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Motivating Patients Toward Weight Loss

Practical Strategies for Addressing Overweight and Obesity

Susan J. Bartlett, PhD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 31 - NO. 11 - NOVEMBER 2003


In Brief: Primary care physicians may feel ill-equipped to counsel patients about practical methods for weight loss, even though the benefits of maintaining a healthy weight are well known. The tools physicians need for tailoring therapy are a range of options that address exercise, diet, and behavior change. Overcoming the barriers to a frank discussion of weight and using available resources for weight management can make a healthy difference for overweight and obese patients.

More than half of all American adults are overweight or obese. Weight-related conditions rank second only to smoking as a preventable cause of morbidity and mortality, and they account for 300,000 deaths each year.1 Added pounds increase the risks of diabetes, cardiovascular disease, stroke, arthritis, gall bladder disease, some gynecologic problems, some cancers, and certain lung ailments.2 Most overweight individuals see a physician at least once a year. As weight increases, so does the frequency of physician visits,3 often for health conditions related to weight. However, of the nearly 13,000 individuals surveyed in the Behavioral Risk Factor Surveillance System, only 42% of obese individuals reported being advised to lose weight by their healthcare providers.4 This is particularly worrisome, given that weight loss in obese individuals has clear and important physical and psychosocial benefits.

In 1998, the National Heart, Lung, and Blood Institute (NHLBI) released clinical guidelines on the identification, evaluation, and treatment of overweight and obese adults.5 Recommendations included that healthcare professionals address risk-factor reduction and weight management strategies with all obese patients. From a public health perspective, healthcare visits provide an important opportunity for clinicians to give patients the information, skills, and support they need to effectively lose weight and keep it off.

Overcoming Reluctance and Pessimism

Weight can be a sensitive subject, and clinicians need a high level of both sensitivity and skill when approaching the subject with patients who may be in denial about the seriousness of the problem. The number of physicians who endorse the importance of counseling patients about weight management continues to increase6; however, several factors influence when and how weight counseling occurs. Primary care providers and cardiovascular specialists are twice as likely as all other types of physicians to identify and address overweight and obesity with their patients.3 Patients receiving care for weight-related conditions, such as diabetes, are also more likely to be counseled about their weight.3

Many providers report being somewhat pessimistic about their patients' ability to successfully manage their weight.7 Patients and providers have heard the dismal statistics concerning weight regain, suggesting that most individuals who lose weight will not be able to keep it off over time. Studies conducted in clinical settings have suggested that many obese people will not achieve and sustain an "ideal" body weight, but growing evidence suggests that even relatively small losses (ie, 10% of body weight) confer significant improvements in health and well-being.2 In our ongoing clinical trials, patients have frequently reported that losing just 4.5 kg (10 lb) results in noticeable improvements in areas such as sleep quality, knee pain (related to osteoarthritis), and energy level.

Additional barriers to counseling patients include a lack of skills and resources needed to help patients lose weight.6 Even in 2003, relatively few US medical schools and residency programs include weight management education and counseling skills training as part of their curriculum. Thus, most clinicians have neither the training nor the support necessary to address weight management successfully with their patients. Many healthcare providers view specialists, such as dietitians or mental health professionals, as better suited to identify and address weight management, offer brief education, and provide appropriate treatment recommendations for their patients. Lack of reimbursement for weight-related discussions certainly doesn't encourage physicians to intervene. With increasing demands on time and growing scarcity of resources, it can be easy for clinicians to focus on the patient's present concern and regard discussions about obesity as a low priority.

Brief Conversations Make a Difference

Increasingly, obesity is viewed within a chronic disease model, underscoring the importance of ongoing discussions and appropriate treatment recommendations. As with all chronic conditions, physicians play a key role in evaluating patients and providing simple brief advice, support, recommendations, and pharmacotherapy or referral for surgery, when indicated. Most individuals view their doctor as their primary source of healthcare information. Conversely, when weight and physical activity are not addressed during physician visits, patients may interpret this to mean that healthy behavior really isn't that important.

As with other health-related behaviors, brief, structured interventions by physicians do have an important public health impact. In one study,8 when physicians counseled their patients to stop smoking, interventions as brief as 3 minutes increased successful quit attempts. Of course, longer counseling often brings better results.

The timing of discussions about weight and lifestyle changes may also affect their efficacy. Naturally, the clinician must first discuss the patient's symptoms and elicit the hidden fears that may have prompted the office visit. A patient who has sore knees may be fearful that she has rheumatoid arthritis, but she is unlikely to be receptive to discussions about losing weight, even if that may clearly benefit her knees. If the subject of weight control is approached right after important new medical information has been provided (eg, a new diagnosis of hypertension), it may be very difficult for the patient to participate in the discussion. Strategies for weight control may be more well received at a follow-up visit, after the patient has had time to absorb the meaning of the diagnosis. Whenever possible, have patients return for a separate visit, perhaps to check blood pressure, and discuss weight control during this visit. Patients may then view diet and exercise as a positive part of the plan to fight the disease.

The chronic nature of weight control means that there will be gains as well as losses. For some patients, stabilizing their weight or increasing physical activity enough to improve fitness is an important initial step toward long-term weight management. Physicians can encourage patients by emphasizing that even small reductions (ie, 10%) in weight are beneficial, and that weight regain, though discouraging, should not be viewed as having failed at weight control. Weight is not cured; it is managed over time. Small weight regains can serve as important reminders to review daily choices and overall lifestyle options to prevent larger gains. Providers, who may also feel a sense of failure when patients do not lose weight between visits, should remember that few of us succeed at making substantial changes on the first attempt.

Physicians can play a critical role in weight management. First, office visits provide an opportunity to identify overweight and obese patients. Any metabolic or other medical causes that may be related to weight gain, including hypothyroidism, should be investigated and ruled out. Review of the patient's current medications will determine if any prime offenders (eg, some antidepressants, antiseizure agents, antihistamines, antihypertensives, or oral diabetes agents) are reliably associated with weight gain. Providers can then link weight to patients' current health and risk factors, thereby reinforcing the importance of reducing weight as part of treatment plans or preventive measures. Healthcare providers can be an important source of factual, unbiased, and up-to-date information about effective therapies and can link patients with other professionals (eg, dietitians, psychologists) for a team approach.

By providing encouragement and hope, having a positive attitude, and working with patients as a "coach," physicians can play a crucial role in their patients' weight management success. Ideally, clinicians would schedule recurring follow-up visits to monitor progress, but few insurance companies cover this approach.

Basic Tools

To help primary care providers and patients with the task of losing weight and keeping it off, basic tools and resources are available from several sources. In 2000, as part of its overall obesity education initiative, NHLBI published an 88-page Practical Guide2 for healthcare providers. Clinicians are strongly urged to obtain a copy of the guide from the NHLBI Web site. Also available is the 228-page Evidence Report.9

The NHLBI Web site also has several tools for healthcare professionals, including a body mass index (BMI) calculator that can be downloaded to a personal digital assistant (PDA), interactive Web pages, and patient handouts that are easy to access. Another part of the Web site lets patients go directly to information, including an interactive questionnaire on risks, guides to physical activity and behavior change, smart shopping tips, healthy recipes, and more help on weight control.

Tailoring the Assessment

One of the most expedient methods to assess health risks in adults is to calculate the patient's BMI. Clinical judgment must be used when evaluating athletes; their BMI may not adequately reflect muscle-to-fat ratios. A man whose waist circumference exceeds 40 in. or a woman whose waist exceeds 35 in. may also have increased health risks. Overall risk, however, is assessed by a combination of BMI, waist circumference, and the presence of additional disease risk factors (table 1).

