What Is Obesity Medicine?

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OBESITY MEDICINE: THE FIELD OF MEDICINE DEDICATED TO THE COMPREHENSIVE CARE OF PATIENTS WITH OBESITY

1, 2 ,3 HOW DO YOU BODY MASS INDEX Classiﬁcation MEASURE (kg/m2): NORMAL WEIGHT OVERWEIGHT CLASS I OBESITY CLASS II OBESITY CLASS III OBESITY

OBESITY? 18.5-24.9 25.0-29.9 30.0-34.9 35.0-39.9 >40

LOOKING BEYOND BMI:

% PERCENT BODY FAT 4 WAIST CIRCUMFERENCE 5, 6, 7, 8

Classiﬁcation: ESSENTIAL FAT ATHLETES FITNESS ACCEPTABLE OBESITY Classiﬁcation: ABDOMINAL OBESITY

2-5% 6-13% 14-17% 18-24% >25%  >40 >102  inches centimeters

 10-13% 14-20% 21-24% 25-31% >32%  >35 >88 inches centimeters

EDMONTON OBESITY STAGING SYSTEM 9

STAGE 0 STAGE 1 STAGE 2 STAGE 3 STAGE 4 No obesity-related Pre-clinical risk factors: Established obesity- Established organ Severe disabilities: end risk factors borderline HTN or related disease: HTN, damage: MI, CHF, stage and limitations (e.g., DM, minor aches, or DM, PCOS, moderate DM comp, signiﬁcant wheelchair use) psychopathology limitations of ADL limitations of ADL

The Edmonton Obesity Staging System applies a staging system of the medical, mental, and possible functional limitations a patient with obesity may experience, helping clinicians assess risk for that individual and evaluate how their weight affects their health.

CHRONIC WEIGHT MANAGEMENT REDUCES CHRONIC WEIGHT MANAGEMENT ALSO REDUCES THE COST OF LIVING BY REDUCING: 10, 11, 12 DISEASE RISK 13 Potential impact of 5% average BMI reduction in the U.S. by 2020:

3.6 Million diabetes 1.9 Million arthritis cases avoided cases avoided MEDICATIONS CO-PAYS TIME OFF WORK HOSPITALIZATIONS AND LOST WAGES 3.5 Million hypertension 0.3 Million cancer cases avoided cases avoided

FOOD COSTS ACCIDENT RISK FOR CANCER MEDICAL VISITS 2.9 Million heart disease and PRONENESS & OTHER CHRONIC stroke cases avoided DISEASES

WHAT DOES COMPREHENSIVE MEDICAL OBESITY TREATMENT INCLUDE? Nutrition Physical Activity Behavior Medication

References: 1 De Lorenzo A, Soldati L, Sarlo F, Calvani M, Di Lorenzo N, Di Renzo L: New obesity classification criteria as a tool for bariatric surgery indication. World J Gastroenterol 2016 22:681-703; 2 Rahman M, Berenson AB: Accuracy of current body mass index obesity classification for white, black, and Hispanic reproductive-age women. Obstet Gynecol 2010 115:982-988; 3 Misra A, Shrivastava U: Obesity and dyslipidemia in South Asians. Nutrients 2013 5:2708-2733; 4 American Council on Exercise: What are the guidelines for percentage of body fat loss? http://www.acefitness.org/acefit/healthy-living-article/60/112/what-are-the-guidelines-for-percentage- of-body-fat (Accessed August 20, 2016). 2009; 5 Jacobson TA IM, Maki KC, Orringer CE, Bays HE, Jones PH, McKenney JM, Grundy SM, Gill EA, Wild RA, Wilson DP, Brown WV: National Lipid Association recommendations for patient-centered management of dyslipidemia: Part 1 - executive summary. J Clin Lipidol 2014 8:473-488; 6 Bays H: Central obesity as a clinical marker of adiposopathy; increased visceral adiposity as a surrogate marker for global fat dysfunction. Curr Opin Endocrinol Diabetes Obes 2014 21:345-351; 7 Carroll JF, Chiapa AL, Rodriquez M, Phelps DR, Cardarelli KM, Vishwanatha JK, Bae S, Cardarelli R: Visceral fat, waist circumference, and BMI: impact of race/ethnicity. Obesity 2008 16:600-607; 8 Wang Z, Ma J, Si D: Optimal cut-off values and population means of waist circumference in different populations. Nutr Res Rev 2010 23:191-199; 9 Sharma AM, Kushner RF: Int J Obes 2009;33:289-95; 10 Health Management Research Center, University of Michigan, 2001; 11 U.S. Bureau of Labor Statistics, Consumer Expenditures in 2006; 12 Colditz, GA: Economic costs of obesity and inactivity. Med Science Sports Exercise 1999; 13 Levi et al: F as in fat: how obesity threatens America’s future. 2012. 14 Waters H, DeVol R: Weighing down America: The health and economic impact of obesity. Milken Institute 2016. Chronic Assessment and Nutrition Physical Activity Behavior Medication Disease of Evaluation What Is Obesity Obesity Medicine?

