm	In inches
Male	>102 cm	>40.2 inches
Female	>88 cm	>34.6 inches
South Asians, Chinese, Japanese
Male	>90 cm	> 35.4 inches
Female	>80 cm	> 31.5 inches
Sub-Saharan African, East Mediterranean, Middle East (Arab)	Use European data until more specific data are available

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Abdominal Fat

Significance of Excess Abdominal Fat

Excess abdominal fat is a component of metabolic syndrome, which has increased risk for:

• Cardiovascular disease
• Type 2 diabetes
• Stroke

It is also correlated with:

• Some cancer (breast, colon)
• Dementia
• An increased risk for:
  • Dyslipidemia
  • Elevated blood pressure
  • Elevated plasma glucose

(Dietary Guidelines Advisory Committee, 2014; M. D. Jensen et al., 2013; Nimptsch et al., 2019)

These risks are also increased with central adiposity in individuals with normal and overweight BMI(Nimptsch et al., 2019). Rigorous diet, exercise, and weight management, similar to that for obese individuals, is warranted for anyone having an elevated waist circumference.

Hormonal Mechanisms Associated with Abdominal F at

Central adiposity is associated with complex hormonal and neuroendocrine changes:

• Insulin levels and insulin resistance are further increased. The resulting high serum glucose is converted by the liver into more intra-abdominal fat (Nimptsch et al., 2019).
• Leptin, which is released by fat cells after a meal, typically calms the appetite. However, in central subcutaneous obesity, there appears to be resistance to leptin, similar to insulin resistance in diabetes (Nimptsch et al., 2019). Therefore, despite high levels of circulating leptins, the obese individual does not feel as sated after eating.

Reducing Abdominal Fat

Diet: Animal research hints at certain foods having a differential effect on abdominal fat. An increase was seen with a high-fat-high fructose diet and dietary monosodium glutamate(Collison et al., 2011). A decrease was seen in obese rats fed blueberries (Seymour, Tanone, Urcuvo-Llanes, & et al., 2011).

Physical Activity: Reducing sedentary behavior may reduce abdominal fat (Belavy, Mohlig, Pfeiffer, & et al., 2014). In one study, in addition to losing excess fat overall, increased activity reduced excess abdominal fat preferentially as well as the corresponding hormonal imbalances (Keating, Machan, O’Connor, & et al., 2014).

Metabolic Syndrome

Metabolic Syndrome includes having 3 or more the following risk factors that increase the risk of cardiovascular disease:

• Elevated Waist Circumference/Central obesity
• Abnormal glucose (elevated fasting or being treated for it)

• Elevated blood pressure
• Low HDL
• Elevated triglycerides

(International Diabetes Federation, 2006; Nimptsch et al., 2019)

Other factors that have been associated with metabolic syndrome include:

• chronic proinflammatory and prothrombotic states
• non-alcoholic fatty liver disease
• sleep apnea

(Kassi, Pervanidou, Kaltsas, & et al., 2011)

Sequellae of Metabolic Syndrome

Metabolic syndrome has been strongly associated with the following:

• Increased diabetes risk (Iacobini, Pugliese, Blasetti Fantauzzi, Federici, & Menini, 2019; International Diabetes Federation, 2006; Nimptsch et al., 2019).
• Increased risk of coronary heart disease (Engin, 2017).
• Increased cardiovascular disease mortality and disease including strokes(Koliaki et al., 2019; Nimptsch et al., 2019).

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Body Mass Measuring Tools

Modern Scales

Some digital scales now calculate other measurements, such as BMI and percent body fat, and track trends in weight and other body measurements. More complex scales are available that measure fat mass vs muscle mass using an electric current. Measurements and tracking capabilities may help motivate and engage some patients in their weight-loss plan. A major limitation of many devices is that the upper weight limit for most of them so far is no greater than the typical bathroom scale, which is 300 to 400 pounds.

Both patients and providers should check the optimal weight ranges on scales before ordering. Scales going up to 600 or 1000 pounds are available.

Other Measures of Body Mass

Clinics specializing in weight management, such as medical weight-loss programs, may assess body mass further. Various instruments measure percent body fat, quantify mass in terms of lean or fat mass and describe its distribution in the body, or measure basal and resting metabolic rates. This level of measurement is not the current standard of care in primary care practices.

For example, underwater weighing (Densitometry) compares weight measured in air and underwater to measure body composition in terms of body fat to lean mass. Modern equipment that may be used in an office includes bioelectric impedance analysis, which uses strength and speed of an electrical signal sent through the body to calculate percent body fat.

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Body Mass Guides Treatment

Weight management practice guidelines are typically based on body mass measurements and weight-related comorbidities. More comprehensive, aggressive treatment is recommended for higher BMI, having one or more weight-related comorbidities, and or having central adiposity.

Treatment Algorithm Based on BMI, Comorbidities, and Past Weight-Loss Attempts

Treatment Guidelines Based on Body Mass Measurement and Comorbidities (AHA/ACA/TOS) (M. D. Jensen et al., 2013)

• If BMI ≥ 25 kg/m², that is, all overweight/obese patients, recommend a reduced-calorie diet and increased physical activity.
• If BMI ≥ 27 kg/m² (or BMI ≥ 25 kg/m² with failed past attempts at weight loss or a weight-related comorbidity), behavioral supports (weight-loss groups and counseling by a trained interventionist, such as a registered dietitian) are indicated.

Guidelines for treatments to be applied as adjuncts to the above treatments:

• When BMI is over 30 kg/m² or when there is a weight-related comorbidity and BMI is over 27 kg/m², the addition of pharmacotherapy (M. D. Jensen et al., 2013).
• When BMI is over 40 kg/m² or when there is a weight-related comorbidity and BMI is over 35 kg/m², referral for weight-loss surgery (M. D. Jensen et al., 2013). or medically supervised very low calorie diets(Yannakoulia et al., 2019).

Additionally, consider referring patients who are morbidly obese or obese with significant comorbid conditions to a specialist in obesity medicine, a small but growing specialty.

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Module Summary

Intro to Obesity Medicine

Obesity prevalence is currently 42.4% in the U.S.

Weight loss is possible, even long term weight loss and is more likely to be successful with treatment.

Assessing Body Mass

Interpretations for body mass assessments are:

• BMI Classifications of Weight (BMI Ranges):
  • Overweight: 25.0 kg/m² to 29.9 kg/m²
  • Obese: BMI in the 30.0 kg/m² and above
• Classes of Obesity (BMI Ranges):
  • Class I: 30.0 kg/m² to 34.9 kg/m²
  • Class II: 35.0 kg/m² to 39.9 kg/m² – severe
  • Class III: >40.0 kg/m² – morbid
• Acceptable Ranges of Body Fat:
  • Women: 25% to 31%
  • Men: 18% to 24%
• Waist circumference (measured at level of anterior superior iliac crests) cut points, indicating greater risk:
  • Women: 35 inches (31.5 inches for Asians)
  • Men: 40 inches (35.5 inches for Asians)
• Excess abdominal fat can increase the risk for cardiovascular disease, type 2 diabetes, and stroke.

(American Council on Exercise, 2015; American Medical Association, 2013)

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References Used In This Module: