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866 PA R T V / Health Promotion and Disease Prevention

Patient Motivation day-to-day life and increased access to high-fat, high-calorie con-
venience food in larger portion sizes are common. 49 In addition,
Before considering treatment options, the patient’s motivation for ethnic minorities might be particularly affected by the living envi-
engaging in weight loss treatment needs to be assessed. Embark- ronment. For example, neighborhoods in New Orleans with 80%
ing on a weight loss and maintenance program requires a com- Black residents had 2.4 fast-food restaurants per square mile com-
mitment to a change in lifestyle and an investment of resources by pared to 1.5 fast-food restaurants per square mile in communities
the patient and the provider. Moreover, the change is not for a with only 20% Black individuals. Black neighborhoods had access
limited time, but rather lifelong. Factors to consider in the initial to six more fast-food restaurants than did mostly White neighbor-
assessment include the patient’s attitude toward weight loss, prior hoods when comparing communities of similar size. Recent find-
50
treatment failures and successes, support system, comprehension ings revealed that persons who live in areas with a higher number
of risk posed by weight status, readiness to initiate lifestyle of fast-food restaurants had a higher BMI compared with persons
changes, 40 self-efficacy for achieving weight loss, 41 time commit- who live in areas with a higher number of full-service restaurants. 51
ment, barriers to behavior change, 42 and financial issues if the
treatment is not covered by insurance. Adverse medical events
have been reported as a motivating trigger for initiating weight TREATMENT OF OVERWEIGHT
loss efforts and are in fact associated with greater weight loss and AND OBESITY
less regain, suggesting that health care professionals might use
these occasions as an opportunity to introduce the topic of weight Treatment Approach
43
management. Individuals experiencing major life events, such as
a relocation, change in marital status, and family illness, may find Treatment for obesity can be approached through lifestyle modi-
it better to delay initiating a weight loss program until they can fication, which includes dietary and exercise programs, pharma-
focus on the behavior changes required. Those individuals with cotherapy, or surgical treatment. The latter two approaches are
significant anxiety, depression, or eating disorders (e.g., binge eat- adjunctive to lifestyle therapy (Table 38-3). The severity of obe-
ing or bulimia) may need to be treated for these conditions before sity and presence of comorbidities determine the approach to
initiating a weight loss program, even if health care professionals treatment (e.g., the coexistence of type 2 diabetes, hypertension,
7
conduct the program. Patients with eating disorders are best or congestive heart failure). In the absence of comorbid condi-
2
served by a referral to a specialist. 44 For the unmotivated patient, tions, patients with a BMI between 25 and 30 kg/m can achieve
the provider needs to review the risks of excess weight and the adequate weight reduction through lifestyle approaches. Phar-
benefits of initiating treatment and discuss how this treatment macotherapy is usually limited to those with a BMI greater than
2
may be different and how the patient will be assisted. If the patient 30 kg/m or, in the presence of comorbidities, to those with a
2
remains uninterested in treatment, the provider needs to address BMI between 27 and 30 kg/m . Surgical therapy is considered for
2
coexisting risk factors and initiate management of these, including a BMI greater than 35 kg/m with comorbid conditions, or when
2
further weight gain prevention. When the patient is ambivalent the BMI exceeds 40 kg/m . However, under certain circum-
about making lifestyle change or initiating a weight loss program, stances, consideration should be given to extending surgical treat-
2
motivational interviewing (MI) strategies, also referred to as re- ment to patients with a BMI between 30 and 34.9 kg/m with a
45
flective listening, can be used. This approach, which will be dis- comorbid condition that can be cured or markedly improved by
cussed in more detail later in this chapter, requires training of the sizable or sustained weight loss. 52 Pharmacologic or surgical ther-
clinician. Once the assessment has been completed, the treatment apy is never used in isolation, but rather is adjunctive to lifestyle
plan needs to be considered and discussed with the patient. modification, which needs to be continued indefinitely after the
use of these other treatment modalities.
Provider Assessment of
Patient’s Objectives
The manner and attitude of the health care professional when ad-
dressing the patient’s obesity and weight management may be an Table 38-3 ■ APPROACHES TO TREATMENT OF OBESITY
important determinant of the patient’s receptivity. There is some BY SEVERITY AND DISEASE RISK
evidence that health care professionals doubt a patient’s motivation Comorbid Conditions
or ability to make lifestyle changes and thus might be nonsupport- and/or CVD Risk
ive of the patient’s goals. 46 The patient needs to define the prob- BMI Factors Treatment Approaches 74
lem and the clinician needs to be nonjudgmental in discussing the 25–30 Absent Lifestyle modification*/Prevention
behavior and the weight problem. When discussing treatment op- of weight gain
tions with the patient, conveying an empathetic understanding of 27–30 2 Present † Lifestyle modification
the challenges that come with the long-term lifestyle changes is im- pharmacotherapy ‡
portant. Finally, eliciting the patient’s objective for the treatment 30 Absent Lifestyle modification
‡
pharmacotherapy
and mutually agreeing on a plan of action for the short- and long 35 2 Present Consider surgical therapy ‡
term will enhance the probability of a positive outcome. 47,48 40 Absent Surgical therapy ‡
Environmental Barriers to Weight Loss *Lifestyle modification includes caloric restriction (400 kcal/day deficit), 30% fat diet,
exercise at least 5 days/week, and behavioral therapy.
† Comorbid conditions warranting drug therapy: High BP, CHD, type 2 diabetes, con-
Environmental obstacles exist partially as a result of our techno-
gestive heart failure, and sleep apnea.
logically advanced society where reduced energy expenditure in ‡ Pharmacotherapy and surgical therapy are adjunctive to lifestyle modification.