Obesity Management Recommendations

Reducing Weight Bias in Obesity Management

Healthcare providers should identify and assess how their attitudes affect care delivery (Wharton et al., 2020). (Level 1a, Grade A). Obesity biases affect behavioral and health outcomes and must be avoided (Breen et al., 2022). This may be avoided by;

1. Increasing Awareness and Self-Reflection through Training. (Level 1a, Grade A)
2. Cultivating Empathy and Compassion while being social with patients. (Level 1a, Grade A)
3. Adopting Patient-Centered Approaches. (Level 1a, Grade A)
4. Offering a range of treatment options available. (Level 2a Grade B)
5. Providing Culturally Competent Care. (Level 2a Grade B)

Lifestyle Modifications

Physical Activity in Obesity Management

Physical exercise improves cardiovascular and mood, reduces visceral fat, and improves mental health (Breen et al., 2022).

1. Engaging in 30-60 minutes of intense aerobic physical activity. (Level 2a, Grade B)
2. Establish resistance training for obese individuals. (Level 2a, Grade B)

Resistance training promotes weight maintenance or modest increases in muscle or fat-free mass and mobility (Level 2a, Grade B).

Increasing exercise intensity and high-intensity interval training increases cardiorespiratory fitness and reduces the time required for similar benefits to moderate-intensity aerobic activity (Level 2a, Grade B).

Regular physical activity

• Improve cardiometabolic risk factors, including hyperglycemia and insulin sensitivity (Level 2b, Grade B), high blood pressure (Level 1a, Grade B), and dyslipidemia (Level 2a, Grade B),
• improves health-related quality of life, mood disorders (depression and anxiety), and body image.

Nutrition and Dieting in Obesity Management

Human diet and lifestyle contribute significantly to obesity, and healthcare providers must advise on the proper diet based on an individual’s daily activity and weight (Obesity Control Program, 2022).

1. Offering a diet plan from a dietician after evaluating the patient’s vitals. (level 4, grade D)
2. Increased consumption of plant vegetables and reduced intake of carbohydrates, proteins, and fats. (Level 2b, Grade B)
3. Nutrition recommendations for adults of all body sizes should be personalized to meet individual values, preferences, and treatment goals (Level 4, grade D)
4.  individualized medical nutrition therapy from a registered dietitian to improve weight outcomes, waist circumference, glycemic control, and established lipid and blood pressure targets (Level 1a, grade A)
5. Adults with obesity and impaired glucose tolerance (prediabetes) or type 2 diabetes
   1. may receive medical nutrition therapy from a registered dietitian to reduce body weight and waist circumference and improve glycemic control and blood pressure. (Level 2a, grade B)
   2. consider intensive behavioural interventions targeting a 5%–7% weight loss; reduce the incidence of type 2 diabetes, microvascular complications, and cardiovascular and all-cause mortality (Level 1a, grade A).
6. Adults consider various medical nutrition therapies to improve health-related outcomes, choosing dietary patterns and food-based approaches that support long-term adherence.
7. Adults living with obesity and type 2 diabetes should consider intensive lifestyle interventions targeting a 7%–15% weight loss, increasing remission of type 2 diabetes, and reduce nephropathy, obstructive sleep apnea, and depression (Level 1a, grade A)
8. A non-dieting approach is recommended to improve quality of life, psychological outcomes, cardiovascular outcomes, body weight, physical activity, cognitive restraint, and eating behaviours.

Pharmacologic Interventions in Obesity Management

In some cases, obesity may be at the severe stages, and pharmacological approaches must be implemented for quick action (Wharton et al., 2020).

1. Administering 3 mg liraglutide (Level 2a, Grade B)
   1. for individuals with BMI ≥30 kg/m2 with adiposity-related complications in conjunction with medical nutrition therapy, physical activity, and psychological interventions
   2. to maintain weight loss achieved through health behaviour changes and prevent weight regain
   3. in conjunction with health behaviour changes for individuals with type 2 diabetes and a BMI ≥ 27 kg/m2 for weight loss and improvement in glycemic control
2. Health professionals may administer the drug alongside other behavior changes. (Level 1a, Grade A)
3. Prescription or over-the-counter medications other than those approved for weight management are not recommended (Level 4, grade D).
4. Individuals are advised to choose drugs not associated with weight gain.

Psychological and behavioural interventions in obesity management.