TABLE 1. Assessment of Risk Factors for Weight-Related Disease

1.Determine the relative disease risk status based on body mass index and waist circumference (see Crespo table 1). Patients at very high and extremely high risk require intense risk-factor modification and management.

2.For patients at high, very high, or extremely high absolute risk, assess:
  • Existing coronary heart disease
  • Presence of other atherosclerotic diseases
  • Type 2 diabetes (fasting plasma glucose > 126 mg/dL or 2-hour postprandial plasma glucose of > 200 mg/dL)
  • Sleep apnea
3.Identify other obesity-associated conditions, such as:
  • Gynecologic abnormalities (eg, menorrhagia, amenorrhea)
  • Osteoarthritis
  • Gallstones (especially during periods of rapid weight loss)
  • Stress incontinence
4.Explore cardiovascular risk factors that have a high absolute risk, including:
  • Cigarette smoking
  • Hypertension or current use of antihypertensive medications
  • High low-density lipoprotein (LDL) cholesterol, defined as > 160 mg/dL or 130-159 mg/dL plus 2 additional risk factors
  • Low high-density lipoprotein (HDL) cholesterol, defined as < 35 mg/dL
  • Impaired fasting plasma glucose (110-125 mg/dL)
  • Family history of premature cardiac heart disease
  • Age > 45 for men or > 55 for women (or postmenopausal)
5.Weigh other considerations, including:
  • Sedentary lifestyle
  • Elevated serum triglycerides
Source: NHLBI Practical Guidelines.2

The patient's motivation to lose weight and readiness to change weight-related behaviors are important components of the assessment. Understanding key psychosocial and motivational factors that facilitate or hinder weight loss attempts is important in developing a weight management plan.

Not everyone who is overweight necessarily needs to lose weight. For instance, overweight patients who have no other risk factors, or only one, and who are not currently motivated to lose weight should be counseled about making lifestyle changes to prevent additional weight gain. Obese individuals (BMI ≥ 30 kg/m2) and overweight persons (BMI ≥ 25 kg/m2) who have abdominal obesity or more risk factors should be actively encouraged to lose weight.2

Proven Strategies for Weight Loss

The safest and most effective weight loss programs all focus on diet, eating behaviors, and physical activity.10 Inadequate attention to any one of these components decreases the likelihood of long-term weight loss, and several approaches to diet modification and exercise have been shown to be helpful.11 A tailored approach that appeals to patients and can be integrated into their current lifestyle is likely to be more readily adopted and sustained.

Diet. The safest and most effective way to lose weight is to reduce caloric intake by 500 to 1,000 kcal/day, resulting in weight loss of 0.45 to 0.9 kg (1 to 2 lb)/wk.2,5,12 That may sound disappointingly low, and patients should be advised that consuming too few calories will not hasten weight loss. Drastic calorie reductions are very difficult to sustain and can impair health. Women should aim to consume 1,000 to 1,200 kcal/day; men should aim for 1,200 to 1,600 kcal/day. Six months of diet, behavior, and exercise therapy is a reasonable timeline for a 10% reduction in body weight.5 The NHLBI guidelines and most public health experts still recommend a higher carbohydrate and relatively low-protein and low-fat approach, but recent evidence suggests that higher-protein diets (eg, the Atkins diet) also appear relatively effective and safe, at least in the short term.13

Many individuals, especially women, are relatively knowledgeable about foods but need encouragement to make the best choices daily. If patients have a preference for a certain diet and believe it may be optimal for them (assuming it incorporates the dietary principles of variety, moderation, and inclusion of all food groups), they may be more motivated to follow a structured eating plan.

General dietary recommendations (table 2) are sufficient for most patients, but, for some individuals, a basic low-calorie diet may not be appropriate. Women who are pregnant or breastfeeding, individuals with psychiatric illnesses including substance abuse or a history of eating disorders, those on potent psychoactive medications, or anyone with serious medical problems that may be worsened by caloric restriction must be counseled carefully.2 In such instances, a registered dietitian can work individually with the patient to prescribe a safe eating plan.

