Given the prevalence of overweight and obesity and their associated health conditions, clinicians will be increasingly tasked with the responsibility of addressing overweight and obesity. This article reviews the 5As approach—assess, advise, agree, assist, arrange—and how clinicians can use the approach facilitate weight management discussions with their patients that met the recommendations provided in the 2013 adult weight management guidelines issued by the American Heart Association/American College of Cardiology/The Obesity Society.
Key points
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Clinicians should use an evidenced-based strategy like the 5As—assess, advise, agree, assist, arrange—to facilitate weight management counseling with their patients.
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Initial weight loss goal should be a 3% to 5% loss over a 3- to 6-month period through engaging in a high-intensity, comprehensive lifestyle change program that includes a moderately reduced calorie diet, increased physical activity, and behavioral strategies.
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Referral to locally available evidence-based weight loss programs should be considered, including the National Diabetes Prevention Program or commercial weight-loss programs like Weight Watchers or Jenny Craig.
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Continued follow-up and surveillance after weight loss are critical for weight loss maintenance.
Introduction
Approximately two-thirds of US adults are overweight or obese. Elevated body weight has been associated with increased risk of cardiovascular disease, type 2 diabetes mellitus, kidney disease, and certain cancers ; however, losing weight can prevent or improve control of some obesity-related chronic conditions. The US Preventive Services Task Force recommends high-intensity counseling interventions for individuals with obesity that include nutrition, physical activity, self-monitoring, goal setting, and group or individuals sessions. In 2013, the American Heart Association, American College of Cardiology and The Obesity Society (AHA/ACC/TOS) released evidenced-based guidelines for the management of obesity among adults. In this article, the clinicians’ roles in weight management are discussed, particularly how to implement these guidelines and other recent advancements in dietary and behavioral approaches into clinical practice.
Introduction
Approximately two-thirds of US adults are overweight or obese. Elevated body weight has been associated with increased risk of cardiovascular disease, type 2 diabetes mellitus, kidney disease, and certain cancers ; however, losing weight can prevent or improve control of some obesity-related chronic conditions. The US Preventive Services Task Force recommends high-intensity counseling interventions for individuals with obesity that include nutrition, physical activity, self-monitoring, goal setting, and group or individuals sessions. In 2013, the American Heart Association, American College of Cardiology and The Obesity Society (AHA/ACC/TOS) released evidenced-based guidelines for the management of obesity among adults. In this article, the clinicians’ roles in weight management are discussed, particularly how to implement these guidelines and other recent advancements in dietary and behavioral approaches into clinical practice.
The Clinician’s role in weight management
Clinicians may assume a variety of roles in the management of obesity, varying based on their interest, education/training, and time. Prior studies of physicians have often cited a lack of training or experience regarding weight management as a major barrier to counseling their patients. Clinicians who did not receive adequate training on obesity might consider continuing medical education in this area if they plan to take a leading role in weight management. For physicians who plan to dedicate significant clinical effort in this area, certification through the American Board of Obesity Medicine ( http://www.abom.org/ ) or other entity might be considered. Lack of time is another common barrier to weight management. Clinicians should also be aware that the recommended intensity of follow-up may require at least monthly visits with patients, if not more frequently. If adequate follow-up for patients cannot be accommodated, then referral to such programs that meet this requirement should be considered. Although some physicians have reported avoiding weight loss discussions for fear of offending their patients, evidence supports the clinician’s role in referring patients into programs, providing accountability for patients, acting to cheerlead for patients during follow-up visits, and maintaining the long-term trusting relationship through the ups and downs of weight loss.
Three key aspects—interest, training, and time—may influence the decision of whether a clinician might take a leading role in weight management or prefer the job of identifying and referring patients to appropriate weight management programs ( Box 1 ). Regardless of whether the clinician decides to take an active or passive role, prior studies have documented the benefits of health care provider engagement in weight management. In a randomized controlled trial of a weight loss intervention in which clinicians referred their patients to the program, patients who rated their physicians as more helpful lost significantly more weight than those who did not rate their physicians highly. When clinicians discuss weight loss without communicating judgment, patients are more likely to achieve a clinically significant weight loss.
