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American Journal of Respiratory and Critical Care Medicine Vol 168. pp. 274-280, (2003)
© 2003 American Thoracic Society

Clinical Commentary

Principles and Practices in the Management of Obesity

Gary D. Foster

University of Pennsylvania, Philadelphia, Pennsylvania

Correspondence and requests for reprints should be addressed to Gary D. Foster, Ph.D., Weight and Eating Disorders Program, University of Pennsylvania School of Medicine, 3535 Market Street, Suite 3027, Philadelphia, PA 19104–3349. E-mail: fosterg{at}mail.med.upenn.edu

It is no surprise to readers of this journal that obesity is associated with impaired respiratory function and is a significant risk factor for obstructive sleep apnea (OSA) (1, 2). Moreover, weight loss appears to be associated with improvements in sleep-disordered breathing (3–6). It is logical then that a consistent clinical recommendation for obese patients with OSA is to lose weight (7, 8). Pack has highlighted the need for pulmonary physicians to treat obesity seriously (9), as for many obese men with OSA, the pulmonary physician may be the first contact with the healthcare system. Treating obesity will not only have effects on sleep apnea but on the many other cardiovascular sequelae that obesity and OSA share, such as hypertension. The purpose of this article is (1) to provide a brief overview of obesity and its assessment; (2) to review the efficacy of behavioral, pharmacologic, and surgical treatments for obesity; and (3) to describe specific steps that physicians can take in the office setting to help patients effectively manage their weight.

THE PROBLEM OF OBESITY

Consequences
The rationale for treating obesity seriously lies in its adverse medical consequences. Adults who are overweight (body mass index [BMI] of 25 kg/m2 or more) or obese (BMI of 30 kg/m2 or more) are at increased risk for early mortality (10, 11) as well as for a variety of medical conditions, including type 2 diabetes, hypertension, dyslipidemia, cardiovascular disease, and sleep apnea (12, 13). Recent data suggest that obesity accounts for 14–20% of all cancer deaths, making it second only to smoking in terms of modifiable risk factors for cancer mortality (11). Obesity also confers significant economic costs, approaching $117 billion annually (13). The psychosocial consequences of obesity include body image disparagement, impaired quality of life, and among the severely obese, depression (14, 15).

The seriousness of obesity is exacerbated by its increasing prevalence. A recent Centers for Disease Control report indicates that 34% of Americans are overweight, and 31% are obese (16). Thus, 65% of the nation has a BMI of 25 or more compared with 56% in 1994 and 46% in 1980 (16, 17). The number of obese Americans has more than doubled (15–31%) over the last 20 years (16, 17), and the number of severely obese persons (BMI of 40 or more) has nearly tripled over the last decade (18). The serious nature and increasing prevalence of obesity have prompted calls for action from the World Health Organization (19) and the U.S. Surgeon General (20). Fortunately, small reductions in body weight (5–10%) are associated with significant improvements in glycemic control, dyslipidemia, and hypertension (12). These improvements, as well as the reductions in waist circumference that accompany weight loss, have positive effects on the metabolic syndrome.

Assessment
Formerly, relative weight was assessed as the percentage ideal body weight (based on height and sex) using life insurance actuarial tables (21). The ideal weights, however, were flawed in several ways, including an overrepresentation of males and those of high enough socioeconomic status to purchase life insurance (22). Moreover, the outcome of interest was mortality, and thus, the risk of morbidity could not be assessed. During the last decade, the BMI has supplanted percentage ideal weight as the preferred method to document relative weight in patient charts. BMI is calculated as follows: weight in kg/height in m2. It is most easily assessed with height and weight grids (see Figure E1 in the online supplement) or by this formula:

Multiply weight in pounds by 703 = A

  1. Divide A by height in inches = B
  2. Divide B by height in inches = BMI

Table 1 presents the various National Heart, Blood, and Lung Institute and World Health Organization categories based on BMI. In general, the higher the BMI, the higher the risk of morbidity and mortality. Risk is also affected by the amount of intraabdominal fat. Several large epidemiologic studies have demonstrated that independent of BMI, abdominal fat distribution is associated with a greater risk for ischemic heart disease, hypertension, stroke, and mortality (23, 24). Greater abdominal fat distribution (assessed by waist circumference) is also associated with greater sleep-disordered breathing (25, 26). Two studies, using computed tomography scans, found that among equally obese patients, intraabdominal fat was greater in OSA than in non-OSA patients (27, 28). Waist circumference serves as good clinical proxy for computed tomography and magnetic resonance imaging assessments of intraabdominal adipose tissue. An upper body fat distribution is defined as a waist circumference of 35 inches or more for women and 40 inches or more in men. Among patients with a BMI of 35 or more, measuring waist circumference is not indicated, as the risk caused by BMI alone is already very significant. Waist circumference is best measured around the abdomen at the level of the iliac crest (29).


