Jarrod Shapiro, DPM
Practice Perfect Editor
Assistant Professor,
Dept. of Podiatric Medicine,
Surgery & Biomechanics
College of Podiatric Medicine
Western University of
Health Sciences,
St. Pomona, CA

Obesity:
Our Worst Enemy - Part 2

Last week, we discussed the major medical problem of obesity, its definition, epidemiology, and potential effects on our podiatric patients. Once we realize the seriousness of this epidemic, we then become obligated to figure out what we can do to help our obese patients. Today, we'll discuss some of the tools available to us and look at some of the recent research on obesity care and counseling.

How Effective Are We?

Let's see just how effective physicians have been in reducing their obese patients' weights. First of all, we have to ask if physicians are even counseling their patients about weight loss. As it turns out, only 42% of obese patients report actually receiving direct counseling from their doctor¹. Clearly, obesity counseling occurs at a rate much less than optimal. How can we be effective at all if we don't even bring up the subject? This leaves the majority of patients obtaining weight loss help from other sources, likely with ulterior profit-driven motives.

The second consideration is to ask how we define effectiveness or success? It has been proposed to define successful treatment not by how much weight is lost in a certain period of time, but rather with reductions in obesity-related diseases and their complications². This may be a somewhat more cumbersome method overall to track progress. However, it makes logical sense to target our outcomes on the direct effects of a disease rather than some indirect marker. Perhaps as a compromise, researchers should track the low hanging fruit of the easily measured weight loss, while also looking at the long term health improvements with longer-term longitudinal outcomes studies.

As it turns out then, the medical community is not very effective in reducing obesity and its long term effects.

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What Does the Research Say?

The question then becomes "If I'm going to help reduce obesity, what is the current best way to do so?"

Screening

According to the US Preventative Services Task Force (USPSTF), patients 18 years and older should be screened for obesity by obtaining a BMI. Patients with a BMI greater than 30kg/m2 should be offered or referred for "intensive multicomponent behavioral interventions".³

Counseling – 5 A's

The current recommended obesity counseling framework consists of the 5 A's.⁴ This is a similar model successfully employed for smoking cessation.

- Assess risk, current behavior, and readiness to change.
- Advise patients to change specific behaviors.
- Agree and collaboratively set goals.
- Assist in addressing barriers and securing support.
- Arrange for follow-up.

counseling and be motivated to actively pursue change

This method has been found to be effective. For example, a recent study surveyed 137 patients of 27 physicians after they saw their doctors. When counseled by their physicians using an approach that incorporated the 5 A's method, patients reported increased motivation to lose weight and intentions to change behavior.⁵ Granted, this study did not determine actual weight loss or decreased obesity-associated outcomes. However, the first step to reducing the problem is to have patients accept counseling and be motivated to actively pursue change.

Additionally, experts advocate for a patient-centered approach to obesity counseling, in which physicians are responsive to patients' needs, desires, values, and preferences. For example, a patient-centered discussion about obesity from a podiatric standpoint would include questions by the physician about how a patient's foot pain or overall functional status may limit his ability to engage in exercise. Note that this conversation would also satisfy one of the A's discussed above, since the physician is assisting the patient in addressing barriers to weight loss.

Further recommendations for more specific treatment including calorie deficit recommendations, exercise routines, pharmacologic therapy, and surgical options can be found in the Journal of the American Medical Association² or Obesity Clinical Guidelines from the National Institutes of Health.⁶

The Podiatrist's Job

I do not want to advocate that all podiatric physicians now become weight loss counseling experts or that we should take our precious time to focus entirely on obesity when designing treatment plans for our larger patients. However, as physicians often dealing with the lower extremity complications of obesity, we need to consider involving ourselves further in this aspect of care. We need to become more involved, because podiatrists have two advantages over other healthcare providers.

First, podiatrists are well known for having friendly demeanors and positive interactions with our patients. Most of our patients know they will be in an emotionally secure environment with their podiatrist. We can leverage this safe position to more effectively drive our patients down a route of positive health. We've already created the environment; now we need to take advantage of it.

I'll finish off with one anecdote that demonstrates this last point. Several years ago, I had a scared neuropathic diabetic, obese, cigarette smoking patient who came to me with an acute abscess involving his first ray. After experiencing a partial first ray resection with a somewhat prolonged recovery (subsequent wound care was required), his entire attitude toward his health changed. After several conversations between us, he stopped smoking entirely, began an exercise program, and modified his diet. At one year follow-up, he had lost a significant amount of weight, continued his smoking cessation, and had greatly improved his overall health. Granted, this is an extreme example, but it demonstrates our patients' potential to change. We just have to tap into that potential.

Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

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References:

Galuska D, et al. Are Health Care Professionals Advising Obese Patients? JAMA, 1999; 282: 1576-1578.
Serdula M, et al. Weight Loss Counseling Revisited. JAMA, Apr 2003; 289(14): 1747-1750.
Screening for and Management of Obesity in Adults: Clinical Summary of U.S. Preventative Services Task Force Recommendations, June 26, 2012, https://www.uspreventiveservicestaskforce.org/
Jay M, et al. From the Patients' Perspective: The Impact of Training on Resident Physicians' Obesity Counseling. JGIM,2010, 25(5):415-422.
Jay M,et al. Physicians' use of the 5As in counseling obese patients: is the quality of counseling associated with patients' motivation and intention to lose weight? BMC Health Services Research, 2010; 10: 159-169.
Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report, September 1998. NIH. Number 98-4083.