Physician-supervised Weight-loss (Overweight, Obesity and Morbid Obesity) Physician-supervised weight-loss programs provide treatment in a clinical setting with a licensed healthcare professional, such as a medical doctor, nurse, registered dietitian and/or a psychologist. These programs typically offer services such as nutrition education, physical activity and behavioral therapy. The cost to participate in a physician-supervised weight-loss program is comparable to the cost of weight-loss programs that do not have a physician on site, for example LA Weight-loss, Weight Watchers and others. Health insurance companies may cover some or all of your treatment if you have heart disease, metabolic syndrome, diabetes or a pre-diabetic condition. The Initial Consult: A physician, physician assistant or nurse practitioner specializing in obesity treatment provides the initial consultation. The initial consult involves a focused medical evaluation for diseases related to obesity. In addition, the medical professional will obtain a weight history, which includes past diet attempts, and may conduct a thorough psychological history. Many patients come to the clinic with undiagnosed diabetes, high cholesterol, thyroid disorders or abnormal liver tests. Several blood tests are often drawn. Overall, the Physician management of obesity includes:
Diet and Behavior Modifications: After the initial assessment, many of the follow-up appointments are with registered dietitians or mid-level providers who are certified in obesity management as well as exercise. Getting a handle on eating behaviors is key to making significant long-term changes. While some do not like to keep food logs that require writing down all food eaten, this exercise has been shown to be important for long-term success. With all the variation in serving sizes, most individuals do not have a good understanding of how many calories are actually consumed in one day. Therefore, it is recommended that, for at least the first six to eight weeks, individuals keep a complete food log. This will also help dietitians get a better handle on areas of the diet to focus on at follow-up visits. Dietitians also work with patients using individualized meal plans for various lifestyles and medical conditions. Many medical conditions, such as insulin resistance, can make it difficult to lose weight on traditional low-fat diets. The dietitian can work individually with the patient to find a meal plan that works for him or her. Also, dietitians teach patients how to actually make the changes such as: how to shop; cooking ideas such as easy preparation methods or healthy recipes; and how to eat out at restaurants. Follow-up Visits: Patients are given the opportunity to revisit a topic or obtain more information on an area of interest during follow-up visits. The frequency of and interval between follow-up visits is determined on a patient-by-patient basis. Monthly visits are encouraged until initial weight-loss goals (5 to 20 percent) are achieved. At that point, three, six or 12-month follow-up visits are encouraged as needed for individual patients. Weekly weigh-ins are a useful tool to hold individuals accountable. Patients are frequently given a meal and exercise plan by their healthcare provider and told to return in two to three months. Getting weighed on a weekly basis (at the same time and day of the week and using the same scale) helps to keep dieters on track. Just knowing there will be a weekly weigh-in decreases caloric consumption. On the other hand, daily weigh-ins are not recommended since small, incremental changes often cause frustration and result in failure. It is also recommended, if possible, that the weekly weigh-in occurs outside of the home. Being weighed in the presence of another person increases accountability and has been shown to decrease caloric intake per week by nearly 20 percent. Medications (Pharmacotherapy): Currently there are three medications that are FDA approved for weight-loss: sibutramine (Meridia®), orlistat (Xenical®) and Noradrenergic products. All are to be used in conjunction with a reduced-calorie diet, exercise and behavior modification. Pharmacotherapy should be reserved for patients with a BMI greater than 30 or a BMI greater than 27 with at least one cardiac risk factor (high blood pressure, high cholesterol, diabetes). Types of Medications for Weight-loss Noradregenics: Phentermine is the most commonly prescribed amphetamine-like medication for weight-loss. Phentermine is only approved for short-term use (less than 12 weeks) in adults; at that point the majority of the patients may have developed a tolerance for the drug and it is no longer as effective. This class of medications are mild stimulants that suppress appetite by altering chemical signals in the brain. Common side effects include jitteriness, dry mouth, constipation, elevated blood pressure and increased pulse rate. It should not be used in people with a history of heart disease, uncontrolled high blood pressure, seizures, or anxiety disorders. Sibutramine: Sibutramine has been FDA approved for adults since 1999 for weight-loss and maintenance of weight-loss. It also works with brain chemicals (serotonin and norepinephrine) to help patients feel full quicker and decrease cravings for food. Patients with poorly-controlled blood pressure, heart disease, arrhythmias, heart failure and stroke should not use sibutramine. Medications may interact with sibutamine including many antidepressants, pain medications, some antibiotics and herbal remedies. It is important that the patient tells his or her provider all medications they are taking, including over-the-counter medication and supplements. Orlistat: In 1998, orlistat was FDA approved for weight-loss in adults and the next year was approved in teens (ages 12 and older). Orlistat is the first non-centrally acting medication that works by decreasing the absorption of fat from the intestines. Orlistat “blocks” approximately 1/3 of fat from the food eaten. Overall, Orlistat is a safe medication. It interacts with few medications (caution with warfarin and cyclosporine) and can be used in most every patient. Patients should be advised to take a multivitamin with chronic use of orlistat due to a potential decreased absorption of fat-soluble vitamins. Side effects of orlistat include diarrhea, gas, oily stools and fecal incontinence. These side effects lessen over time and can be avoided by following a low-fat diet. Weight Maintenance: Many people can follow a diet and lose weight, the challenge, however, comes in maintaining the weight-loss. Any changes in eating and exercising behaviors must become habitual, which takes time. Most programs offer monthly visits that provide behavior modification help (strategies to help change habits) that encompass things such as: record keeping; eating behavior and associated activities; eating slowly; portion control; vitamins, minerals, fiber and water; enhancing exercise; attitudes, self-esteem and quality of life; and holiday and stress eating. Realistic Expectations: Unrealistic goals of a comprehensive weight management program often result in failure. This methood should not be expected to achieve “ideal” body weight, often set as a measure of success. A modest weight-loss can offer profound benefit in preventing or delaying the onset of co-morbid medical problems and should be viewed as a success. This realistic goal of a 10 to 15 percent weight-loss from initial weight will keep one focused, as well as improve their quality of life and help manage any obesity co-morbid medical problems.
|