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  		TABLE 1. Weight classifications based on bmi (13, 30)

 
Etiology
Although the basis of obesity (positive energy balance) could not be more simple, the factors affecting this energy imbalance are varied and complex. These factors include genetic, metabolic, and hormonal influences (30) that likely predispose some persons to obesity and may set the range of possible weights that an individual can achieve. Although it is clear that behavioral factors, such as increased portion sizes and decreased activity (31, 32), are responsible for the increased prevalence of obesity, up to 50–70% of the variance in body weight in any one individual is accounted for by genetic factors (33, 34). Over 300 genes have been linked to obesity, but single gene mutations (e.g., leptin deficiency) are extremely rare in human obesity (35). A genetic predisposition does not preclude clinically meaningful weight loss but does suggest that equivalent changes in eating and activity will produce different results among those of varying genotypes.

TREATMENT

Treatment of obesity is largely based on BMI and comorbidities (Figure 1) . Although behavioral approaches are used across the BMI continuum, pharmacologic and surgical treatments are indicated among those with higher BMIs who have previously attempted more conservative approaches. This section reviews the fundamental aspects of dietary, behavioral, pharmacologic, and surgical treatments.



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  		Figure 1. Obesity treatment algorithm based on body mass index and associated risk from Price and colleagues (70).

 
Selecting a Diet
There is considerable popular debate about what is the "best" diet for weight loss. It is clear that when the calorie level of an energy-deficit diet is kept constant, macronutrient composition (fat, protein, or carbohydrate) does not influence weight loss (36–38). Thus, if weight loss is the goal, it is calories that count. The more important question is whether the health affects of weight loss are different based on macronutrient composition. The literature is replete with studies documenting significant health effects of a weight loss with high-carbohydrate, low-fat diet, including the prevention of type 2 diabetes (13, 39). Three recent studies of 6 to 12 months provide preliminary evidence of the benefits of a low-carbohydrate diet in terms of triglycerides, high-density lipoprotein, and insulin sensitivity (40–42). Longer studies with more comprehensive assessments of cardiovascular, bone, and kidney outcomes are needed to assess the long-term safety and efficacy of low-carbohydrate approaches. Clinically, the most important issue is consuming a variety of foods in manner that is healthy and sustainable. Approaches that are overly restrictive are likely to be short lived.

Behavioral Treatment
The goal of behavioral treatment is to help obese patients identify and modify eating, activity, and thinking habits that contribute to their excess weight (43). Although recognizing that biology may set a range of possible weights, behavior therapy helps obese individuals develop a set of skills (e.g., a low-fat diet, a high-activity lifestyle, a realistic cognitive style) to regulate weight at the lower end of that range. Behavioral treatment usually includes multiple components, such as self-monitoring, nutrition education, stimulus control, slowing eating, exercise, problem solving, and cognitive restructuring. These components comprise the behavioral "package," which has been summarized in self-help manuals, such as the LEARN Program for Weight Control (44) and advocated by commercial programs such as Weight Watchers. Among all of these components, self-monitoring (i.e., keeping records of food intake) is the strongest correlate with weight loss in both short-term (12 weeks) and long-term (17 months) studies (45, 46).

Efficacy.
Behavioral treatment typically yields a 10% reduction in body weight during the first 6 months of treatment (43). Without continued contact, however, patients generally regain one-third of this weight within 1 year, and usually experience a complete regain within 5 years (43). Studies conducted over the last decade indicate that continued contact between the patient and the practitioner significantly enhances weight maintenance (47, 48). In addition, regular physical activity is a consistent predictor of maintenance of weight loss (49, 50).

