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Journal of Obesity and Weight-Loss Medication

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Journal of Obesity and Weight-Loss Medication ISSN: 2572-4010 Grief and Waterman. J Obes Weight-Loss Medic 2019, 5:024 DOI: 10.23937/2572-4010.1510024 Volume 5 | Issue 1 Journal of Open Access Obesity and Weight-Loss Medication RESEARCH ARTICLE Approach to Obesity Management in the Primary Care Setting Samuel N Grief* and Megan Waterman Check for Department of Family Medicine, University of Illinois at Chicago, USA updates *Corresponding author: Dr. Samuel N Grief, MD, FCFP, FAAFP, Professor, Clinical Family Medicine, Department of Family Medicine, University of Illinois at Chicago, 1919 West Taylor Street, Suite 143, Chicago, IL 60612, USA development of obesity [8,9]. Children are exposed to Abstract a large number of television advertising throughout Obesity is an American epidemic, affecting 35% of US childhood, including exposure to high-calorie, low adults, and 17% of US children [1]. These rates of obesity are above the Healthy People 2020 targets of 30.5% and nutrition-dense food ads. A study undertaken by the 14.5%, respectively [2]. Obesity is defined as a Body Mass Kaiser Foundation confirmed the pervasive nature of Index (BMI) ≥ 30 kg/m2 [2]. media advertising and its link to the development of Obesity costs hundreds of billions of dollars to the health childhood obesity [10]. care system annually, is associated or directly related to 60% of type 2 diabetes and is a well-recognized risk factor Socioeconomic status (SES) is often implicated as a for high blood pressure, heart disease and stroke [3,4]. risk factor for obesity. Disparity among socioeconomic groups is thought to be a primary cause of obesity, This article will review the causes, screening recommenda- tions, and roles of diet, exercise, lifestyle counseling, phar- with the higher income groups enjoying lower rates of macotherapy and bariatric surgery related to obesity and its obesity in Westernized countries [11]. This link between management. A simple overview of obesity management SES and obesity is dependent upon geography. Lower can be seen in Figure 1. rates of obesity exist among the lower SES groups in non-Westernized countries, likely due to poor nutrition, Etiology among other reasons [11]. Obesity is a complex, multifactorial disease that Another less obvious but still likely cause of obesity develops from the interaction between genotype and includes sleep deficit [12]. Sleep deprivation induces the environment. Our understanding of how and why hormonal changes that favor the development of obesity occurs is incomplete; however, it involves the obesity, including causing higher levels of ghrelin and integration of social, behavioral, cultural, physiological, lower levels of leptin [13,14]. metabolic, and genetic factors [5]. Genetics has been a common variable researched among scientists, and the Screening for Obesity link has been proven between genetic predisposition The United States Preventive Services Task Force and likelihood of developing obesity [6]. Multiple (USPSTF) recommends that clinicians screen all adults obesity-genes have been identified and confirmed to for obesity (B recommendation) [15]. The National predispose to obesity and impair appetite and food Institutes of Health and the Canadian Task Force on regulation in the hypothalamus [6]. However, given Preventive Health Care also recommend the use of BMI the rapid rise of obesity in the past three decades in and waist circumference to screen adults for obesity the United States and other Westernized countries, [16,17]. environmental factors are likely the major culprits in causing this unhealthy trend [7]. Diet and Exercise Sedentary lifestyle, such as time spent in front Which works better for achieving and maintaining of media sources, shows a strong correlation with weight loss, diet alone, exercise alone, or both? Citation: Grief SN, Waterman M (2019) Approach to Obesity Management in the Primary Care Setting. J Obes Weight-Loss Medic 