Obesity: Diagnosis and Management

00:01 Obesity is considered a public health crisis in the United States and for good reasons.

00:07 So, today, we’re going to be discussing a little bit about the epidemiology of obesity as well as its definitions.

00:13 And then we’ll move quickly into the best dietary for obesity which is always a very controversial subject.

00:20 And there have been some new innovations, new medications are available for the treatment of obesity and the application of bariatric surgery has absolutely exploded in the United States over the past five years.

00:31 So, we’ll be talking about some of the pluses and minuses of those treatments as well.

00:38 So, just to start with a little bit of epidemiology.

00:41 Currently, over one-third of US adults are obese.

00:44 And after remaining steady for a number of years, about seven years, that percentage increased in the last measurement period between 2011 and 2014.

00:55 17% of children and adolescents have obesity.

00:59 That level increased a lot between 2000 and 2010 and has since leveled off a bit.

01:06 But one thing we do see and is very persistent is that African-Americans and Latinos have higher rates of obesity compared with white Americans.

01:17 And so, it's worthwhile just to think about the definition of obesity a little bit.

01:21 Underweight is less than 18.5 kg/m².

01:25 Normal weight, 18.5 to 25.

01:29 Overweight, 25 to 29.9.

01:32 And then, obese is 30 kg/m² or more.

01:35 Now, this is in itself a little bit controversial because that's applied to a general population in the United States.

01:43 There has been a push to maybe redefine these levels, maybe lower these thresholds, particularly for people of Asian descent.

01:54 So, that’s something to pay attention to and you may want to, depending on your practice, actually maybe change that application a little bit and those thresholds.

02:02 What about effects of diet? I think one of the more popular diets traditionally has been a low-fat diet, which can work to reduce body weight.

02:11 In clinical trials, the average reduction is about 5 kg.

02:15 That’s something significant.

02:16 Or 11 pounds.

02:17 However, a low carbohydrate diet in systematic reviews is generally more effective than low-fat diet alone.

02:24 So there, you can achieve an average body weight reduction of about 7 kg.

02:31 So, there’s more of a benefit.

02:32 And overall – and this is something that’s surprising to many patients and clinicians too.

02:37 Dietary fat really doesn't have a large effect on weight loss.

02:41 It’s really about carbohydrates and the concentrated calories that come in processed carbohydrates and sugar sweetened beverages.

02:51 Those are the key targets in improving body weight.

02:55 And I think that in counseling patients about their body weight, which I do all the time, do understand that diet is a very personal issue.

03:03 It has emotional attachments and cultural attachments beyond just being something you do to maintain your energy and promoting whatever bodyweight you have.

03:15 So, you have to respect that from your patient's perspective before you start counseling.

03:19 And that's why I always begin with the patient's values and opportunities.

03:23 There's something in there that they don't really care about, maybe it’s sugar sweetened beverages, maybe it's some sweets that they’re eating or maybe it's going to fast food three times a week that they want to break that habit anyway, start with that.

03:37 Start with using your patient's motivations and find some opportunities to make small changes.

03:44 There are patients out there who can go on a fasting diet and eat zero carbohydrates for a few weeks.

03:52 And really, their weight will improve dramatically and then they can stick to something beyond that.

03:58 That’s a highly-motivated patient who is a little bit more advanced.

04:01 I find that that patient is in the minority in my practice, a very small minority.

04:07 Instead, I try to capitalize on the small opportunities, take the stuff that the patient really doesn't care about eating too much or drinking too much, and start with that.

04:16 Eliminate that.

04:17 Replace it with a healthy habit and try to always promote this positively, like this is – instead of drinking this sugar sweetened beverage, try some extra water.

04:27 It will hydrate you and make you feel better, plus you are spending less money, for example.

04:31 And so, really try to get back behind the patient's values and be positive.

04:38 This a great opportunity for team-based care.

04:42 It’s a lot more effective if I'm providing that information as well as well as a health coach and a dietitian and their family and the patient really believes in it too because they’re always at the center of the patient care team.

04:55 And don't forget about exercise.

04:57 Adding exercise to a nice easy-to-tolerate diet like a Mediterranean diet or a low carbohydrate diet is going to result in probably three extra kilograms of weight loss as well.

05:10 When you start to put that together, 10 kg – 10, 12 kg of weight loss, that's going to start to make a difference in things like diabetes and hypertension.