Pharmacotherapy
The use of pharmacotherapy to treat obesity is compromised by a history of inappropriate practices (e.g., the use of thyroid supplementation in those who are euthyrioid) and unsafe agents (e.g., phentermine–fenfluramine combination). Such a history has adversely affected physicians' use of antiobesity agents, even those that been carefully evaluated in long-term, randomized controlled trials. Table 2 summarizes the three most frequently used antiobesity agents. Phentermine is the most frequently used antiobesity agent (51), although its approval for only short-term (a few weeks) use limits its utility in managing a chronic condition such as obesity. The longest study of phentermine is only 36 weeks. Part of phentermine's popularity comes from its relatively low cost, as most healthcare plans do not cover medications to treat obesity.


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  		TABLE 2. Summary of pharmacologic agents for obesity

 
Pharmacotherapy is indicated for patients with a BMI of 30 or more or 27 or more with an obesity-related comorbidity. Yanovski and Yanovski have recently provided an excellent and systematic overview of all antiobesity agents (52). This section will focus on the only two medications approved by the Food and Drug Administration for long-term use.

Sibutramine.
Sibutramine (Meridia), approved by the Food and Drug Administration in 1997, is a serotonin and norepinephrine reuptake inhibitor. It facilitates satiety (rather than suppressing appetite) and has the effect of reducing food intake (53). The most common side effects are headache and dry mouth, which occur in 20–30% of patients and are mild and well tolerated (54). Sibutramine is associated with a significant increase in blood pressure and heart rate in a small number of patients (approximately 2%). Overall, the mean increases in blood pressure (1–3 mm Hg) and heart rate (four to five beats per minutes) are small relative to placebo (54). However, both blood pressure and heart rate should be measured before treatment and at regular intervals, typically monthly, thereafter. Sibutramine is not appropriate for those with poorly controlled hypertension or those with a history of coronary artery disease, congestive heart failure, stroke, or arrhythmias. Sibutramine is prescribed at 5, 10, or 15 mg every day. The most common starting dose is 10 mg, which is typically increased to 15 mg after 1 month.

Orlistat.
Orlistat (Xenical), approved by the Food and Drug Administration in 1998, is a gastric and pancreatic lipase inhibitor that selectively prevents the absorption of fat. Approximately 30% of fat consumed is not absorbed and, therefore, is excreted. The most common side effects are gastrointestinal events related to the mechanism of action (e.g., oily spotting, flatus with discharge, fatty/oily stool), and these occur in approximately 20% of patients (55). These effects can be minimized by adding small amounts of pysllium (mucilloid) (56). Orlistat is prescribed 120 mg three times a day before meals containing fat. To avoid the depletion of fat-soluble vitamins, a daily multivitamin (taken 2 hours before or after orlistat, typically at bedtime) should be prescribed. Orlistat is contraindicated in patients who have malabsorption syndromes.

Efficacy.
Both sibutramine and orlistat have been evaluated in dozens of randomized, placebo-controlled trials and are shown to be safe and effective in properly selected patients, producing weight losses of 8–10% at 2 years (54, 55). The greatest promise for successful weight loss and maintenance may be in the combination of behavioral approaches and pharmacotherapy. The combination of these approaches enhances the weight loss achieved by either method alone. Increasing the "dose" of behavior therapy (coupled with equivalent doses of sibutramine), increased weight loss could be increased from 4–16% (57).

The availability of safe and effective medications suggests the possibility of longer-term use of pharmacotherapy as in other chronic conditions such as diabetes and hypertension. Both orlistat and sibutramine are approved for long-term use. Data are only available for up to 2 years, but 5-year studies are underway. Any use longer than 2 years should be accompanied by signed informed consent after a consideration of the risk and benefits. The most consistent finding in the pharmacologic treatment of obesity is that when agents are discontinued weight is regained. Thus, chronic treatment should be given serious consideration in appropriate patients.

Surprisingly, no study has examined the potentially synergistic effects of combining sibutramine and orlistat for initial weight loss. Anecdotally, sibutramine may be better suited for patients with impairments in satiety or those who binge eat, whereas orlistat may be more appropriate in those with cardiovascular disease or those able to adhere to a 30% fat diet.

