In addition, the imperative for weight regain may be influenced by the length of time and degree of overweight before these losses. A strong focus on weight maintenance after loss is therefore vital, requiring regular and ongoing support at the clinical level. The balance of treatment may also vary, such that physical activity takes on a more important role than in initial weight loss.19
9. Evaluate and act on hunger
Hunger is the biological drive to need to eat. Appetite is the psychological drive to want to eat. The former is inbuilt and difficult to divert. The latter is an interaction between physiology and cognitions, resulting in a learned response, and can therefore be unlearned (e.g. eating associated with drinking, time of day and social occasions). Where genuine hunger is diagnosed as the reason for energy imbalance, the clinician needs to consider foods, drinks and drugs that can delay or avert hunger. Low energy-dense, high-fibre foods and drinks (i.e. fruits, vegetables, grains, water) are first-line approaches to this.26 However, there is some evidence supporting the use of products such as chewing gum, capsaicin (e.g. chillies, curries, red peppers), nuts and green tea as mild hunger suppressants.27 If unsuccessful, recourse to medication (e.g. phentermine, exanatide and liraglutide) might be considered, particularly if metabolic syndrome is a comorbidity.
However, it is often noticed that obese patients do not report genuine hunger but have a ‘learned’ appetite. Food intake in these cases is driven by other factors, generally psychological, or in some cases simple habit. Psychological issues, including occupational, family or existential stresses or adverse childhood experiences,28 should be considered and dealt with, or the patient referred to appropriate treatment, preferably before starting weight-control management.
10. Understand individual motivation and stages of change
In the modern ‘magic bullet’ environment, it is common for patients to expect their clinicians to provide a simple effort-free way to lose weight. This can result in a precontemplative or neutral motivational state from which the necessary changes in energy balance are unlikely to occur. Techniques such as motivational interviewing, recognising a stages-of-change model of motivation, are necessary to shift the motivation from ‘extrinsic’ to ‘intrinsic’, so the patient can learn to self-manage what is essentially a chronic, long-term and often relapsing problem.29
Obesity, and particularly the lifestyle factors and determinants associated with weight gain, have important implications for health, but established treatment techniques for dealing with these issues at the clinical level are far from universally effective. Australia was one of the first countries to develop clinical guidelines for managing overweight and obesity. Although these guidelines are evidence based and well considered, the continuing growth of the problem suggests that these have not been fully effective in dealing with the problem. The current article adds some practical suggestions in addition to the existing guidelines that aim to improve the understanding of the weight loss process, increasing patient engagement and add treatment options for the primary care clinician. MT