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August 2020, Volume 70, Issue 8

Primary Care Diabetes

The SECURE model: A comprehensive approach for obesity management

Nitin Kapoor  ( Department of Endocrinology, Christian Medical College, Vellore, india )
Sanjay Kalra  ( Department of Endocrinology, Bharti Hospital, Karnal, India. )
Sunil Kota  ( Diabetes and Endocare Clinic, Berhampur, Odisha, India )
Sambit Das  ( Hi Tech Medical College and Hospital, Bhubaneshwar, India )
Stephen Jiwanmall  ( Dept. of Psychiatry, Christian Medical College, Vellore, India )
Rakesh Sahay  ( Department of Endocrinology, Osmania Medical College, Hyderabad, India )


With rapidly increasing prevalence of obesity worldwide, it has become imperative to generate a comprehensive and easy to use clinical model for its management. We propose a simplified yet systematic approach to an obese patient, for a personalised patient centric obesity management. The SECURE model encompasses three domains in evaluation of the patient (Severity assessment, Etiological evaluation and Comorbidity workup) and the other three pillars for obesity treatment (Urge life style changes, Role of medications and surgery and Expected goal setting). This provides a clinical action checklist that may be useful even in other chronic non communicable disorders.

Keywords: Obesity management, Step-wise approach, bariatric protocol




Obesity management is challenging for all health care providers, including specialist endocrinologists, bariatric surgeons, dietitians and generalists.1 The myriad etiopathologic basis, multifaceted clinical presentations, multiple potential complications, and multifarious comorbid conditions, all contribute to this challenge.2,3 The availability of various treatment strategies, each with its own strengths and limitations, serves to confuse, rather than clarify, matters. The screening and diagnostic criteria, as well as intervention threshold used for obesity care are still not standardized globally.4 This adds to the bafflement faced by health care providers. In this manuscript the authors propose a simple yet a strategic approach for the evaluation of obesity, that can provide a comprehensive mana gement plan specific to a given patient.


Person centred care


All these characteristics call for person-centred approach to obesity management. This, however, is easier said than done. Person-centred care is defined as a way of approaching health care delivery to people using health and social services as equal partners in planning, developing and monitoring care to ensure it meets their needs.5 In the context of obesity, this includes assessment and addressal of the biomedical and psychosocial etiologic and clinical aspects of obesity.6-8 The vast spectrum of the biopsychosocial determinants and impact of obesity makes this difficult to do.


Secure model


To simplify-the approach to obesity, and to help navigate the management plan of obesity for a given patient. We propose the SECURE model. SECURE is an alliterative six item rubric which guides the physician in their endeavour to provide person centred care. SECURE encourages the health care provider to assess the Severity of obesity, explore its Etiology, and screen for Comorbid conditions and complications. This process facilities a stepwise, comprehensive clinical anthropometric and biochemical workup. In turn, this equips the health care provider to Urge lifestyle and behavioural changes that will help manage obesity and mitigate its adverse effects, Along with this, Role of the meal replacement, medication and surgery must be discussed. Expectation setting for realistic weight loss targets is an essential part of the risk /cost benefit analysis, and helps in reaching optimal decision regarding choice of intervention and intensity. (Figure)


Secure philosophy


Thus SECURE includes three pillars in the domain of assessment and three in intervention. Both domains, assessment and intervention are concordant with the biopsycho-social model of health, and with the philosophy of person centred care. The focus on Urging lifestyle modification, discussion of Role of various treatment options, and emphasis on realistic Expectation setting in congruent with the twin policies of informed decision making and shared decision making.


Secure usage


SECURE builds upon, and simplifies, earlier rubrics of obesity care. These include the 5A framework published by the Canadian Obesity Network, and the SECURED as well as Baro Sixer models proposed by us. The 5A document from Canada is a comprehensive guide to obesity management; SECURE paraphrases its guidance with brevity and focus, in a secure manner, SECURE amalgamates the information contained in SECURED and BaroSixer, with enhanced brevity and impact.9




The SECURE rubric can be used beyond obesity, to help manage other chronic conditions as well. In fact, the philosophy of SECURE is perfectly suited to conditions such as diabetes and dyslipidaemia. We hope that SECURE will find utility as a clinical action checklist, as well as a learning tool, for obesity as well as other chronic diseases.




1. Yoon KH, Lee JH, Kim JW, Cho JH, Choi YH, Ko SH, et al. Epidemic obesity and type 2 diabetes in Asia. Lancet (London, England). 2006;368:1681-8.

2. Kapoor N, Furler J, Paul TV, Thomas N, Oldenburg B. The BMIadiposity conundrum in South Asian populations: need for further research. J Biosoc Sci 2019;51:619-21.

3. Kapoor N, Furler J, Paul TV, Thomas N, Oldenburg B. Normal Weight Obesity: An Underrecognized Problem in Individuals of South Asian Descent. Clin. Ther.. 2019;41:1638-42.

4. Kapoor N, Furler J, Paul TV, Thomas N, Oldenburg B. Ethnicityspecific cut-offs that predict co-morbidities: the way forward for optimal utility of obesity indicators. J Biosoc Sci 2019;51:624-6.

5. Luig T, Anderson R, Sharma AM, Campbell-Scherer DL. Personalizing obesity assessment and care planning in primary care: patient experience and outcomes in everyday life and health. Clin. Obes. 2018;8:411-23.

6. Kapoor N, Chapla A, Furler J, Paul TV, Harrap S, Oldenburg B, et al. Genetics of obesity in consanguineous populations - A road map to provide novel insights in the molecular basis and management of obesity. EBioMedicine. 2019;40:33-4.

7. Jiwanmall SA, Kattula D, Nandyal MB, Devika S, Kapoor N, Joseph M, et al. Psychiatric Burden in the Morbidly Obese in Multidisciplinary Bariatric Clinic in South India. Indian J Psychol Med. 2018;40:129-33.

8. Kapoor N, Job V, Jayaseelan L, Rajaratnam S. Spot urine cortisolcreatinine ratio - A useful screening test in the diagnosis of Cushing's syndrome. Indian J Endocrinol Metab. 2012;16(Suppl 2):S376-7.

9. Sharma AM. The 5A model for the management of obesity. CMAJ : 2012;184:1603; author reply -4.


Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: