key: cord-0747746-i6r153sf
authors: O’Shea, Donal; Kahan, Scott; Lennon, Lorna; Breen, Cathy
title: Practical Approaches to Treating Obesity: Patient and Healthcare Professional Perspectives
date: 2021-04-30
journal: Adv Ther
DOI: 10.1007/s12325-021-01748-0
sha: b79a5128baff6876f3b9ff6c65014e972964734b
doc_id: 747746
cord_uid: i6r153sf

Obesity is a chronic and treatable disease carrying risk for numerous health complications, including cardiovascular disease, respiratory disease, type 2 diabetes mellitus and certain cancers. While there is a great need to address the topic in clinical practice, healthcare professionals (HCPs) often struggle to initiate conversations about weight. In this paper, guidance on how to raise and address the subject of weight with individuals is provided from an HCP and patient perspective using the 5As framework. This model facilitates advising individuals on the benefits of weight loss and supports them to develop achievable and sustainable weight management plans. With obesity rates still rising across the globe, it is imperative that more HCPs become skilled in raising and addressing the issue.

While primary care physicians are central to managing obesity, a multidisciplinary approach involving all care providers should be utilised to consider environmental and psychosocial influences impacting obesity, and to address psychological and physiological challenges associated with achieving and sustaining long-term weight loss.

The 5As framework is transferable across disciplines.

The need to address obesity is now undisputed and pressing. Characterised by excess weight gain [1] , obesity is a modern-day health epidemic that requires long-term, individualised care. While the majority of healthcare professionals (HCPs) claim they are confident discussing weight and tailoring management strategies for individuals with overweight and obesity, they also believe that the proportion of patients successfully achieving weight loss goals remains comparatively low [2] . This disconnect between HCPs' assessment of their competency and their effectiveness in counselling individuals to achieve treatment goals represents a central issue in supporting more effective obesity management. It is essential, therefore, that practitioners consider the complex drivers of weight gain across the physiological, environmental and psychosocial spectra. This article provides guidance on how to raise and address weight, and is based on previously conducted studies and does not contain any new studies with human participants or animals performed by any of the authors.

With its numerous compounding factors, obesity is increasingly being recognised as a treatable disease, and health bodies across the globe have begun reclassifying it in acknowledgement [3] [4] [5] . Multiple physiological mechanisms interplay to add to the challenge of losing and maintaining weight loss.

Weight loss is associated with marked and persistent alterations in the levels of hormones involved in the regulation of satiety [6] . For example, weight loss in individuals with obesity has been shown to produce sustained reductions in levels of leptin, glucagon-like peptide-1, peptide YY, cholecystokinin, insulin and increased ghrelin [7, 8] , all of which reduce satiety and may contribute to weight regain. Furthermore, weight loss is associated with changes in neural function and activity, with increased activity in areas associated with processing of food-related stimuli and decreased activity in areas associated with restraining responses to food [9] . Studies also show that people on weight loss diets experience more food cravings than non-dieters, and that these are stronger and more difficult to resist [10] . Finally, diet-induced weight loss is associated with reduction in total and resting energy expenditure [11] .

As the biological mechanisms of weight regulation become more clearly understood, it is important that HCPs acknowledge the processes underlying weight regain to enable development of management strategies that not only promote initial weight loss but also maintain that weight change in the long term.

Another key aspect that categorises obesity as a disease is its association with numerous metabolic, mechanical and psychological comorbidities. Excess weight has now been linked to more than 200 diseases [12] , and weight loss is associated with clinically meaningful improvements in many of these. Table 1 summarises some of the common complications of obesity. The importance of treating obesity is further illustrated by accumulating evidence of its association with more severe COVID-19 infection, leading to increased risk of hospitalization, admission to intensive care units and death [13] .

There are a number of frameworks aimed at helping HCPs better support people to manage weight; the '4 Ms' was designed to help timerestricted physicians assess for obesity [24] , and the newer 'ABCDEF' approach provides guidance on taking a weight history, previous weight loss attempts, evaluation for weight-related morbidities, treatment and long-term follow-up [25] . The 5 As model was developed by the Canadian Obesity Network to aid the delivery of meaningful weight management consultations, and has proven effective in improving physician-patient communication, patient motivation [26, 27] , and HCPs' confidence in discussing weight loss interventions [28] . This paper shares practical solutions to common challenges faced by HCPs, using the flow of the 5 As framework (ask, assess, advise, agree, assist) and incorporating the views and experiences of a person living with obesity.

Ask Permission: Starting the Conversation Individuals living with obesity experience body weight stigma in multiple aspects of their life, which can lead to feelings of guilt, shame and self-criticism [29] . With this in mind, it is important to be aware of behaviours that could trigger such negative feelings and result in a reluctance to discuss weight.

