The Multidisciplinary Approach to Weight Loss: Defining the Roles of the Necessary Providers

| June 9, 2008

by George L. Blackburn, MD, PhD; Isaac Greenberg, PhD; Anne McNamara, RN; Daniel Rooks, PhD, FACSM; Shannon Fischer, MA; and Kristina Day, RD, LD

Introduction
Obesity has become one of the gravest health concerns in the modern era. Multidisciplinary care aimed at small steps and practical approaches to lifestyle change can be an effective means of treatment for many patients who find it difficult to lose weight. Each member of the team—physicians, dietitians, exercise specialists, behavioral therapists, and nurses—brings a unique set of skills to bear on patient needs. Physicians, for example, address medical issues that might affect weight loss and help patients feel comfortable in a medical setting, while dietitians help patients gradually learn to eat less and incorporate healthier foods into their diets. Exercise specialists teach practical ways to integrate physical activity into day-to-day life; behavioral therapists help patients mentally prepare for the process of lifestyle change and address barriers to change; and finally, nurses, as with physicians, can help patients feel comfortable in a medical setting and assist in the management of medical complications that might affect their ability to lose weight.

Obesity is a chronic disease, and healthcare providers must be prepared to treat patients for many years. Use of person-to-person, telephone, and internet approaches to communicate can promote continued adherence to lifestyle changes. With the help of every member of a multidisciplinary team and ongoing commitment from patients, small, practical steps and goals can lead to long-lasting, healthy weight loss.

Background
Effective treatment strategies for overweight and obesity have been elusive. Over the years, it has become evident that drastic weight loss goals and narrow approaches to the treatment of obesity are rarely effective, and that a broader, multidisciplinary strategy based on small, practical lifestyle changes is more achievable for patients and produces longer-lasting results.1,2 This article discusses some of the small steps involved in the multidisciplinary treatment paradigm through the eyes of each member of the team: the doctor, the registered dietitian, the exercise specialist, the behavioral therapist, and the nurse.3

Early stages of the most effective interventions include weekly person-to-person contact for more than six months, which can be accomplished with combinations of individual and group treatment sessions led by members of the multidisciplinary team.3, 4 Maintaining weight loss during this period requires continued commitment from not only the patient, but also the specialists, and as with any other chronic disease, obesity requires further long-term treatment. Monthly telephone or in-person contacts are known to be most effective at preventing weight regain,4 though the internet has been used and may provide a convenient alternative or supplement to weight loss support—particularly as the patient grows increasingly self-sufficient. However, data are unclear whether it is as effective as in-person sessions.3

The Physician: Addressing the Issue of Weight Loss

The physician is often seen as the best source of health information for a patient,5 and advice from such a healthcare provider can significantly increase patient motivation.5,6 Nonetheless, the majority of obese adults reported that their healthcare professional did not advise them to lose weight.

Too often during routine medical visits, the subjects of weight, nutrition, and physical activity are overlooked by the physician or brought up only as an afterthought, which can affect the level of perceived importance the patient assigns to these topics. Given the high personal and economic costs of obesity and its comorbid conditions, weight-related instructions and advice should be discussed early in the visit in simple, nontechnical language.7

Many physicians are unaware of how to approach the subject of weight. Asking permission to discuss weight and weight loss is a simple way to build rapport with patients and address this traditionally sensitive topic. Once the subject has been broached, the physician can use patient-centered communication to learn how patients feel and what they know. This opens the door to discussions on motivation and provides the physician with the opportunity to assess health literacy, an issue common to medical care.

Such discussions take far less time than expected; if uninterrupted, patients usually speak about themselves for approximately two minutes.8 In general, a simple, three-minute lifestyle interview9 can give physicians a sense of whether patients’ nutritional patterns are reasonable, whether they are interested in losing weight, and what their emotional and physical obstacles might be.

The physician is often seen as the lynchpin of a multidisciplinary team, and is usually the first member, after the nurse, to discuss issues of weight and lifestyle with patients. By using patient-focused communication strategies and emphasizing the importance of nutrition and obesity-related lifestyle factors, the physician can encourage patients to adhere to medical advice and view obesity as a significant but treatable health concern.

The Registered Dietitian: Laying the Foundation for Dietary Change

In a multidisciplinary approach to obesity treatment, the primary role of the registered dietitian (RD) is to guide the patient toward simple, effective strategies to improve their diet quality and decrease overall energy intake. Confusion about food and diet is widespread, however, there are several simple strategies patients can use to reduce energy intake without inducing feelings of hunger than can lead to binge eating.

