Counseling Patients With Obesity

Issues of Concern

Determining Which Patients To Counsel

Before initiating a conversation about weight, the first step is determining which patients are overweight or obese. Body mass index (BMI) and waist circumference are standard methods to screen for excess weight. BMI is easy to perform in most clinical settings and is often calculated as part of the vital signs in the electronic medical record. BMI is a screening tool used to identify patients who would benefit most from weight counseling and is a reliable determinant of adiposity-related health risks. Although it is a helpful tool, BMI must be used in combination with examining the patient and evaluating their muscle mass and body habitus. In addition, measuring a patient's BMI at every visit will help practitioners identify significant changes in body weight that may coincide with the development of other chronic diseases.

Waist circumference is a screening tool that measures abdominal (central) fat and is a surrogate marker for cardiometabolic health.[14]

BMI Criteria for Underweight, Normal Weight, Overweight and Obese

• Overweight (25.0–29.9 kg/m^2)
• Obesity class I (30.0–34.9 kg/m^2) 
• Obesity class II (35.0–39.0 kg/m^2) 
• Obesity class III (≥40.0 kg/m^2) 

Waist Circumference Criteria for Increased Cardiovascular Risk 

• Men, ≥102 cm 
• Women, ≥88 cm 

Waist circumference measurements are unnecessary for patients with BMIs ≥35.0 kg/m^2.

Limitations in BMI

BMI is less accurate for assessing healthy weight in some groups because it does not distinguish the weight proportion due to fat or muscle. BMI is, therefore, less accurate in certain populations, including certain ethnic groups (such as South Asian, Chinese, and Japanese population groups), weight-lifters, pregnant women, the elderly, people with a physical disability, people with eating disorders, people under 18 years of age, and those with extreme obesity. Among Asians, lower BMI cut-offs for overweight (≥23.0 kg/m^2) and obese (≥27.0 kg/m^2) are utilized to account for increased health risks.[15]

Clinical Significance

Obesity is increasingly recognized as a treatable complex chronic disease. The interplay of multiple physiological, psychological, and environmental mechanisms adds to the challenge of losing and maintaining weight. Therefore, healthcare practitioners must tailor their counseling to the individual and focus on specific preferences and needs. Several approaches have been studied and suggested to counsel patients about weight effectively.[16][17] Below is a review of the data on counseling for weight loss. 

Transtheoretical Stages of Change Model

The transtheoretical stages of change model has long been considered a practical approach in lifestyle modification. Still, its effects vary considerably in producing sustainable weight loss in overweight and obese individuals.[18][19] This model assumes that behavioral change is complex and unfolds in stages. The stages of change describe the individual's current intention and engagement toward a targeted health-related behavior. In the first stage, the pre-contemplation stage, the individual has not yet acknowledged any problem behavior that needs changing. In the second stage, termed contemplation, the individual is aware that a problem exists but has yet to commit to action. At the preparation stage, people intend to and are preparing to make the change in the next month. Next, at the action stage, people begin to modify their behavior. In the last maintenance stage, the new behavior is continued for at least six months. Accurately determining the patient's stage of change is essential since different therapeutic processes and counseling techniques are more effective at different stages. Thus, providing stage-based individualized counseling can enhance a patient's progress through the stages. For example, discussing the health consequences of being overweight and obese is relevant in the pre-contemplative and contemplative stages of change but is less pertinent in the action and maintenance stages. In these stages, practitioners should focus the counseling on methods to achieve success toward an individual's goals by reviewing any existing barriers and encouraging exercise to aid in weight maintenance.  

5A's Model

There is growing evidence in the literature for using the 5A model (ask, assess, advise, agree, assist/arrange) to aid in delivering meaningful consultations in weight management. The 5A model also effectively improves physician-patient communication, patient motivation, and healthcare practitioner confidence in counseling patients.[20][21][22][23][24] Below lists the application of the 5A model in counseling patients who are overweight or obese. 

Ask Permission

• Individuals with excess weight experience weight stigma in multiple areas of their lives, including healthcare. When discussing this topic, it is vital to ask the patient's permission. It is best first to address the patient's primary reasons for the visit to help ensure they feel respected. 
• It can be helpful to ask the patients about their health goals to initiate the discussion. Doing so will help to understand the patient's motivations and help to develop a realistic plan for change.
• Since obesity is a complex topic to discuss, being nonjudgmental and empathic will open the conversation and create a positive, safe space for patients. Not all counseling must be done in one visit. Instead, the topic should be revisited and reinforced at subsequent visits. 

Assess

• Visual assessment is a poor way to diagnose excess weight. Use BMI and waist circumference, as described above, for screening tools in the clinical setting. While weight data is helpful to the healthcare practitioner, respect the patient's wishes if they feel uncomfortable or decline to be weighed.
• Review clinical and laboratory investigations for comorbidities, including sleep apnea, fatty liver disease, cardiovascular disease, and endocrine diseases. The health care practitioner should treat comorbidities and all present health risks.
• A key component in assessing a patient's weight is a thorough history of the patient's weight, dietary patterns, level of physical activity, sleep habits, and mental health. Make sure to ask the patient for the following information: 
• Dietary patterns using a 24-hour diet recall.
• The current level of physical activity, making sure to note the patient's employment, amount of time spent in sedentary activities, and physical limitations.
• The patient's readiness for change, and adjust counseling accordingly, as described above in the stages of change model.
• The patient's eligibility for pharmacotherapy, bariatric procedures, and surgery and their level of interest in these options.

Advise

• Modest weight loss (5-10% of total body weight) can reduce morbidity and mortality.[25] It may be helpful to briefly review the hormonal and metabolic changes that make weight loss challenging, thus, helping patients understand weight plateaus and hunger cues. Improved nutrition should be emphasized as the primary driver of weight loss, as opposed to physical activity; physical activity is essential for weight maintenance but less for weight loss.[26][27] The healthcare practitioner must allow the patients to drive the conversation and set their own goals. 

Agree

• The patient must set realistic and achievable short-term and long-term goals. Goals should be in the SMART format - specific, measurable, achievable, relevant, and timely to increase the likelihood of self-accountability and success.[28]
• Set clear expectations from the beginning on the expected rate of weight loss, usually 1-2 pounds weekly, with the caveat that this rate will vary by individual. 
• The treatment plan should be agreed upon between the practitioner and the patient, considering the risks, benefits, and individual circumstances.
• When initiating pharmacotherapies, the practitioner should continue to stress the importance of behavioral changes with diet, exercise, sleep, and stress reduction. 

Assist/Arrange

• The practitioner should help the patient overcome identified barriers, recommend self-monitoring, and provide written materials based on individual interests and needs. Using web-based applications and services may help patients achieve their individualized goals. A written plan for patients can help them remember the agreed-upon plan details. 
• When appropriate, the practitioner may provide patients with a list of local community resources (e.g., local gyms, community exercise programs, walking groups, and sporting groups) based on the patient's interests and abilities.
• At follow-up visits, the practitioner should review food and physical activity diaries and reassess progress and barriers to the agreed-upon goals. 
• Arrange frequent visits to ensure the weight management plan is effective and to help provide additional support and recommendations promptly. Visits every 1 to 3 months are preferred. 
• Consider referrals to other support providers who may help the patients reach their goals. Such referrals may include, but are not limited to, dieticians, eating disorder specialists, psychologists, sleep specialists, physical therapists, and bariatric specialists.

Motivational Interviewing Techniques for Weight Loss Counseling

Motivational interviewing is a patient-centered counseling technique that facilitates patients' likelihood of behavioral change by exploring and resolving ambivalence.[29] Its nonconfrontational and collaborative style addresses physicians' concerns about lecturing ambivalent patients and distinguishes it from other evidence-based behavioral strategies.[30][31][32] Research suggests that this approach may be helpful in weight management, including weight loss and maintenance.[33] Motivational interviewing is rooted in four principles: engaging, focusing, evoking, and planning.[34]

During motivational interviewing, the principles may flow from one to the next or may recur or overlap. During the engaging process, the goal is to establish a supportive and collaborative relationship. The focusing process involves developing a specific direction for the conversation. Evoking allows patients to consider what and how to change without coercion or persuasion. Finally, the planning phase requires discussing how the change will occur.