As part of the management approach, HCPs should consider why the individual has visited the clinic; it may not always be appropriate to begin with a conversation about weight. Addressing the presenting complaint first can

Recognising that obesity is a treatable disease is important for HCPs as well as many paƟents. It not only facilitates a shiŌ in aƫtude toward managing the disease, but it also enables HCPs and paƟents to realise there are treatment strategies that are available and effecƟve. Moving away from terms such as 'weight loss' and 'dieƟng' to terms such as 'obesity treatment planning' can help change the way in which obesity is perceived.

HCPs may believe that people living with obesity are not interested in weight loss; however, they should aim to understand the underlying reasons. Individuals with obesity may feel frustrated by previous weight-loss aƩempts, have experienced sƟgmaƟsing encounters with HCPs and be frightened to raise the topic or aƩempt it again. In parallel, unsuccessful aƩempts may make physicians feel they are not in a posiƟon to help. These negaƟve past experiences can result in paƟents and HCPs parƟcipaƟng in consultaƟons with false beliefs about the person in front of them, creaƟng a significant barrier to producƟve conversaƟons about weight management -efforts to overcome these challenges must be made.

help to reduce feelings of stigmatisation and set up the consultation for success.

While it can be difficult to raise the topic of weight, there are several strategies that can help. Being non-judgmental and empathetic positively opens up the conversation [30] , reduces fear of stigma and criticism and helps to form a strong patient-provider partnership.

Evidence and experience suggest that a vital step in the intervention process is asking for permission to raise the sensitive issue of weight [28] . A respectful example of such a question might be 'Can we talk about your weight today?' However, language and wording may vary depending on individual HCP preference, language and culture. If the individual wishes to talk about weight, the next step is to acknowledge and advise that weight management is challenging and express willingness to provide ongoing support. However, it is important to note that not all people will feel ready to discuss their weight. Instead of persisting, the optimal course of action may be to ask whether they would be open to revisiting the topic in the future; again, putting the decision into the hands of the individual.

An obvious but frequently omitted step in the assessment process is asking the patient to check their weight. A recent survey found that more than half of primary care physicians (PCPs) were unable to visually assess body mass index (BMI), with the majority underestimating it [31] . Visual assessment is a poor way of determining an individual's weight; as with any other condition, e.g. hypertension, an accurate assessment is essential for informing subse-quent management steps. Routinely asking all patients if weight can be checked as part of a consultation eliminates the possibility of underestimation, thus reducing the risk of continued, undetected weight gain [32] . Measuring waist circumference in addition to BMI can also be helpful in evaluating cardiometabolic risk in some individuals [33] .

A key component in delivering individualised weight loss interventions is the identification of the root causes and drivers of weight gain. Taking a weight history assessing the individual's weight onset, triggering factors, impact of weight on quality of life, previous weight loss attempts, life events during previous weight loss attempts and pattern of weight gain should be explored [25] . The use of open questions by the HCP enables active listening and encourages the individual to share their experience. Determining such factors can enable both the HCP and the person living with obesity to gain a clear picture of what the drivers of weight gain might be, facilitating the development of tailored care plans. Furthermore, this step could disclose whether a new patient has come to the clinic having already lost weight, informing subsequent management steps.

A recent survey found that many healthcare professionals see limited clinical value in a 5-10% weight loss [2] . However, there is good evidence that modest weight losses can reduce the risk and improve the management of obesity-related complications (Fig. 1) .

Depending on the severity of obesity, individuals will need appropriate medical equipment. It is important to have scales that measure a range of weights and blood pressure cuffs that adjust to fit larger sizes. Also providing sturdy chairs without arm-rests can help make people feel more comfortable in waiƟng and consultaƟon rooms.

Advising individuals with overweight/obesity of the health benefits of 5-10% weight loss can help to centre the consultation on realistic expectations. Delivery is key, as avoiding jargon and using patient-friendly terminology has proven more impactful than using unfamiliar medical terminology [34] , e.g. 'increased risk for T2D' versus 'hyperglycaemia'.

During weight loss counselling, HCPs should keep in mind the identified root causes for each individual and explore the modifiable aspects with them to incorporate into a tailored weight management plan. Advice may centre around eating well (which foods to incorporate in each meal and how much; caloric density of specific foods and alcoholic beverages), being physically active (to support weight loss and for general health), and addressing psychological aspects related to weight (e.g. binge eating, emotional eating), behavioural therapy, medications and referral to bariatric surgery services in some cases [35] .

Having given advice on the relevant aspects of weight, a plan should be agreed, which is a common pitfall in trying to achieve too much too fast. Goals should be specific, measurable, achievable, relevant and timely (SMART) to increase the likelihood of success [36] . An example of a SMART goal is 'I will walk for 20 min at lunchtime on Monday, Wednesday and Friday', which is more constructive than agreeing a vague plan to 'start exercising'.

While it is important to consider the health benefits of a 5-10% weight reduction when setting targets, losing 5-10% of baseline body weight as a first attempt might be unrealistic for some individuals. Setting unrealistic weight loss goals is not only common among HCPs, as people often visit practitioners hoping to reduce weight at a rate that is unlikely to be sustainable in the long term [37] . Thus, setting clear HCP and patient expectations from the very beginning is key for avoiding disappointment if goals are not met. In addition, HCPs should work

While it is important for HCPs to understand the specific health complicaƟons associated with overweight and obesity, lisƟng these to individuals can be counter-producƟve. ReiteraƟng the negaƟve aspects of obesity without offering a realisƟc soluƟon can contribute to feelings of helplessness and make individuals despair of ever being able to make the necessary changes to manage weight and reduce their risk for mulƟple comorbidiƟes. In addiƟon, emphasising that individuals need to lose weight to prevent these negaƟve health consequences could undermine weight losses the individual has already succeeded in making. A more suitable approach might be to advise people more broadly on the adverse effects of excess weight while iteraƟng that even small weight losses can improve these risks.

It is important to remember that both people living with obesity and HCPs may carry weight biases or have been subjected to weight sƟgma. Similarly, both individuals are frequently exposed to adverƟsing and media campaigns about unrealisƟc weight-loss targets and inaccurate informaƟon about obesity on a daily basis. The more steps an HCP can take toward beƩer educaƟng themselves about obesity, its underlying factors and sustainable weight-loss strategies, the more they can recognise that it is a treatable and manageable disease that requires individualised care. Consequently, HCPs can apply their beƩer knowledge with their paƟents and make meaningful differences to each person.

collaboratively with individuals to create plans that aim to reduce weight at a comfortable pace for each person [38] . For example, this might involve setting smaller targets as opposed to setting the first target as the total desired weight loss. Unrealistic goals may result in failure [39] , which could deter individuals from re-attempting weight loss. A weight loss of 5 kg may be Fig. 1 Health benefits of a 5-10% weight loss. a Detailed summary of health benefits that can be achieved with a 5-10% weight loss from baseline including quantitative/measurable benefits on cardiometabolic and glycaemic parameters, and life expectancy. b Simplified version of the health benefits that are achievable with a 5-10% weight loss, in patient-friendly language. HDL high-density lipoprotein, LDL low-density lipoprotein, BP blood pressure, HbA1C haemoglobin A1c, T2DM type 2 diabetes mellitus; *with 10 kg weight loss; in individuals who have undergone bariatric surgery. References clinically meaningful in terms of risk factor reduction for some individuals, and in other individuals may improve the ability to carry out an important daily task that was not possible before. Small accomplishments such as these should be recognised as successes, and attitudes must be shifted in alignment with each individual's capabilities.

Having established the importance of setting realistic, personalised goals, the next step is to agree the specific elements of a helpful plan. Eating behaviours are a key target of all weightloss interventions and, in order to elicit changes, individuals must assess their typical eating patterns and identify aspects they wish to change [40] . Individuals may have endured stigmatising conversations about their dietary habits in the past, therefore it is important to ask permission to discuss it. An appropriate question might be, 'Would it be helpful to look in a bit more detail at how food or activity is fitting into your typical day?' Following identification of dietary habits, through use of, e.g., a food diary, the HCP and patient can explore together any the specific dietary changes that might be helpful, such as increasing fibre and protein intake, and reducing intake of energydense foods and drinks [5] . Alongside tracking eating behaviours, HCPs may also encourage individuals to self-monitor physical activity patterns and weight. Care providers should encourage individuals to set goals relative to their current mobility and to slowly increase the amount of time the person is active [38] . In parallel with reducing the burden of obesity-related complications, physical activity and associated weight loss should aim to improve an individual's quality of life.

Although possible according to trials such as the DiRECT trial of an intensive primary careled weight management intervention using total diet replacement for those with T2D [41] , weight loss of greater than 10% is unlikely with behavioural changes alone, due to metabolic adaptations. Consequently, while behavioural interventions are the basis of all weight management interventions, pharmacotherapy and/ or bariatric surgery should be considered for additional benefits [40] .