Eating less. Over the past 30 years, the mean daily energy intake of Americans has increased from 2,450kcal to 2,618kcal for men and from 1,542kcal to 1,877kcal for women.10 Larger food portions are a primary contributor to higher energy intake, and consequently, the rise in obesity prevalence.11 Data indicate that the more food is served, the more people eat.12

When counseling and educating clients, food and nutrition professionals must consider that the portion sizes of foods sold in the marketplace may have considerable influence on the portion sizes that individuals view as typical and appropriate to consume on a single eating occasion.13 RDs can help patients eat less by teaching them to leave a little food behind at each meal—a realistic and achievable goal.

Eating better. Effective weight loss education must include strategies to not only eat less, but to also eat better. Lower fat, whole foods (i.e., fruits, vegetables, legumes, and whole grains) can help patients reduce overall intake and increase total nutrient consumption. Fresh produce is particularly high in water, adding weight and volume to increase satiety without adding energy.14

Evidence shows that subjects in a reduced-fat and increased fruit and vegetable group lost 33 percent more weight at six months than those who only decreased their fat intake.21 This is consistent with Ledikwe, et al., who demonstrate that a low-energy-dense diet is associated not only with reduced calorie intake and increased food consumption, but also with higher diet quality than a high-energy-dense diet.15

The Exercise Specialist: Integrating Physical Activity into a Healthy Lifestyle
Physical activity is an important aspect of any weight loss treatment; the combination of diet and exercise is the most effective behavioral approach to obesity treatment, better than either alone.16 Despite the significant physical and mental benefits associated with regular physical activity, many of those most in need (i.e., the overweight and obese) may perceive it as daunting.17, 18 It is crucial, therefore, for the specialist to clarify the definitions for physical activity and exercise. Physical activity includes any movement involving contractions of the muscles and energy expenditure, and exercise is a type of physical activity.19

Non-exercise activity thermogenesis (NEAT), or general lifestyle activity, is an integral part of any weight loss attempt; it can account for a difference of up to a 2,000kcal expenditure per day in active versus sedentary individuals.19 Patients can be encouraged to stand while using the phone, iron while watching television, run errands on foot, take stairs instead of elevators, walk down the hall rather than e-mail a coworker, and so on—the possibilities are endless. Furthermore, studies have shown that lifestyle activity can be as effective as a more structured program in lowering blood pressure and body-fat percentage.20 Where NEAT is concerned, every step counts.

Unlike NEAT, which occurs as a result of basic lifestyle, exercise is designed to improve one or several fitness parameters: cardiorespiratory fitness, muscular strength, or balance and flexibility. Walking is one of the most common and convenient exercises. Steps can be accumulated throughout the day as individuals walk in the course of completing tasks (NEAT) and in purposeful, planned exercise. Additionally, though many individuals often assume that physical activity, especially planned exercise, needs to be performed in single bouts, several studies indicate that two or more intermittent bouts of exercise throughout the day produce health benefits equivalent to single, longer periods of exercise.21, 22 Three 10-minute walking sessions can seem far more achievable than a single 30-minute session.

The exercise specialist should guide patients toward small, achievable goals, such as adding one minute to a 10-minute walk, climbing one extra flight of stairs on the way to work, or adding 100 steps at a time to a day’s total. Pedometers are one of the most useful tools as individuals increase their physical activity. By increasing physical activity in small increments over time, patients are able to achieve longer-term goals of 10,000 daily steps or 175 minutes of movement/day—without frustration or a sense of failure. The crucial point is that patients should be encouraged to increase their physical activity throughout the day in any way possible, using a variety of lifestyle changes and planned exercises.

The Behavioral Therapist: Mentally Preparing the Patient
Failure to maintain diet and exercise modifications may occur when a patient is not mentally prepared for long-term interventions. Many people participating in a weight loss program for the first time are nervous and afraid, which can promote resistance to change. Behavior therapy provides the mental preparation and structure that can help patients manage obstacles and identify and achieve their goals.23, 24

Motivational interviewing (MI), a directed, client-centered counseling style developed by Miller and Rollnick, recommends that caregivers roll with resistance.25 For example, statements demonstrating resistance to change should not be challenged by the clinician, but rather used as momentum to further explore the patient’s views.26 Using this strategy, behavioral therapists can gently approach the reasons for the resistance to necessary lifestyle changes (e.g., previous failures, lack of time, lack of knowledge, and an unsupportive environment) and address them directly. MI behavior counselors can use this theory to guide clients toward awareness of discrepancies between current behavior (e.g., late-night binging, sedentary lifestyles) and their goals, such as lower weight or increased health.26 As treatment progresses, individuals learn to work through their resistance on their own, and eventually come to define their own problems and
solutions.

After the benefits of losing weight have been firmly established, targeted goals must be created. Patients commonly set unrealistic “goal weights,” greatly overestimating the amount of weight they can feasibly lose and maintain; many are unaware that losing only 5 to 10% of initial body weight can significantly decrease the severity of obesity-related risk factors, including hypercholesterolemia, hypertension, and diabetes.16, 27 Behavioral therapists can use this information to help patients realize the benefits they stand to gain with small, modest weight loss, guiding them toward the much more achievable weight goal of 5 to 10% of their starting body weight.
In encouraging individuals to integrate diet and physical activity into their lives, no change is too small—indeed, one change can become the catalyst to successful maintenance of a total lifestyle modification. Small steps, feasible goals, and recognition of their own mental barriers to change are the means by which change occurs.

The Nurse: Keeping the Patient Involved
In any clinical care setting, the nurse is an important figure in the patient’s experience. In a multidisciplinary weight loss effort, this role becomes even more critical. As one of the initial contacts, the nurse sets the stage for first impressions.28 Negative attitudes or stigma toward overweight or obesity can make patients uncomfortable and hinder treatment.29, 30 By the same token, nurses are in a unique position to enhance patient comfort and encourage ongoing involvement with weight loss efforts.

Enhancing patient comfort begins with small, simple modifications. Waiting rooms are often poorly equipped to serve obese subjects. This can lead to embarrassment even before the medical consultation begins. By adding larger chairs, benches, and loveseats, patient size can be readily accommodated. As the visit progresses, private weighing and larger gown sizes and medical equipment, such as blood pressure cuffs, can make a very real and positive impression on an overweight patient.

Once the consultation begins, it is important to invest time in the patient and take a detailed history. Many medical conditions common to obesity are treated with medications that can prevent weight loss or even promote weight gain. These include antidepressants,31 thiazolidinediones,32 and ACE inhibitors.33 Additionally, the often overlooked social environment is an important treatment component for an overweight patient. A detailed history can identify potential barriers to weight loss, such as negative attitudes of family and friends, lack of opportunities for physical activity in the neighborhood, or job stress.

Finally, studies show that 89 percent of patients going into weight loss surgery clinics have internet access, and 85 percent use the internet to search for relevant bariatric information.34 However, not all online information is accurate, and nurses are in a good position to encourage patients to discuss what they find online and provide them with sound, medically-based sites.

In the multidisciplinary team, the nurse is the key patient contact and the nexus for communication between team members. He or she is in a unique position to educate patients, make them feel comfortable and accepted, and gain access to the kind of information that will help direct optimal treatment strategies.

Conclusion
It takes a multidisciplinary effort to help patients meet and overcome the challenges of lifestyle change needed to succeed at weight loss; all of the skills brought to bear by the physician, the dietitian, the exercise specialist, the psychologist, and the nurse are essential, as are long-term commitment and clear, frequent communication.

Every aspect of a patient’s life is relevant to the weight loss effort. If a clinician is harried, judgmental, or uncomfortable with the subject of weight loss, he or she may impede treatment. Likewise, losses achieved during initial treatment must be maintained via ongoing contact between patient and providers. Continued support is necessary, not just for a few months or a year, but for many years.3, 4

Obesity is a chronic, progressive, and life-threatening disease. But for all that portends, small but lasting lifestyle modifications can produce significant health benefits.

At any given time, approximately 33 to 40 percent of adult women and 20 to 24 percent of adult men are trying to lose weight.35 More often than not, their goals differ from those of the medical community.

A modest weight loss of 10 percent is associated with significant health benefits,16, 27, 36 and many patients are only 200kcal a day short of a 20 to 30-pound weight loss over the course of a year. To succeed, they need only correct a 10-percent imbalance between energy in and energy out. The small, practical steps (see Table 1) described here can help them do just that, and in so doing, prevent obesity-related morbidity and mortality.

Acknowledgments
Manuscript preparation was supported by the S. Daniel Abraham Chair in Nutrition Medicine at Harvard Medical School, The Harvard Center for Healthy Living, Boston Obesity Nutrition Research Center (BONRC) P30-DK-46200, and Center for Nutritional Research Charitable Trust. The authors thank Rita Buckley for services provided in the development of the manuscript.

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