Special Considerations

Adapting Weight Loss Programs To Meet the Needs of Diverse Patient Populations

Standard obesity treatment approaches should be tailored to the needs of patients. It is, however, difficult to determine from the literature how often this occurs and whether it makes weight loss programs more effective. Very few published reports of such adapted programs can be identified, particularly when a distinction is made from reports that include or focus on special populations but do not report any particular steps taken to modify the intervention for these populations. In addition, it is impossible to compare directly the amount of weight lost using specially adapted programs with that achieved when more standard approaches are used. Studies reporting these programs are sometimes pilot studies or descriptive reports. Where randomized controlled trials or quasi-experiments are available, they usually do not include an internal comparison with a program involving no adaptations. 

Large individual variation exists within any social or cultural group; furthermore, there is substantial overlap among subcultures within the larger society. There is, therefore, no "cookbook" or standardized set of rules to optimize weight reduction with a given type of patient. A theoretical and qualitative analysis of cultural appropriateness in obesity treatment programs has been conducted, and it provides some guidance for incorporating patient characteristics and perspectives when designing and delivering weight loss programs (257).  For example:

I. Adapt the setting and staffing to the patient population. The setting should:

• be physically accessible to the patient;
• have features likely to be familiar to the patient;
• be free of negative psychosocial connotations;
• be devoid of aspects that create a large social distance among patients or between patient and practitioner; and
• promote active patient participation and high patient self-esteem and self-efficacy.

The staff should be culturally self-aware and culturally competent in working with persons of diverse cultural backgrounds and income or educational levels. For example, cultural adaptation of programs has been approached with the assumption that community centers may be preferable to hospitals or medical offices as venues for conducting lifestyle weight reduction programs. Or, some programs have included peer educators as a possible way of helping to overcome background and social class differences by providing a bridge of knowledge, experience, and perspective between patients and practitioners.

II. List assumptions about the type of patient for whom the program will be best suited and evaluate the extent to which these assumptions are appropriate for prospective patients. Where appropriate, modify the program to avoid the need for certain assumptions. Consider patients':

• preexisting knowledge base;
• day-to-day routine;
• discretionary time;
• financial resources and living situation;
• cultural preferences for types of food and activity.

For example, redesign printed materials to be suitable for patients with low literacy skills or poor vision. Offer dietary and physical activity recommendations that will be feasible for low-income patients living in inner-city areas with limited access to supermarkets or with high crime rates.

III. Consider how the obesity treatment program fits in other aspects of the health care and self-care of the patient(s), and integrate other aspects where appropriate. For example, for those patients with diabetes, information about weight reduction should be aligned with other diabetes management advice.

IV. Expect and allow for program modifications based on patient feedback and preferences. Program appropriateness can be increased when patients can express their needs and preferences, and the program is then adapted to those needs and preferences. This is especially applicable when practitioners have limited common experience with patients.

In recent years, a fat acceptance, nondieting advocacy group has developed. This has emerged from concerns about weight cycling and its possible adverse effects on morbidity and mortality. However, recent evidence suggests that intentional weight loss is not associated with increased morbidity and mortality. For this reason, the guidelines have been made explicit on the importance of intervention for weight loss and maintenance in the appropriate patient groups.