Working with Your Doctor to Overcome Overweight and Obesity

This information was made possible by an unrestricted educational grant from McNeil Nutritionals. Introduction: Time for a change Throughout much of recorded history, people struggled to get enough food to eat. Today, many people in the world, and even in the United States, remain undernourished. However, the majority of Americans face the opposite situation: they are overweight and find it difficult to lose the unwanted pounds. This is a major public health issue because being overweight can lead to serious health problems. Every year in the United States, about 300,000 adults die from causes related to excess body weight. We cannot change our genetic make-up, but the good news is that we can make a difference in two of the key factors that contribute to premature death: cigarette smoking and eating habits. Millions of Americans have already improved their health by giving up smoking. Individually, in our communities, and as a country, it is time for us to make a comparable change in the way we eat.  This type of change is needed in order to address the epidemic of overweight and obesity in the United States.   What causes overweight and obesity? Our bodies convert the food we eat into energy. Just about every action we take requires energy. We need energy in order to move, to exercise, to play, do chores, to walk and talk, even to think. The energy contained in food is measured in kilocalories, often described simply as “calories.” When we take in more calories than we use up during our daily activities, the excess calories are stored in our bodies as fat. If you use up, or “burn” all the calories that you eat, your weight stays the same. Being overweight results from taking in more food energy—or calories—than we use up in the course of our daily lives.   Why lose weight? Being overweight increases the risk of developing a number of serious medical conditions, such as coronary heart disease, type 2 diabetes, high cholesterol, high blood pressure, breathing disorders during sleep, some types of cancer, osteoarthritis, gallstones, certain forms of urinary incontinence, and menstrual irregularities. In addition, for people who already have coronary heart disease, type 2 diabetes, high cholesterol or high blood pressure, being overweight increases the dangers of the underlying condition. Fortunately, if you are concerned about these health risks, there are a number of specific steps you can take to improve your health. First: find out if you are underweight, normal weight, overweight, or obese. (See "Beyond Pounds: The Measurements That Count" to find out where you stand.) Second: take stock of your eating habits and your level of physical activity. (You can use the Nutritional History Form, below, to evaluate your current eating habits.) Third: develop a specific plan-of-action to improve your food choices and to increase your activity level. (See "Steps You Can Take" for suggestions.) Fourth: put that plan into action…and stick with it. Whenever you decide to take action, your doctor is there to help. It is also a good idea to enlist the support of friends or family members. But remember that, ultimately, the responsibility for your health, your weight, and your activity rests squarely on your shoulders.   Nutrition History Form       Reprinted with permission from Taking a nutrition history: a practical approach for family physicians. American Family Physician, March 15, 1999. Copyright American Academy of Family Physicians. All rights reserved.   Beyond pounds: The measurements that count Know your Body Mass Index (BMI) Over the past twenty years, Americans have become more familiar with specific measurements related to health, such as cholesterol levels and blood pressure readings. When it comes to weight-related health risks, there are three important numbers that you should know. The first is your actual weight in pounds; the second is your Body Mass Index, or BMI; and the third is your waist measurement. Your BMI is based on your height and weight. Doctors consider BMI to be a better measure of health risk than your actual weight in pounds. In fact, the medical terms "overweight" and "obesity" are based on BMI values. A BMI of between 25 and 30 is defined as overweight, and a BMI of 30 or more is considered obese. The higher your BMI, the greater your risk of developing a weight-related illness, such as type 2 diabetes or heart disease. Physicians refer to certain measurements that provide valuable information about a patient’s condition as "vital signs." Standard vital signs include blood pressure, pulse rate, breathing rate, and body temperature. The AAFP Panel on Overweight and Obesity recommends that the BMI become a new vital sign, to be recorded during routine visits to the doctors' office. That is because, like blood pressure, a BMI reading that is too high should be recognized and treated. What is your BMI? Are you overweight or obese? You can find out by using the BMI Calculator or BMI Chart. The same BMI scale applies to both men and women. What is your waist circumference? Body fat that accumulates in the stomach area (described as "abdominal obesity") is more of a health risk than body fat that builds up in the buttocks and thigh areas. For this reason, your waistline provides valuable information about your risk for heart disease, high blood pressure, high cholesterol, and type 2 diabetes. Doctors consider a waist circumference too high if it is 40 inches or more in men, or 35 inches or more in women. Like the BMI, the AAFP Panel on Overweight and Obesity recommends that the waist circumference be measured during routine check-ups. The proper location to measure the waist is at the smallest spot under the rib cage and above the belly button.   