Introduction

Obesity is a complex, multifactorial disease that has been increasing in prevalence in the United States (U.S.). According to the most recent data in 2017-2018, the prevalence of obesity among adults in the U.S was 42.4%, surpassing 40% for the first time.1 Given the increased risk of morbidity and mortality that is associated with obesity, it is very important that health care providers appropriately screen patients and provide effective evidence-based treatment strategies.

1. Obesity is a chronic, complex disease

Obesity is a complex, multi-faceted disease that is multi-factorial in etiology. It is highly prevalent in the U.S., with 1 in 3 adults estimated to be obese.2 This disease condition has increased by 70% in the last 30 years,2 and is estimated to be one of the leading causes of disease and mortality worldwide.3 Obesity is estimated to increase U.S. national healthcare spending by $149 billion annually,4 and has recently been shown to worsen outcomes in patients with Coronavirus Disease 2019 (COVID-19).5

2. Obesity is multi-factorial in etiology

Obesity’s increasing prevalence is universal6 correlated with dietary changes, lack of exercise, inheritance, and chronic medical conditions. For example, there is an estimated inheritability of obesity measuring between 44-77%, with parental obesity the strongest predictor for childhood obesity in children less than 6 years of age.7 As a provider in the state with the highest number of obese adults and children,8 a core knowledge of obesity and how to stem its worsening rate is required reading.

3. Obesity is a fat mass and sick fat disease and is associated with multiple comorbid conditions

Obesity is considered a fat mass and sick fat disease. Fat mass disease is characterized by an increase in body fat that results in abnormal and pathologic physical forces that can cause immobility, stress on weight-bearing joints and tissue compression leading to health complications, such as, obstructive sleep apnea and osteoarthritis.9 Sick fat disease (adiposopathy) is defined as deranged adipocytes and adipose tissue, which occurs due to adipocyte hypertrophy and adipocyte tissue expansion that results in pathologic endocrine and immune responses that promote metabolic diseases such as diabetes mellitus, high blood pressure and dyslipidemia.10 These health complications indirectly contribute to major cardiovascular risk factors as well as certain cancers (endometrial, uterine, cervical, ovarian, bladder, brain, breast, colorectal, liver, gallbladder, stomach, thyroid, head and neck, pancreatic, leukemia, Non-Hodgkin’s lymphoma, and multiple myeloma).11,12

4. Various methods can be used to screen patients for obesity

Most common and cheapest screening tool for obesity is body mass index (BMI). BMI is a person’s weight in kilograms (kg) divided by the square of height in meters (m2). For the general population, BMI > 25 kg/m2 is considered overweight and BMI > 30 kg/m2 is considered obesity. BMI has limitations in assessing adiposity in individuals with increased muscle mass, decrease in muscle mass, men versus women, different races, and postmenopausal status.13 Waist circumference should also be obtained as it is cost effective and is well-correlated with the risk of metabolic and cardiovascular disease. Central obesity is defined as waist circumference > 40 inches (102 centimeters) for men and > 35 inches (88 centimeters) for women.14 For individuals, accurately determining percent body fat, android fat, and visceral fat is a better assessment of adiposity compared to BMI alone. Percent body fat mass is highly variable, and is considered abnormal if ≥ 32% in women and ≥ 25% in men. Methods to measure body composition vary regarding accuracy, reproducibility, expense, and accessibility. These include Dual Energy X-Ray Absorptiometry (DXA) which is easy to use, but expensive; calipers that are user dependent and inexpensive; bioelectrical impedance that is inexpensive and can be unreliable in patients with significant obesity; and air displacement that is accurate, expensive and dependent on clothing and hydration.15–19

5. Treatment of obesity requires a multidisciplinary approach

Patients are more likely to engage in weight loss efforts when it is recommended by their primary care physicians.20 The first step toward creating an individualized treatment plan for a patient with obesity is to compile the patient’s history and physical exam with laboratory and diagnostic testing. Routine laboratory assessment may include fasting glucose levels, hemoglobin A1c, fasting lipid levels, liver enzymes, electrolytes, creatinine & blood urea nitrogen, thyroid stimulating hormone, complete blood count, urine for albumin, and vitamin D. Individual testing may include evaluation for insulin resistance, hypercortisolism, oligomenorrhea/amenorrhea, hyperandrogenemia and polycystic ovary syndrome in women, and hypogonadism in men.21,22

6. An evidence-based dietary approach should be implemented for effective treatment of obesity

The primary focus of any intervention for weight loss should be reducing total energy intake and creating a negative energy balance.23,24 The Guidelines (2013) for Managing Overweight and Obesity and Adults recommend one of the following dietary strategies to produce weight loss in patients who are overweight and obese: (1) caloric reduction to 1200 to 1500 kilocalories (kcal)/day for women and 1500-1800 kcal/day for men; (2) energy deficit of 500 to 750 kcal/day based on the patient’s baseline energy requirement; or (3) an evidence-based diet that restricts or eliminates specific types of foods, such as foods that are high in fat or carbohydrates. There are a variety of evidence-based dietary approaches that have been shown to be effective in achieving an energy deficit and subsequent weight loss. When prescribing a calorie-restricted diet, patients’ preferences, ability, and health status should be taken into consideration. Health care providers should also consider referring patients to a nutritional professional for specific dietary counseling and advice.23

