- CONDITION CENTERS
With more than 6 of every 10 American men and women overweight or obese,1 incorporating counseling on dietary indiscretion and physical inactivity into most health care visits might help stem the approximately 300,000 deaths that obesity causes annually.2 Yet, how many health care providers actually discuss obesity, or help the 85% of patients who do not exercise enough or are sedentary3 take constructive steps toward weight loss? If the constant increase in the number of overweight Americans is any indication,4 few are doing so. In reality, health care professionals advise only 34% to 42% of obese adults to lose weight.5-7
Often, clinicians perceive that patients find this issue sensitive and intrusive; become frustrated because many patients cannot or do not lose weight; believe that weight loss is a patient responsibility; or feel unprepared to address nutrition and exercise. With prescription- strength and OTC weight-loss agents now available, pharmacists may need to hone their counseling skills with respect to obesity.
The consequences of obesity?a condition that results from a chronic energy intake/energy expenditure imbalance8? are well-known. Energy-dense foods and technology that makes tasks effortless have skewed that balance toward greater intake and less energy expenditure, creating a nation of heavier people.9 Table 1 lists basic facts about obesity that health care professionals who counsel overweight or obese patients should know.
The pharmacist?s best opportunity to counsel patients about obesity is when they present with conditions known to be associated with obesity or when they pick up obesity-management drugs. During counseling, pharmacists need to look for chances to raise the issue of weight or, if the patient mentions weight, to ease into the subject respectfully and nonjudgmentally.
Sometimes, cloaking counseling as curiosity allows the patient to elaborate. Asking, ?Just out of curiosity, what prompted you to consider [or have you considered] weight loss?? might start a conversation. It is crucial also to believe that patients are capable of changing their behaviors and to listen carefully.14
Motivational, tolerant interviewing is designed to help patients move through the stages of change more rapidly than if they were left to their own devices. It provides support and encouragement. It discourages apathy and uses open-ended questions to help patients see where they are and lead them to where they need to be. This confrontation is not argumentative or coercive.15 Asking, ?How do you think your current weight affects your health?? lets patients verbalize their own observations. It recognizes that the decision to change is the patient?s.
Resistance is normal. Should patients assume that an obesity-management drug makes exercise optional, they may be resistant to suggestions concerning exercise. Asking, ?What did the prescriber tell you about diet and exercise?? will let the patient review information. It also will identify information gaps, presenting an opportunity to provide additional education.14 Ultimately, motivational interviewing focuses on building self-efficacy in a way that incorporates an individual?s readiness to make a change.15
Weight-loss drugs may sound like magic, but they should be reserved for people with weight-related health problems who are willing to adhere to a healthy diet and regular exercise. The best candidates for these drugs have the following characteristics:
Combining medication, calorie restriction, and increased activity can result in a weight loss of 5% to 10% of weight within a year. Although this amount may seem small, modest weight loss often decreases blood pressure, serum lipids, and insulin levels.16
Counseling the patient who presents a prescription for an obesity-management drug should emphasize that these drugs must be used with a change in eating habits and an increase in activity. All currently approved prescription weight-loss drugs work by suppressing the appetite, except orlistat. Orlistat, a lipase inhibitor that decreases dietary fat absorption by 30%, limits the number of calories available to the body. Its common side effects are cramping, diarrhea, flatulence, intestinal discomfort, and leakage of oily stool. Alli, the OTC half-strength version of prescription orlistat, has been approved by the FDA.16
Sibutramine increases the levels of certain neurotransmitters to reduce appetite. Hypertension and increased heart rate are possible side effects, so sibutramine is contraindicated in patients with uncontrolled hypertension, a history of heart disease, congestive heart failure, irregular heartbeat, or stroke. Other common side effects include headache, dry mouth, constipation, and insomnia.16
The older obesity-management drugs were approved based on very short-term, limited data. Phendimetrazine, methamphetamine, and phentermine should not be used by people with heart disease, hypertension, hyperthyroidism, or glaucoma. These drugs are approved for short-term use only. They have potential for physical dependence or addiction.16
Pharmacists also should remember that some prescription drugs are associated with weight gain. Table 2 lists several of these drugs. In the event that a patient taking 1 of these drugs complains of weight gain or difficulty losing weight, nutritional counseling can help. Additionally, consultation with the prescriber about possible alternatives might be in order, especially if the weight gain is contributing to nonadherence.17
Patients who struggle with their weight need considerable support and guidance. If weight control were just simple mathematics (calories in < calories used), everyone would be thin. Pharmacists should get serious about counseling patients who are overweight or obese and should develop an armamentarium of tools patients can use. Two good tools are as follows:
1. Mokdad AH, Serdula MK, Dietz WH, Bowman BA, Marks JS, Koplan JP. The spread of the obesity epidemic in the United States, 1991-1998. JAMA. 1999;282:1519-1522.
2. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA. 1993;270:2207-2212.
3. Physical activity and health: a report of the Surgeon General. Atlanta, Ga.: US Dept of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 1996.
4. Prevalence of overweight among adolescents?United States, 1988-91. MMWR Morb Mortal Wkly Rep. 1994;43:818-821.
5. Galuska DA, Will JC, Serdula MK, Ford ES. Are health care professionals advising obese patients to lose weight? JAMA. 1999;282:1576-1578.
6. Stafford RS, Farhat JH, Misra B, Schoenfeld DA. National patterns of physician activities related to obesity management. Arch Fam Med. 2000;9:631-638.
7. Wee CC, McCarthy EP, Davis RB, Phillips RS. Physician counseling about exercise. JAMA. 1999;282:1583-1588.
8. National Institutes of Health Technology Assessment Conference Statement: methods for voluntary weight loss and control, March 30-April 1, 1992. Nutr Rev. 1992;50:340-345.
9. Hill JO, Melanson EL. Overview of the determinants of overweight and obesity: current evidence and research issues. Med Sci Sports Exerc. 1999;31(11 suppl):S515-S21.
10. King AC, Tribble DL. The role of exercise in weight regulation in nonathletes. Sports Med.1991;11:331-349.
11. Garrow JS, Summerbell CD. Meta-analysis: effect of exercise, with or without dieting, on the body composition of overweight subjects. Eur J Clin Nutr. 1995;49:1-10.
12. Prochaska JO. Strong and weak principles for progressing from precontemplation to action on the basis of twelve problem behaviors. Health Psychol. 1994;13:47-51.
13. National Heart, Lung and Blood Institute. NHLBI Obesity Education Initiative. Available at: www.nhlbi.nih.gov/about/oei/index.htm. Accessed July 28, 2007.
14. Mengel MB, Holleman WL, Fields SA. Fundamentals of Clinical Practice. 2nd ed. New York, NY: Kluwer Academic Publishers; 2002.
15. Miller W, Rollnick S. Motivational Interviewing. New York, NY: Guilford Press; 2002.
16. Bray GA, Ryan DH. Drug treatment of the overweight patient. Gastroenterology. 2007;132:2239-2252.
17. Leslie WS, Hankey CR, Lean ME. Weight gain as an adverse effect of some commonly prescribed drugs: a systematic review. QJM. 2007;100:395-404.