Clinical Pearls What Is Obesity Medicine?

1) Obesity medicine is the ﬁeld of medicine dedicated to the comprehensive care of patients with obesity. 2) Obesity medicine clinicians often use measurements other than BMI to diagnose obesity. 3) The comprehensive clinical approach to obesity treatment involves nutrition, physical activity, behavior, and medication. 4) Even modest (5%) weight loss is clinically meaningful and reduces the cost of living for patients with obesity. 5) In 2014, the direct and indirect costs associated with treating obesity and obesity-related conditions totaled $1.42 trillion.14 6) Comprehensive obesity treatment may include intermediary procedures or surgical intervention.

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Visit bit.ly/obesity-treatment to watch the Fundamentals of Obesity Treatment Course on demand through the Obesity Medicine Academy. This course, worth 4.5 CME/CE credit hours, provides a high- level overview of the six components of clinical obesity treatment and offers tips for implementing basic evaluation and treatment techniques in practice.

Chronic Disease Assessment and Nutrition Physical Activity Behavior Medication of Obesity Evaluation

Want more? The Obesity Medicine Academy is the premier online learning platform for evidence-based, peer-reviewed education. The Academy’s library contains more than 200 hours of clinically focused education on the most effective approaches for treating obesity and obesity-related conditions. Continue learning now at www.OMAcademy.org.

About the Obesity Medicine Association The Obesity Medicine Association (OMA) is the largest organization of clinicians dedicated to preventing, treating, and reversing the disease of obesity. Members of OMA believe treating obesity requires a scientiﬁc and individualized approach comprised of nutrition, physical activity, behavior, and medication. When personalized, this comprehensive approach helps patients achieve their weight and health goals. Learn more at www.obesitymedicine.org.

About the Obesity Treatment Foundation The Obesity Treatment Foundation is a 501(c)(3) charitable organization developed to elevate awareness among health care providers that obesity is a chronic disease and to amplify the quality and quantity of clinician-driven, practice-based obesity treatment research. Learn more at www.obesitytreatmentfoundation.org.

101 University Blvd. Ste. 330 | Denver, CO 80206 | p 303.770.2526 | f 303.779.4834 | [email protected] © Obesity Medicine Association. All rights reserved. Materials may not be reproduced, redistributed, or translated without written permission. CHRONIC DISEASE OF OBESITY

The Deﬁnition of Obesity Obesity is a chronic, relapsing, multi-factorial, neurobehavioral disease, wherein an increase in body NEUR AL OB fat promotes adipose tissue dysfunction and abnormal IC EH ED AV fat mass physical forces, resulting in adverse metabolic, M IO R biomechanical, and psychosocial health consequences. A L

E Health Consequences of Obesity I M N

Obesity Is a M

R U

System Disease C Multi-factorial

O E

Myocardial Infarction • Stroke • D Disease N

Peripheral Vascular Disease • E Cardiovascular Hypertension • Congestive Heart Failure and Cor Pulmonale • Hypertension • Thromboembolic IC Events • Varicose Veins E T N E V N IR E Type 2 Diabetes • Gout • O IG N EP Endocrine Polycystic Ovary Syndrome • ME / NT TIC Infertility GENE

Nonalcoholic Fatty Liver Disease • Gastrointestinal Cholelithiasis • GERD • Hernias Metabolic Syndrome Is a Complex Condition

Nephrolithiasis • Glomerulopathy • Renal Renal Cancer

Breast Cancer • Endometrial DYSLIPIDEMIA Oncology Cancer • Esophageal Cancer • Colon Cancer • Pancreatic Cancer ELEVATED BLOOD PRESSURE Hematology Prothrombic State • COMMON Multiple Myeloma COMPONENTS ELEVATED GLUCOSE Dyspnea • Obstructive Sleep OF METABOLIC CENTRAL Pulmonary Apnea • Hypoventilation ADIPOSITY Syndrome • Pickwickian SYNDROME Syndrome • Asthma

