Mapping your obese patient's longevity journey: From assessment to follow-up

Highlights:

• Obesity is a condition that impairs the quality of life and could cause long-term complications that negatively influence longevity
• Metabolic syndrome is a cause and consequence of obesity. It also contributes to an increased risk of mortality
• The first step to your patient’s weight loss journey starts by discussing and understanding your patient’s feelings and attitudes toward weight loss, as this helps you map the challenges they face in their weight loss quest
• Understand the drivers behind your patient’s weight increase by assessing your case's physical, clinical, metabolic parameters, and dietary history
• Longevity-driven dietary approaches involve reducing caloric intake and replacing nutritional components with those that positively influence the healthy lifespan
• Physical activity is a crucial component that supports weight reduction and also promotes healthy longevity
• Follow-up is essential, as the weight management journey does not end upon losing weight but continues for a lifetime to maintain it  

Introduction

Obesity is a complex disease that involves adiposity (excess body fat), impairing the quality of life, increasing the risk of long-term health complications, and negatively influencing longevity. It is defined in the context of body mass index (BMI) as having a BMI of 30 or higher. According to the Centers for Disease Control and Prevention and the American Diabetes Association, obesity is divided into three classes (higher is worse). Class I is a BMI of 30 to <35, Class II is a BMI of 35 to <40, and Class III is 40 or higher. Class III is sometimes referred to as “severe” obesity.

Metabolic syndrome: A cause and consequence of obesity

Metabolic syndrome (MetS) is a cluster of conditions, including abdominal obesity, atherogenic dyslipidemia, hyperglycemia, and hypertension. Abdominal obesity is the most frequently observed component of MetS and responsible for many health complications (1). Research indicates that MetS is associated with a two-fold increase in coronary heart disease and cerebrovascular disorder and a 1.5-fold increase in the risk of all-cause mortality. This is considered a form of premature, accelerated aging because the prevalence of these conditions increases at old age (2). Epidemiological studies indicate that the prevalence of MetS ranges between 20 to 45% and is expected to rise to 53% by 2035, highlighting the potential impact of this condition as a public health concern (1).

Understanding your patient

First, it is essential to identify the cause of obesity, whether primary (increased caloric intake coupled with a sedentary lifestyle) or secondary factors (genetic, hormonal, or medicine-related) (3). This is crucial because mapping the primary drivers of obesity would help tackle the condition's root causes. Otherwise, the problem remains. In addition, try to identify other comorbid conditions your patient might have due to obesity (3). This could help you tackle multiple conditions your clients could suffer from by correcting their weight.

The United States Department of Health and Human Services created the “5 As” model, which could help you better understand your patient's case and develop useful solutions for their particular problem (4). This framework includes five domains: ask, assess, advise, assist, and arrange (5). Below, we will discuss the patient journey from the first time they visit your clinic until follow-up.  

Obesity Management: Initiating the discussion

Obesity management should follow a stepwise approach with realistic weight loss goals to reduce health risk. In addition, maintaining weight loss should be part of the plan (6). This intervention is part of a life-long plan to maintain achieved results.

Before getting to the management process, the initial step is having a discussion with the patient/client (3). This part is crucial because it is where most engagement with the patient is required. The initial discussion has three components: introducing obesity as a health issue, understanding patient concerns about the problem, and explaining the benefits of weight reduction (3). Here are a few tips while holding the initial discussion:

• First and foremost, respect your client’s privacy. This means that discussions are held in private sessions and not in front of others.
• To initiate the discussion about obesity management, ask questions like “are you concerned about your weight?”.
• Do not use words like "heavy”, “excess weight”, and “fat”. Instead, use understandable non-hurtful terms like BMI.
• Do not blame or shame the client for their weight issue.
• Try to understand more about the case by asking questions like, "have you attempted to lose weight before?" to understand better if the patient had failed attempts. If so, try to find out what caused them to stop.
• Try to link their health problems (like knee pain) and obesity.
• Highlight how obesity can further worsen their condition and their overall health.
• Check your client’s readiness to initiate weight management on a scale (0–10). If the client is motivated, begin treatment (higher scores better motivation). If not, discuss the benefits of treatment and the stepwise approach to achieving goals, then reassess.

Physical, clinical, dietary, and other assessments

Physical measurements include aspects of the body, such as height (measured with a stadiometer) (3, 7). To measure height, ask the patient to inhale deeply and stand straight on heels on the ground without wearing shoes. The head and buttock should be touching the stadiometer. Another aspect to include is weight, which can be done with a scale (7). Using both of these measurements, the BMI can be derived to categorize better the level of patient obesity (7, 8). Another physical measurement to be included is the waist circumference, which could be utilized as a cardiometabolic risk factor predictor in patients  (3). It is measured by making the patient stand straight and locating the right iliac crest on the upper hip bone, followed by placing a measuring tape around the abdomen at the iliac crest. It is important to understand that waist circumference is sensitive to patients' age, gender, ethnicity, and height (3). The dual-energy X-ray absorptiometry is a more useful technique for measuring body fat. It provides rapid, non-invasive regional and whole-body composition measurements (9, 10). Also, it comes at a relatively low cost (11). Magnetic resonance imaging is another method used to quantify the total fatty tissue in the body more accurately. However, it is more expensive than the abovementioned techniques. In addition to the previous, bioimpedance is a useful technique utilized in research and clinical practice (11). It is quick and simple to use but not entirely accurate.