Multicomponent psychological interventions, i.e., behavioral modification, cognitive therapy (Breen et al., 2022) (level 1a, grade A)

Recommendations

• Provide CBT techniques to help individuals identify and modify dysfunctional thoughts, emotions, and behaviours related to food and physical activity (Obesity Control Program, 2020; Breen et al., 2022) (level 1a, grade A).
• Employ MI techniques to enhance motivation, increase self-efficacy, and support behaviour change (level 2, grade B).
• Encourage the practice of mindfulness to enhance self-awareness, reduce emotional eating, and promote healthier eating habits (level 2, grade C).

Addressing Underlying Psychological Factors

Emphasize the importance of addressing underlying psychological factors contributing to obesity, such as stress, emotional eating, and body image concerns.

Implement strategies to improve emotional well-being, coping mechanisms, and stress management.

Healthcare provides longitudinal care with consistent messaging (Breen et al., 2022) (level 1a grade A)

Supporting Behavior Change

Healthcare professionals ask for permission from patients to educate them on the importance of psychological entities and their impact on weight loss.

Recognize the challenges individuals face in adopting and maintaining healthy behaviours.

Provide support and guidance to help individuals set realistic goals, develop action plans, and overcome barriers to behaviour change. Provide follow-up sessions (level 1 grade A)

Bariatric Surgery in Obesity Management

The procedure is long-term and recommended for patients with a BMI ≥40 kg/m2 or BMI ≥35 kg/m, and a thorough evaluation must be done prior (Breen et al., 2022). (Level 4, Grade D)

It is recommended for 120% of the 95^th percentile of the above criterion of those with only certain significant comorbid conditions such as type 2 diabetes, idiopathic intracranial hypertension, and obstructive sleep apnoea, among others.

Preoperative conditions include intervention with the clinical dietitian as well as other disciplines, such as social work, as part of psychological interventions (Level 1, Grade D).

Common Bariatric surgery procedures

• Sleeve gastrectomy
  • This is a restrictive mode with an expected 60 to 70 percent weight loss one year after the surgery.
  • Hospital stay: under two days; recovery: up to two weeks

• Laparoscopic adjustable gastric banding
  • Restrictive; 40 to 50 % expected weight loss; hosptial stay: one day; recovery: one week
• Mini gastric bypass
  • Restrictive and malabsorptive; 70 to 80 % expected weight loss after a year; Hospital stay: 2-3 days; Recovery: 2-4 weeks
• Gastric bypass
  • Restrictive and malabsorptive; 70 to 80 % expected weight loss after two years; Hospital stay: up to 4 days; Recovery: up to 4 weeks

All the above have chronic complications of weight regain

Follow-up after surgery

• It depends on the acute and chronic complications associated with each different procedure.
• Keeping an eye on and treating comorbid conditions, such as psychological distress and suicide risk.
• Supporting behavioral change by referring people to psychological counseling or doing brief interventions
• Assessment of nutritional status inclusive of supplements such as vitamins
• Supporting sustained levels of physical activity and appropriate nutrition, such as through establishing an eating plan or offering a reference to a dietician
• Setting up re-evaluation and re-intervention as necessary (for instance, a bariatric physician’s regular examination of laparoscopic adjustable gastric bands is essential for re-evaluation of the stability and integrity of the prosthesis).
• Follow-up visits depend on the recommendation of the surgeon or GD and the severity of the complications that might arise but are recommended bi-weekly or tri-weekly for up to 12 weeks.

Management of complications

• Antibiotics and referral to surgeon debridement for wound infections observed from redness around incisions or foul smell, increased tenderness, or swelling of the wound
• Referral to a surgeon for anosomotic leak (tachycardia, fever, oliguria, worsening abdominal pain) and emergency referral for DVT (severe pain, swelling, and tenderness)
• Dietary modification of small regular meals containing protein and complex carbs and acarbose of refractory cases of dumping syndrome
• Depression-refer to psychologist
• Ringers lactate for a few days or treat with normal saline for nephrolithiasis.

Assessing Obesity 

BMI (normal 18-25) and waist circumference (risk for males>102, females > 88) in individuals are factors determining obesity (Breen et al., 2022) (level 2a, grade B). Healthcare professionals must ask, assess, advise, agree, and assist obese patients (Breen et al., 2022).

The Edmonton Obesity Staging System assists in tracking the condition (Breen et al., 2022). (Level 4, grade D)

Children: Preservation of Adolescent Weight

Teenage and Adult Weight Loss

A 5-10% BMI reduction in 6 months is considered successful for adults.

In adults with a BMI over 35, weight loss of 15-20% in 6 months is considered successful.

