Obesity and Sedentary Lifestyle Guidelines

Obesity and sedentary lifestyle are escalating national and global epidemics that warrant increased attention by physicians. Manson and colleagues issue a call to action for physicians and provide guidelines directed at the pivotal role of physicians in the prevention and management of obesity. “The Escalating Pandemics of Obesity and Sedentary Lifestyle: A Call to Action for Clinicians” appears in the February 9, 2004 issue of Annals of Internal Medicine and is available online athttp://archinte.ama-assn.org/cgi/reprint/164/3/249.

Physicians can play a key role in combating the epidemics of excess weight and physical inactivity. They clearly have access; the average American makes three office visits per year, and 60 percent of office visits are made to primary care physicians. Their advice is usually sought out and respected, and there is evidence that physician advice can motivate patients to change unhealthy behaviors. Yet, physicians generally do not capitalize on these opportunities. In fact, many physicians do not routinely assess weight and physical activity or offer advice on these factors.

Research has shown that those patients who received advice to lose weight were significantly more likely to try losing weight than those who did not receive such advice. Rates of counseling about physical activity may be even lower. Only 34 percent of adults who had seen a physician in the prior year reported being counseled about physical activity at their last physician visit.

The low rates of physician counseling generally are attributed to lack of training, lack of time for counseling in practice settings, a dearth of appropriate patient education materials, and little or no reimbursement. Although full-scale counseling about weight loss and physical activity would be ideal for patients who need it, a simple, direct acknowledgment of the problem and straightforward suggestions for remedies are excellent starting points that require little training.

A strategy based on the National Heart, Lung, and Blood Institute’s guidelines on obesity and the surgeon general’s reports on physical activity and obesity offers physicians an easily adapted blueprint for incorporating information about weight and physical activity into their discussions with patients, and includes the following:

• At each visit, measure the patient’s weight and height, and calculate his or her body mass index (BMI). If the BMI is 25 or more, measure the waist circumference; assessing the waist-hip ratio provides little additional advantage and is appreciably more difficult and time consuming. If the BMI and waist circumference are within the healthy range (BMI less than 25 and waist circumference less than 40 in [102 cm] for men and less than 35 in [89 cm] for women), congratulate the patient and offer encouragement about the importance of maintaining a healthy weight. If the patient’s BMI is not in the healthy range, describing the health risks of excess weight may help motivate him or her to begin losing weight. A BMI of 30 or higher doubles the risks of coronary heart disease and premature mortality, and more than triples the risk of developing type 2 diabetes.

• If the patient is receptive to losing weight, set a target of 5 to 10 percent below baseline weight at a rate of 0.22 to 0.9 kg (0.5 to 2 lb) lost per week. This amount of weight loss generally can be accomplished with an energy deficit of 500 to 1,000 kcal per day that is best achieved by restricting intake through smaller portion sizes, minimizing snacks and desserts, replacing high-fat and high-calorie foods with low-fat and low-calorie choices, and increasing physical activity. Strength training should be recommended as an integral part of increased physical activity because the associated increase in resting metabolic rate may contribute to weight loss.

• A patient with a starting BMI of 30 or higher (or BMI of 27 or higher with comorbidities) whose weight does not respond to a lower calorie diet and increased physical activity after six months may be a candidate for pharmacotherapy.

• Bariatric surgery may be an option for psychologically stable, severely obese patients (BMI of 40 or higher) or those with a BMI of 35 or higher with comorbidities when concerted efforts of lifestyle modification and pharmacotherapy have failed. Bariatric surgery has been shown to have salutary effects on obesity-related diabetes, hypertension, lipid profiles, and quality of life. Comorbidities such as hypertension and hyperlipidemia should be managed intensively.

• For sedentary patients, a comment such as, “It must be hard to stay physically active with all the time you need to spend at a desk job,” may open the door to a discussion about exercise. A description of the current guidelines promoting 30 minutes of moderate-intensity activities on most days of the week could dispel the notion that exercise must be a hard, sweaty chore that must be crammed into already busy days. Something as simple as writing a prescription for exercise (walk briskly at least five days a week, covering a mile in 15 to 20 minutes) demonstrates to the patient the importance of physical activity.

• Reminding the patient that the goal is to accumulate 30 minutes of physical activity a day opens up possibilities for exercise that extend beyond a long stint on a treadmill, such as taking the stairs whenever possible or getting off the bus a stop early and walking the rest of the way to work. The use of a pedometer also can help. The feedback provided by simple self-monitoring strategies such as this may help encourage daily activity. A reasonable long-term goal is 10,000 steps per day.

• Recent guidelines from the Institute of Medicine suggest that 60 minutes per day of moderate or vigorous physical activity may be needed for weight loss and optimal health. However, similar benefits may be achieved with 30 minutes of activity per day and a reduced caloric intake.

FDA Advisory on Antidepressants

The U.S. Food and Drug Administration (FDA) has issued a Public Health Advisory that provides further cautions to physicians, their patients, and families and caregivers of patients about the need to closely monitor adults and children with depression, especially at the beginning of pharmacotherapy, or when the doses of antidepressants are changed with an increase or decrease in the dose. The Public Health Advisory containing new label warnings and cautions is available online at:http://www.fda.gov/cder/drug/antidepressants/default.htm.

The FDA has been closely reviewing the results of antidepressant studies in children since June 2003, after an initial report on studies with paroxetine (Paxil), and subsequent reports on studies of other drugs, appeared to suggest an increased risk of suicidal thoughts and actions in the children given antidepressants. There were no suicides reported in any of the trials. On close examination of the initial reports, it was unclear whether certain behaviors reported in these studies represented actual suicide attempts, or other self-injurious behavior that was not suicide-related.

The FDA has initiated a full review of these reported behaviors by experts in such evaluation. However, it is not yet clear whether antidepressants contribute to the emergence of suicidal thinking and behavior. The agency is advising physicians, patients, families, and caregivers of adults and children that they should closely monitor all patients being placed on therapy with these drugs for worsening depression and suicidal thinking, which can occur during the early period of treatment. The agency also is advising that these patients be observed for certain behaviors that are known to be associated with these drugs, such as anxiety, agitation, panic attacks, insomnia, irritability, hostility, impulsivity, akathisia (severe restlessness), hypomania, and mania, and that physicians be particularly vigilant of patients who may have bipolar disorder.

The drugs under review include bupropion (Wellbutrin), citalopram (Celexa), fluoxetine (Prozac), fluvoxamine (Luvox), mirtazapine (Remeron), nefazodone (Serzone), paroxetine (Paxil), sertraline (Zoloft), escitalopram (Lexapro), and venlafaxine (Effexor). The only drug that has received approval for use in children with major depressive disorder is fluoxetine. Several of these drugs are approved for the treatment of obsessive-compulsive disorder in pediatric patients (i.e., sertraline, fluoxetine, and fluvoxamine). Fluvoxamine is not approved as an antidepressant in the United States.