Eligibility for pharmacotherapy or bariatric surgery is based on degree of obesity (usually determined by BMI and/or waist circumference) and obesity-related comorbidities. Eligibility criteria are similar across regions [5, 40, [42] [43] [44] , although BMI cutoff values are lower in Asian populations [45] (Fig. 2) . Rather than offering

Advising individuals with obesity to make small increases in their movement can go a long way in improving mobility and enabling people to perform tasks that are important to them. For example, if a person is able to walk for 5 minutes at a Ɵme, advising them to increase their mobile Ɵme by 30 seconds each day could eventually mean they are able to walk to the bus stop or to work. Other achievements might include being able to try their own shoelaces, fit into a cinema seat or fasten a car seat belt. Being able to do these things again can make a real difference in the quality of a paƟent's life. Successfully achieving these small goals on a regular basis can build an individuals' confidence in their ability to make posiƟve changes. Consequently, people are more likely to lose a sustainable weight, gradually, over the long term and reach a weight that enables them to lead a fuller life. Fig. 2 Guidance on level of intervention to consider [5, [40] [41] [42] [43] [44] [45] 59] . BMI body mass index (reported in kg/m 2 ). Consult local guidelines for specific recommendations. *In some non-Asian regions, people with type 2 diabetes can be considered behavioural, pharmacotherapy and bariatric surgery sequentially, all relevant options should be discussed with individuals as early as possible ( Table 2 ).

The treatment approach should be agreed between the individual and HCP following consideration of risks, benefits and individual circumstances. When initiating pharmacotherapy, the HCP should stress the importance of ongoing behavioural changes, as all weightmanagement pharmacotherapies are indicated in conjunction with a reduced calorie diet and/ or increased physical activity [47, 49, 51, 53] .

Regular follow-up is imperative for identifying less successful approaches early, yet, remarkably, only 24% of people with obesity in the US report having follow-up appointments in place after their initial weight-loss consultation [56] . HCPs should agree a suitable timeframe for regular weight-related consultations to ensure ongoing support.

Given the complex and multifactorial nature of obesity, it is unsurprising that HCPs may need to refer onward to more specific services. Depending on healthcare systems and available resources, HCPs may need to signpost or refer individuals to more specialist providers such as psychologists, dietitians, physiotherapists, endocrinologists, commercial weight loss programmes, or bariatric centres to ensure all elements of weight gain are managed adequately and appropriately where needed [57] . Indeed, a recent study conducted in the UK found that providing support through referral to specialist services was more effective than solely advising individuals to lose weight [58] .

Obesity rates are rising across the world, and HCPs can play an important role in supporting individuals to manage this disease. Management should focus on improving health, Weight management agents should always be used in conjunction with appropriate behavioural interventions a Semaglutide is an investigational product and has not been approved by the FDA or EMA at the time of writing What else should be considered during the referral process?

When individuals are referred to specialist services, HCPs may need to consider waiƟng list duraƟons. Depending on health-care systems and resources, people might have to wait weeks to years to visit a specialist centre. As such, a plan should be devised to help individuals with overweight/obesity in the interim period. Even helping people to maintain their current weight, if not lose weight, is a posiƟve achievement.

including assessing for and addressing the drivers and complications of obesity. Although PCPs lie at the centre of this approach, efforts to manage overweight and obesity should be shared among all care providers to ensure the delivery of interventions that consider the environmental and psychosocial influences that impact obesity at a behavioural level, while addressing the physiological and psychological challenges of long-term weight management.

Funding. The journal's Rapid Service fee for this manuscript has been supported by an educational grant from Novo Nordisk A/S. Compliance with Ethics Guidelines. This article is based on previously conducted studies and does not contain any new studies with human participants or animals performed by any of the authors.

Open Access. This article is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, which permits PracƟcal ways HCPs can help: advice from a person living with obesity 1. Consider weighing every individual, even those who don't look overweight 2. Advise slightly overweight individuals to lose weight 3. Make sure the consultaƟon room is a welcoming environment by providing: a) scale that will weigh them and is secure to stand on b) sturdy examinaƟon table c) sturdy chairs without arm-rests d) blood pressure cuffs that fit large sizes 4. Understand that every person is an individual and should be treated as such 5. Offer pracƟcal advice by keeping an informaƟon sheet that lists: a) where your paƟent can buy suitable weighing scales in the local area b) where they can buy a step counter c) local weight loss meeƟngs, including commercial support groups where available 6. Treat what the person came in for before menƟoning their weight 7. Emphasise the benefits of small weight losses 8. Emphasise the benefits of small increases in movement 9. Enter a consultaƟon with realisƟc expectaƟons 10. Ensure the paƟent goes away with realisƟc expectaƟons about weight losses 11. Be a part of the soluƟon, not a part of the problems your paƟent has probably faced unƟl now any non-commercial use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/bync/4.0/.

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