5 Tips: Discussing weight and health with your patients

An estimated 63% of Canadians live with overweight or obesity.1 Obesity is a complex chronic disease.2 Excess body weight is associated with many chronic health conditions, including hypertension, type 2 diabetes, cardiovascular disease, osteoarthritis and certain types of cancer. Obesity is also linked with increased risk of several mental health conditions and various functional limitations.2 Pharmacists are often the first point of contact for patients seeking advice on weight loss and have opportunities to provide practical, evidence-based recommendations to help their patients reduce their risk of obesity-related health complications. The following five tips will help you discuss weight and health with your patients. Be sensitive People living with obesity experience significant weight bias and stigma. Pharmacists should demonstrate sensitivity and ask permission to discuss weight with a patient. Asking permission displays compassion and empathy, and strengthens the provider–patient relationship.3 Approach the topic from a place of empathy, acknowledging the complex interplay of factors that contribute to obesity and the difficulty in sustaining healthy behaviour changes.3 Use person-first language, such as “a person living with overweight/obesity” rather than “an overweight/obese person.” Avoid stigmatizing language or imagery; shaming is an ineffective strategy to encourage behaviour change.4 Assess severity Obesity is defined according to body mass index (BMI), measured in kg/m2. It is used as a surrogate for body fat. BMI should be used as a practical screening tool to identify those at risk of cardiometabolic disease, as BMI ≥ 30 kg/m2 is associated with increased cardiovascular risk and all-cause mortality. Lower BMI cut-offs may be used for patients of certain ethnicities.3 Obesity classifications based on BMI can be found online (see Table 1 in reference #3) BMI may misestimate health risks in certain populations and up to 40% of the population may live with an elevated BMI but be “metabolically healthy.”3,5,6 The Edmonton Obesity Staging System (EOSS) addresses this issue by combining BMI classification with an evaluation of obesity-related comorbidities.3 The EOSS describes the various stages of complications and suggests management strategies for each level (see Table 3 in reference #3). The EOSS has been shown to be superior to BMI and waist circumference alone at predicting all-cause mortality.7 Provide lifestyle counselling Pharmacists can deliver advice on healthy eating and physical activity, and help patients set realistic health goals. A number of dietary approaches have demonstrated efficacy for weight loss, including calorie restriction and various eating patterns including Mediterranean, vegetarian, low carbohydrate, and DASH, among others.8 Moderate-to-vigorous physical activity for 30–60 minutes per day, on most days of the week, can contribute to modest weight and fat loss, improved cardiometabolic parameters, and weight maintenance after weight loss.9 Helping patients find a dietary approach and exercise modality they enjoy and can sustain is the key. While medical nutrition therapy or exercise program design are outside the scope of pharmacy practice, pharmacists can share evidence-based resources such as those from Diabetes Canada10 and the Heart and Stroke Foundation.11 Pharmacists can administer structured, evidence-based nutrition plans. A 2021 study found that a pharmacist-led, low-calorie, low-carbohydrate therapeutic nutrition intervention in patients with type 2 diabetes was superior to usual care in reducing body weight, BMI, medications required and cardiometabolic markers.12 In helping to set realistic goals, pharmacists should remind patients that many factors influence whether weight is lost. Rather than focusing on the number on the weight scale, pharmacists should help patients “[redefine] success as healthy behaviour change regardless of body size or weight.”7 Manage pharmacotherapy Behaviour changes such as healthy eating and physical activity alone result in an average weight loss of just 3%–5%, which is often not sustained over the long term. Pharmacotherapy should be considered when these changes have been ineffective or insufficient.13 Four medications are indicated in Canada for long-term obesity management: liraglutide, naltrexone-bupropion, orlistat and semaglutide injection. They should be used as adjuncts to health-behaviour changes and have been shown to produce clinically significant weight loss and health benefits compared to placebo over a duration of at least one year (Table 1).13 Pharmacotherapy may be considered for patients with BMI ≥ 30 kg/m2 (or ≥ 27 kg/m2 with obesity-related complications) and should be considered early in the development of obesity. Efficacy should be assessed after three to six months at a therapeutic dose. If treatment goals are met, medication should be