28-Year-Old Woman Struggling with Obesity
Sarah, a 28-year-old female, presents for a routine annual follow-up. She was diagnosed with depression 3 years ago, which is currently well controlled. She has a history of obesity and has been implementing lifestyle changes with little success. She has cut back on fast food, and is trying to follow a low-fat diet. She exercise 1-2 times per week, but has had limited weight loss. Her past medical history includes obesity (BMI 32.1 kg/m2), depression, and GERD. Current medications: paroxetine 20 mg daily, drospirenone/ethinyl estradiol daily, famotidine 20 mg twice daily.
Setting: Telehealth
PATIENT NAME: Sarah Smith
DOB: 12/1/1995
REASON FOR VISIT: Annual wellness visit
VITAL SIGNS:
Labs (today):
Patient Interview: 12-15 minutes
Feedback: There will be verbal feedback with the standardized patient following the role-play.
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Please review the brief Clinical Overview before participating in your session with Sarah.
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Written by: Christopher D. Still, DO, FACN, FACP
Conversations about weight loss can be difficult for patients for many reasons, including negative experiences with healthcare professionals (HCPs) in the past. It is an exciting time to have that conversation, however, because of the safe and effective treatment options that are now available for treatment of obesity.
It is important for HCPs to be prepared when asking the patient if they would like to talk about their weight. As with any other behavioral disease, it is important that we ask, assess, advise, and treat or refer out. As an obesity specialist, patients come to see me specifically about their weight, so it is not as difficult for me to have that conversation. However, it is more difficult for primary care providers, as it takes time to talk about weight and the patient’s weight journey, including difficulties they have had in the past, what has worked in the past, and—of most importance—what did not. HCPs can try to help patients overcome those barriers as they go through the patient’s journey with them.
Often the patient may be the one to initiate a conversation about weight. Many primary care providers get asked about medications by patients who have seen direct-to-consumer advertisements for antiobesity drugs. Because these busy HCPs may see the patient only rarely for an annual checkup, they should use the opportunity to have a meaningful discussion about weight, even if the patient is undergoing treatment for something unrelated. If there is limited time for the visit, offering information about diet and pharmacotherapy options may be all that is possible. In these cases, it may be best to schedule a follow-up appointment for a patient-centered discussion about treatment options in more detail. If the wait for a follow-up appointment is unreasonably long, it may be better to do as much as possible within that visit and provide the patient with information they can consider on their own, including medication benefits, insurance coverage, and adverse events.
Cornerstones of Weight Loss
Diet, exercise, and behavior modification are the cornerstones of any weight loss treatment strategy, whether it includes medication, surgery, or a device. Therefore, we always talk about diet, increasing physical activity, and behavior modification first. However, the STEP 5 trial showed that participants receiving the once-weekly glucagon-like peptide-1 receptor agonist semaglutide plus intensive behavioral therapy had a 15.2% decrease in body weight compared with the 2.6% decrease seen in the placebo plus intensive behavioral therapy group. Although diet and exercise are important, alone they are not as effective as medications. In addition, when you recommend lifestyle modifications, diet quality is an important consideration. When a person is on a reduced-calorie diet and takes in only 1000-1200 calories per day, it is very important that they eat good-quality nutrients, as well as increase water intake, and decrease sedentariness or increase physical activity.
Importance of Patient-First Language
I think the use of patient-first language such as “patients with obesity” and “patients with overweight” is important when we discuss weight with patients. We do not want to blame patients for their weight or their medical problems. Many HCPs tell their patients that if they would only lose weight, then X, Y, and Z would get better. That may be true to a point, but patients are in your clinic for your help not only with their medical issues, but also with their weight loss journey.
HCPs should be empathetic and set the patient up with realistic expectations of 5% to 10% weight loss increments. I think that is very important, and the more accountable we can be in our patient’s journey, the better the patient will do. How we talk to patients, setting realistic expectations, and scheduling follow-up are key to the conversation about assessing, advising, and treating.
Setting Realistic Goals for Weight Loss Regardless of Strategy
Often when we start antiobesity medications, we see unrealistic weight loss expectations in patients, patients’ families, and even HCPs. Patients often state that they want to get down to the weight they were many years ago. In my own practice, when a patient’s goal is to lose 100 pounds or >20% of their weight, I suggest they do it in 5% to 10% increments. This way, if they plateau at 15%, they still will feel that they have achieved a goal and will be less likely to become discouraged. If the patient stays on their antiobesity medication, they likely will maintain that weight.
I think setting up realistic expectations with patients having bariatric surgery is also important, as they expect to get down to their “normal weight” with bariatric surgery but may not. Maciejewski and colleagues found that at the 1- and 10-year timepoint post bariatric surgery, patients had lost approximately 30% of their baseline weight. If someone does not want to start medication and only wants to do lifestyle modifications, they can expect a 5% to 8% weight loss. Some people lose more, and some people lose less. In my practice, I typically see a 3% to 6% weight loss with diet and exercise, but with the newer medications, a 16% to 20% weight loss is possible. So, it is important that patients understand the results they likely will achieve no matter which treatment option they choose and remain aware of all their options so that if a particular treatment is not successful, they can choose a different option.
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