Neurologic Intracranial Hypertension • Stroke • Nerve Entrapment

1 Osteoarthritis (Knees, Hips) • Impact of Insulin Resistance Musculoskeletal Immobility • Low Back Pain • Myalgia • Impaired Balance • Gait Disturbance Impaired Dyslipidemia Glycemia Stasis Pigmentation • Venous Stasis Integument Ulcers • Cellulitis • Skin Tags • INSULIN Intertrigo • Carbuncles RESISTANCE Depression • Low Self-esteem • Hopelessness • Psycho-social Body-image Dissatisfaction • Diminished Sex Drive • Impaired Intimacy and Obesity Metabolic Syndrome Hypertension Sexual Relationships

Type 2 Diabetes How Obesity Relates to Metabolic Syndrome and Insulin Resistance Early Cardiovascular Disease  Metabolic consequences of obesity include the components of metabolic syndrome plus proinﬂammatory and prothrombic states. Macrovascular Disease Microvascular Disease Stroke, Coronary Heart Disease Retinopathy, Nephropathy, Neuropathy  Type 2 diabetes is closely associated with obesity and begins with insulin resistance that starts 10 to 15 years prior to diagnosis. All content, unless otherwise noted, is adapted from the Obesity Algorithm®. 1. ACCORD STUDY, ADVANCE STUDY JAMA. 2008;300(17):2051-2053 © Obesity Medicine Association. All rights reserved. Materials may not be reproduced, redistributed, or translated without written permission. What Is Obesity Assessment and Nutrition Physical Activity Behavior Medication Medicine? Evaluation Chronic Disease of Obesity

Clinical Pearls Chronic Disease of Obesity

1) The negative health impacts of obesity can be broadly characterized as metabolic, biomechanical, or psychological. 2) Hunger and satiety are regulated extensively by a complex system of hormones released by the gastrointestinal system, adipose tissue, and brain. 3) Obesity is strongly associated with multiple cancers, including esophageal, endometrial, and breast cancer.

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Chronic Disease Assessment and Nutrition Physical Activity Behavior Medication of Obesity Evaluation

About the Obesity Medicine Association The Obesity Medicine Association (OMA) is the largest organization of clinicians dedicated to preventing, treating, and reversing the disease of obesity. Members of OMA believe treating obesity requires a scientific and individualized approach comprised of nutrition, physical activity, behavior, and medication. When personalized, this comprehensive approach helps patients achieve their weight and health goals. Contact Us 101 University Blvd. Ste. 330 | Denver, CO 80206 p 303.770.2526 | f 303.779.4834 | [email protected] www.obesitymedicine.org

© Obesity Medicine Association. All rights reserved. Materials may not be reproduced, redistributed, or translated without written permission. ASSESSMENT AND EVALUATION A COMPONENT OF CLINICAL OBESITY TREATMENT 5 A’S OF OBESITY MANAGEMENT 1 1 2 ASK ASSESS y For permission to y BMI, waist discuss body weight circumference, obesity stage y About readiness 3 for change y Drivers and complications of excess weight ADVISE y About health beneﬁts of modest weight loss (5-10%) y About long-term ARRANGE/ strategy and ASSIST AGREE treatment options y On realistic y Identify and expectations, address barriers targets, and y Provide resources behavioral changes y Schedule regular follow-up 5 4 AVOID DEROGATORY LANGUAGE

USE INSTEAD OF

Overweight Fat PATIENT HISTORY Unhealthy Weight Obese Weight Gain Medical Heavy Morbidly Obese  Age of onset  Past/current  Highest/lowest weight medical problems Eating Habits Diet  Rate of weight gain  Surgical history  Inciting factors/major  Allergies Physical Activity Exercise life events  Current medications Previous Weight Loss Eating Disorders  What’s been tried  Prior diagnosis PERFORM A PHYSICAL  What worked  Medical treatment(s)  What didn’t work EXAMINATION  Motivators Family  Obesity Nutrition  Metabolic diseases BLOOD  Psychiatric disorders PRESSURE NECK  Eating patterns CIRCUMFERENCE  Triggers  Reasons for eating out Social  Household factors  Readiness  Motivators Physical Activity  Education  Occupation  Current level of activity  Family/household EKG  Favorite activities WAIST  Sleeping behavior  Activities able CIRCUMFERENCE  Major life stresses/events RESPIRATORY to maintain RATE  Tobacco/alcohol/cannabis  Barriers /other drug use

