|Year : 2013 | Volume
| Issue : 1 | Page : 10-13
Approaching young patient with obesity in family practice
Abdullah Ali Khawaji, Bander Abdullah Al. Asmery
Department of Family Medicine, Health Affairs, Aseer Region, Saudi Arabia
|Date of Web Publication||8-Oct-2013|
Abdullah Ali Khawaji
Department of Family Medicine, Health Affairs, Aseer Region
Source of Support: None, Conflict of Interest: None
Obesity is a common health problem in Saudi Arabia. Family physicians (FPs) have vital role in the prevention and treatment of obesity. This article aims to provide physicians at family practice with a practical approach which could help obese patients to reduce their weight. Ahmed is a 29-year-old Saudi male who came to family medicine clinic seeking advice regarding gaining weight. How FP should deal with this patient?
Keywords: Approach, family practice, obesity, obesity in young patient
|How to cite this article:|
Khawaji AA, Al. Asmery BA. Approaching young patient with obesity in family practice. Saudi J Obesity 2013;1:10-3
| Introduction|| |
Obesity in young people in Saudi Arabia is common. According to national studies and surveys, about 35.5% of young adult suffer from obesity.  Family physicians (FPs) and primary health care physicians (PHCPs) play vital roles in prevention and management of obesity through early detection, health promotion and education (family medicine a practical approach).  The objective of this article include providing FP and PHCP with practical approach which will help them to deal with young patients with obesity.
| Steps of Managing the Above Mentioned Patient|| |
- In the beginning, FP must introduce himself to patient, welcome him and try to establish good rapport in order to conduct excellent consultation.
- If the patient is visiting you for the first time, it is mandatory to explore the socio-demographics such as age, marital status, educational status and employment.
- Taking brief history regarding current health problem (diabetes, hypertension, dyslipidemia), past admission, surgical operation and drug use or misuse is important.
- FP should explore the patient's idea about weight gain, his concern, expectation from this visit in addition to ask about effect of his weight on his work, social, psychological, sexual life, in addition to identifying the real reason for visit.
- Review of system should include enquiries about the symptoms of secondary causes of obesity particularly hypothyroidism and Cushing's syndrome.
- Dietary history is paramount (quantities and qualities of main mail, snacks, soft drinks) and should be assessed in detail.
- FP should ask about performing physical activities including type of exercise, duration and frequency.
- FP should assess the readiness of patient regarding weight loss using 5As approach.
- After taking comprehensive history, focused clinical examination should be conducted and include the following:
- Taking height, weight and calculating body mass index (BMI).
- Measuring blood pressure.
- Measuring waist circumference and calculating waist/hip ratio.
- Thyroid gland, heart, abdomen and lower limbs should be examined.
- After taking history and examination, FP should discuss with patient the following points:
- Appreciation of patient regarding his awareness about his weight.
- Degree of readiness to lose weight and motivations for this issue.
- Degree of obesity and its risk in the future (diabetes, hypertension, heart diseases, joint problems…etc.).
- The target of weight loss that he would like to have in a phased manner (3, 6, 12, 24 months).
- How to reduce the weight by following modification of life-styles (diet, exercise and behavioral therapy).
- Calculating the daily calories intake from different dietary groups.
- Distribution of total calories according to meals.
- Agree and sign contract with the patient regarding weight loss program.
| Discussion|| |
We applied the above mentioned steps to Mr. Ahmed. He was approached as following: Ahmed is a 29-year-old Saudi male teacher who came to family medicine clinic seeking for advice regarding concern about his weight. Ahmed was normal till 5 years ago when he graduated from the college and married. Since that time he noticed that his weight increasing. He mentioned that he is worry because his father was obese and had sudden death as a result of heart attack. He came expecting that FP will prescribe some pills to help him to lose weight. Past history was insignificant and systemic review did not reveal any complaint. Asking about the effect of weight on his life showed that he could not play football with his colleagues and felt that standing for long period duration teaching lead to low backache. Regarding physical activity, Ahmed was good football player in the college but after graduation and marriage he stopped physical activity. Dietary history showed that Ahmed eats traditional Saudi diet consisting of kabsa (lunch), breads, fatty milk and frequent intake of fast food rich in calories and saturated fats. He mentioned that he like to eat cakes, dates, chips, pasta in addition to drinking carbonated drinks frequently Pepsi/Cola. Ahmed was non-smoker or alcoholic and his mood was stable. Ahmed spends his day as following : t0 eaching till 1:00 pm, sleeps for 3 h afternoon and 6 h at night, watching TV for 3-4 h daily.
Physical examination showed the following findings:
Blood pressure: 120/75 mmHg, pulse: 78 beat/min of normal characters, weight: 91 kg, height: 168 cm, waist circumference: 106 cm. BMI = 32.2 kg/m 2 . Thyroid gland was not enlarged, heart and chest examination was normal, no organomegaly or lower limbs swelling or dilated vein.
| Management|| |
At this visit, doctor should clarify Ahmed the following points regarding his problem:
FP should counsel Ahmed regarding exercise as therapy for losing weight. The following points should be explored before prescribing exercise:
- Ahmed suffers from obesity grade one (BMI = 32.2), which resulted from sedentary life-styles (physical inactivity, watching TV for long periods) and eating non-health diet that is rich in high calories and fats. 