Below are three different motivational interviewing skills highlighted in the obesity medicine literature. 

FRAMES (Feedback, Responsibility, Advice, Menu Options, Empathy, and Self-Efficacy) is an effective technique for patients who are responsive to education about health risk behavior.[33] This technique is routinely used at the start of the motivational interviewing conversation. 

• Feedback about personal risk: the practitioner provides factual and objective data regarding the risks of excess weight or obesity-related comorbidities. For example, discussing lab and imaging results that suggest fatty liver disease and reviewing the importance of healthy weight and lifestyle in the management plan.  
• Responsibility of patient: the practitioner emphasizes that the ability to change comes from the patient and that the health care practitioner can provide support. For example, "you have the ultimate control over your eating; there are steps you can take to ensure your success." 
• Advice to change: the practitioner provides the patient with a written prescription for behavior change. For example, "After our review of your diet preferences and lifestyle, the healthier nutrition plan to help you lose weight would be a plant-based diet."
• Menu of options: the practitioner must again emphasize the patient's choice to change and provide individualized strategies to help the patient achieve healthcare goals. For example: reviewing options for anti-obesity medication therapy and referrals to bariatric procedures. 
• Empathy: the practitioner provides emotional support for the patients while they consider their options and goals. For example, "changing your diet is very challenging. The beginning is always the hardest. Remember, you don't have to be perfect to succeed."  
• Self-efficacy enhancement: the practitioner communicates confidence in the patient's ability to change and reminds the patient of the reasons for change. For example, "You have a solid plan to reduce night-time snacking. Your health and family are major drivers in accomplishing your goals." 

Evoking Change Talk

Change talk is a consciously directed strategy in motivational interviewing to resolve ambivalence and promote behavioral change.[35] Sustain talk is speech that favors the status quo. Evoking change talk helps to shape the patient's statements toward behavioral change. Some examples include focusing on the disadvantages of the status quo, recognizing the advantages of change, and expressing optimism about change. Methods for evoking change talk include asking open-ended, provoking questions or extreme questions, such as "What concerns you about your current situation?" or "What is the best case scenario if you change your behavior?". In addition, using a Likert scale can help determine patients' confidence to change and their view on their likelihood of success. For example, "How important is it for you to lose weight?" or "On a scale from zero to ten, how likely is it that you will be successful in losing weight?". Finally, the practitioner must emphasize and review the patient's change statements while providing assurance and hope. 

OARS (Open-ended Questions, Affirmations, Reflections, and Summaries) is a communication technique that aids the practitioner in evoking change talk.[36]

• Open-ended questions: avoid asking "yes" or "no" questions. Broad questions allow patients to express their desires and concerns openly. For example, "What is new since we last met?" or "If you could change one habit to help reach your health goals, what would that be?"
• Affirmations: always express empathy during difficult conversations and celebrate accomplishments. When patients achieve a goal, rejoice in their success with them. 
• Reflective listening: this step allows the practitioner to guide the patients to the answer. The practitioner asks the patients to express their thoughts and then reflects on these thoughts without advising the patients on the next steps. For example, "You mentioned that you dislike traveling due to difficulties fitting into the seat. That sounds very stressful since your family lives far away."
• Summarizing: this step involves recapping the conversation with the patients while focusing on change talk and allowing the patients to correct any misunderstandings. It is often practical to end the discussion with an open-ended statement, such as "I am wondering what you think your next step should be."

Keys to Weight Loss Counseling

• Identify a dietary pattern that is realistic and manageable for the patient to adhere to long-term. Provide specific dietary examples and resources to the patient, such as the low glycemic index diet for patients with type 2 diabetes, the DASH diet for patients with hypertension, or the whole foods plant-based diet for patients with cardiovascular disease. Focus on what the eating patterns have in common rather than what separates them.[37] Consider individualized plans that fit with the patient's lifestyle, including meal delivery services and web-based platforms to help the patient with dietary self-monitoring.[38]
• Advise the patient on limiting the intake of foods and beverages high in calories, fat, sugar, and sodium.
• Highlight the importance of reading food labels to help avoid ultra-processed foods and choose products containing fewer calories, fat, sugar, and sodium.
• Educate the patient on limiting meals at restaurants, selecting healthy options when dining out, consuming more fruits and vegetables, avoiding large portions, and eating foods with low energy density, such as fruits and vegetables. 
• Plan a stepwise approach to increase physical activity for sedentary patients. For instance, advise short sessions of 5 to 10 min daily and increase weekly to the desired level of physical activity. Assess physical limitations and consider referrals to specialists, including physical therapy, occupational therapy, and orthopedics. 
• If the patient is a candidate for pharmacotherapy or procedural interventions, gauge the patient's desire for these options and discuss the next steps.