What is Metabolic Syndrome? A high waist circumference can be one sign of a condition called Metabolic Syndrome. Although most people have never heard of it, this syndrome is quite common; it affects about one out of every four adults in the United States. Metabolic Syndrome often progresses to type 2 diabetes—and treating the syndrome can help prevent this form of diabetes. A person has Metabolic Syndrome if they have at least 3 of the 5 conditions listed in the table below. If you think you may have Metabolic Syndrome, it is important to discuss the possibility with your doctor so that you can undergo the appropriate diagnostic tests. Treatments for Metabolic Syndrome involve basic lifestyle changes, such as losing weight, eating a healthier diet, and increasing your activity level. Your doctor can help you develop a specific plan for making the necessary changes.   Treatment for Metabolic Syndrome Condition Treatment: Lifestyle Changes Practical Suggestions Abdominal obesity (measured by waist circumference) Men: greater than 40 inches Women: greater than 35 inches Weight loss Increased physical activity Cut 250 calories a day*; lose 1/2 pound a week; aim for losing 20 pounds in a year 30 minutes of moderate activity 5 days a week High blood pressure 130/85 mm Hg or greater Weight loss Reduced salt intake More fruits and vegetables Low-fat dairy products Aim for 20-pound loss/year Salt shaker off the table; no salt when cooking Get at least 5 servings/day Get 3 glasses of skim milk, low-fat yogurt, cheese/day Low HDL (good) cholesterol Men: less than 40 mg/dL Women: less than 50 mg/dL Stop smoking Weight loss Increased physical activity Cut carbohydrates, eat more monounsaturated fats Aim for 20-pound loss/year 30 minutes of moderate activity 5 days a week Replace cookies, candy, cakes with unsalted almonds, walnuts, peanuts High triglycerides level 150 mg/dL or greater Weight loss Reduce simple carbohydrates Limit alcohol Raise omega-3 fatty acids Aim for 20-pound loss/year Replace soda, juices with seltzer, water, diet soda Limit: 2 drinks/day for men; 1 drink/day for women Eat fish twice/week High blood sugar after fasting 110 mg/dL or greater Weight loss Increase soluble fiber Aim for 20-pound loss/year* Replace white bread with brown bread, whole grains, cereals *(For example: replacing two 2-ounce cans of sugar sweetened soda with a beverage sweetened with a sugar substitute, such as sucralose (SPLENDA®) can cut over 350 calories per day.   Losing weight vs. not gaining weight The average American gains 40 pounds between the ages of 20 and 40. So awareness of healthy eating and physical activity to prevent weight gain is important for all adults, not just those who are overweight or obese. The practical suggestions offered below are relevant to anyone interested in making food choices and staying active in a way that contributes to their overall health.   Consulting your doctor about weight control Talk to your doctor about healthy eating and physical activities that can help you lose weight, improve your fitness, and decrease the chances of developing heart disease, high blood pressure, or type 2 diabetes. Be sure to set realistic goals. Small changes can make a surprising difference in your health. Your doctor can offer practical suggestions that do not require a complete overhaul of your current way of life. In some cases, your physician may refer you to a nutrition specialist, such as a registered dietitian, for in-depth counseling about food choices. You may want to start the conversation by asking a few questions of your own. For example: Ask your doctor for any educational brochures on topics such as eating habits, counting calories, or physical activity Request to have your BMI measured and ask your doctor what it means with regard to your health status Have your waist circumference measured and discuss the significance of the measurement with your doctor Be prepared to describe your current diet and activity level and what changes might promote better health Think about how much change you're willing to make before you visit your doctor Ask if specialists are available on your health plan and in your area, such as dietitians or physical trainers   Steps you can take What's in Your Drink? Drink Amount Calories soda (non-diet)   12 oz. 140 sweetened iced tea    16 oz. 200 orange juice   16 oz.  200 apple juice    10 oz. 150 sports drink    32 oz. 200 punch    16 oz. 240 Non-Nutritive Sweeteners Sweetener  Suitability for Cooking and Baking Acesulfame-K (Sweet One, Sunett)  Good, particularly as a blend Aspartame (Equal, NutraSweet)  