Provider resources for patient care

Specifics for patients

What advice should you give your patients about diet, exercise, and treatment options? The key is simply to start the conversation with your patient and help determine what works best for each individual. Do not expect that you need to be an expert in all topics. Here are some quick ideas about how to begin.

Dietary specifics

Consistent themes for dietary recommendations should include the intake of healthy foods in moderate quantity on a long-term basis (i.e., it must be sustainable).  Healthy foods mean five servings of fruits and/or vegetables per day, limiting dietary fat to <30% of total calories, saturated fat to <10% of total calories, and avoiding trans fats, high fructose corn syrup, highly processed foods, and over consumption of alcohol. Make sure patients know how to read food labels (https://www.fda.gov/food/new-nutrition-facts-label/how-understand-and-use-nutrition-facts-label). Although low carbohydrate diets have the best data for weight loss in clinical trials, the best diet for your patients will be the one they can stick to.

Here are the main types of diets recognized for weight loss plans:

• Low-calorie diet = 800-1500 kcal/per day
• Low-fat diet = <30% kcal/day from fat
• Low carbohydrate diet = <20-25% kcal/day from carbohydrates
• Ketogenic diet = <10% kcal/day from carbohydrates
• Mediterranean diet = five servings of fruits and/or vegetables per day, complex grains, small amount of lean meat, olive oil, nuts
• Intermittent fasting (time-restricted feeding)= limit food consumption to 8h/day or 5 days/wk
• Vegetarian = avoid animal and fish meat
• Vegan = Avoid all animal and fish products

Patients need to learn the difference between what is healthy and what they are, in fact, eating. They can modify their dietary behavior over time by tracking their food, then adjusting their diet as they see how different changes work. A great way to track food is through free apps:

• Lose It! - Weight Loss That Fits
• FatSecret - Calorie Counter and Diet Tracker for Weight Loss
• Cronometer: Eat smarter. Live better.
• SPARKAMERICA - SparkAmerica
• Calorie Tracker & BMR Calculator to Reach Your Goals | MyFitnessPal
• Noom: Stop dieting. Get lifelong results.
• WeightWatchers Weight-Loss Program—Lose Weight and Keep it Off | WW USA
• Some apps that charge a fee may be easier to use and include more features and program support. Here are some fee-based apps:

Physical activity specifics

To improve cardiovascular health, the surgeon general has recommended 60 minutes per week of moderate-intensity physical activity, but more recently, a minimum of 150 minutes per week of moderate-intensity physical activity has become the standard for metabolic health. However, successful weight losers and weight maintainers report exercising 45-60 minutes or more per day. Activity trackers (e.g., Fitbit, Garmin Inspire, Oura, Leaf) can help reduce sedentary behavior; many diet apps (above) track activity. 

The data on weight loss through physical activity alone is not convincing, but it is an important facet in maintaining good health. Encourage your patients to find activities they enjoy. If patients are struggling with weight loss plateaus, they may consider increasing (or starting) strength training/building exercises and building the intensity of their physical activity (with your review of their readiness from a health standpoint, of course!).

Behavior modification specifics

Losing weight is about setting goals and strategizing how to achieve them. Self-monitoring is among the most proven strategies and includes tracking calories eaten and physical activity, as well as weighing in, and meal and exercise planning.  Other useful strategies include mindfulness (only eating when hungry), avoiding saboteurs, situations, and stresses that lead to mindless eating, and resisting using food as a reward.  Some people need accountability, in which case it can be useful to have frequent provider visits, to join a commercial weight loss program, or just to check in with a reliable friend. Much more information on behavior change strategies is found in the Behavioral Health section of this website.

Anti-obesity medication specifics

A presentation by Dr. Perreault on anti-obesity medications can be found HERE.