TABLE 2. Recommended Elements of a Basic Low-Calorie Diet for Healthy Adults

ComponentRecommended Daily Intake

Calories
Protein
Carbohydrate
Fat (saturated and unsaturated)
Cholesterol
Sodium chloride
Calcium
Fiber
500-1,000 kcal/day reduction
About 15% of total calories
≥ 55% of total calories
≤ 30% of total calories
< 300 mg/day
< 2,400 mg/day
1,000-1,500 mg/day
20-30 g/day

A caloric reduction of 500-1,000 kcal/day usually results in a weight loss of 0.45-0.9 kg (1-2 lb) per week, a safe and effective rate. No current data suggest that it is necessary to adjust these amounts for any age-group or for gender. A registered dietitian can provide individualized plans, if needed.

Source: National Heart, Lung, and Blood Institute, Obesity Education Initiative Expert Panel: The Practical Guide: Identification, Evaluation and Treatment of Overweight and Obesity in Adults. National Institutes of Health publication no. 00-4084, Rockville, MD, October 2000.

Eating behaviors. Helping patients discover why they eat is as important as knowing what they eat. Patients who have been overweight their entire lives may not know what hunger truly feels like. Parents who reward their children's good behavior with food may unknowingly create a lifelong confusion between being fed and being loved. Some people just eat when they're bored. Others are simply not aware of the amount they consume while watching television.

Patients may need extra help to develop a self-awareness about when and why they eat what they eat. Keeping a simple daily log of the time, place, and amount of all food consumed may provide some important insights. Healthcare providers must look at the whole patient—not just the physiologic or medical aspects. Physicians do not need to be specially trained as weight management counselors, but they must be willing to learn more about the patient. For example, single mothers may not have the time or resources to join a formal weight loss program, but they can still make choices about food preparation, how often they eat out or bring lunch, etc. Understanding the patient's current psychosocial status will help the clinician tailor appropriate messages about losing weight.

A patient's failure to change may indicate the presence of latent emotional or psychological issues that should be addressed. For instance, though many people experience improvements in mood with weight loss, weight loss is not an effective treatment for major depression. Instead, depressed individuals should be offered treatments that have proven efficacy (eg, counseling, pharmacotherapy, or both).14 When the depression has been adequately addressed, efforts to lose weight can be undertaken. Similarly, patients who have a history of eating disorders may be at increased risk of relapse, and they may benefit from referral to an eating disorder specialist.

Physical activity. Regular physical activity is an essential component of all weight management programs.2,5 In overweight people, exercise history and social support (ie, encouragement from family and friends) are two factors associated with becoming and staying active. During office visits, advice to become physically active is often provided, but many times concrete strategies to help patients adopt and maintain regular exercise are not offered. Many of the same behavioral and motivational strategies that promote dietary adherence are also effective in establishing regular exercise habits: setting specific and realistic goals, regularly monitoring goal attainment, developing skills to overcome barriers, and having a plan to deal with lapses (see the Patient Adviser, "Weight Loss Success: Small Steps to Reach Your Goal").

Enhancing Motivation

What can clinicians do when patients simply do not feel ready to do anything about their weight? Readiness is an important consideration, and patients must be given an opportunity to honestly assess and discuss their current feelings about undertaking a significant weight loss effort at this time. Similarly, timing is another important determinant of success, and serious weight management efforts should be undertaken when individuals are able to devote significant time and energy to their goals.

Some strategies can be used to enhance motivation in patients. By asking a few questions (table 3) about patients' readiness to try losing weight and by understanding what they will need to change, clinicians can assess patients' status. If patients are not ready to begin a weight loss program, discussing their previous experiences will help them recognize other areas of their lives where they have already taken on important challenges (eg, earning a degree, raising children). By emphasizing patients' success through commitment and persistence in other areas, motivation can be increased. A few minutes spent understanding the patients' current circumstances, perceived barriers, and motivational readiness are a good start. Little benefit is derived in discussing the specific behaviors of what to do to lose weight when the patient is not ready to even think about the tasks ahead.