Limited use - - not heat stable Neotame  Limited Saccharin (Sweet-10, Sugar Twin, Sweet'N Low)  Good, particularly as a blend Sucralose (SPLENDA)  Excellent There is no shortage of weight loss books, programs, diets, and products on the market. The real challenge is finding an approach that is right for you and figuring out how to sustain new, healthier behaviors over time. Your doctor can help you determine what measures are practical and achievable based on your needs, interests, and willingness to embrace change. Here are a few general points to keep in mind: General measures Don't try to make major, dramatic changes overnight. If you are expecting to achieve too much, too quickly, you may be setting yourself up for disappointment. Set your sights on modest changes in your food choices or activity level. This can produce a feeling of accomplishment, which can help motivate you over time. For example, aim for eating more vegetables next week, rather than for losing 50 pounds next year. Weight loss is not the only measure of success. By increasing your activity and eating healthier foods, you can improve your health even if your weight stays the same. Weigh yourself regularly. Eating better Trends in eating habits may help explain why so many people in the United States are overweight and obese today. Americans currently consume 23% more sugar than we did in 1970, and soft drinks are the major source of the added sugar in our diets. On average, the foods we ate had 24% more total fat in 2000 than in 1970. And we eat meals away from home roughly twice as much as we used to. To begin to reverse these trends, the AAFP Panel on Obesity offered a variety of specific and practical suggestions about the way we eat. The panel recommends that people try to incorporate these changes one at a time rather than all at once: Eat only at the kitchen table. Don't drive, watch television, or talk on the phone when you eat. Push the plate away when you are no longer hungry. Don't wait until you feel completely full to stop eating. Eat only because you are hungry, not because you are bored, stressed, or tired. Go grocery shopping on a full stomach. Try having a diet soda, water, or a glass of skim milk instead of a regular soda. Learn more about the differences between different beverages in "What's in your drink?" For people who don't want to give up the sweet taste, sugar blended drinks (that contain a combination of sugar and non-nutritive sweeteners) are an option. Use a non-nutritive sweetener instead of sugar. Find out which non-nutritive sweetener might work best for you.  Substitute: whole grain breads for white bread brown rice for white rice baked or grilled chicken for fried chicken fresh fruit for fruit juice a small order of fries instead of a large order Read the labels on snack foods, and choose the ones with less fat and fewer calories. Being more active Regular physical activity has been shown to help prevent heart disease, type 2 diabetes and osteoporosis, as well as other chronic conditions. It is important for maintaining good health in all adults and children, regardless of whether their weight is a problem or not. As the following suggestions make clear, lifestyle changes do not have to be drastic. Simple measures applied every day can make a significant difference over time. Increase whatever physical activity you are currently doing by adding 10 minutes a day, or increase the intensity from low to moderate. (See "How Active Are You?" for an idea of different activity intensity levels.) Don't use a remote control when watching TV. Simply getting up to change the channel can make a difference in your activity level. Limit time spent online, watching TV, and playing video games to less than two hours per day. Take the stairs instead of the elevator or, get off one floor earlier and take the stairs to the last floor. Park at the far end of the parking lot and walk to your destination, rather than parking as close as possible. Get off the bus one stop earlier and walk the rest of the way. Do more household chores (e.g., dusting, vacuuming, weeding). Walk/run with the dog and/or the kids. Use an exercise machine (e.g., treadmill, bike) while watching TV. Take "active" vacations—go hiking or ride bicycles. Walk to do errands (e.g., grocery store, post office, etc.) instead of driving. Consider buying a pedometer, which measures how many steps you take a day, and gradually increase the number of steps you take every day. (Pedometers can be purchased at sporting good stores.) Don't be embarrassed about exercising!   How Active Are You? Moderate physical activity Hard physical activity Very hard physical activity Walking a mile in 15-20 min  (3-4 mph) Walking or jogging  (12 min/mile) Jogging (<10 min/mile) Treading water   Swimming laps (light effort) Swimming laps (vigorous effort) Bicycling (10 mph) Bicycling (12 mph) Bicycling (> 14 mph) Dancing or tai chi High impact aerobics Step aerobics (6- to 8-in steps) Yard work/gardening Mowing lawn with hand mower Digging a ditch Hiking Playing doubles tennis Playing singles tennis Vacuuming Moving furniture Playing basketball or soccer Playing actively with children Weight lifting In-line skating Adapted with permission from Blair SN, Dunn AL, Marcus BH, et al. Active living every day: 20 Weeks to lifelong vitality. Champaign, Ill.: Human Kinetics; 2001.   