Selecting treatment

The selection of an appropriate weight reduction therapy begins with the evaluation of the patient's obesity-related health risk. Heavier patients typically have more health complications and a greater mortality, particularly if they have a large waist-to-hip ratio and hypertension, hypercholesterolaemia, or type II diabetes. T§..b!.e..,.3 summarizes the characteristics of people with a greater or lesser need for weight loss. (22> Women generally have less need than men because women typically carry excess weight in their lower body. Similarly, the risks of obesity are reduced in older as compared with younger individuals. Thus, after conducting a risk appraisal, the practitioner may find him- or herself trying to ease weight preoccupation in a 60-year-old female who carries 10 extra kilograms in her hips and thighs, while exhorting a 25-year-old male with a rotund belly and family history of diabetes to take his weight more seriously.

Table 3 Some modifiers of BMI-associated morbidity and/or mortality risk

Treatment options

The treatment algorithm in Fig 1 shows that there are numerous options for obesity. Therapy is selected on the basis of the patient's body mass index, risk profile, and prior history of weight-reducing efforts. Generally, the more obese the patient and the greater the health complications, the more aggressive the intervention selected. Thus an individual with a body mass index over 40 kg/m2, and a history of yo-yo dieting, will probably require long-term treatment by appetite suppressant medication and, if this is ineffective, gastric surgery.

Fig. 1 A conceptual scheme showing a three-stage process for selecting a treatment for obesity. The first stage (the classification decision) divides people into four levels based on body mass index. This level dictates which of four steps is appropriate in the second stage (the stepped-care decision) to determine the least intensive, costly, and risky approach among the treatment alternatives. The solid arrow between the two boxes identifies the treatment most likely to be appropriate. The third stage (the matching decision) is used to make a final treatment selection, based on the patient's need for weight reduction, because of comorbid conditions or other risk factors. The arrow (between boxes) with open circles indicates a reduced need for weight reduction because of the absence of risk factors. The arrow with closed circles shows the more intensive treatment option, appropriate for people with a significant comorbid condition. For example, the appropriate treatment for patients with a body mass index of 27 to 29 kg/m2 who do not have health complications would be a commercial programme or self-help approach. In contrast, pharmacotherapy may be considered for people with a body mass index of 29 kg/m2 and type II diabetes. Patients with significant psychiatric problems, or who want more support in changing diet and exercise habits, can be referred for adjunctive care. (Courtesy of Dr T.A. Wadden and Dr K. Brownell.)

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