continued. If goals are not met, an alternate medication may be added or substituted. Similar to treating hypertension or diabetes, the benefits of obesity pharmacotherapy endure only while the patient continues treatment. The Obesity Canada guidelines contain helpful tables to aid in personalizing medication choices for each patient.13,14 Pharmacists should not recommend prescription medications, nonprescription medications or supplements for weight loss other than those mentioned above, due to lack of evidence of efficacy or potential safety concerns.13 As dietary changes are made and/or weight is lost, pharmacists must monitor and potentially adjust other medications a patient may be taking. Antihypertensives and antihyperglycemics are particularly important to monitor closely due to the risk of hypotension and hypoglycemia.15 Pharmacists should also help patients avoid, where possible, medications that may contribute to weight gain and be able to suggest potential alternate therapies (see table 8 in reference #3). Metformin may be considered for prevention of weight gain in people with severe mental illness who are being treated with antipsychotic medications associated with weight gain.13 Teamwork Obesity is multifactorial and patients benefit from working with an interdisciplinary team. In addition to the foundation of nutrition and physical activity, the pillars of obesity management are psychological intervention, pharmacological therapy and bariatric surgery. Pharmacists can refer patients to their primary care practitioner, psychologists, registered dieticians and exercise specialists, among other qualified professionals. Building referral networks in your community can be beneficial to both your patients and your practice. Summary Pharmacists can play a key role in promoting weight loss and reducing the risk of obesity-related complications in their patients by demonstrating sensitivity, evaluating the severity of obesity and risk of complications, providing lifestyle counselling, and managing pharmacotherapy. By working with other professionals to promote safe, effective, evidence-based care, pharmacists can help patients achieve and maintain healthy behaviours, which in turn can reduce the risk of obesity-related health complications and improve quality of life. Tim Smith is co-founder and metabolic health coach at Simplicity Wellness, a lifestyle coaching practice that helps people living with or at risk of cardiometabolic disease improve their health through behaviour changes. Tim is also the Pharmacy Practice Advisor for Pharmacists Manitoba and works in community practice at various locations across four provinces and territories. References: 1. Statistics Canada. Overweight and obese adults, 2018. June 25, 2019. (accessed January 5, 2023). 2. Twells LK, Janssen I, Kuk JL. Canadian adult obesity clinical practice guidelines: epidemiology of adult obesity. (accessed January 5, 2023). 3. Rueda-Clausen CF, Poddar M, Lear SA, et al. Canadian adult obesity clinical practice guidelines: assessment of people living with obesity. (accessed January 5, 2023). 4. Kirk SF, Ramos Sals X, Alberga AS, et al. Canadian adult obesity clinical practice guidelines: reducing weight bias in obesity management, practice and policy. (accessed January 6, 2023). 5. Nuttall FQ. Body mass index. Obesity, BMI, and health: a critical review. Nutr Today 2015;50(3):117-28. (accessed January 6, 2023). 6. Coulman K, Sauchelli Toran S. Body mass index may not be the best indicator of our health - how can we improve it? The Conversation. Released July 29, 2020. (accessed January 6, 2023). 7. Wharton S, Law DCW, Vallis M, et al. Obesity in adults: a clinical practice guideline. CMAJ 2020;192:E875-91. (accessed January 5, 2023). 8. Brown J, Clarke C, Johnson Stoklossa C, et al. Canadian adult obesity clinical practice guidelines: medical nutrition therapy in obesity management. (accessed January 7, 2023). 9. Boulé NG, Prud’homme D. Canadian adult obesity clinical practice guidelines: physical activity in obesity management. (accessed January 7, 2023). 10. Diabetes Canada. Just the basics. (accessed January 29, 2023). 11. Heart and Stroke Foundation. Eating for a healthy heart. (accessed January 29, 2023). 12. Durrer C, McKelvey S, Singer J, et al. A randomized controlled trial of pharmacist-led therapeutic carbohydrate and energy restriction in type 2 diabetes. Nat Commun 2021;12,5367. (accessed January 21, 2023). 13. Pedersen SD, Manjoo P, Wharton S. Canadian adult obesity clinical practice guidelines: pharmacotherapy for obesity management. (accessed January 6, 2023). 14. Obesity Canada. Pharmacotherapy for obesity in adults. (accessed February 7, 2023). 15. Riley K, McKelvey S, Reece B. The evolving role of therapeutic nutrition. Canadian Healthcare Network. January 27, 2022. (accessed January 29, 2023).

5 Tips: Discussing weight and health with your patients

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