You can take it off and keep it off Believe it or not, many popular diets do work. If you go on a high-carbohydrate diet or a high-fat diet or a meal replacement diet, you can lose weight. Without help, however, it will be difficult to keep it off. That is why it is so important to find healthy food choices that you actually like and physical activity that you genuinely enjoy. To find out what is involved in successful long-term weight loss efforts, researchers created the National Weight Control Registry (NWCR). This group conducted interviews with more than 4,000 obese people who managed to lose a significant amount of weight and keep it off for many years. Their average individual weight loss per person was 67 pounds. It is no surprise that most of these people lost weight by changing what they ate and increasing physical activity. Only 9% of them lost weight by dieting alone. The researchers of the NWCR reported that there were some approaches shared by everyone in the group. They all Ate a low-fat diet high in complex carbohydrates Weighed themselves frequently (most did so weekly) Ate breakfast every day Dedicated at least 60 to 90 minutes a day to physical activity   Weight-loss programs Some commercial weight-loss programs, such as Weight Watchers, TOPS, Jennie Craig, and Slim for Life, combine good advice with support about nutrition and physical activity. This type of support from an organized group may help you achieve and maintain weight loss. Tell your family physician if you are participating in a weight-loss program. If you have one or more serious conditions (in addition to being overweight or obese), or if you're taking multiple medications, you need to work with your doctor to choose a program that is safe and appropriate for you.   Weight-loss medications Some medicines are effective in helping obese patients lose weight. The guidelines for people who are candidates for medical therapy for weight loss are those with a:  BMI of 30 or more and no risk factors for additional conditions BMI of 27 or more (but less than 30) with one or more obesity-related condition(s) or other disease(s) If you feel that medical therapy might be helpful in your efforts to control your weight, speak with your doctor about the risks and benefits of these medicines. Over-the-counter dietary supplements Some people choose to take over-the-counter dietary supplements that contain ephedra or ephedrine and caffeine in an effort to lose weight. Tell your doctor if you take supplements that contain any of these ingredients. While some supplements can enhance short-term weight loss, their safety is questionable. They are associated with: Nausea Vomiting Psychiatric symptoms such as anxiety and change in mood Hyperactivity of the autonomic nervous system Palpitations According to the FDA, case reports have linked serious adverse events, including heart attack, seizure, stroke, and death, with the use of these supplements. A cause-and-effect relationship remains uncertain, but it is wise to be cautious and to seek a doctor's opinion before using these types of products.   Conditions and medications that may prevent weight loss In some people, overweight or obesity may be related to a medical condition, or a medication they are taking, which interferes with their weight loss efforts. If you have, or think you might have, any of the conditions on this list, or you are taking any of the medications listed, speak with your doctor about measures you should take to manage your weight. In some cases, specific treatments for your medical condition, or a switch in medications, can make a difference in your efforts to manage your weight.   Some Medical Conditions that May Make it Difficult to Lose Weight Category Condition Hormonal Disorders Hormonal disorders  Polycystic ovarian disease Cushing's disease Diabetes Hypothyroidism Cardiovascular Congestive heart failure Idiopathic hypertrophic cardiomyopathy Heart valve disorders Sleep Obstructive sleep apnea Upper airway resistance syndrome Eating Disorders Bulimia "Carbohydrate craving" syndrome Medications that May Cause Weight Gain Condition Medication Allergies Antihistamines (such as Claritin, Allegra) High blood pressure Alpha blockers (such as Hytrin, Cardura) Beta blockers (such as Betapace, Blocadren, Tenormin) Methyldopa (Aldoment) Contraception Progestins (a component of certain oral contraceptives, such as Lo/Ovral and Ortho-Tri-Cylcen) Depression Tricyclic antidepressants (such as Norpramin and Sinequan) Diabetes Insulin Sulfonylureas (such as Diabinese and Glucotrol) Epilepsy Valproate (such as Depakene) Manic-depressive illness Lithium (such as Eskalith and Lithobid) Schizophrenia Neuroleptics (such as Zyprexa and Risperdal)   Overweight and obesity in children Childhood overweight and obesity have become increasingly common over the past 20 years. Today, about 1 out of 7 American children between the ages of 6 and 19 are overweight. Overweight and obesity in children are problems for many reasons: Being overweight can have a