Regarding clinical assessment, this should be done with the help of a physician. In this domain, blood parameters and the presence of comorbidities are assessed (7). Also, the medical history of your patient is considered (3). Other aspects like sleep, sleep patterns, and regularity should be assessed because research has indicated that sleep disturbance contributes to obesity (12). Also, psychological health needs to be checked since many people with obesity tend to have various mental issues, like depression and anxiety (13).

In addition to the above, a detailed dietary history assessment should be taken (3). In this context, clients are asked to recall their:

• 24-hour cycle eating habit (daily cycle of food intake).
• Type of diet (amount and quality of consumed calories).
• Portion size.
• Cooking techniques (any cultural influence, food preparation techniques, and home cooked versus restaurant meals).
• Ingredients (fresh or processed).
• Daily sodium intake (this should be considered when planning the diet).
• Beverage consumption habits (intake of alcohol (>1 drink for females and >2 drinks per male are Associated with weight gain) and sweetened drinks).
• Fiber consumption (assess the total daily intake, if low, provide diets that supplement a sufficient amount. Give examples of foods containing fibers to see if patients consume it).
• Fat and carbohydrate consumption (high glycemic index food, like noodles, white rice, and pasta should be minimized or eliminated. Fried food, red, processed meat, and bakery products are sources of high fat intake).
• The meal's timing (irregular and late-night meals have negative implications on obesity and its management).

It is essential to understand that dietary assessment is a 2-step process. Typically, nutritionists start by asking about ingredients, cooking techniques, portion size, and timing. The second step involves assessing the aforementioned information to estimate the amount of carbohydrates, fibers, and fats in the patient’s diet.

Finally, physical activity (PA) needs to be assessed to tailor the plan to your client better. A valuable tool to assess PA and sedentary behaviors is the Global Physical Activity Questionnaire (3). Remember to:

• Assess the whole lifestyle of your client. Regular exercise with a sedentary lifestyle could make it more challenging to lose weight.
• Ask and understand the patterns of your client’s physical activity (If any) like type (walking, swimming), intensity (light, moderate, or intense), duration (minutes, hours), and frequency (how many times per day or week). This is to help you better map energy expenditure when giving them their plan.
• Assess the sedentary behavior, like sitting for extended periods facing computers and TV, including the time spent.
• Ask your client about the problems they think could be barriers to maintaining their physical activity to work around them.
• Identify physical activities your client could enjoy and include them in their therapeutic regimen.

Longevity-driven diet to lose weight

Caloric restriction (CR), a decrease in consumed calories, is one of the approaches used to lose weight (14). The literature also highlights that CR (without malnutrition) brings many benefits to longevity by acting on pathways that influence aging and lifespan (15, 16). Also, CR brings favorable physiological changes that hold positive outcomes, like reduced lipid metabolism, improvement in circadian rhythm, and decreased inflammation, for your client’s health and longevity. Here are some dietary solutions you can give to your clients to help them lose weight (3).

Nutrient

Recommended intake

Calories

A calorie deficit of 500-750 kcal. Energy deficit will result in weight loss regardless of macronutrient composition (7).

Carbohydrates

Try to include non-starchy, low-glycemic index fruits and vegetables, as these promote longevity and reduce the adverse effects of aging (17). Examples of non-starchy vegetables include asparagus, green beans, beets, and broccoli (18).

Proteins

This should be around 25-35% of the total calorie intake. This is because proteins increase thermogenesis, preserve muscle mass, and leads to better weight loss. Examples of foods containing protein are lean meat, seafood, beans, peas, nuts, dairy, eggs, and lentil (19).  

Total fat

The recommended amount of fat is 10% of caloric intake. Examples of foods containing monounsaturated fat include almonds, cashews, and avocados. Polyunsaturated fats are found in oily fish like salmon and plants like chia seeds (20). It is important to avoid hydrogenated trans fats that are still commonly used in pastries and other highly refined foods.

Fibers

There should be 14 grams of fiber per 1000 calories.