- Doctor should inform Ahmed that this grade of obesity will put him at high-risk of developing diabetes, hypertension, dyslipidemia, heart disease, joint problems and some tumors.
- Doctor should discuss with Ahmed "to which degree he is ready to lose weight" and benefits of reducing weight.
- In case that Ahmed is ready to reduce his weight the following advices should be explained for him.
Ahmed has extra (21 kg) which should be reduced.
- In order to lose this weight, Ahmed should reduce 5-10% of his current weight during the coming 6-12 months.  (2-4 kg/month).
- The total daily calories to achieve such reduction were calculated as 1,600 calories/day.
- Patient was informed that distribution of the above calories will be as 55% for carbohydrate, 30% for fat and 15% for protein.
- Patient was advised to have three main meals and two snacks.
- Ahmed was advised to restrict to the following tips regarding diet:
- To take vegetables or fruit before main meals.
- To drink one glass of water before each meal.
- To eat slowly and grind food well.
- Should not fill stomach.
- Should not fill plate with large amount of food.
- Should not eat while watching TV or reading.
In addition to the above mentioned steps of management, the following investigations should be requested for Ahmed: Fasting glucose, lipids and thyroid function test (thyroid-stimulating hormone, T3, T4). 
- Assure that Ahmed is fit for performing exercise by using physical activity readiness questionnaire. 
- Discussing the type, frequency, duration of physical activities.
- Prescribe the appropriate type of exercise that the patient chooses staring with warming for 5-10 min and then active exercise for 10 min for the 1 st week to reach 45 min/day for 5 days/week.
After this session, Ahmed should be provided with health education pamphlets about obesity and dietary plan and to give appointment after 1 month.
In the second visit Ahmed attended according to his appointment. In this visit, FP assessed the following:
During this consultation, Ahmed stated that he did not have any complaint or concern, his compliance with diet was fair but his compliance with physical activity was excellent as he walked 45 min/daily since the last visit. He mentioned that compliance with diet was not as expected especially when he goes with friends and eat outside his home. He lost 1.5 kg during the last 4 weeks which was less than target (2-4 kg).
- Any new compliant or concern.
- Compliance with diet and exercise.
- Checking weight and BMI.
- Achieving the target of weight loss (2-4 kg).
- Barriers to compliance with medical advices if any.
Based on these finding, FP reinforced Ahmed to be more compliant in addition to increase the duration of exercise to 1 h/day and to reduce total daily calories to 1,400 calories/day.
Ahmed was referred to dietician in order to give more specific health education regarding diet therapy. In this visit, the investigations were reviewed and revealed normal results. Ahmed was given an appointment after 2 months.
In the third visit, Ahmed came to FP who assessed him for any complaint, concern, compliance with diet and exercise and checked his weight status. Patient mentioned that he was seen by dietician and spent with him about 30 min. He stated that the session was good and got more benefits from his advices. He was compliant with diet and exercise. His weight reduced by 5 kg (achieved the target agreed on in the last visits). Patient asked physician regarding prescribing anti-obesity drug which may lead to reduce more weight.
FP responded saying that Ahmed did good job regarding all advices and the target of lost weight. He reinforced Ahmed to continue the non-pharmacological therapies (diet, exercise and behavioral therapy). FP told Ahmed that most of drugs used in treating obesity will not lead to lose more than 5-10 kg and only one drug of them is licensed in Saudi Arabia (orlistat) which may be associated with fecal incontinence. The patient responded that he will think about using this drug and will discuss it with physician next visit. During this visit, FP assessed Ahmed for depression, which revealed normal. Ahmed was given appointment after 2 months.
In the fourth visit, Ahmed attended family medicine clinic according to appointment. FP welcomed Ahmed and asked him regarding progress in weight loss. Ahmed mentioned that he complied with medical advices but he lost just 2 kg since the last visit which is less than the target weight to be lost (at least 4 kg). It was noticed that Ahmed lost about 6 kg since the first visit in spite of good compliance to life-styles modifications and behavioral therapy.
Ahmed said that he read about orlistat and he can tolerate any side-effect and he wants to be given this medication.
FP prescribed orlistat as 120 mg TID after food and gave appointment after 3 months.  He informed Ahmed that this drug will help reduce weight but he should follow instructions as mentioned in the last visits otherwise his weight will increase again.
In the fifth visit, Ahmed was happy as his weight reduced by 6 kg during the last 3 months and he did not develop any side-effect, his compliance with diet and exercise and drug were excellent. Family doctor congratulated him for his effort to reach about 70% of targeted weight and insisted for continuing life-styles and drug and to attend after 3 months.
In the six visit, Ahmed brought his wife (Salma): Stating that this person was the most important one in my life as she helped me and introduced her support during the last 10 months to return back to my normal weight. FP welcomed the couple and thanked Ahmed's wife for her care and support for her husband stating that family member involvement in managing obesity is paramount. Now, Ahmed weight is (70 kg, BMI = 24.8 kg/mÆ) which is about to his ideal weight. Physician informed Ahmed that his weight will increase unless he follow and comply to the same advices and to continue his drug for further 3 months in order to avoid regain weight and then to be seen after 6 months.
| Conclusion|| |
Management of young obese patients in family practice is challenging. Good relationship, setting specific goals with patient are the essential elements of successful weight reduction program. Counseling patients regarding diet, exercise are the most important steps to reduce weight. Exploring and solving barriers at each visit will motivate obese patients to comply with non-pharmacological therapies.
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