Clinical Obesity Issues from an Internist’sPerspectiveSamuel Klein

The marked prevalence of obesity and its causal relation-ship with serious medical complications make obesity animportant clinical issue for all practicing internists andprimary care physicians. Most internists recognize that obe-sity is a serious medical problem and that losing weight is abeneficial and important clinical goal for obese patients.However, internists are poorly equipped to treat obesity forseveral reasons. First, most physicians have not been trainedin weight-loss strategies and in obesity management. Im-portant historical (e.g., diet and physical activity history,identification of potential triggers for excessive food intake,and life stressors) and physical examination (e.g., bodymass index and waist circumference) information are notroutinely obtained at the office visit. Internists may recom-mend that their patients eat less and exercise more but arenot prepared to implement appropriate treatment strategiesneeded to help their patients achieve those goals. The clin-ical-practice guidelines recently established by National In-stitutes of Health (1), and the lucid summary of theseguidelines developed by the North American Associationfor the Study of Obesity (NAASO) (2) represent majoradvances in clarifying the clinical issues and treatmentapproaches for obese patients that should prove useful tophysicians. Second, there is a general sense that treatment ofobesity is ultimately doomed to failure and that patients whoare able to lose weight initially will regain this lost weightover time. Therefore, many internists are skeptical that theycan help their patients make the necessary lifestyle changesto achieve successful weight loss and maintenance. Manyare not aware that modest weight loss can be very effectivein reducing the comorbid complications associated withobesity (3). Although most obese patients will never be ableto reach their ideal body weight, many can lose 5% to 10%of their body weight and keep that weight off for long

periods of time (4). Third, many internists do not haveappropriate equipment, such as scales that can weigh verylarge patients and large size blood pressure cuffs, needed forobese patients. Fourth, many internists do not have access tohealth-care professionals who can help them manage theirobese patients. Dietitians, exercise trainers, behavior thera-pists, and psychologists/psychiatrists who have expertise inobesity management are not easily found. In addition, whenthese health-care providers are available, obtaining theirservices is not possible for many patients because of thelack of insurance coverage. Fifth, many physicians see alarge volume of patients and their patient-care schedule isvery tight. They have a limited amount of time to cover alarge agenda of issues with their patients. It is difficult toextend the office visit to help patients implement successfullifestyle changes for weight loss. The lack of insurancecoverage for obesity treatment is another disincentive forspending time on weight management. Sixth, modern med-ical practice is geared toward the use of medications to treatchronic diseases. Although the current medications avail-able to treat obesity may have clinically important benefits(5), the additional weight loss achieved with the use of thesemedications is modest. Moreover, weight loss medicationsare much more effective when used in conjunction witha weight management program than when prescribedalone (6).

A chronic disease model is a useful paradigm for devel-oping the treatment approach needed for obesity. Obesityshares many features of a chronic disease: the pathogenesisof obesity involves both genetic and environmental influ-ences, obesity cannot be cured but it can be managed,relapses occur when treatment is stopped or not followed,and some patients are refractory to standard therapy. Inaddition, like many other chronic diseases, such as hyper-tension and dyslipidemia, obesity increases a patient’s riskfor adverse clinical events. Therefore, one of the goals ofobesity therapy is to prevent the occurrence of future dis-eases. Not all patients who have hypertension or hypercho-lesterolemia will have a myocardial infarction or a stroke.Similarly not all patients who are obese will develop obe-sity-associated illnesses. However, decreasing body weight

Center for Human Nutrition, Washington University School of Medicine, St. Louis, Missouri.Address correspondence to Samuel Klein, M.D., Director, Center for Human Nutrition,Washington University School of Medicine, 660 S. Euclid Avenue, Box 8031, St. Louis,MO 63110-1093.E-mail: sklein@im.wustl.eduCopyright © 2002 NAASO

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(and decreasing blood pressure or blood cholesterol) de-creases the incidence of new obesity-related diseases (7).The therapeutic approach to obesity requires life-long inter-vention with additional attention and understanding for ex-pected relapses that will undoubtedly occur in most patients.

In contrast to many other chronic diseases, obesity is alsoa lifestyle issue and adopting a healthier lifestyle is thecornerstone of obesity management. Humans have evolvedunder difficult conditions where obtaining adequateamounts of food was a constant struggle. The drive to eatand the ability to store excess energy intake as fat enhancedour survival in harsh environments. The recent increase inthe prevalence of obesity observed in most industrializedcountries can be attributed to marked changes in our envi-ronment. Our current environment favors a positive energybalance and accumulation of fat because of labor-savingdevices, sedentary jobs, and abundant food supplies. Thisenvironment makes it difficult to prevent or treat obesityand requires considerable control over complex factors forlong-term success.

Two strategies need to be implemented to help physiciansimplement appropriate strategies for weight management ofobese patients. First, it is important to disseminate practicaland consistent information to physicians. This should in-clude distribution of NAASO’s practical guidelines to cli-nicians, publishing position papers on obesity in the leadingInternal Medicine and Family Practice journals, presentingobesity symposia at the major national medical-societymeetings, developing obesity-management training pro-grams, and incorporating obesity management issues atindividual medical society Web sites. First, it would beuseful for the major clinical medical societies to develop anobesity consortium, in partnership with NAASO, to provideleadership in the efforts to educate physicians with a con-sistent approach for weight management. Second, it is im-portant to address reimbursement policies for obesity man-

agement. Obesity needs to be considered a disease anddeserves coverage like other diseases. It is unrealistic toexpect physicians to spend the time and effort needed toaddress obesity issues with their patients without appropri-ate reimbursement for their services. This is an extraordi-narily complex problem that will likely require lobbyingand educational efforts by both physicians and patients.

AcknowledgmentsNational Institutes of Health grants DK37948 and

DK56341.

References1. National Institutes of Health, National Heart, Lung, and

Blood Institute. Clinical guidelines on the identification,evaluation, and treatment of overweight and obesity inadults—the evidence report. National Institutes of Health,National Heart, Lung, and Blood Institute. Obes Res. 1998;6(Suppl 2):S53–S54.

2. NAASO. The practical guide to the identification, evaluation,and treatment of overweight and obesity in adults. SilverSpring, MD: NAASO. http://www.naaso.org

3. Goldstein DJ. Beneficial health effects of modest weight loss.Int J Obes. 1992;16:379–415.

4. Bjorvell H, Rossner S. Short communication: a ten-yearfollow-up of weight change in severely obese subjects treatedin a combined behavioural modification programme. Int JObes. 1992;16:623–5.

5. Davidson MH, Hauptman J, DiGirolamo M, et al. Weightcontrol and risk factor reduction in obese subjects treated for2 years with orlistat. JAMA. 1999;281:235–42.

6. Craighead LW, Stunkard AJ, O’Brien RM. Behavior ther-apy and pharmacotherapy for obesity. Arch Gen Psych. 1981;38:736–8.

7. Sjostrom CD, Lissner L, Wedel H, Sjostrom L. Reductionin incidence of diabetes, hypertension and lipid disturbancesafter intentional weight loss induced by bariatric surgery: theSOS Intervention Study. Obes Res. 1999;7:477–84.

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