Obesity Management Requires an Individualized Approach
New Orleans—Data from the National Health and Nutrition Examination Survey (NHANES) estimate that 69% of US adults are overweight or obese and approximately 17% of US children 2 to 19 years of age are obese. The economic impact of the obesity epidemic places a significant burden on healthcare expenditures, with the estimated costs in the United States exceeding $215 billion annually. Various studies have also found that, on average, obese individuals pay $1429 more annually for healthcare than nonobese individuals.
“Obesity has multiple pathophysiologic origins,” said Daniel Einhorn, MD, FACP, FACE, clinical professor of medicine, University of California, San Diego, who discussed the obesity epidemic during a symposium at the CRS meeting. The etiology of obesity involves genetic, environmental, and behavioral factors. The American Medical Association officially recognized obesity as a disease in 2013.
The American College of Cardiology, the American Heart Association, and The Obesity Society recently released a joint guideline for the management of overweight and obese adults. Published in Journal of American College of Cardiology in July, the guideline outlines 3 classes of obesity based on body mass index (BMI): (1) class 1, 30 kg/m2 to 34.9 kg/m2; (2) class 2, 35 kg/m2 to 39.9 kg/m2; and (3) class 3, ≥40 kg/m2. Dr. Einhorn noted a study by Kragelund et al published in Lancet in 2005 that examined the pros and cons of BMI for defining overweight and obesity. The advantages include that BMI generally correlates with metabolic disease and fat mass. It is also easy to calculate since weight and height are readily available in patient charts. However, BMI does not distinguish between muscle and fat, underestimates obesity, and may not always correlate with metabolic disease.
Health Consequences of Obesity
Obesity is associated with cardiometabolic defects, various systemic complications, and increased mortality, according to Dr. Einhorn, medical director, Scripps Whittier Diabetes Institute. Medical complications of obesity include:
• Cancer
• Cataracts
• Coronary heart disease
• Gallbladder disease
• Gout
• Gynecologic abnormalities
• Nonalcoholic fatty liver disease
• Osteoarthritis
• Phlebitis
• Pulmonary disease
• Stroke
Dr. Einhorn also discussed risk stratification for obese individuals. Current classifications of obesity based on BMI, waist circumference, and other anthropometric measures have limitations when applied to individuals in clinical practice, according to a study by Sharma et al published in 2009 in International Journal of Obesity. The researchers proposed a new clinical staging system that ranks individuals with excess adiposity on a 5-point ordinal scale, while incorporating obesity-related comorbidities and functional status into an assessment. It is referred to as the Edmonton Obesity Staging System (EOSS; Table 1). Dr. Einhorn highlighted a 2011 study published in Canadian Medical Association Journal that used data from NHANES 3 to compare EOSS versus BMI for predicting mortality. The findings showed EOSS independently predicted increased mortality even after adjustment for contemporary methods of classifying adiposity, suggesting that EOSS may offer improved clinical utility in evaluating obesity-related risk and prioritizing treatment options.
Obesity Management
Weight loss can be achieved and maintained with lifestyle intervention, pharmacologic therapy, or surgical intervention. To help primary care practitioners develop a framework for obesity counseling, Dr. Einhorn recommended implementing the “5 As” of obesity of management:
• Ask for permission to discuss weight and explore readiness for change
• Assess obesity-related health risk(s) and potential root causes of weight gain
• Advise on obesity risks and discuss benefits of treatment options
• Agree on realistic weight loss expectations and a SMART (Specific, Measurable, Achievable,
Rewarding, and Timely) plan to achieve behavioral goals
• Assist in addressing drivers and barriers, offer education and resources, refer to appropriate
provider, and arrange follow-up
“Treatment plans and goals should be realistic and tailored to individual patient needs,” he said.
Treatment Options
Patients who struggle with weight loss and who meet criteria may benefit from a weight loss medication to help control appetite, according to Donna H. Ryan, MD, FACP, professor emeritus, Pennington Biomedical Research Center, who provided a rationale for how medications may aid in obesity management:
• Help patients who are unable to succeed with weight loss via lifestyle intervention and those who
have medical risks
• Help more patients achieve modest weight loss to achieve health benefits
• Help patients lose greater amounts of weight to maximize health benefits
• Help patients maintain long-term weight loss
Dr. Ryan reviewed key messages and recommendations outlined in the new management guideline for obese and overweight individuals (Table 2).
In treating this patient population, she said clinicians should use a complications-centric approach to weight management and select the medication based on the patient’s profile. The American Association of Clinical Endocrinologists’ algorithm, outlined by Garber et al in Endocrine Practice in 2013, provides a unique approach to weight management driven by cardiometabolic disease and biomechanical complications.
The FDA recently approved 3 medications to help patients lose weight and gain greater health benefits when initiated in conjunction with a diet plan. In 2012, the FDA approved 10 mg lorcaserin as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adults with an initial BMI ≥30 kg/m2 or a BMI ≥27 kg/m2 in the presence of at least 1 weight-related comorbidity. The safety and efficacy of lorcaserin was evaluated in randomized, placebo-controlled trials.
Dr. Ryan shared results from the BLOOM [Behavioral Modification and Lorcaserin for Obesity and Overweight Management] study that included overweight and obese individuals without diabetes. Reported in New England Journal of Medicine in 2010, Smith et al found that after 1 year in a phase 3 trial, 47.5% of patients receiving lorcaserin lost ≥5% of their body weight compared with 20.3% of patients in the placebo group. Furthermore, among the patients who received lorcaserin during the first year and those who had lost ≥5% of their baseline weight, 67.9% of those patients maintained their weight loss in the second year compared with 50.3% of patients who switched to placebo.
Also in 2012, the FDA approved phentermine plus topiramate extended release (ER). It is indicated as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adults with an initial BMI of ≥30 kg/m2 (obese), or a BMI ≥27 kg/m2 in the presence of at least 1 weight-related comorbidity. Dr. Ryan highlighted results from the CONQUER trial, published by Gadde et al in Lancet in 2011. The study randomized patients to receive either placebo or 2 different doses of phentermine plus topiramate ER (7.5 mg/46 mg or 15 mg/92 mg) for 1 year. The findings showed that placebo, the 7.5 mg/46 mg, and the 15 mg/92 mg groups lost 1.2%, 7.8%, and 9.8% of baseline body weight, respectively, at 56 weeks. Also, 70% of patients who took the 15 mg/92 mg dose and 62% of patients who took the 7.5 mg/46 mg dose achieved ≥5% weight loss after 1 year versus 21% in the placebo group.
Just recently, the FDA approved naltrexone hydrochloride and bupropion hydrochloride extended-release tablets, the third drug indicated for weight loss.
Bariatric surgery is another treatment option for patients who are unable to succeed with weight loss with less intensive approaches and who have medical risks. “Treatment decisions must be made jointly with patients. Obesity management is about improving health and well-being and not just the BMI,” Dr. Ryan concluded.—Eileen Koutnik-Fotopoulos