Other Issues

When to Refer for Bariatric Surgery

• There have been significant advances in pharmacotherapies for weight loss. However, bariatric surgery remains the most effective weight loss treatment. Pharmaceutical options may not be available to all patients due to side effects, cost, or contraindications to the medication. Surgical interventions are an option for patients with clinically severe obesity (BMI ≥40 kg/m^2 or BMI ≥35 kg/m^2 with comorbid conditions) who are unable to lose weight.[39] It is particularly beneficial to patients with obesity-related comorbidities, including diabetes, cardiovascular disease, and osteoarthritis. Often, bariatric surgery is not discussed with patients, and referrals are offered late in the plan. The work-up toward bariatric interventions is lengthy and usually requires a minimum of 6 months before intervention. Therefore, clinicians should make efforts to discuss procedural or surgical options early.

Recommendations on How to Maintain Lost Weight

• Patients may often find it difficult to maintain their weight loss long-term. Research shows that physical activity strongly predicts keeping weight off long-term. In addition to being physically active, treatment adherence to diet is also key to long-term success.[40][41]  
• Practitioners must educate patients that a lack of weight loss does not imply a lack of benefits. Less than 3% of Americans meet the basic qualifications for a "healthy lifestyle," as defined by four characteristics: 150 minutes of moderate-vigorous activity a week, a healthy diet, not smoking, and having a healthy body fat percentage.[42]  Multiple studies have demonstrated that a 5 to 10% total body weight loss can significantly benefit overall health, morbidity, and mortality.[43][44] Therefore, counseling should focus on healthy behaviors that promote weight maintenance.

Enhancing Healthcare Team Outcomes

Managing excess weight is challenging and complex and requires an interprofessional team approach that includes clinicians, nurses, pharmacists, dieticians, and nutritionists. While once a condition relegated to the domain of the primary care provider, it is now realized that weight management requires the expertise of a collaborative interprofessional team with an individualized patient-centered approach. To achieve optimal clinical outcomes, the patient and the healthcare team must discuss, mutually define, and agree upon the healthcare goals. Many studies have identified barriers to managing obesity, including lack of training, time, resources, and knowledge. One study cites that 45% of clinicians do not feel qualified to treat obesity.[45] 

For patients who are overweight or obese, nearly 50% have received education on weight loss, 50% on diet education, and 41% on exercise counseling.[46] Strategies for the health care team to improve the care of patients with obesity include regularly measuring BMI, routinely assessing patients' readiness for behavioral change, and training team members on the 5A model of patient counseling so that each member can participate in all or some of the five skills of the weight management plan.

Evidence-based Approach

An interprofessional team who provides a holistic and integrated approach to weight management will achieve the best possible clinical outcomes. [Level 1] For example, referrals to a health coach or dietician are beneficial if a patient has specific dietary questions. Referrals to psychology with eating disorder expertise are essential for patients with eating disorders. For patients with physical limitations, referrals to physical therapy are often necessary. Other interdisciplinary team members can include bariatric endocrinology, integrative cardiology, gastroenterology proceduralist, and bariatric surgeons. Each can collaboratively help guide the patient toward better health and effective weight loss. Pharmacists can counsel patients and check for drug interactions if medication is part of the management strategy.

Collaboration, shared decision-making, and open communication are critical elements for optimal outcomes. The 5A strategy represents one well-studied model that effectively guides patients toward their weight loss goals (Level 2). The interprofessional care provided to the patient must use an integrated care pathway combined with an evidence-based approach and good communication between the team members and the patient. [Level 5]