profound, negative effect on self-esteem. Overweight and obesity that begins in childhood often continues into adulthood, leading to increased risks for heart disease, high blood pressure, and other serious medical conditions. Type 2 diabetes was once considered a disease of adults only. Now, as a result of the epidemic of overweight and obesity, an increasing number of adolescents are developing this disease. Parents pass on much more than their genetic traits to their children; the way they act and the food choices they make can also have a profound effect on their children’s food choices as well on as their interest in physical activity. If you or your spouse is overweight or obese, you can help yourself as well as your children by making healthier eating habits into a family affair. You don't have to empty your refrigerator and start from scratch. Even small, positive changes in what you eat and how you eat can potentially make a difference in overweight and obesity issues in children over time. The consumption of sugar is a good example.  Families can make a point of learning what foods are rich in sugar content, and can begin to choose alternatives based on that knowledge. This is important because, since 1970, the amount of sugar consumed in the United States has increased 23%. Many prepared foods marketed to children and teenagers, such as soft drinks, sugar-sweetened beverages, cakes, cookies, and candy, contain corn-based sweeteners, refined cane and beet sugars, and other syrups. Among young people, soft drinks are the major source of added sugars. Choosing water, or a beverage sweetened with a non-nutritive, or non-caloric sweetener such as sucralose (SPLENDA®), or a sugar-blended beverage (made with lower amounts of sugar products combined with a non-nutritive sweetener) can decrease the total amount of calories children take in.   Specific suggestions for helping your overweight child If your child is overweight or obese, or if he or she gets little or no exercise, there are many ways that you can help them develop different, healthier habits. Working with your family physician or pediatrician Ask your child's doctor to calculate and plot his or her BMI every year Ask your doctor if there has been any inappropriate weight gain and, if so, ask your doctor for recommendations on how to deal with it. General measures Let your child's appetite determine how much he or she eats. Don't demand a "clean plate." Don't use food as a reward or punishment. Talk with your child about making healthy choices, not about weight or appearance. Eat together as a family more, and try to eat out less. When families do not eat meals together, they tend to eat fewer fruits and vegetables and more fried food and soft drinks. Creating a more active family Limit time spent online, watching television, and playing video games to a maximum of two hours per day for children over age 2. [Note: The American Academy of Pediatrics has advised that children younger than 2 years of age should not watch television at all.] Use an exercise machine, such as a treadmill or stationery bike, while watching television. Take active vacations—go hiking or ride bicycles. Whenever possible, walk instead of drive, for errands such as going to the grocery store or post office. Eat together as a family more, and try to eat out less. When families do not eat meals together, they tend to eat fewer fruits and vegetables and more fried food and soft drinks. Eating better as a family Drink more water. Limit soft drinks and fruit juice to 4 oz. per day for children under 2 and less than 6 oz. for children over 2. Put a clear limit on high calorie snacks such as potato chips, granola bars, and cookies. Eat more vegetables and fresh fruits. Keep healthy snacks, such as fresh fruit, vegetables, and whole grain crackers, in the house. Eating too quickly often results in overeating, so try to play the "Put the Fork Down" game. Put your fork or finger food down between bites and take your hand away and try to catch one another not taking a break between bites. Making the best of fast food Sometimes you just don't have any other option but fast food. In these situations, follow these suggestions to keep the total calorie count from getting out of hand: Order a regular-size hamburger instead of a large cheeseburger Skip french fries altogether Drink water, diet soda, or skim milk instead of regular, sugar-sweetened soda Choose a regular-sized drink instead of a large drink   Breaking old habits Many of our choices with respect to the foods we eat, how we eat, and how we exercise (or don't exercise) are unconscious. In other words, we often develop habits as children, or as young adults, and we stick with those habits as we age without giving much thought to how our choices may affect our health. The goal of this section on aafp.org, is to bring those unconscious choices to light, and to offer reasonable suggestions for new choices and new behaviors that will contribute to better health.   Bibliography AAFP Physicians Panel on Obesity. Practical advice for family physicians to help overweight patients. An American Family Physician Monograph. 2003.

Written by familydoctor.org editorial staff.