ALSO EXAMINE: - Resting Metabolic Rate - Body Mass Index 1. Vallis M, Piccinini-Vallis H, Sharma AM, Freedhoff Y: Clinical review: Modiﬁed 5 As: Minimal intervention for obesity counseling in primary care. Can Fam Physician 2013 59:27-31. - Body Composition © Obesity Medicine Association. All rights reserved. Materials may not be reproduced, redistributed, or translated without written permission. What Is Obesity Chronic Nutrition Physical Activity MedicationBehavior Medication Medicine? Disease of Assessment and Obesity Evaluation

Clinical Pearls Assessment and Evaluation

1) Obtain the patient’s current weight and a thorough weight history during the initial evaluation. 2) Obesity can be deﬁned by an elevated BMI, body fat percentage, waist circumference, and other metabolic factors. Bioelectric impedance is the most commonly used method of measuring body fat percentage. 3) During the physical examination, acanthosis nigricans is a sign of insulin resistance. 4) Laboratory tests and EKG are an important part of the evaluation to diagnose diseases related to obesity. 5) The initial assessment should determine if the patient has other medical problems related to obesity. These co-morbidities need to be monitored as well.

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Chronic Disease Assessment and Nutrition Physical Activity Behavior Medication of Obesity Evaluation

DIETARY FACTORS TO CONSIDER There are many different dietary options that work, but the right one to use will depend on the individual patient.  Personal preferences  Ethnic or religious requirements CONSIDER THE PATIENT’S:  Allergies and food intolerances  Comorbidities: Hypertension, type 2 diabetes, dyslipidemia, gout, recurrent kidney stones, liver or kidney disease  Nutritional needs COMMON NUTRITIONAL APPROACHES

Low-carbohydrate Diet Low-fat Diet

Characteristics Characteristics <45% of calories from carbohydrates <20% fat, 55-65% carbs, ~15% protein Ketogenic (< 50 g carbohydrates) <10% saturated fat

Health Beneﬁts Health Beneﬁts  triglycerides,  HDL cholesterol  total cholesterol,  LDL cholesterol

Mediterranean Diet DASH Diet

Characteristics Characteristics

35-40% fat Dietary approaches to stop hypertension Fish, nuts, healthy fats, fruits, vegetables, whole Not intended for weight loss unless caloric grains, legumes, dairy intake is restricted

Health Beneﬁts Health Beneﬁts  cardiovascular mortality,  type 2 diabetes  blood pressure

Vegetarian Diet Meal Replacements

Characteristics Characteristics

Exclusion of all or most animal proteins Pre-packaged foods Protein sources: Low-fat dairy, soy, legumes, Isocaloric energy-restricted meal replacements whole grains, nuts, seeds Can be used with any dietary approach

Health Beneﬁts Health Beneﬁts

 LDL cholesterol,  cardiovascular mortality, Greater weight loss with 2 meal replacements per day  type 2 diabetes compared to less frequent use.1

1. Tsai AG, Wadden TA. Obesity 2006;14(8):1283-1293.

Regardless of macronutrient composition, all diets should include physician education and patient monitoring to maintain safety and achieve the optimal long-term effects.

© Obesity Medicine Association. All rights reserved. Materials may not be reproduced, redistributed, or translated without written permission. What Is Obesity Chronic Assessment and Physical Activity Behavior Medication Medicine? Disease of Evaluation Nutrition Obesity

Clinical Pearls Nutrition

1) The diet that works is the one the patient can stick with and incorporate into their lifestyle long- term. 2) Think beyond calories – current evidence suggests that not all calories are created equal. 3) Saturated fats and unsaturated fats provide a source of energy, but like calories, not all fats are created equal. 4) Meal replacement strategies can be very effective for weight loss and weight maintenance.

