Obesity Expert Advises on Helping Psychiatric Patients Manage Obesity

The prevalence of obesity has significantly increased in the past 25 years, and now affects 40% of Americans, including nearly 10% who have “extreme obesity,” defined as a body mass index (BMI) of 40 and above, Gudzune said. Yet she noted that fewer than half of individuals with obesity receive weight-loss counseling from their primary care physicians.

Research has also shown that physicians engage in less rapport-building with obese patients and are less likely to perform certain physical exams on obese patients, such as pap smears. “Weight bias is incredibly prevalent in our society, and that is also true in the medical setting,” Gudzune said.

“Obesity is a chronic, relapsing, progressive disease, so it’s not enough to just tell people to eat less and move more,” she said. “How we as clinicians communicate with our patients about obesity really matters.”

Two effective techniques for clinician communication involve the use of motivational interviewing techniques and the “5As framework,” originally created to help people quit smoking. Both techniques are associated with increased patient confidence around making dietary changes and better results, Gudzune said.

The 5As framework for obesity involves the following: 1) Assess the patients’ condition. 2) Advise on the benefits of weight loss and the risks of obesity. 3) Agree on goals and strategies. 4) Assist with creating a treatment plan. 5) Arrange for follow-up to monitor goals and progress made.

Gudzune advised clinicians to use BMI for initial obesity screenings, and if patients screen positive, to use the Edmonton Obesity Staging System, which also factors in comorbidities, physical and psychological symptoms, functional limitations, and quality of life. The tool also helps determine the intensity of services that a patient needs.

Gudzune said it is important to have realistic expectations when considering treatment options. Patients treated with a multicomponent lifestyle intervention that addresses nutrition, physical activity, and behavior change typically lose between 2% and 8% of baseline weight. Whether in person or virtual, key components of such programs include multidisciplinary teams with mental health and other clinicians, frequent clinician-patient contact, and accommodation of patient preferences.

Individuals who need to lose 10% or 20% of their weight, such as those with cardiometabolic disorders, may need anti-obesity medications to do so. “Are there examples of patients who successfully lose 20% of their body weight with exercise and dietary changes alone?” Gudzone said. “Yes, but those are the exceptions, not the rule. We need to be thinking about matching our treatments with the goals.”

Gudzune reviewed meta-analytic data showing average weight losses for the following medications, as well as the results of trials involving individuals with serious mental illness (SMI) when available:

Gudzune noted that metabolic-bariatric surgery results in the best weight loss, averaging 25% to 40%. Sometimes patients are not ready to consider such higher-level interventions, she added, “so it is important to meet patients where they are.” ■