Obesity: A Complex Chronic Disease (2/6)

In the first post in this series I introduced the paper that inspired me to write this series and went over my thoughts on the first of their proposed steps for better patient management when it comes to obesity. The paper, “Obesity in adults: a clinical practice guideline”, outlines over 70 recommendations made by experts on patient management for those living with obesity, divided into 19 full length chapters. While I have not read the full 19 chapters yet (I intend to do so due to my interest in this topic), I am outlining my thoughts on the summary arc of five steps that they proposed to better help patients. In this post, I will go over step 2.

Step 2: Assessment

This seems like a fairly straight forward step, but in reality, it can be much more complicated. What the researchers are proposing with this step is to assess not only the patient’s risk of developing conditions related to obesity, but also to determine if there is an underlying medical condition that is contributing to the weight gain and possibly to the difficulty losing the weight.

To recap, this step can only occur if the patient is ready to have the conversation about their weight and if the patient is ready to create goals surrounding their health. Once it has been determined that the patient is ready, assessment can proceed.

In order to assess risk and underlying conditions there are physical examinations and questions that need to be asked. A few of the physical assessments pertain to ascertaining measurements. This includes weighing the patient, measuring the patient’s waist circumference, and calculating the patients BMI. When compiling these measurements, the health care professional must remain respectful and professional. The professional must also recognize, according to the guideline, that these measurements have their own shortcomings. For instance, BMI (body mass index) on its own has not been conclusively shown to be a predictor of risk for certain conditions, nor is it always accurate, especially if the patient has a high muscle content. Waist circumference and visceral adipose tissue on the other hand, has been studied to be an indicator for increased risk of cardiovascular disease. So while these measurements are important, they should not be the only crutch to rely on.

The authors emphasise taking a comprehensive history in this step. They state that in doing so, the health care provider can obtain a better understanding of the root cause of the patient’s weight management journey. This element is something extremely familiar to Naturopathic Doctors as the initial intake is generally about an hour long. This time is taken to get to know the patient’s unique personal and family history. Taking the time to accurately do this step can help identify where treatment can begin. For instance, if through a detailed history, the health care provider uncovers symptoms relating to another complex condition, like hypothyroidism, the professional can then order tests specific to that condition. In doing so, the physician can collaboratively come up with a treatment plan (more on this is in part 3) that targets the underlying condition, instead of the weight alone.

As mentioned above, this step also includes assessing for the patient’s risk of developing certain conditions. The certain conditions can include diabetes, high cholesterol, heart disease, depression, joint dysfunction etc. There are tests and questions to ask to determine if the patient is at risk for a number of conditions that can complicate a patient’s healing process. For example, if determined in this step that the patient is pre-diabetic, then this would be something that also needs to be addressed in the collaborative treatment plan.

However, one of the major drawbacks of this step is time. While some health care professional like naturopathic doctors have the time complete a comprehensive assessment, some professional do not have that time luxury. While a lot can be done in a short period of time, there is the risk of missing an important piece of the puzzle if the appropriate time is not taken. I would be curious to see if the authors have a suggested time limit for this step in the longer chapter, but in my read of the summary arc, it does not appear that this is a consideration. Considering, that the professional will need to complete steps 1-4 in office with the patient, will health care professional who do not have the time luxury be able to get everything in?

Overall, I think that this is a pertinent and important step. Determining the root cause and the possibility for developing other conditions allows for better targeted treatment. With a clearer goal in mind, the health care professional is better equipped to help the patient manage their weight. This of course is not possible if step 1 is not correctly accomplished and the professional still holds weight biases, as this would lead to ineffective counselling and weight only target treatments.

Step 2 boils down to determining the root cause, assessing for future risk, and testing what is necessary.

I hope this walks through not only what the authors intended step 2 to be, but also shares a little of my insights as a student into this topic. Stay tuned for the next part where I’ll go over Step 3!

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Boucher Institute of Naturopathic Medicine, Principles of Naturopathic Medicine, https://boucherclinic.org/blog/principles-of-naturopathic-medicine/

Han TS, van Leer EM, Seidell JC, Lean ME. Waist circumference as a screening tool for cardiovascular risk factors: evaluation of receiver operating characteristics (ROC). Obes Res. 1996;4(6):533-547. doi:10.1002/j.1550-8528.1996.tb00267.x

Wharton S, Lau DCW, Vallis M, et al. Obesity in adults: a clinical practice guideline. CMAJ. 2020;192(31):E875-E891. doi:10.1503/cmaj.191707

Yoshida D, Toyomura K, Fukumoto J, et al. Waist circumference and cardiovascular risk factors in Japanese men and women. J Atheroscler Thromb. 2009;16(4):431-441. doi:10.5551/jat.no539