Obesity

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In Process

Author / Curator: Jacob Mirsky MD MA

Faculty Advisor:

GUIDELINES:
The format of each page are recommended guidelines. They should be fluid as each topic will have a unique flow.

(1) Be concise.

(2) Be evidence-based. (Everything should have a reputable citation and resource)

(3) Be clinically relevant. (Avoid unnecessary discussion of pathophysiology and epidemiology if it does not help clinical decision-making).


Learning Objectives 

  • Appreciate the obesity epidemic and its impact on the rise of multiple comorbidities
  • Understand the importance of multimodal assessment of contributing factors to obesity
  • Learn how to assess obesity in a primary care setting and possible reversible factors
  • Develop a method for approaching the treatment of obesity in clinic

Top Teaching Points

- Obesity is a chronic disease that results from genetic, developmental, behavioral, medical, environmental, social and culture factors and is characterized by excess body fat that leads to reduced quality of life, development of multiple co-morbidities, and increased mortality.

- Always identify a goal weight and identify internal motivators to help get patients to that weight

- The goal of weight loss therapy is to improve or eliminate obesity-related comorbidities and to decrease the risk for future obesity-related medical complications. Effective interventions focus on decreasing energy intake relative to energy expenditure, and combine nutrition education, diet and exercise counseling and behavioral strategies for sustained weight loss.

Background

- Epidemiology: more than 1/3 US adults, with risk factors including age, diet, lower socioeconomic status and education level, genetic predisposition, psychological factors such as stress, poor sleep, medication adverse effects, and sedentary lifestyle. [1][2][3][4][5][6][7][8][9]

- Physiology / Pathophysiology: Obesity results from a positive energy imbalance, both due to calorie consumption as well as neuro-hormonally regulated metabolism.[10][11] It is important to know that many of the contributors to obesity are not easily reversible. The body "remembers" changes, and reversing a weight trigger may not work to reverse the weight gain. For example, if weight was gained as a result of use of a weight-promoting medication, discontinuation of the medication may or may not reverse the weight gain. Physiological changes with weight gain occur and often cannot be undone solely by willful "lifestyle change".

- Progression and Complications of Disease: coronary heart disease, type 2 diabetes, hypertension, obstructive sleep apnea, hyperlipidemia, gallstones, fatty liver disease, gastroesophageal reflux disease, asthma, osteoarthritis, some types of cancer, psychiatric disorders, and many others

Diagnosis

- Definition: Body Mass Index ≥ 30 kg/m2

BMI
Class 1 30-34.9 kg/m2
Class 2 35-39.9 kg/m2
Class 3 > 40 kg/m2

- History:

  • lowest and highest weight as adult
  • review of medications that may have weight gain as a side effect (e.g. antidepressents, antipsychotics, mood stabilizers, antiepleptics, diabetes medications, steroids, beta blockers)
  • assessment of psychosocial stressors (e.g. social, financial, etc.)
  • evidence of addiction, psychiatric disease and/or eating disroders
  • motivations for weight loss
  • previous weight loss attempts (e.g. diet, exercise, Weight Watchers, HMR, medications)
  • interest in medications or surgery
  • 24 hour diet recall to investigate high calorie foods and portion size
  • physical activity
  • goal weight

- Signs and Symptoms:

  • stress
  • depression
  • fatigue
  • dyspepsia
  • sleepiness

- Differential Diagnosis:

  • medication effects (glucocorticoids, antihyperglycemics, second-generation antipsychotics, antiepileptics, antidepressants)
  • hypothyroidism

- Physical Exam Findings:

  • Height and weight to calculate BMI [12][13][14][15]
  • Waist circumference over iliac crest (high risk if > 35 inches for women and > 40 inches for men) independently increases health risk if those with BMI < 35 [16]
  • Blood pressure to assess for hypertension [17]

- Recommended Work-up[18]:

  • A1C, lipid panel, LFTs, TSH
  • consider screening for vitamin D deficiency, obstructive sleep apnea, depression

Management

- General: weight loss therapy is recommended for patients with BMI 25-30 or high-risk waist circumference who have cardiovascular risk factors OR for anyone with BMI > 30; there are several approaches but generally aim for 10% of weight over 6 months at a rate of 1-2 pounds a week, which may greatly reduce complications, many of which were supported by the 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults [19][20]

- Non-pharmacological treatment should be first-line approach for all patients: nutrition education (e.g. choosemyplate.gov), diet (e.g. Atkins, Zone, Ornish, LEARN), exercise, behavior therapy (e.g. mindful eating, self-monitoring, stress management) [21][22][23][24][25][26]

