Outpatient

• Appropriate functions for the primary care physician include: assessment of degree of health risk from BMI and WHR (see Diagnosis); assessment of motivation to lose weight; helping patients to set goals of therapy; office counseling or referral to a registered dietitian or weight loss program for in-depth counseling on diet, exercise, and behavior modification; long term follow-up
• Many reputable commercial and community programs exist for obesity treatment. Desirable programs should include diets which meet the RDA for nutrients, exercise counseling, behavior modification, and provision for long term maintenance. Physicians can provide valuable additional monitoring and long term follow-up.

Occasionally, treat patients with severe obesity (BMI > 40 kg/m2) with a gastric bypass or stapling procedure. This involves complex pre-surgical evaluation, surgery and followup and should be done in a center skilled in this treatment. Surgical treatment is the most effective long term weight loss treatment available for morbid obesity.

• Exercise alone rarely causes significant weight loss, but may improve long term results of weight loss treatment and should be an integral part of any weight loss program.
• Exercise regimens involve 30 minutes 3-5 times/week. Increasing calories expended in activities throughout the day is also important.
• Many patients benefit from an "exercise prescription"

• Diet restriction is the cornerstone of obesity management (low-fat, high-complex carbohydrate and high-fiber)
• A 500 kcal (2.10 MJ) reduction in calorie per day intake will result in approximately 1 pound (0.45 kg) weight loss per week
• Very low calorie diets (VLCD)
  • 400-800 kcal (1.68-3.35 MJ) per day are usually based on liquid formulas and cause more rapid weight loss
  • Complications of VLCD include: dehydration, orthostatic hypotension, fatigue, muscle cramps, constipation, headache, cold intolerance, and relapse after discontinuation
  • Contraindications of VLCD include: recent myocardial infarction or cerebrovascular accident, renal or hepatic disease, cancer, pregnancy, insulin-dependent diabetes mellitus, some psychiatric disturbances
  • Physician supervision is important for VLCD

• Educating the patient about the value of weight reduction is important
• Behavior modification can improve dietary adherence and long term results of weight loss and should be included in any weight loss program
• A self help brochure "On Your Way to Fitness" can be ordered for $1.00 per copy from Shape Up America, P.O. Box 9738, Bridgeport, CT 06699. It gives information for exercise self-assessment and increasing exercise for obese patients. Patients can also visit the website www.shapeup.org.