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Approach to medical management of obesity



Approach to medical management of obesity

Alpana Shukla, MD, MRCP(UK), FTOS
Assistant Professor of Research in Medicine
Weill Cornell Medicine, New York

 

Obesity is a chronic, relapsing, multifactorial neurobehavioral disease that requires multi-disciplinary, individualized, long-term management.

Body fat mass is regulated via coordinated adjustments of both food intake and energy expenditure in response to short-term signals such as gut peptides and long-term signals, namely leptin. Environmental factors (e.g. availability of highly palatable foods, food composition, physical activity), genetic and developmental factors, and  hypothalamic inflammation can influence this signaling. In obesity, these signals are disrupted.

Several studies show that metabolic adaptation including changes in levels of hunger and satiety hormones, and change in energy expenditure (not just “lack of will power”)  make long-term weight loss maintenance difficult and promote weight regain.

Body mass index is used to classify obesity but it is an imperfect measure of adiposity/body fat. A lower cut-off is recommended for individuals of Asian descent. Waist circumference measurements indicate central adiposity which is associated with cardiometabolic risk.

Assessment of patients should include a detailed history of weight trajectory, previous weight loss attempts, eating pattern and behavior, triggers for overeating, physical activity and sleep pattern. Medication history should be reviewed to identify weight gain promoting medications, such as certain antidiabetics, antihypertensives, psychiatric medications and others. Where clinically appropriate and feasible, weight neutral or weight loss promoting medications should be considered as alternatives to help weight management.

There is a dose-response relationship between weight loss and improvement in obesity-related comorbidities. The threshold for benefit is low: 3% weight loss can improve glucose levels in patients with diabetes. Weight loss of 5-10%  improves metabolic markers like blood pressure, lipids and HbA1c, and has been shown to improve mobility, depression and quality of life. Some comorbidities such as steatohepatitis and sleep apnea require ³10% weight loss for significant improvement.

Lifestyle interventions are the cornerstone of treatment and must be patient-centered. Adherence to diet rather than the type of diet is predictive of weight loss success. Prescribe a calorie restricted diet based on preferences and health status and preferably refer to a nutrition professional for counseling. Advising patients to eat their carbohydrate portions at the end of the meal after protein and vegetables can help reduce glucose spikes in patients with diabetes and prediabetes. Exercise alone has modest weight loss effect but has weight-independent cardiometabolic benefits and helps weight loss maintenance. Encourage self-monitoring (weighing at least weekly) to help patients stay focused.

Pharmacotherapy should be considered as an adjunct to diet, exercise, and behavioral modification for patients with overweight and obesity (BMI 30 kg/m2 or 27 kg/m2 with weight-related comorbidity) There are six FDA-approved anti-obesity medications; currently available options in Qatar include orlistat, liraglutide and semaglutide. Off-label use of metformin is recommended based on its safety and efficacy as shown in the diabetes prevention program and other published studies. Anticipate inter-individual variability in response to weight loss pharmacotherapy. Efficacy and safety of medications should be assessed monthly x 3 months then at least every 3 months. Consider individual risk vs benefit, clinical phenotype, cost and patient preference in tailoring treatment.

 

References

 

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