Surgical Treatment
The significant health hazards of severe obesity (BMI of 40 or more) and the modest weight losses produced by conservative treatments led to the development of surgical interventions. There are four types of bariatric procedures: vertical banded gastroplasty, Roux-en-Y gastric bypass, gastric banding, and biliopancreatic diversion (see the online supplement Figure E2 and Table 3) . All of these involve some degree of gastric restriction through the creation of a small pouch (15–200 ml) distal to the esophagus that limits intake. In addition, the gastric bypass and biliopancreatic diversion produce modest to significant malabsorption, respectively, through bypassing parts of the intestine. Gastric bypass is the treatment of choice for most patients (58, 59). It produces greater weight loss and weight loss maintenance than the purely restrictive approaches and less complications than the biliopancreatic diversion (59, 60). Although complication rates vary by procedure, perioperative morbidity and mortality are 10% and less than 1%, respectively. Later complications include incisional hernias, wound infections, and vitamin deficiencies (59). Bariatric surgery has impressive effects on obesity-related conditions, such as type 2 diabetes and sleep apnea (58, 61). Most bariatric procedures are now performed laparoscopically, although the exact rates are unknown (62). Although technically more difficult than open procedures, laparoscopic procedures are associated with a decreased length of hospital stay and fewer wound infections and incisional hernias (63).


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  		TABLE 3. Surgical treatments for obesity

 
Surgical treatment is only appropriate for patients with BMIs of 40 kg/m2 or more (or 35 kg/m2 or more in the presence of significant health complications) who have also attempted more conservative treatments (59). Patients should undergo a comprehensive assessment by a multidisciplinary team (i.e., psychologist, nutritionist, and internist) to identify any contraindications and set realistic expectations about the procedure and its outcome (64, 65). It should be noted that liposuction is a cosmetic rather than a bariatric procedure. The metabolic effects of this modest amount of weight loss, in the absence of energy restriction, are unknown.

PRACTICAL GUIDELINES

Independent of the treatment modality selected (behavioral treatment, pharmacotherapy, surgery), the endpoint of obesity treatment is to help patients eat less and move more. This section summarizes some practical aspects of helping patients change their eating and activity patterns. A useful website (29) provides valuable patient handouts.

Many physicians may feel ill-equipped to address obesity management for reasons ranging from insufficient training to the lack of reimbursement (66, 67). Despite these sentiments, the magnitude of the obesity epidemic demands attention from all from all physicians, especially those treating sleep-disordered breathing. Just as pulmonary physicians have made counseling for smoking cessation a priority, there must also be an emphasis on talking about effective weight management. Comprehensive weight management is not possible during a consultative visit, but beginning to broach the issue of weight management in a constructive and hopeful manner can provide a supportive environment for change. Comprehensive follow-up may be provided by the primary physician, a registered dietitian, or a commercial weight control program (e.g., Weight Watchers). Little is known about the effects of commercial programs. Recently, Weight Watchers was shown to be superior to self-help, producing a modest weight loss of 4.3 kg at 1 year and 2.9 kg at 2 years (68).

Talking with Patients about Weight Control
No matter what type of obesity treatment is ultimately recommended, effective and compassionate treatment of obese patients requires an understanding of the cultural context in which treatment occurs. As Stunkard and Sobal have suggested (69), disparagement of obese individuals is the last socially acceptable form of prejudice. It is not surprising, therefore, that healthcare providers seem to share society's negative view of the overweight (67). In one study, 63% of family practice physicians attributed obesity to a lack of willpower, and more than a third described their obese patients as "lazy" (70). Such characterizations are likely to lead to behaviors that may be discriminatory. There are numerous clinical anecdotes about how obese patients have been treated disrespectfully in the medical setting. Such experiences need to be remedied because they lead to interactions that, at best, provide medical care at the expense of a patient's self-esteem or, at worst, prevent obese patients from seeking healthcare altogether. The following recommendations, based on clinical experience, seek to put obese patients at ease in the medical setting and promote competent, compassionate care (71). There are no data to suggest that these practices improve weight loss or patient care. They are provided to facilitate an examination of current practices that may not be receptive to obese patients.

Assume that obese individuals know they are overweight.
If they have not heard it from a healthcare professional, they have probably been told by friends, family, or even strangers. Simple phrases (such as "What do you think about your weight?") will allow you to assess the patient's interest and/or motivation for weight control in a nonjudgmental fashion. They also allow you to hear the patient's perspective before making any recommendations for weight loss or describing the ill effects of excess weight.