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Chronic Disease Assessment and Nutrition Physical Activity Behavior Medication of Obesity Evaluation

© Obesity Medicine Association. All rights reserved. Materials may not be reproduced, redistributed, or translated without written permission. PHYSICAL ACTIVITY A COMPONENT OF CLINICAL OBESITY TREATMENT HEALTH BENEFITS:

IMPROVES REDUCES Cardiovascular function Blood pressure Blood glucose regulation Risk of certain cancers Dyslipidemia Mortality rate Independence Medications Socialization Dementia risk Sexual function Pain HDL cholesterol Depression

HOW MUCH PHYSICAL ACTIVITY IS ENOUGH? NOT ALL PHYSICAL ACTIVITY IS EXERCISE GENERAL — Moderate aerobic exercise 150 min/week HEALTH BENEFIT + strength training at least 2x/week Non-Exercise Activity Thermogenesis (NEAT) PREVENTION OF — 150-250 minutes per week* Common daily activities, such WEIGHT GAIN — 150-300 minutes per week** as walking, standing, and climbing stairs, can result in up to 2,000 kcal of energy PREVENTION OF — 200-300 minutes per week* expenditure per day. WEIGHT REGAIN — 300-420 minutes per week**

*Donnelly J. Am College Sports Med. 2009. **U.S. Health and Human Services. 2008. CORE START GETTING STARTED COMPONENTS OF AN EXERCISE Low or no-impact activities PRESCRIPTION Balance training FREQUENCY TYPE INTENSITY ENJOYMENT Strength training TIME

© Obesity Medicine Association. All rights reserved. Materials may not be reproduced, redistributed, or translated without written permission. What Is Obesity Chronic Assessment and Nutrition Behavior Medication Medicine? Disease of Evaluation Physical Activity Obesity

Clinical Pearls Physical Activity

1) Know the physical activity guidelines and share them with your patients. They can’t hit the mark if they don’t know the goal. 2) Set realistic expectations with your patients about physical activity and weight loss. While weight loss is difﬁcult with physical activity alone, it is necessary for successful weight maintenance. 3) Work with your patients to determine the physical activities that meet their interests, needs, and abilities. 4) Identify appropriate resources to share with your patients, such as those available from the Obesity Action Coalition. 5) Have your patients self-track their progress and review it together at follow-up visits.

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Chronic Disease Assessment and Nutrition Physical Activity Behavior Medication of Obesity Evaluation

BEHAVIORAL THERAPY TECHNIQUES

MOTIVATIONAL INTERVIEWING

CORE SKILLS FOR Self- Problem- Monitoring Solving MOTIVATIONAL INTERVIEWING

Open questions Cognitive Contingency Restructuring Management Affirmations OBESITY COGNITIVE Reflections BEHAVIORAL S THERAPY SPIRIT OF ummaries Social Stimulus MOTIVATIONAL Support Control Wadden and Foster, Med Clin North Am INTERVIEWING 2000:84:441. Stress Compassion Management Acceptance Partnership E INTERPERSONAL vocation THERAPY

Resolution of conflicts

Adaptation for change

Focus on only one or two problem areas

Target deficits

BEHAVIORS OF SUCCESSFUL STAGES OF CHANGE WEIGHT MAINTAINERS*

Pre-contemplation: No intention to change / unaware of need to change eat breakfast every day 1  Action: Build self-awareness; discuss risks and beneﬁts; explore ambivalence 78%

Contemplation: Aware of a need to change / interested in changing within next six months weigh themselves at 2  Action: Resolve ambivalence; explore pros and cons; assess knowledge 75% least once per week

Preparation: Open to and willing to change within next 30 days 62% watch less than 10 3  Action: Resolve ambivalence / get commitment hours of TV per week

Action: Initiation of change / committing to goal 90% exercise, on average, 4  Action: Provide tailored self-help materials and encouragement for small changes about one hour per day

Maintenance: Continued change for longer than six months *National Weight Control Registry Data; Wyatt et al. Obes Res 5 2002 Feb;10(2):78-82; Butryn et al. Obesity 2007 Dec;15(12) 3019-6;  Action: Continued positive reinforcement and periodic follow-up Raynor et al. Obesity 2006 Oct;14(10); Phelan et al. Obesity 2006 Apr;14(4):710-6.

© Obesity Medicine Association. All rights reserved. Materials may not be reproduced, redistributed, or translated without written permission. What Is Obesity Chronic Assessment and Nutrition Physical Activity Medication Medicine? Disease of Evaluation Behavior Obesity

Clinical Pearls Behavior

1) Behaviors are affected by brain neurotransmitters, specifically dopamine and serotonin, and are often beyond an individual’s willpower. 2) Recognizing that positive behavioral change can be achieved and maintained is integral to clinically significant weight management. 3) Motivational interviewing and collaborative goal-setting are effective tools in the primary care setting. 4) Understand your role as a clinician in helping patients with the stages of change, utilizing the 5 A’s of obesity management1, and implementing SMART (specific, measurable, achievable, relevant, time-based) goals. 5) Sleep disorders, disordered/dysfunctional eating, and carbohydrate cravings can influence and be influenced by behaviors.

