Improving the Treatment of Obesity in the New Year and Beyond
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Review Article in New England Journal of Medicine (January 19, 2019)
Baton Rouge, LA – A review article in this week's New England Journal of Medicine offers guidance to physicians and other health care practitioners who seek to help patients meet their New Year's weight loss resolutions. The paper begins with an overview of the obesity epidemic and the factors responsible for it.
"The increased marketing and consumption of large portions of high calorie, highly palatable foods has expanded our nation's waistline, as has the decreased physical activity required by most jobs and leisure-time activities, as compared with 50 years ago," said lead author Steven B. Heymsfield, M.D., a professor of Medicine at the Pennington Biomedical Research Center, Louisiana State University. "More than two-thirds of Americans are now overweight or obese and are at increased risk of the chronic diseases associated with excess adiposity, including type 2 diabetes, hypertension, dyslipidemia, obstructive sleep apnea, and some cancers."
The paper explains that some individuals appear to be particularly vulnerable to developing obesity because of a genetic tendency toward this condition. "Eleven rare forms of obesity, each attributable to a single gene mutation, have now been identified," reported Dr. Heymsfield, "but far more study is needed to illuminate the likely complex interaction of multiple genes that contributes to most common forms of obesity."
To meet New Year's resolutions, many health care practitioners will advise patients
to cut calories and increase physical activity, the basis for most weight loss efforts.
However, for individuals with obesity who have been unsuccessful with weight loss,
this advice should be complemented by the patient's participating in a high-intensity,
behavioral counseling program which provides 14 or more individual or group treatment
sessions over six months.
"High-intensity behavioral programs, as delivered by a trained interventionist, such as a registered dietitian, can help patients change their eating and activity behaviors and lose approximately five to eight percent of their starting weight in six months," said co-author Thomas A. Wadden, Ph.D., a professor of Psychology in Psychiatry in the Perelman School of Medicine at the University of Pennsylvania and director of Penn's Center for Weight and Eating Disorders. "Weight loss of this size often improves health complications of obesity, including high blood sugar, high blood pressure, and elevated lipid levels, such as trigylcerides."
The authors, consistent with recent guidelines for weight management published by several organizations, noted that if primary care practitioners themselves are unable to offer high-intensity behavioral counseling they can refer patients to programs in the community, provided these programs have published peer-reviewed evidence of their safety and efficacy.
"Many YMCAs now offer weight management programs for overweight/obese individuals with prediabetes, and some commercial-based programs may also be recommended," said Wadden.
Medications approved by the Food and Drug Administration (FDA) for chronic weight management are an option for patients who are obese, defined by a body mass index (BMI) of 30 kg/m2 or more, as well as those who have a BMI greater than 27 kg/m2 and weight-related health complications.
"Four new medications have been approved by the FDA since 2012," stated Dr. Heymsfield, "all of which, when combined with behavioral counseling, increase patients likelihood of achieving a five to 10 percent reduction in initial weight, as compared with the use low-to-moderate intensity (<1 session per month) counseling alone."
The authors' review, however, revealed that weight loss medications appear to be prescribed less frequently than might be expected, given the magnitude of the obesity epidemic. Use of the medications, as a class, appears to be limited by factors including concerns about long-term safety, out-of-pocket costs to patients, disappointment that weight losses are not larger, and the problem of weight regain when patients stop taking the medication.
"The chronic use of weight loss medications, as approved by the FDA, may be necessary for optimal long-term weight management, just as medications for type 2 diabetes, hypertension, and dyslipidemia must be taken chronically to control these disorders," added Wadden. "Obesity, for most individuals, is a chronic disease that requires long-term behavioral and medical management."
Individuals with severe obesity, characterized by a BMI greater than 40 kg/m2, or greater than 35 kg/m2 with obesity-related health complications, may benefit from bariatric surgery, if behavioral counseling and weight management medications are not sufficient.
"Our review revealed that Roux-en-Y gastric bypass and the newer sleeve gastrectomy induce losses of approximately 25 to 30 percent of initial weight, respectively, at one year," noted Heymsfield. "Losses which are generally well maintained and associated with remission or marked improvement in obesity-related diseases, particularly type 2 diabetes."
The authors observed improved short- and long-term safety with these procedures over the past decade, owing to the increased use of laparoscopic methods. They concluded that further study is needed of the long-term efficacy of sleeve gastrectomy, which has replaced Roux-en-Y gastric bypass as the most widely conducted procedure in the United States, accounting for 43 to 49 percent of all bariatric operations performed in 2013, respectively. The review did not consider newer weight loss devices, such as gastric balloons or pacing devices, because of the limited long-term safety and efficacy data available.
Researchers concluded their review by underscoring that only a small fraction of
patients for whom these three classes of treatment (i.e., high-intensity behavioral
counseling, weight management medications, and bariatric surgery) are indicated actually
receive them. Barriers to patients receiving appropriate weight management include
inadequate physician training in obesity medicine, the slow recognition by health-care
providers and systems that obesity is a serious, chronic disease, and the limited
reimbursement of the full range of treatments available. Obesity, in the authors'
view, must be treated with the same concern and resources with which chronic diseases
such as type 2 diabetes and hypertension are managed.
Editor's Note: Dr. Heymsfield reports receiving fees for serving on advisory boards for Medifast, Tanita, and Novartis. Dr. Wadden reports receiving fees for serving on advisory boards for Novo Nordisk, Nutrisystem, Orexigen Therapeutics, and Weight Watchers and receiving grant support, on behalf of the University of Pennsylvania, from Eisai, Novo Nordisk, and Weight Watchers.
The Pennington Biomedical Research Center is at the forefront of medical discovery as it relates to understanding the triggers of obesity, diabetes, cardiovascular disease, cancer and dementia. It is a campus of Louisiana State University and conducts basic, clinical and population research. The research enterprise at Pennington Biomedical includes approximately 80 faculty and more than 25 post-doctoral fellows who comprise a network of 44 laboratories supported by lab technicians, nurses, dietitians, and support personnel, and 13 highly specialized core service facilities. Pennington Biomedical's more than 500 employees perform research activities in state-of-the-art facilities on the 222-acre campus located in Baton Rouge, Louisiana.