Listen carefully to the patient's presenting problem, independent of weight.
Few patients consider weight to be their primary problem, especially those presenting to the pulmonary physician. As Stunkard (72) pointed out, patients define the presenting problem. If weight is a precipitating condition, focus on the factors that affect the presenting problem and weight. For example, it is not likely to be useful to tell an obese patient with dyslipidemia to lose weight. Encouraging the same patient to decrease intake of saturated fat and make small changes in activity, however, will likely influence weight and lipids. Such advice is better received by patients who are often told to lose weight in response to many medical problems.

Provide the same care to obese patients as to nonobese patients.
Lean individuals with hypertension or type 2 diabetes are encouraged to watch their diets but are also provided appropriate medication for their conditions. Too often, obese patients are told to lose weight, and appropriate pharmacologic care may not be provided in a timely manner.

Create a Patient-friendly Office

  • Just as airline seats are frequently too small for significantly obese patients, so are the equipment and furnishings found in many medical practices. Attention to the following details (described more fully in the repository) facilitates an environment that is receptive to obese patients: (1) have a scale that can weigh all patients; (2) have gowns available that fit larger patients; (3) use larger blood pressure cuffs when appropriate; (4) provide some armless chairs in your waiting room.

Improving Adherence
The principles and practices of the behavioral treatment of obesity have been briefly summarized previously here and are reviewed in detail elsewhere (43). However, several straightforward guidelines can help patients improve their adherence to the behaviors necessary for effective weight control (73). These practices can be effectively implemented during brief physician visits (74).

Establish a specific plan (what).
Help patients select a specific plan (e.g., limit eating to 300 kcal between 7:00–10:00 P.M. or walk for 20 minutes after dinner on Monday, Wednesday, and Friday) rather than a general platitude (e.g., eat less at night or exercise more). The more specific the goal, the better.

Identify facilitators and barriers to success (how).
Help patients think through what steps will be necessary to achieve their goals (e.g., purchasing alternative foods for evening consumption, having a spouse help with household duties after dinner).

Follow-up at the next visit.
Have the patient make a written record of the plan and key steps in its implementation. In addition, make a brief note in the chart documenting the specific plan. At the next visit, review the patient's progress with the plan. If successful, what strategies did the patient use to achieve the goal? If unsuccessful, what things got in the way, and how can they be removed in the future? Patients benefit more from examining how behavior changed or did not change rather than focusing on why things did not go as planned.

Avoid criticizing patients.
Weight control is tough work, and patients need to know that you will not give up on them. Help patients identify problem areas and take responsibility for addressing them. Criticizing patients or questioning their motivation does little for improving adherence and has adverse effects on the patient–physician relationship.

Unrealistic Expectations
One of the greatest challenges in the clinical management of obese patients is the significant disparity between actual and expected weight losses. Although professionals generally accept a 10% weight loss as successful (based on the associated improvements in comorbidities), patients typically seek weight losses that approximate 30% reductions in body weight (75, 76). We found that patients viewed a 25% weight loss as just "acceptable" and a 17% weight loss as "disappointing" (76). Several recommendations may help patients accept more modest weight loss outcomes as successful such as focusing on nonweight outcomes and discussing biological limits. These and other methods are reviewed in the online supplement.

A Final Note
Although the prevention of obesity is a more lasting solution to the obesity epidemic (77), pulmonary physicians, as well as all healthcare professionals, need to treat obesity seriously. Physicians can provide a great service to obese patients by reminding them that their worth is not measured on the scale. Reaffirming a patient's self-worth, independent of body weight, is perhaps one of the most powerful interventions a physician can provide an obese patient (72).

Acknowledgments

G.D.F. serves on the Speaker's Bureau for Abbott Laboratories (makers of Sibutramine/Meridia) and Roche Laboratories (makers of Orlistat/Xenical) and on the Scientific Advisory Board of Healthetech.

FOOTNOTES

Supported in part by National Institutes of Health grants HL70301, DK56114, and AT1103.

This article has an online supplement, which is accessible from this issue's table of contents online at www.atsjournals.org

Received in original form May 22, 2002; accepted in final form May 28, 2003

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