1. Vallis M, Piccinini-Vallis H, Sharma AM, Freedhoff Y: Clinical review: Modiﬁed 5 As: Minimal intervention for obesity counseling in primary care. Can Fam Physician 2013 59:27-31.

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Chronic Disease Assessment and Nutrition Physical Activity Behavior Medication of Obesity Evaluation

Purposes: Mechanisms of Action: Treat the disease of obesity Anti-obesity medications alter Facilitate the management physiology, not only behaviors. of eating behavior Decrease hunger Block fat absorption Slow the progression of weight Decrease appetite Increase adherence by gain and regain How Anti-obesity Increase satiety mitigating biological or Improve the weight, health, and Decrease cravings genetic factors Medications Make quality of life of the patient a Difference Anti-obesity medications are most effective as part of a comprehensive treatment plan that includes nutrition, physical activity, and behavior modiﬁcation.

The Anti-obesity Medications:

Medication Class Mechanisms of Action for Weight Loss

Phentermine*, Phendimetrazine*, Decreases appetite and food intake through release of Sympathomimetic amines catecholamines in hypothalamus Diethylpropion*

Orlistat (Xenical®, alli®) Pancreatic lipase inhibitor Decreases absorption of fat

® Serotonin 5HT2c agonist Decreases food intake and increases satiety through Lorcaserin (Belviq ) activation of POMC neurons in hypothalamus

Phentermine/ Reduces appetite, decreases food consumption and satiety ® Sympathomimetic amine + anti-epileptic enhancement through release of catecholamines in the Topiramate ER (Qsymia ) hypothalamus

Naltrexone/Bupropion Stimulates POMC; naltrexone blocks beta Exerts effect on appetite regulatory center and the (Contrave®) endorphin-mediated suppression of alpha MSH reward system to regulate appetite and reduce cravings

® Increases satiety, decreases food intake and appetite via GLP-1 Liraglutide (Saxenda ) GLP-1 agonist receptors in brain

*FDA-approved only for short-term usage but frequently prescribed off-label for longer durations. Good Practices When Prescribing Anti-obesity Medications Manage Your Patients’ Expectations in Advance DOCUMENT Discuss anticipated results prior to treatment and set realistic goals. Rationale: Initial drug prescription and prescription changes Every Visit: Vital signs, appearance, mood, Weight loss is often slower than patients expect beneficial and adverse effects What a patient calls a plateau is often the expected treatment response PARTICIPATE Maintaining weight loss is difficult without an Utilize the Obesity Medicine Association’s intervention plan CME to keep up with trends and learn best Regular or intermittent medications may be prescribing practices necessary for long-term maintenance CONSULT Obesity is a chronic disease requiring lifelong treatment Always review the PI Long-term favorable patient health outcomes are Be aware of the stoppage rules: 5% weight loss the primary goal of therapy at 12 weeks of full-dose therapy for phentermine, phendimetrazine, diethylpropion, orlistat, 5-10% weight loss produces health benefits lorcaserin, phentermine/topiramate, and naltrexone/bupropion, and 4% weight loss at 12 weeks of full-dose therapy for liraglutide Always check with your local and state medical/pharmacy boards before prescribing anti-obesity medications. Local and state laws and regulations may vary. What Is Obesity Chronic Assessment and Nutrition Physical Activity Behavior Medicine? Disease of Evaluation Medication Obesity

Clinical Pearls Medication

1) Medication is an evidenced-based tool to support the physiologic and behavioral changes necessary for sustained weight loss. 2) As with other chronic diseases, medications for the treatment of obesity should be used long-term. 3) Medications used to treat other chronic diseases may cause weight gain. It is important to identify these medications during the initial evaluation and switch the patient to a weight- negative medication if possible. 4) Individualizing treatment to meet the patient’s needs is important and should include a comprehensive treatment plan in addition to anti-obesity medication. 5) Individuals who have undergone bariatric surgery may also beneﬁt from an anti-obesity medication post-surgically to control their disease, particularly if they experience weight regain.

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Chronic Disease Assessment and Nutrition Physical Activity Behavior Medication of Obesity Evaluation