TABLE 3. Questions to Assess Patient Readiness and Motivation to Lose Weight

What are your goals concerning weight and exercise? Do these seem realistic to you?

What behavioral changes are you ready to make right now? (eg, give up smoking, start an exercise program, change my eating habits)

Are there any behaviors you do not feel ready to work on right now?

Have you tried making lifestyle changes in the past? What has kept you from succeeding in the past?

What are you willing to change to become successful this time?

Is there anything preventing you from exercising? (eg, unsafe neighborhood, cost, access, support system)

Considering everything else going on in your life right now, is this truly the right time to make a serious lifestyle change?

Can you set a specific date when you will be ready to begin?

Are you able to devote time each day (eg, 15-30 min) toward planning and achieving your goals?

What do you need or want from others to help you succeed? (eg, support from family and friends, enrollment in an exercise class, transportation to and from Weight Watchers meetings, help with menu planning)

Do you feel comfortable asking for help?

What are you willing to do right now? Let's discuss the specific behaviors you are going to address first (make notes in patient chart). How confident are you, on a scale of 1-10, that you will be able to meet each of these goals?

How can I help you with this? (Provide referrals to other specialists as indicated.)

Just in case it's needed, what kind of back-up plan can we develop if your plans are not working as well as we hoped?

Setting goals comes naturally to most of us; however, outlining a series of progressive, achievable goals is not an innate skill. Goal setting is the process of specifying what needs to be done, when and how to do it, and what the anticipated outcomes will be. Effective goals are established across three time frames—long-range, medium-term, and short-term. It is often easier to begin with the long-range goals that are more global, then formulate medium-term goals (ie, what will be accomplished in the next 6 months), and end with the immediate changes needed to achieve short-term goals. Goals must be specific, target behaviors directly, and have measurable outcomes. Physicians can play a vital role by directing patients to set goals in key areas (eg, diet, exercise, and behavior) and confirming that the goals are realistic and achievable.

Patients may take their goals more seriously if they receive a copy written on a prescription or office notepad. They are less likely to forget details and more likely to at least try to make the goal. They may also feel more accountable. Recording the patient's goals in the clinic notes serves to reinforce the importance of focusing on day-to-day behaviors, underscores the link between behaviors and health, and prompts physician inquiries about results during the next office visit.

Monitoring progress at follow-up visits should begin by reviewing the steps taken toward goals. Details in the patient's chart can help direct the conversation (eg, "You were going to try walking for 15 minutes 3 days a week at lunch. How did that go?"). By asking specific questions and focusing on results, clinicians help patients create a natural link between their behavior and their desired health outcomes. Acknowledgment of efforts, along with a little praise and encouragement, can boost self-confidence, motivate continued efforts, and be the highlight of the visit for the patient.

Feedback should not be limited to a review of what has happened. Patients need help to develop a proactive approach to weight management by anticipating high-risk situations, such as a vacation or stressful work period, and plan accordingly.

Slips and setbacks are common. In some instances, patients will report impressive changes in weight or physical activity patterns between office visits. More often, however, this will not be the case. Setbacks are precisely when physicians can have an important impact on the patient's subsequent behavior. Although earlier attempts may not result in sustained weight loss, important lessons about relapse are learned that ultimately culminate in success.

Successful change in any area, no matter how seemingly small, is not a trivial event. When patients feel discouraged or motivation is waning, it is especially important to focus on daily behaviors in relation to long-term goals. By focusing on positive changes and offering praise and encouragement, clinicians can inspire patients to be willing and ready to set and achieve new goals before the next office visit.

Community Support

If little progress is seen between visits, it may help to ask the patient whether additional skills and support would facilitate weight management. While some individuals prefer to address their weight on their own, many find that the knowledge, motivation, social support, and accountability offered by weight loss programs are very helpful. Many quality community programs (eg, Weight Watchers) offer a safe, proven approach to weight loss9 with the convenience of multiple locations and times. Other commercial programs also have safe and effective weight loss plans, but some require clients to consume foods purchased through the program, increasing costs significantly.

Hospital and teaching universities in urban centers may offer low-cost weight loss programs. Often, a few sessions with a dietitian can be very helpful for reviewing appropriate portion sizes (an unfamiliar concept to many in our "supersize" culture) and customizing an eating plan. When patients have obesity-related conditions, such hypertension, diabetes, or hypercholesterolemia, the likelihood is greater that their health insurance will pay for some dietary counseling.

Some patients benefit more from support and education to increase their levels of physical activity. Again, safe and effective community-based exercise programs designed to meet a wide range of needs are widely available at YMCAs or YMHAs, community recreation centers, or community colleges. Patients who desire more individualized attention may consider working with an exercise and fitness specialist. Organizations such as the American College of Sports Medicine, the American Council on Exercise, and the National Strength and Conditioning Association can help locate certified trainers in your area.

Adjuvant Therapies

Sometimes more intensive therapy is warranted when diet and exercise fail to yield satisfactory results, or for morbidly obese patients at high risk.

Psychotherapy. At times, psychological factors may play an important role in sustaining unhealthy lifestyle habits. Chronic overeating and highly sedentary behavior are important markers of psychological distress. Untreated depression and anxiety disorders are often contraindications to an intensive weight loss effort, and these should be addressed before a program is undertaken.5 Exercise is known to be a potentially effective treatment for mild-to-moderate depression (and an adjunct to treatment for all types of depression)15; however, individuals will require ongoing monitoring to assess symptoms. Whenever psychological distress and disordered eating patterns are present, referral to a mental health specialist for further evaluation and possible medication is prudent.

Pharmacotherapy. For some, the risks associated with obesity warrant consideration of drug therapy. Generally, weight loss drugs should be used as part of a comprehensive program of diet, physical activity, and behavior change in an obese or overweight patient who has a BMI ≥ 27 kg/m2 with other obesity-related risk factors or diseases.2 Currently, the most commonly prescribed weight loss drugs are sibutramine hydrochloride monohydrate, (a norepinephrine, serotonin, and dopamine reuptake inhibitor) and orlistat (an agent that blocks dietary fat absorption in the gut). Pharmacotherapy should be discontinued if a patient does not lose 2 kg (4.4 lb) within the first 4 weeks of therapy, because those who do not respond initially are unlikely to respond at all, even with an increase in dosage.2 Patients diagnosed as having hypothyroidism who are given thyroid replacement hormone will stop gaining weight, but they will not lose any weight unless they follow a diet, exercise, and behavioral change program.

Patients must be monitored appropriately (eg, weight loss, blood pressure, pulse, lab tests as indicated) and given opportunities to ask questions while using weight loss medications.2 The recommended monitoring schedule includes an initial follow-up visit in 2 to 4 weeks, then monthly visits for 3 months, and every 3 months thereafter. After a year, physicians can determine the appropriate interval for visits.

Gastric surgery. Unless the patient is at least 100 lb overweight with a BMI ≥ 40 kg/m2 or a BMI ≥ 35 kg/m2 with serious obesity-related conditons, has weight-related health conditions, and other attempts at weight loss treatment have failed, surgery is not recommended.2 Surgery requires lifelong medical monitoring and is associated with significant complications and mortality rates ranging from 2% to 4%, but it does result in sustained weight losses. A detailed review of indications and recommendations for pharmacotherapy and gastric surgery is provided in the NHLBI guide.2

Creating Healthier Lives

Counseling patients about weight loss requires specific knowledge and skills. Physicians play an important role in providing the knowledge, motivation, and opportunities that patients need to achieve and maintain a healthy weight. Physicians can also give support and direction to coordinate more intensive multidisciplinary approaches for patients who have long-standing weight problems or additional concerns. The escalating rates of overweight and obesity among US adults and children compels all healthcare providers to address the issue and stem the growing health problems that result from excess weight. Fortunately, basic tools, resources, and practical, effective treatment recommendations are available to clinicians who offer direction and support to patients who wish to effectively manage their weight.

