How to Use the 5 As Model to Help Your Patients Lose Weight

CASE:
Patient A.J. is a 45-year-old female who comes in for an annual physical. She has a history of Class 2 obesity, hypertension and hypercholesterolemia. You noticed that she gained 20 pounds since her last visit six months ago. She has no complaints. You would like to discuss her weight gain. What is the next step?

Ask her if it is okay to discuss her weight.

Ask

Ask is the first phase in the 5 As model (Ask, Assess, Advise, Agree, Assist and Arrange). 5 As is a model for motivational interviewing. It has been used in many different areas, such as smoking cessation, dietary change and reducing alcohol consumption.¹ It has also been shown to be beneficial in obesity management. It influences patients to be more motivated and confident to change their behavior.

When you take the time to seek your patient’s permission to discuss their weight, you appear non-judgmental, and you open the floor for better communication. The patient is more receptive to what you have to say next. Weight can be a very emotional subject. Some patients don’t want to discuss it at that moment. If the patient decides it is not a good time to discuss it, then at least you are leaving the door open for when they are ready.

Here is a summary of the 5 As model:

Ask	·      Ask for permission to discuss body weight. ·      Explore readiness for change
Assess	·      Assess BMI, waist circumference, and obesity stage. ·      Explore drivers and complications of excess weight.
Advise	·      Advise the patient about the health risks of obesity, the benefits of modest weight loss (i.e. 5-10 percent), the need for long-term strategy, and treatment options.
Agree	·      Agree on realistic weight-loss expectations, targets, behavioral changes, and specific details of the treatment plan.
Arrange/Assist	·      Assist in identifying and addressing barriers; provide resources; assist in finding and consulting with appropriate providers; arrange regular follow up.

Bays HE, McCarthy W, Christensen S, Tondt J, Karjoo S, Davisson L, Ng J, Golden A, Burridge K, Conroy R, Wells S, Umashanker D, Afreen S, DeJesus R, Salter D, Shah N. Obesity Algorithm Slides, presented by the Obesity Medicine Association. www.obesityalgorithm.org. 2020. https:// obesitymedicine.org/obesity-algorithm-powerpoint/

CASE:
A.J. is appreciative that you asked her about her weight. This has been a challenging time for her. She was recently placed on paroxetine for her depression and noticed a 20-pound weight gain. She has started exercising three days a week for 30 minutes and cutting out simple sugars in her diet. However, she has not seen a difference in her weight. She is frustrated with this weight gain. She doesn’t understand why she has gained weight and why it is so hard to lose weight. She had no problem in the past.

Assess

The next phase in the 5 As model is to Assess. When assessing the patient, you should focus on their weight loss history, BMI, causes of obesity, complications of obesity, current nutrition and exercise regimen.

Weight Loss History. Taking a good weight loss history will make it easier to advise your patient because you know what worked and what did not. The weight loss history includes their highest weight, lowest weight, what diet and exercise changes they have made, and what medications they took. I also like to ask what caused them to regain weight.

Causes of Obesity. Obesity is a chronic, progressive, relapsing and multi-factorial neurobehavioral disease.⁷ Physicians previously thought obesity was only due to overeating and less exercise. The advice was to “move more and eat less.” This advice was frustrating to patients because when they “moved more and ate less,” it was not guaranteed they would lose significant weight. Some people would gain the weight back once they stopped the lifestyle change.

However, assessing the cause of obesity allows you to address the cause of obesity and create an individualized approach to help your patient lose weight. Causes of obesity could be due to medical conditions (such as polycystic ovary syndrome – PCOS – or Prader-Willi Syndrome), neurobehavioral (depression and anxiety) or endocrine (thyroid disease) issues, genetic/epigenetics, immune conditions and environmental causes.

Table 1: Medications That Promote Weight Gain

Drug classes	Medications That Promote Weight gain	Alternatives	Weight Neutral
Atypical antipsychotics	Olanzapine, Quetiapine, Risperidone, Aripiprazole	Ziprasidone
Anticonvulsants and mood stabilizers	Gabapentin, Divalproex, Carbamazepine	Zonisamide, Topiramate	Lithium, Lamotrigine
Hypoglycemic agents	Tolbutamide, pioglitazone, glimepiride, gliclazide, glyburide, glipizide, sitagliptin	Metformin SGLT-2 GLP-1 agonist
Hormones	glucocorticoids
Antidepressants	Amitriptyline, Mirtazapine, Paroxetine	Bupropion Fluoxetine

Adapted from Domecq JP, Prutsky G, Leppin A, et al. Clinical review: Drugs commonly associated with weight change: a systematic review and meta-analysis. J Clin Endocrinol Metab. 2015;100(2):363-370. doi:10.1210/jc.2014-3421

Advise

In this phase, you can discuss the health risks and complications of obesity. There are more than 200 complications that accompany obesity. It is also helpful to discuss with the patient how losing only 5% to 10% of their current weight can be beneficial. (See Table 2.)

Table 2: Amount of Weight Loss Needed to Effect Medical Condition Improvement

Medical Condition	Amount of weight loss needed to effect medical condition improvement
Prediabetes improvement	2.5% to 10% weight loss
Type 2 diabetes improvement	2.5% to >15% weight loss
Knee pain improvement	5% to 10% improves knee functionality, speed, walk distance and pain
Non-alcoholic steatotic hepatitis	>10% weight loss
Quality of life score	5% to >15% weight loss
PCOS and infertility	2.5% to 5% weight loss will improve ovulatory cycles
Obstructive sleep apnea	>10% weight loss

Ryan DH, Yockey SR. Weight Loss and Improvement in Comorbidity: Differences at 5%, 10%, 15%, and Over. Curr Obes Rep. 2017;6(2):187-194. doi:10.1007/s13679-017-0262-y

Agree

The fourth phase is to agree on the weight loss expectations and lifestyle changes the patient will start implementing. I like to have at least one to three lifestyle changes the patient will agree to and begin to implement. I find that the patient can become overwhelmed with too many lifestyle changes. I remind the patient that they can always add other changes once they have mastered the initial plans.

It is vital to discuss weight loss expectations. Some patients believe they should lose 20 pounds in one month. When they don’t hit the goal, they are disappointed and ready to quit. Focus on realistic goals, such as one to two pounds per week, so that the patient can reach their goal and feel positive about the experience.

If the patient is interested in appetite suppressants to assist them with their weight loss, here are a few FDA-approved medications used for weight loss.

Table 3: FDA-approved Anti-obesity Medications

Medication	Average Weight loss	Side Effects	Contraindications
Phentermine	13%	Elevated blood pressure and pulse, insomnia, constipation and dry mouth	Uncontrolled hypertension CVD Glaucoma Hyperthyroidism
Phentermine-Topiramate (Qysmia)	9.3%	Paresthesias, dizziness, dry mouth, constipation, dysgeusia and insomnia	Uncontrolled hypertension CVD
Liraglutide 3mg (Saxenda)	6.2%	Nausea, vomiting and abdominal pain	Family history of medullary thyroid cancer or MEN 2 Pancreatitis
Semaglutide 2.4 mg (Wegovy)	14.9%	Nausea, diarrhea, vomiting and constipation	Family history of medullary thyroid cancer or MEN 2 Pancreatitis
Naltrexone-buproprion (Contrave)	6.1%	Nausea/vomiting, constipation, headaches, dizziness, insomnia and dry mouth	Uncontrolled hypertension Seizures Bulima nervosa Taking narcotics for pain
Plenity	7.1%	Abdominal distension, infrequent bowel movements and dyspepsia	Esophageal anatomic anomalies Suspected strictures
Orlistat (Alli)	10.2%	Fatty/Oily stool, fecal urgency, oily spotting, increased defecation and flatulence

Tchang BG, Aras M, Kumar RB, et al. Pharmacologic Treatment of Overweight and Obesity in Adults. [Updated 2021 Aug 2]. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK279038/

Arrange/Assist

The last phase is to Arrange and Assist. This phase addresses the challenges and barriers that will come up along the weight-loss journey. It is common for people to get overwhelmed with the challenges during the weight-loss journey and quit, so it is essential to address upcoming challenges and map out ways to overcome them. Whether tempted to eat out during lunch or unable to work out due to their children being sick, taking the time to address the most common challenges will help the patient normalize the obstacles and create a plan to overcome them.

You may be reading this and wondering when you have time to do all of these 5 As in your regular practice. You can split up the 5 As. You can have the patient return to discuss their weight and other options in two to four weeks. Studies show that frequent follow-up is helpful in a person’s weight loss success.⁶

You can also have the patient follow up with a local dietitian or obesity medicine specialist. You can go to the Obesity Medicine Association website at obesitymedicine.org to find a doctor in your area.

Ultimately, you are helping the patient start the process on their weight-loss journey and achieve a happy and healthy lifestyle.

CASE:
After discussing that paroxetine is the culprit for her current weight gain, you suggest switching her to bupropion, increasing her physical activities to five days a week and keeping a food log. A.J. is happy you took the time to discuss her weight and figure out why she is gaining so much weight. She is ready to take action. You will see her back in two to four weeks.