- Pharmacological treatments: weight-loss medications are reserved for patients with BMI ≥30 (or for those with BMI ≥ 27 and a major comorbidity), and insufficient weight loss with diet, exercise, and behavior therapy; medications are more effective when combined with ongoing dietary and behavior modification[27][28]

  • Phentermine and Topiramate (Qsymia) 7.5 mg/46 mg qd
  • Lorcaserin (Belviq) 10 mg BID
  • Orlistat (Xenical, Alli) 120 mg TID with meals
  • Liraglutide (Saxenda) 3 mg subcutaneous injection qd
  • Burpopion-naltrexone 8 mg/90 mg qd and then escalate

- Surgical treatments: bariatric surgery is highly effective for some patients and is an option if BMI ≥ 40 or if BMI ≥ 35 with obesity-related co-morbidities; other criteria include[29][30][31][32][33]:

  • Absence of medical contraindications, i.e. surgical benefit outweighs surgical risk
  • Prior unsuccessful attempts at weight loss using dietary/behavioral/medical approaches
  • Any mental health conditions are under adequate control
  • No substance or alcohol use disorder, or ongoing remission for at least one year
  • Ability to understand and adhere to post-operative care, including follow-up appointments and mandatory vitamin and mineral supplementation.
  • Adequate social and financial supports to allow for adherence to post-op care.

Other Teaching Pearls

  • Investigate whether your home institution has a comprehensive weight management clinic that you can refer to patients to
  • Achieving and maintaining weight loss is made difficult by the reduction in energy expenditure that is induced by weight loss[34][35]
  • Characteristics of those who are likely to succeed include frequent self-monitoring, a weight loss of more than 2 kg in four weeks, frequent and regular attendance at a weight loss program, and the subject's belief that his or her weight can be controlled [36][37]

Trial Summaries

  • STAMPEDE: in moderately obese patients with uncontrolled diabetes, bariatric surgery plus intensive medical therapy resulted in a lower A1C than medical therapy alone [38]

Ongoing controversies / New updates

  • The obesity-survival paradox is the inverse association between BMI and mortality that has been reported in patients with many disease states and in several clinical settings [39]
  • Exercise is a key aspect of obesity management, but it is still unclear how much "activity trackers" such as FitBit will contribute to multimodal weight loss approaches in the years to come [40][41]

Teaching Resources

Blogs:

Videos:

Podcast episodes:

Core review articles / Guidelines:

Other links:

References

  1. Flegal et al.: Trends in Obesity Among Adults in the United States, 2005 to 2014. JAMA 2016;315:2284-91.
  2. Stegenga et al.: Identification, assessment, and management of overweight and obesity: summary of updated NICE guidance. BMJ 2014;349:g6608.
  3. Stunkard et al.: The body-mass index of twins who have been reared apart. N. Engl. J. Med. 1990;322:1483-7.
  4. Rosenheck &: Fast food consumption and increased caloric intake: a systematic review of a trajectory towards weight gain and obesity risk. Obes Rev 2008;9:535-47.
  5. Hu et al.: Television watching and other sedentary behaviors in relation to risk of obesity and type 2 diabetes mellitus in women. JAMA 2003;289:1785-91.
  6. Chen & Qian: Association between lifetime stress and obesity in Canadians. Prev Med 2012;55:464-7.
  7. Wu et al.: Sleep duration and obesity among adults: a meta-analysis of prospective studies. Sleep Med. 2014;15:1456-62.
  8. Suzuki et al.: Obesity and appetite control. Exp Diabetes Res 2012;2012:824305.
  9. Jensen et al.: 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. Circulation 2014;129:S102-38.
  10. Stegenga et al.: Identification, assessment, and management of overweight and obesity: summary of updated NICE guidance. BMJ 2014;349:g6608.
  11. Murray et al.: Hormonal and neural mechanisms of food reward, eating behaviour and obesity. Nat Rev Endocrinol 2014;10:540-52.
  12. Stegenga et al.: Identification, assessment, and management of overweight and obesity: summary of updated NICE guidance. BMJ 2014;349:g6608.
  13. Kushner & Ryan: Assessment and lifestyle management of patients with obesity: clinical recommendations from systematic reviews. JAMA 2014;312:943-52.
  14. Suzuki et al.: Obesity and appetite control. Exp Diabetes Res 2012;2012:824305.
  15. Jensen et al.: 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. Circulation 2014;129:S102-38.
  16. Kushner & Ryan: Assessment and lifestyle management of patients with obesity: clinical recommendations from systematic reviews. JAMA 2014;312:943-52.
  17. Garvey et al.: AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY COMPREHENSIVE CLINICAL PRACTICE GUIDELINES FOR MEDICAL CARE OF PATIENTS WITH OBESITY. Endocr Pract 2016;22 Suppl 3:1-203.
  18. Garvey et al.: AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY COMPREHENSIVE CLINICAL PRACTICE GUIDELINES FOR MEDICAL CARE OF PATIENTS WITH OBESITY. Endocr Pract 2016;22 Suppl 3:1-203.
  19. Kushner & Ryan: Assessment and lifestyle management of patients with obesity: clinical recommendations from systematic reviews. JAMA 2014;312:943-52.
  20. Jensen et al.: 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. J. Am. Coll. Cardiol. 2014;63:2985-3023.
  21. Booth et al.: Effectiveness of behavioural weight loss interventions delivered in a primary care setting: a systematic review and meta-analysis. Fam Pract 2014;31:643-53.
  22. Loveman et al.: The clinical effectiveness and cost-effectiveness of long-term weight management schemes for adults: a systematic review. Health Technol Assess 2011;15:1-182.
  23. Ahern et al.: Extended and standard duration weight-loss programme referrals for adults in primary care (WRAP): a randomised controlled trial. Lancet 2017;389:2214-2225.
  24. National Task Force on the Prevention and Treatment of Obesity.: Medical care for obese patients: advice for health care professionals. Am Fam Physician 2002;65:81-8.
  25. Garvey et al.: AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY COMPREHENSIVE CLINICAL PRACTICE GUIDELINES FOR MEDICAL CARE OF PATIENTS WITH OBESITY. Endocr Pract 2016;22 Suppl 3:1-203.
  26. Dansinger et al.: Comparison of the Atkins, Ornish, Weight Watchers, and Zone diets for weight loss and heart disease risk reduction: a randomized trial. JAMA 2005;293:43-53.
  27. Garvey et al.: AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY COMPREHENSIVE CLINICAL PRACTICE GUIDELINES FOR MEDICAL CARE OF PATIENTS WITH OBESITY. Endocr Pract 2016;22 Suppl 3:1-203.
  28. Thomas et al.: Weight-loss maintenance for 10 years in the National Weight Control Registry. Am J Prev Med 2014;46:17-23.
  29. Garvey et al.: AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY COMPREHENSIVE CLINICAL PRACTICE GUIDELINES FOR MEDICAL CARE OF PATIENTS WITH OBESITY. Endocr Pract 2016;22 Suppl 3:1-203.
  30. Colquitt et al.: Surgery for weight loss in adults. Cochrane Database Syst Rev 2014;:CD003641.
  31. Schauer et al.: Bariatric surgery versus intensive medical therapy for diabetes--3-year outcomes. N. Engl. J. Med. 2014;370:2002-13.
  32. Courcoulas et al.: Three-Year Outcomes of Bariatric Surgery vs Lifestyle Intervention for Type 2 Diabetes Mellitus Treatment: A Randomized Clinical Trial. JAMA Surg 2015;150:931-40.
  33. Gloy et al.: Bariatric surgery versus non-surgical treatment for obesity: a systematic review and meta-analysis of randomised controlled trials. BMJ 2013;347:f5934.
  34. Leibel et al.: Changes in energy expenditure resulting from altered body weight. N. Engl. J. Med. 1995;332:621-8.
  35. Fothergill et al.: Persistent metabolic adaptation 6 years after "The Biggest Loser" competition. Obesity (Silver Spring) 2016;24:1612-9.
  36. Soini et al.: Weight loss methods and changes in eating habits among successful weight losers. Ann. Med. 2016;48:76-82.
  37. Thomas et al.: Weight-loss maintenance for 10 years in the National Weight Control Registry. Am J Prev Med 2014;46:17-23.
  38. Schauer et al.: Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N. Engl. J. Med. 2012;366:1567-76.
  39. Bosello et al.: Obesity or obesities? Controversies on the association between body mass index and premature mortality. Eat Weight Disord 2016;21:165-74.
  40. Jakicic et al.: Effect of Wearable Technology Combined With a Lifestyle Intervention on Long-term Weight Loss: The IDEA Randomized Clinical Trial. JAMA 2016;316:1161-1171.
  41. Finkelstein et al.: Effectiveness of activity trackers with and without incentives to increase physical activity (TRIPPA): a randomised controlled trial. Lancet Diabetes Endocrinol 2016;4:983-995.