Determining Goals

Weight maintenance: sustaining a stable body weight within the normal BMI range (18-25)

Weight maintenance for prepubertal children & Weight Loss for post-pubertal children

Weight loss

• Post-pubertal children and adults with BMI 25-35 aim for a 5-10% BMI reduction in 6 months (Canadian class I, level B)
• Adults with BMI above 35 aim for a 15-20% BMI reduction in 6 months (Canadian class II, level B)
• BMI reduction: Guiding individuals towards achieving a lower BMI category (Canadian class II, level B)

Specific Targets for Different Age Groups and BMI Categories

• Prepubertal Children: Focus on weight maintenance and promoting healthy habits (Canadian class III, level C)
• Post-Pubertal Children and Adolescents: Aim for gradual and sustained weight loss (5-10% BMI reduction in 6 months) (Canadian class II, level B)
• Adults
  • Losing 5-10% of BMI in 6 months for adults with BMI 25-35 (level 4, grade D)
  • Losing more than 15-20 % of BMI in 6 months for adults with BMI above 35 (level 4, grade D)

Personalized Treatment Plans

• Focus on EU and WHO guidelines, i.e., individualized plans
• Recognize individual needs and circumstances in obesity management
• Develop personalized treatment plans based on factors such as medical history, lifestyle, cultural considerations, and personal preferences (Class III, level C)

Emerging Technologies and virtual medicine in obesity management

1. Healthcare providers need to provide education on web-based platforms to track the health record and prevent obesity. (Level 2a, grade B)
2. Healthcare providers should follow up on their patient’s status by contacting them. (Level 4, grade D)
3. Wearable tracking devices should be provided to patients to measure physical activity. (Level 1a, grade A)

Weight management over the reproductive years for adult women living with obesity

1. Healthcare providers must ensure the targets of adult obese women are met at different stages.

Preconception weight loss (level 3, grade C)

Gestational weight gain of 5 kg to 9 kg through pregnancy; 0.17 to .27 kg/week for the 2^nd and 3^rd trimesters (level 4, grade D)

Minimum postpartum weight loss.

Gestational weight gain (level 3, grade C)

1. Pharmacological weight management should not be used for pregnant and breastfeeding women (Level 4, grade D). Instead, women with no exercise effects should have 150 minutes a week of intense exercise (Level 3, grade C)
2. Healthcare professionals should not prescribe metformin for gestational weight gain in pregnant women living with obesity (level 1b, grade A).

No weight-management medications during pregnancy or breast-feeding (level 4, grade D)

Women on oral contraception therapy discontinue four weeks to surgery; postmenopausal women discontinue HRT 3 weeks to surgery (Level 3, grade C)

Women living with obesity be offered additional breast-feeding support because of decreased rates of initiation and continuation.

1. Delay pregnancy for 12 to 18 months of the period of active weight loss (level 3, grade C)

Obesity Management and Indigenous People

(Wharton et al., 2020)(Level 4, Grade D)

Engaging with the patient’s social realities and validating their experiences

• Engage with the patient’s social realities and validate their experiences of stress and systemic disadvantage influencing poor health and obesity.
• Advocate for access to obesity-management resources within publicly funded healthcare systems.
• Help patients recognize that good health is attainable and negotiate small, attainable steps relevant to their context.
• Address resistance, apathy, and paralysis in patients and providers.
• Self-reflect on potential bias influenced by systemic racism and explore patient motivations and mental health.

Building relationships and knowledge:

• Build patient knowledge and capacity for obesity self-management by exploring co-occurring health, social, environmental, and cultural factors.
• Incorporate the patient’s individual and community-based concepts of health and healthy behaviors.
• Deeply engage in learning common values and principles regarding communication and knowledge-sharing in Indigenous contexts.

References

Breen, C., O’Connell, J., Geoghegan, J., O’Shea, D., Birney, S., Tully, L., & Gaynor, K. (2022). Obesity in adults: A 2022 adapted clinical practice guideline for Ireland. Obesity Facts, 15, 736-752. https://doi.org/10.1159/000527131

Obesity Control Program. (2022). Saudi Guidelines on the prevention and management of overweight and obesity: Second edition 2022. Ministry of Health, Kingdom of Saudi Arabia.

Wharton, S., Lau, D., Vallis, M., Sharma, A., & Biertho, L. (2020). Obesity in adults: A clinical practice guideline. Canadian Medical Association Journal, 192(31), E875-E891. https://doi.org/10.1503/cmaj.191707