Last month we looked at surgical interventions for patients with morbid obesity. This month, we turn to the much more common problem of how to medically manage patients who are overweight or obese.
Case Study: On the same day that you saw Naomi, who expressed an interest in bariatric surgery to treat her morbid obesity, you also saw Lauren. Lauren is a 30-year-old woman who recently experienced a series of life stressors, including the serious illness of a parent and the loss of a long-term romantic relationship. Also during the past year, she left her job and moved back to the town where she had grown up in order to take her of her sick mother. Thankfully, Lauren’s mother is improving, but the past few months have taken a physical and emotional toll on Lauren. More specifically, she has gained 50 lbs. Lauren says,
“I have never weighed this much in my life. How do I lose all of this extra weight?”
As a first step, you calculate her body mass index (BMI). Lauren is 5 feet 4 inches tall and weighs 165 lbs. To calculate her BMI, you can either use an online calculator or convert her height to meters and weight to kilograms. The formula to calculate BMI is
BMI = weight (in kg)/(height (in m))2.
Using this equation, you find that Lauren’s BMI is 28.3 kg/m2, placing her in the overweight (but not obese) range for BMI. Now you should review her options for medical management. These options include lifestyle modifications such as behavioral changes, improved diet, and increased exercise. They may also include medications currently approved for weight loss in the United States.
What do you do next?
Although Lauren came to you for help with weight loss, you are not the only professional who will be involved in her care. You can refer Lauren to a vetted psychologist, nutritionist, physical trainer, and/or pharmacist for additional support.
Behavioral changes and stress management play critical roles in helping patients lose weight and keep weight off. You encourage Lauren to begin counseling to better understand how her eating is impacted by stress. If she is amenable to group support, support systems can be found through commercial programs (like Weight Watchers), religious organizations, the local YMCA, and community overeating support groups.
Despite the controversies and hard-line stances, there are numerous high-quality diets that are effective for weight loss and health long-term. The key component of any diet is decreased caloric intake. Safe, effective diets can be vegetarian, low-fat, low-carbohydrate, or protein-heavy/low glycemic index diets. A referral to a nutritionist would be a great idea. Similarly, you should encourage Lauren to start exercising, and work her way up to 150 minutes of exercise a week. You have already completed a physical examination, and she is in good cardiovascular health. Lauren does not have any co-morbid conditions, so you give her the green light to start an exercise program.
What about pharmaceutical options for treating obese and overweight patients?
In the United States, the Food and Drug Administration has approved five medications for long-term weight loss management: orlistat, lorcaserin, phentermine/topiramate, naltrexone/bupropion, and liraglutide. Indications for prescribing these medications are a BMI over 30 kg/m2 or a BMI over 27 kg/m2 with the presence of certain co-morbid conditions (including diabetes, hypertension, etc.). These medications are prescribed for use in conjunction with lifestyle changes.
Orlistat works by inhibiting pancreatic lipase, leading to the excretion of 30% of dietary fat in stool. Not surprisingly, its side-effects include gastrointestinal distress and decreased absorption of fat-soluble vitamins.
The remaining four medications work by regulating appetite. Lorcaserin is a selective serotonin 2C receptor agonist. Side-effects include nausea, headache, dizziness, constipation and hypoglycemia in diabetic patients. These medications are contraindicated during pregnancy.
Phentermine increases norepinephrine to suppress appetite while the mechanism of how topiramate produces weight loss is not well-understood. Side-effects include insomnia, paresthesias, dizziness, nausea and constipation.
Naltrexone/bupropion side-effects are headache, nausea/vomiting, diarrhea/constipation, and headache. Bupropion inhibits dopamine and norepinephrine reuptake, while naltrexone is an opioid receptor agonist.
Lastly, liraglutide is an injectable that works as a glucagon-like peptide-1 (GLP-1) receptor agonist. However, there are significant risks of medullary thyroid carcinoma and acute pancreatitis associated with this medication.
What sort of medical management would you recommend for Lauren?
Lauren should start with behavioral support, including psychological counseling, nutritional evaluation, and exercise. At this time, she is not a candidate for long-term pharmaceutical intervention because her BMI is less than 30 kg/m2 and she lacks co-morbidities.
Visit our Patient Education page, which includes an Obesity Shared Decision Making Tool called PEPtalk Weight Management. This weight management tool is designed to promote wellness and self-management through shared decision-making between patients and clinicians. It provides patients with the knowledge, skills, and confidence to actively participate with their clinicians when making decisions that can improve their health and healthcare.
Bray GA, Frühbeck G, Ryan DH, Wilding JP. Management of obesity. Lancet. 2016;387(10031):1947-56.
Patel D. Pharmacotherapy for the management of obesity. Metab Clin Exp. 2015;64(11):1376-85.
Dr. V. Silverstein