• Phentermine +/- topiramate is a great choice for someone who complains of fatigue or lack of energy as a reason they cannot comply with healthy behaviors.  Phentermine (15, 30 & 37.5 mg qd) and topiramate (50 mg BID) are both generic and very cheap to pay for out of pocket.  Phentermine comes in a 37.5 mg tablet that can be broken in half.  Qsymia is the trade name combination of phentermine and topiramate (3.75/23, 7.5/46, 15/92 qd).  Patient assistance can be found at Qsymia Engage
  The drug is $98/month.  Coupons are available elsewhere but are not cheaper.  Avoid topiramate in a woman who could or is trying to become pregnant. 
• Buproprion + naltrexone is a great choice for someone who complains of food addictions or gets considerable calories from alcohol.  Buproprion (300 mg qd) and naltrexone (25 mg qd) are both generic and very cheap to pay for out of pocket.  Many people take buproprion already (they may need the dose increased to 300 mg qd though), so naltrexone can simply be added (it comes in a 50 mg tab that should be broken in half for a 25 mg qd dose).  Contrave is the trade name combination of buproprion and naltrexone (90/8 two tabs BID).  Patient assistance can be found at Pay $99 or Less + Free Shipping - CONTRAVE® (naltrexone HCI/bupropion HCI)  The drug is $99/month.  Coupons are available elsewhere but are not cheaper.  Remember, naltrexone has a stand-alone indication for alcohol use disorder.
• Orlistat is a great choice for people who do not want a centrally acting appetite suppressant.  It comes in a prescription form (Xenical 120 mg QAC) or over the counter (Alli 60 mg QAC) with similar efficacy.  Alli is available through Amazon for $63 for 120 pills (this is the cheapest price).  Note that Orlistat has considerable GI side effects.
• Lisdexamfetamine (50, 60 or 70 mg qd) is indicated for binge eating disorder and may have particular utility in someone with obesity and ADHD, since it has a stand-alone indication for the latter.  It requires doses >50 mg/day to be effective for weight loss.  It is only available as a trade name drug (Vyvanse).  Many insurance companies will cover it as long as it is prescribed under the ADHD indication.  Patient assistance can be found at https://www.vyvanse.com/coupon.  Price is variable.  Manufacturer coupons are available at other websites as well. 
• Liraglutide is a great choice for people who are always hungry. Liraglutide is only available by trade name (Saxenda) and is a subcutaneous injection taken daily.  It is titrated weekly and takes 4 weeks to reach the maximum dose (start at 0.6 mg qd and increase by 0.6 mg per week up to 3.0 mg qd).  The slow titration improves GI tolerability.  It is not a stimulant and has cardiovascular benefits.  Patient assistance can be found at https://www.novocare.com/saxenda/savings-card.html.  Price is variable depending on insurance.  Coverage has improved with the launch of Wegovy (below). 
• Semaglutide is another great choice for people who are always hungry. Semaglutide is only available by trade name (Wegovy) and is a subcutaneous injection taken weekly.  It is titrated every 4 weeks and takes 20 weeks to reach the maximum dose. The slow titration improves GI tolerability.  It is not a stimulant and has cardiovascular benefits. It is by far the most potent anti-obesity medication.  Patient assistance can be found at https://www.novocare.com/wegovy/savings-card.html.  Price is variable depending on insurance.  Coverage has improved due to patient demand. 
• Plenity is an inert hydrogel.  It is not a medication per se and has no bioactive ingredients.  It is something people take as their lunch and dinner to fill their stomach (3 tabs twice daily).  It is a great choice for someone worried about medication interactions.  It costs $99/mo and is available at myplenity.com. 

*Using a specialty pharmacy, like Alto, for trade name anti-obesity medications can be enormously helpful to acquire them.

Bariatric specifics

The first rule of surgery is to find a highly experienced surgeon.  Bariatric surgeons routinely perform sleeve gastrectomy and gastric bypass (Rou-en-Y) for weight loss. Gastric banding is no longer recommended.  Bariatric surgery is by far the most effective means for weight loss and has the best record for weight loss maintenance; however, patients must be mentally prepared for a major life change for the procedure to have its optimal result. How patients respond to the pre-surgical intervention (done by the surgical team) is a good prognostic indication of how much weight they will lose. Do not refer your patient to bariatrics if they are not interested in surgery.