Obesity in Primary Care: Referrals and Surgery

It‘s important when we see a patient with obesity that we document his or her body mass index (BMI) and outline an optimal therapeutic plan. If we lack the resources, time, or knowledge to carry out this therapy, consider referring the patient to a weight loss–lifestyle intervention program. For patients with morbid obesity who have not been successful following a lifestyle intervention program (hopefully including weight loss medications), the possibility of undergoing bariatric surgery should be seriously considered.

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Following are answers to the questions primary care physicians most often ask about obesity referrals and surgery:

• When should I refer a patient with obesity to an endocrinologist?

Obesity therapy should be interdisciplinary. Issues related to nutrition; physical activity; appetite; quality of sleep; and anxiety, depression, and stress need to be addressed. In addition, patients with obesity usually have associated medical problems, such as diabetes, hypertension, hyperlipidemia, and metabolic syndrome, that also require attention.

It is difficult for a single provider to address all these issues during a single visit. Collaboration with other colleagues-nutritionists, physical therapists, psychologists, and endocrinologists-is advised.

• How can I help my patients become more physically active?

Insurance companies do not usually cover a consult with an exercise physiologist, but many patients have osteoarthritis and metabolic syndrome, with an increased risk of heart disease. Physical therapy can be very helpful in providing patients with the right tools to increase their physical activity. Given these circumstances, a consult with a physical therapist should be considered. When patients are at increased cardiometabolic risk, an evaluation by an exercise physiologist in cardiac rehabilitation may be very helpful.

Next: Depression, Anxiety, and Eating Disorders

• What about depression, anxiety, and eating disorders?

Depression is prevalent in patients with obesity. Consider a consult to a psychologist to help improve patients’ anxiety-depression. This consult may help them better deal with the stressors in their lives that may be responsible for their overeating. In some circumstances, it may be also important to rule out eating disorders, such as the binge eating of bulimia.

• Is this patient a candidate to undergo bariatric surgery?

To be a candidate for bariatric surgery, a patient needs to have a BMI ≥ 40 kg/m². The cutoff is > 35 kg/m² if he or she has associated medical problems, such as hypertension, type 2 diabetes, elevated cholesterol, significant osteoarthritis, obstructive sleep apnea, or gastroesophageal reflux. Secondary causes of obesity, such as hypothyroidism and Cushing disease, should be ruled out.

The patient, his or her family, and the physician need to be convinced that a medically supervised weight loss program has not been successful in helping the patient lose weight and, more importantly, keep the weight off. At that point, bariatric surgery should be seriously discussed. Reviewing with the patient the potential risks, the need to take vitamins long term, and the need to come to follow-up visits is also very important.

Coming soon, the final part of this Special Report on Obesity in Primary Care, a post-test to assess your knowledge of the latest developments in patient care. Watch your email for eNewsletters from Patient Care and visit our homepage at www.patientcareonline.com to check for updates.

Previous sections can be found here:

Obesity in Primary Care: 12 Big Questions

Obesity in Primary Care: Making the Diagnosis

Obesity in Primary Care: The Comorbidities

Obesity in Primary Care: Treatment