7. Appropriate physical activity is essential to achieving weight loss

In addition to dietary and behavioral interventions, physical activity is an essential component to achieve weight loss. It is recommended that patients engage in at least 150 minutes per week of moderate to vigorous intensity exercise for at least 3 days per week. To maintain weight loss or prevent weight gain, 200-300 minutes per week of moderate-intensity physical activity are recommended. In addition to aerobic physical activity, resistance training is also essential for weight loss by promoting fat loss and preserving fat-free mass and should consist of single-set exercises using major muscle groups 2 to 3 times per week. Physical activity also prevents or slows the progression of many chronic comorbid diseases associated with obesity, including hypertension, type 2 diabetes mellitus, and dyslipidemia.24–26

8. Motivational interviewing increases patient motivation and behavioral change in weight management consultations

Motivational interviewing (MI) can be defined as a patient-centered method of guiding to elicit and strengthen personal motivation for change. This interviewing style initially started as treatment for addiction but since its inception, it has been utilized for a wide range of illnesses and conditions requiring a lifestyle change, including obesity.27,28 MI can be summarized in the 5 A’s (Ask, Assess, Advise, Agree, Assist). Ask: Using open-ended questions to inquire about current lifestyle and dietary habits while limiting judgmental language and evaluating the patient’s readiness to change. Assess: Evaluating a patient’s current health status and psychosocial effects of obesity (i.e. Metabolic, monetary, mechanical, etc.) Advise: Developing a practical and comprehensive plan of lifestyle modifications. Agree: Working with the patient to set realistic goals for weight loss. Assist: Identifying and targeting any barriers as well as providing additional support, such as appropriate follow-ups, counseling services, and social work for financial assistance.29 Additional effective and brief MI techniques include the FRAMES and OARS models. The FRAMES technique includes Feedback about personal risk, Responsibility of the patient, Advice to change, Menu of strategies, Empathy, and Self-efficacy. The OARS model consists of Open-ended questions, Affirmations, Reflections, and Summaries.12

Utilizing MI can allow patients to work through their own reluctance to accomplish significant lifestyle change in their weight loss journey.

Although lifestyle modifications, such as dietary changes and a regular exercise regimen should be the cornerstone of any weight loss program, there are many patients that would benefit from pharmacotherapy. According to the American Heart Association guidelines, patients who should be eligible for weight loss medication are those patients with BMI of 30 or greater, or those 27 or greater with obesity-related comorbidities who have not attained at least 5% weight loss after at least 6 months of intensive behavioral changes. These related comorbidities include diabetes, hypertension, congestive heart failure, or dyslipidemia.30 There are only a few medications that have been FDA-approved for weight loss, such as phentermine, phentermine/topiramate, naltrexone/bupropion, and orlistat. It is important to remember that many of these can carry contraindications based on patient’s illnesses. Patients generally lose an average of 10-15% of their starting body weight with pharmacotherapy.31 More recently, the glucagon-like peptide 1 (GLP-1) agonists (i.e. liraglutide and semaglutide) have gained more attention as highly effective FDA-approved treatments not only for their significant weight loss benefits but also for their ancillary benefits of improving cardiac morbidity and mortality.32 There is much research currently in development regarding these and other potential treatments in the battle against obesity.

Patients who have failed to lose adequate weight despite intensive behavioral modifications and have the appropriate BMI criteria (as stated above) may qualify for bariatric surgery. The two most common types of bariatric surgery are the sleeve gastrectomy and gastric bypass. The sleeve gastrectomy, in which approximately 80% of the stomach is removed, has recently become the most common type overall. This is most likely due to the easier nature of the procedure, lower complication rate, and lower risk for future revisions.33 Patients who receive bariatric surgery usually have significant weight loss, with an average loss of over 30% starting body weight that was maintained at least 5 years post-procedure. This was obviously dependent on the type of surgical procedure received.34 Some of the notable benefits of bariatric surgery are the improvements in comorbid conditions. Diabetes, hypertension, asthma, and obstructive sleep apnea have all been well-documented to significantly improve following surgery.35 Of course, it is important for patients to remember that they should still adhere to other lifestyle modifications even after the procedure to receive the full benefits.

Conclusion

Obesity is a serious global health problem and the state of Mississippi leads the nation with the highest rate of obesity. Given the complex, multifactorial nature of obesity, a comprehensive multidisciplinary approach is necessary for screening and appropriate treatment. A lifestyle intervention plan should encompass a caloric-reduced diet, appropriate physical activity, and counseling on behavioral modifications. Pharmacotherapy and bariatric surgery may also be indicated to facilitate weight loss and improve morbidity and mortality. These interventions are important tools in treatment of obesity and decreasing the overall prevalence and complications.