References

  1. McGinnis JM, Foege WH: Actual causes of death in the United States. JAMA 1993;270(18):2207-2212
  2. National Heart, Lung, and Blood Institute, Obesity Education Initiative Expert Panel: The Practical Guide: Identification, Evaluation and Treatment of Overweight and Obesity in Adults. National Institutes of Health publication No. 00-4084, Rockville, MD, October 2000
  3. Fontaine KR, Faith MS, Allison DB, et al: Body weight and health care among women in the general population. Arch Fam Med 1998;7(4):381-384
  4. Galuska DA, Will JC, Serdula MK, et al: Are health care professionals advising obese patients to lose weight? JAMA 1999;282(16):1576-1578
  5. National Heart, Lung, and Blood Institute: Clinical Guidelines on the Identification, Evaluation and Treatment of Overweight and Obesity in Adults: Executive Summary. National Institutes of Health, Rockville, MD, 1998. Available at https://www.nhlbi.nih.gov/guidelines/obesity/ob_xsum.htm. Accessed August 15, 2003
  6. Wechsler H, Levine S, Idelson RK, et al: The physician's role in health promotion revisited: a survey of primary care practitioners. N Engl J Med 1996;334(15):996-998
  7. Orleans CT, George LK, Houpt JL, et al: Health promotion in primary care: a survey of US family practitioners. Prev Med 1985;14(5):636-647
  8. Clinical Practice Guideline: Treating Tobacco Use and Dependence. US Department of Health and Human Services, Public Health Service, 2000
  9. National Heart, Lung, and Blood Institute: Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: the Evidence Report. National Institutes of Health publication No. 98-4083, Rockville, MD, 1998. Available at https://www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm. Accessed August 18, 2003
  10. Thomas PR, Stern JS (eds): Weighing the Options: Criteria for Evaluating Weight-Management Programs. Committee to Develop Criteria for Evaluating the Outcomes of Approaches to Prevent and Treat Obesity. Washington DC, Institute of Medicine, National Academies Press, 1995
  11. Andersen RE: Exercise, an active lifestyle, and obesity: making the exercise prescription work. Phys Sportsmed 1999;27(10):41-48
  12. Millman M (ed): Access to Health Care in America. Committee on Monitoring Access to Personal Health Care Services. Washington DC, Institute of Medicine, National Academies Press, 1993
  13. Foster GD, Wyatt HR, Hill JO, et al: A randomized trial of a low-carbohydrate diet for obesity. N Engl J Med 2003;348(21):2082-2090
  14. Depression Guideline Panel: Depression in Primary Care II: Treatment of Major Depression: Clinical Practice Guidelines. Agency for Health Care Policy and Research publication No. 93-0551, US Government Printing Office, 1993
  15. Brosse AL, Sheets ES, Lett HS, et al: Exercise and the treatment of clinical depression in adults: recent findings and future directions. Sports Med 2002;32(12):741-760


Dr Bartlett is a clinical psychologist and faculty member in the division of rheumatology at Johns Hopkins School of Medicine in Baltimore. Address correspondence to Susan J. Bartlett, PhD, Johns Hopkins Rheumatology, Johns Hopkins AAC, Suite 1B.15, Baltimore, MD 21224; address e-mail to: [email protected].

Disclosure information: Dr Bartlett discloses no significant relationship with any manufacturer of any commercial product mentioned in this article. No drug is mentioned in this article for an unlabeled use.


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