Practical Approaches to Treating Obesity: Patient and Healthcare Professional Perspectives.

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.

Key Summary Points

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Introduction

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.

Obesity is a Treatable Disease

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 [3-5]. 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].

Table 1

Summary of common obesity-related complications

Increased risk for	Evidence
T2D [14–16]	1.5-fold increased risk with BMI of 25.0–29.9 kg/m2 5 times increased risk with BMI of ≥ 40 kg/m2 Elevated risk in Asian population due to greater prevalence of visceral versus peripheral adiposity compared with Caucasian population
CVD [16, 17]	Greater waist circumference associated with development of disease Risk of premature death from CVD caused by high BMI is increased 2–3-fold in people with obesity
NAFLD [18]	Obesity is most significant risk factor Positive correlation between BMI and disease severity
OA [19]	Weight is greatest modifiable risk factor
OSA [20]	> 10-fold increased risk with BMI > 29.0 kg/m2
GORD [21]	1.4-fold increased risk with BMI of 25.0–30 kg/m2 1.9-fold increased risk with BMI of ≥ 30 kg/m2
Cancer [22]	Strong evidence for increased cancer risk related to excess body weight across colorectal, oesophageal, kidney and pancreatic cancers across both sexes Strong evidence for increased risk of endometrial cancer and post-menopausal breast cancer in women
Depression [23]	People with obesity have 55% increased risk of developing depression

CVD cardiovascular disease, GORD gastroesophageal reflux disorder, NAFLD non-alcoholic fatty liver disease, OA osteoarthritis, OSA obstructive sleep apnoea, T2D type 2 diabetes.

The 5 As Approach to Obesity Counselling

There are a number of frameworks aimed at helping HCPs better support people to manage weight; the ‘4 Ms’ was designed to help time-restricted 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 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.

Assessment

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 subsequent management steps. Routinely asking all patients if weight can be checked as part of a consultation eliminates the possibility of under-estimation, 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.

Advise

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).

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: 1 Wing RR, et al. Diabetes Care. 2011; 34: 1481–6. 2 Van Gaal L, et al. Eur Heart J 2005; 7: 21–6. 3 Aucott L, et al. Hypertension. 2005; 45: 1035–41. 4 Lindstrom J, et al. Diabetes Care 2003; 26: 3230–6. 5 Tuomilehto et al. N Engl J Med 2001; 344: 1343–50. 6 Luo J, et al. Oncotarget 2017; 8: 81,719–720. 7 Tee MC, et al. Surg Endosc. 2013; 24: 4449–56. 8 National Cancer Institute: Obesity and Cancer Available at: https://www.cancer.gov/about-cancer/causes-prevention/risk/obesity/obesity-fact-sheet, accessed 25 September 2019. 9 Kritchevsky SB, et al. PLoS ONE 2015; 10: e0121993

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].

Agree

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 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 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 weight-loss 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 energy-dense 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 care-led 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, 42–44], although BMI cutoff values are lower in Asian populations [45] (Fig. 2). Rather than offering behavioural, pharmacotherapy and bariatric surgery sequentially, all relevant options should be discussed with individuals as early as possible (Table 2).

Fig. 2

Guidance on level of intervention to consider [5, 40–45, 59]. BMI body mass index (reported in kg/m2). Consult local guidelines for specific recommendations. *In some non-Asian regions, people with type 2 diabetes can be considered

Table 2

Summary of dosing regimens of available and investigational weight management pharmacotherapies

	Route of administration	Dose
Orlistat [46–48]	Oral	Prescription: 120 mg three times daily OTC: 60 mg three times daily
Phentermine/topiramate [49, 50]	Oral	Up to 15 mg/92 mg daily
Liraglutide [51, 52]	Subcutaneous	3 mg daily
Naltrexone/bupropion [53, 54]	Oral	Up to 32 mg/360 mg daily
Semaglutidea [55]	Subcutaneous	2.4 mg daily

Weight management agents should always be used in conjunction with appropriate behavioural interventions

aSemaglutide is an investigational product and has not been approved by the FDA or EMA at the time of writing

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 weight-management pharmacotherapies are indicated in conjunction with a reduced calorie diet and/or increased physical activity [47, 49, 51, 53].

Assist

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].

Conclusion

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, 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.

Why carry out this study?

Obesity is chronic and treatable, and confers risk for numerous health conditions including cardiovascular disease, type 2 diabetes and, more recently, severe COVID-19; however, despite this, global incidence is rising.

As such, there is a pressing need to address it in clinical practice; however, healthcare professionals often struggle to initiate conversations about weight.

This paper provides guidance on how to sensitively and effectively address the topic of weight from the perspective of both a healthcare professional and people living with obesity through use of the 5As framework.

What was learned from the study?

The 5As framework for tackling obesity in clinical settings was described in detail, with relevant examples.

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.