Some tips for healthier eating include (3, 21):

• Highlight to your patient that a high-fiber diet promotes satiety, which is associated with lower body weight.
• If the patient feels hungry during a diet, advise to include fresh steamed grilled or sauteed vegetables.
• Suggest that your patient replace fatty cuts of meat with lean meat such as poultry to help reduce saturated fat intake. Seafood is a source of omega-3 fats that offer a range of health benefits.
• Advise your patients not to skip meals (as this reduces the metabolic rate). Intermittent fasting can be an effective way to achieve a calorie deficit. This requires educating the client on how to do it right.
• Explain that reducing portion size by using smaller plates might help them in their journey since it will make them more conscious about the amount of food eaten.
• Ask your patient to fill half the plate with salad, one quarter with protein, and the remaining quarter with carbohydrates. Also, advise them to start eating the salad first because it increases their sense of satiety.
• Suggest healthy cooking techniques, like grilling, baking, boiling, and steaming. Mention that grilling meat has been associated with increased production of carcinogenic compounds.
• Recommend that your patients avoid unhealthy ingredients and replace them with healthy ones. For example, replacing mayonnaise dressing in a salad with vinegar or olive oil.
• Explain the importance of chewing food to help digestion and benefit from nutrients.
• Encourage your client to avoid watching the TV, chatting, or reading while eating as it could make them unconscious about the amount of food they consume. A good replacement could be sliced low-calorie vegetables. Cucumber or carrots in front of a TV can help partially scratch the same itch while delivering nutrients and very few calories.
• Recommend replacing unhealthy snacks with healthier options. For example, low-fat fruit yogurt instead of ice cream and steamed or grilled chicken instead of fried one.
• Educate your patient to read the food label and understand the nutritional value of the food they eat. Ask them to avoid energy-dense foods, processed sugar, saturated fat, or low-fiber products.
• Work with your patient to address their unhealthy cravings to manage them better.
• Suggest to your client to include an “accountability partner” (could be a family member or a partner) because research has shown that having their support could help reach weight loss goals.

You must also focus on your patient’s eating habits while socializing. This is because people tend to make poorer dietary choices while socializing, especially in fast-food restaurants (22). To encourage your patients towards healthier outcomes, be sure to (3):

• Recommend that your client read the menu carefully before making a choice. Suggest that they choose low energy dense meals or go for a smaller portion plus an extra salad on the side if choosing a high energy density meal.
• Recommend that they customize their plate (whenever possible) and seek healthy choices. For example, replace French fries with boiled potatoes.
• Encourage your patients to order in smaller portions while eating out. Also, explain that it is always best to order side dish salads and start the meal with them.
• Advise your patients to drink water or unsweetened beverages.
• Highlight the importance of including protein-containing food sources, like chicken, eggs, or low-fat dairy, in their meal.
• Suggest that your clients choose healthy fruit-based desserts, like fruit yogurt.

Losing weight and promoting longevity with physical activity

Physical activity has been found to be a very effective means to lose weight and promote healthy longevity. The literature indicates that with PA, the all-cause mortality rate drops by about 30% to 35% (23, 24). Also, the risk of developing other diseases, like type 2 diabetes, decreases. PA is important because research indicates that people put weight loss as the main motive to engage in PA (25).

The World Health Organization recommends that adults aged up to 65 years do at least 150 minutes of moderate-intensity aerobic exercise (like walking and cycling) or 75 minutes of vigorous aerobic activity (like aerobic fitness or exhaustive running) per week (26). A combination of 30 minutes of aerobics, 15 minutes of workplace activity, and 15 minutes of muscle strengthening activity is recommended. When deciding on your patient’s PA, remember to consider their age, gender, metabolic health, and musculoskeletal conditions before making any recommendations (3). Remember the following when making a plan for your patient:

• For patients with no prior PA, initiate exercises by recommending light-intensity activities, like doing house chores such as dusting, cooking, cleaning, and ironing clothes. Ask your patient to include walking (15-20 minutes) thrice weekly as a start.
• Patients with mild PA recommend moderate-intensity exercises, like dancing, cycling, walking, stretching, golf, tennis, and others.
• For active patients, recommend higher intensity activities, like running, swimming, weight lifting, and brisk walking.
• Encourage some changes in your patient’s behavior. For example, suggest that your patients commute to the grocery stores and take the stairs instead of the elevator.  

After the above, follow-up with your patients is critical to maintain success. Suggest daily logging of their food intake and PA in dairies or mobile applications (through wearable devices) (3). This way, if there are any barriers, they could be modified and addressed in subsequent sessions. Also, during these visits, weight loss and BMI are measured and plotted to monitor progress. 

Final remarks

Obesity is burdensome to both the patient and society. Patients suffer not only from negative physical effects but also psychological implications. A weight loss journey with longevity in mind starts from the first moment your patient enters your clinic and continues for a lifetime. Qualities that you need to nurture in your patient are resilience, commitment, and patience. This is because the journey to lose weight is not easy, and it does not stop at the stage of weight loss but continues for a lifetime to maintain success. Remember, an optimal weight loss strategy involves a multicomponent intervention that requires collaboration between stakeholders, like nutritionists, life coaches, physicians, and others.

References

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