When Marijane Hynes, MD, ACP Member, first became interested in counseling obese patients, her bosses let her start by allocating four hours a week to the undertaking. In 2009, her institution opened a full-time weight loss clinic. Today, it's a fully staffed, multidisciplinary clinic including physical therapists, dieticians, and even medical students.
Weight loss used to be an unappealing specialization, she recalled. “I used to be this boring person to work with,” joked Dr. Hynes, who is an associate clinical professor of medicine at The George Washington University School of Medicine in Washington, D.C.
Now, “Nutrition is exciting,” she said during her talk, “Nutrition and the Gut: You Are What You Eat,” at Internal Medicine Meeting 2017.
In the following video, Dr. Hynes discusses widespread interest among internists in obesity counseling.
Who's at risk?
To explain the rise of obesity, consider the near-ubiquity of its risk factors, Dr. Hynes said:
Minority race. Not only does obesity prevalence vary by race, but the way it affects health differs. For example, Dr. Hynes said Asians are considered obese when their body mass index (BMI) reaches 27 to 28 kg/m2, not the usual cutoff of 30 kg/m2. And the waist circumference cutoff, usually 35 inches for women and 40 for men, is lower for Asian patients, too (35 inches in men and 32 inches for women). Waist circumference is important when considering risks such as cardiovascular disease, diabetes, and cancer.
Female sex, lower education, and less money. Obesity is particularly common among women who have not finished college. Dr. Hynes also observed that obese women are less likely to be promoted, furthering the cycle of lower incomes.
Medications. Weight gain can result from atypical antipsychotics, selective serotonin reuptake inhibitors, and antihistamines.
Sleep. “We're a nation of short sleepers,” Dr. Hynes said. People who sleep five hours or less a night are prone to eating 500 more calories a day than people who sleep more than that. Women are especially likely not to sleep enough. “They have their kids in bed with them, their pets. You've really got to work on about 7 to 7.5 hours,” she said.
Stress and mental illness. These factors often coincide with disordered sleep, Dr. Hynes said. About two years ago, her clinic began online counseling with patients about stress. They benefited from just two to three sessions. “A lot of people eat because they are really stressed. Others eat because they are bored. We really try to talk to them about how to decrease boredom.”
Eating out. “I can't tell you how many patients think that if they eat in a restaurant that is not a fast-food restaurant that they are getting healthy food,” she said. But some of those servings can be 1,400 to 1,500 calories per plate. “So you really have to sit down with your patients and talk to them. Tell them to stop eating out so much.”
Sedentary lifestyle. Many of her patients can't lose weight because of their jobs. “I'm on the computer half the day, too. So you've got to move,” she said. Dr. Hynes asks patients to set a timer to remind them to move around for five minutes out of every hour and for 15 minutes at lunch. “Everybody can do that.”
More simple tips
A few other simple tips, which every internist can implement, can go a long way toward treating obesity, said Dr. Hynes.
Obesity counseling can result in life-changing outcomes, Dr. Hynes explains in the following video.
Her first pearl is that patients should increase their intake of fruits and non-starchy vegetables, soluble fiber, whole grains, and water.
In addition to learning about nutrition, patients should have a strategy for self-monitoring. Dr. Hynes recommends apps such as MyFitnessPal and Lose It! Another app, Fitness Blender, teaches patients to exercise at their desks.
Daily weigh-ins are optimal, but weekly is acceptable too. If patients can't weigh themselves that often, then at least monthly weigh-ins are in order.
Work with patients to individualize the plan. “Everybody gets to the obese road a different way,” she said. “I have had people who have been in car accidents. They couldn't walk for a few years. Postpartum depression. The list goes on and on.”
Some patients may have gained weight as a result of sexual abuse in the past. If patients need psychiatric care, they are never going to lose weight without it, she said. Her clinic offers free initial visits with psychiatric fellows and then connects patients with affordable mental health treatment.
Lose weight, then exercise
In the beginning, Dr. Hynes advised, patients trying to lose weight should work on diet. “Losing weight is from the diet,” Dr. Hynes explained. “After you lose the weight, it's a lot about the exercise, but on the way down, it's mostly about what you put in your mouth.”
Patients should have a dietary goal of reducing their calorie consumption by 500 calories per day. Meal replacement plans using nutritional supplements, either as nutritional drinks or bars, work. The more meals that are replaced, the more such replacements work, Dr. Hynes said.
“I know it's processed food, but it teaches people how to eat less. Any frozen dinner that's about 300 calories [is good],” she said. “[Meal replacement] drinks, also, are helpful instead of skipping meals or as a meal replacement.”
A rule of thumb is to multiply a patient's current weight by 10 to determine how many calories per day the person should consume to maintain that weight. So, a 200-pound patient needs about 2,000 calories per day to maintain. To lose weight, decrease by 500 calories a day. That, times seven days, is 3,500 calories, which equals a caloric weight loss of one pound per week.
An approximate algorithm is that patients who weigh more than 250 pounds should be on 1,700-calorie-a-day diet. Those who are 200 pounds should be on 1,500-calorie-a-day diets. Those who weigh 170 pounds or less should be on 1,200-calorie-a-day diets.
It's important, she added, to avoid factoring in the calories expended when patients exercise. “If you walk a mile, you can't have a ham sandwich,” she said.
When patients lose weight, the base metabolic rate drops, so decrease daily calories by about 150 calories for every 10% of weight lost, she advised.
Once patients lose weight, they can focus on exercise to maintain the loss. Dr. Hynes said she has a low threshold for recommending physical therapy to get patients moving. “It's covered by most insurances, and it can really change people's lives,” she said. Aquatherapy is useful, as are walking plans for people who have knee pain or who haven't been active for a long time. Lidocaine patches or diclofenac topical gel applied pre-exercise can help with this as well.
Behavioral changes require monitoring, monitoring, and more monitoring, Dr. Hynes said. Ask patients who can help them in the home. But be cautious of the “food police.” Family members should not consider the patient “cheating” if they eat poorly. “It's not adultery,” she said.
Also, keeping patients in the pipeline of regular doctor visits is important, according to Dr. Hynes. “Textbooks say patients should come in every week. My patients don't have that kind of money or time. We have found in our clinic as long as they come once a month on a regular basis, we can work with them.”
While losing weight, more visits are better, but even one visit a month can help. Once weight is lost, a check-in visit every two or three months helps keep the weight off, she said.
Dr. Hynes said she prescribes metformin if a patient has prediabetes, but she doesn't recommend other weight-loss drugs in the first three months of seeing a new patient. After that, she will add medical therapy, especially for women, who have a harder time losing weight than men.
There are currently five weight-loss drugs on the market. Dr. Hynes has found the combination of topiramate and phentermine to work best, even though it has more side effects, and cannot be used in women who desire pregnancy. She uses 15 mg of phentermine and 50 mg of topiramate. Bupropion and naltrexone are useful for people who have comorbid conditions such as nicotine dependence or depression. Liraglutide is effective at high doses, but it can be expensive, costing $700 a month in the Washington, D.C., area, Dr. Hynes said.