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Am I interested in counseling patients on diet, physical activity, and behavior change to lose weight?
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Have I had enough training where I feel comfortable and confident taking a lifestyle history and working collaboratively with patients to devise an evidence-based action plan?
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Do I have enough time available in my panel to accommodate frequent follow-up visits with patients every 2 to 4 weeks?
Weight management in clinical practice
Clinicians’ key duties involve identifying appropriate patients for referral, determining the weight management strategy, and following up on patients’ progress. Regardless of whether the clinician takes an active or passive role, using an evidence-based behavior change strategy, such as the 5As, assess, advise, agree, assist, arrange ( Box 2 ), can help guide assessment and counseling. Conversations that use the 5As have been associated with increased motivation to lose weight and greater patient weight loss success.
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Assess
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Advise
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Agree
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Assist
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Arrange
Identifying Appropriate Patients for Weight Management—Assess
In order to identify appropriate patients for weight management, clinicians should determine the individual’s degree of obesity, cardiovascular and other risk factors, and his or her readiness to change. This is the first step in the 5As approach, assess.
Obesity should be assessed by body mass index (BMI), which reflects an individual’s degree of adiposity. BMI is typically an accurate approximation of adiposity, although this measure may be inaccurate for elite athletes with substantial muscle mass. BMI is often calculated automatically in electronic health records ( Box 3 ). The US National Institutes of Health have classified BMI into 6 categories based upon the values-associated risks of death, diabetes, hypertension, and atherosclerotic coronary heart disease ( Table 1 ). All classes of obesity are linked with high cardiovascular disease risk (BMI ≥30 kg/m 2 ) and should be target for weight management. For patients with overweight, all may be eligible for weight management services; however, those patients who have other risk factors should be particularly targeted.
| Category | BMI (kg/m 2 ) | Eligible for Weight Management? |
|---|---|---|
| Underweight | <18.5 | No |
| Normal weight | 18.5–24.9 | No |
| Overweight | 25.0–29.9 |
|
| Class I obesity | 30.0–34.9 | Yes |
| Class II obesity | 35.0–39.9 | Yes |
| Class III obesity | ≥40.0 | Yes |
If the patient meets criteria for weight management based on BMI and risk factors, then the clinician and patient should agree that weight loss is appropriate. Clinicians should assess whether the patient is ready to make the changes necessary to succeed at losing weight. If a patient does not currently have time available to dedicate to lifestyle, or if other issues are greater competing priorities, then deferring weight loss for another time is appropriate.
Educating About Health Risks and Benefits of Change—Advise
The second step in the 5As approach is advise, which gives the clinician the opportunity to educate the patient about his or her weight and the health risks linked with overweight and obesity. At minimum, patients should be advised that the greater the BMI, the greater the risk of cardiovascular disease, type 2 diabetes, and death. Weight loss can reduce blood pressure, improve cholesterol profile and blood sugar, and decrease risk of developing diabetes. However, clinicians should be aware that weight loss through lifestyle changes has not led to decreased cardiovascular events.
Overweight and obesity have been linked to certain gastroenterological conditions such as gastroesophageal reflux disease (GERD) and nonalcoholic fatty liver disease (NAFLD). Weight loss has been shown to improve these conditions. Other gastroenterological conditions linked with obesity are described in other articles in this issue.
Collaborating to Establish Weight Management Goals—Agree
The third step in the 5As process is agree, in which the patient and clinician agree upon goals. It is critical for clinicians to help their patients set goals that are quantifiable, achievable, and likely to lead to meaningful health benefits (eg, a goal of losing 5% of an individual’s starting weight over the next 6 months to lower blood sugar and prevent the development of diabetes). The 2013 AHA/ACC/TOS guidelines suggest appropriate goals and health benefits that can be expected with certain weight losses ( Box 4 ).
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