5:024. doi.org/10.23937/2572-4010.1510024 Accepted: January 07, 2019: Published: January 09, 2019 Copyright: © 2019 Grief SN, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Grief and Waterman. J Obes Weight-Loss Medic 2019, 5:024 • Page 1 of 8 • DOI: 10.23937/2572-4010.1510024 ISSN: 2572-4010 Identify and Diagnose Obesity Set weight loss goals Treat with lifestyle modification (Diet and Exercise) (BMI > or = 30 or BMI 25-29.9 and co-morbidities) Treat with Pharmacotherapy (BMI > or = 27 and co-morbidities or BMI > or = 30 and failed weight loss on above lifestyle modification) Treat with weight loss surgery BMI > or = 35 and at least 2 co-morbidities or BMI > 40 Continue monitoring weight loss and Lifestyle modification (maintenance) Figure 1: Management of obesity. Interventions that included both reduced energy intake effective than physical activity counseling at achieving (eg, ≥ 500 kcal/d) and increased physical activity (eg, ≥150 weight loss [20]. The American Association of Clinical minutes a week of walking), with traditional behavioral Endocrinologists (AACE), in their latest obesity clinical therapy, generally produced larger weight loss than practice guidelines, strongly recommend the triad of interventions without all 3 specific components [18]. a healthy meal plan, physical activity, and behavioral A meta-analysis of weight-loss clinical trials confirmed interventions for all patients who are treated for obesity that interventions combining both diet and exercise [21]. achieved and maintained greater weight loss over a four-year period vs. either diet or exercise alone [19]. Diet Various dietary strategies, including low carbohy- There is strong evidence that physical activity alone, drate, low fat, high fat, high protein, moderate carbo- i.e., aerobic exercise, in obese adults results in modest hydrate, and Mediterranean-style have been studied weight loss and that physical activity in overweight for weight loss, with similar short/long-term weight and obese adults increases cardiorespiratory fitness, loss outcomes [22-27]. Other dietary strategies are use- independent of weight loss [16]. However, other ful for treating obesity. Portion control, documenting evidence shows that nutrition counseling is more Grief and Waterman. J Obes Weight-Loss Medic 2019, 5:024 • Page 2 of 8 • DOI: 10.23937/2572-4010.1510024 ISSN: 2572-4010 Table 1: FDA-approved weight loss drugs. Weight Loss Drug Dosage Range Weight Loss % after Side Effects (Daily) 24-56 weeks Bupropion/Naltrexone 90/8 - 360/32 mg 7.2 - 10.1% (24 weeks) Nausea, dizziness, insomnia, dry mouth, bowel (Contrave) changes Liraglutide (Sexenda) 0.6 - 3 mg 8.0% (56 weeks) Nausea, diarrhea, nasopharyngitis, headache Lorcaserin (Belviq) 10 - 20 mg 4.7 - 5.8% (52 weeks) Nausea, Headache, dizziness, dry mouth, constipation, cough Orlistat (Xenical) 120-360 mg 2.9% (52 weeks) GI disturbance, cholelithiasis Topiramate/phentermine 23/3.75 - 92/15 mg 8.1 - 10.2% (52 weeks) Paresthesia, dizziness, dysgeusia, (Qsymia) constipation, dry mouth what you eat, weighing oneself and planning meals all (anorexiant) by prescription but is only approved for help in both weight loss and weight maintenance [19]. up to 12 weeks consecutive use by the FDA [39,40]. The regular use of portion-controlled servings of con- Other anorexiants are available, but their potential ventional foods improves the induction of weight loss in for side effects (physical/psychological addiction, behavior-based approaches [28-30]. Meal replacement hypertension, insomnia, palpitations, dry mouth, strategies have also been shown to improve outcomes gastro-intestinal disturbance, etc.) makes them less in overweight and obese individuals [31]. optimal for use in obesity management [41]. Long-term pharmacotherapeutic agents, such as phentermine/ Low Calorie Meal Plans (LCMPs) have been defined topiramate, lorcaserin, naltrexone/bupropion, and as meal plans that pro vide approximately a 500 to 1,000 liraglutide all have relatively similar efficacies over a kcal/day reduction from usual intake [32]. Very Low-Cal- 1-year period [39,42]. orie Meal Plans (VLCMPs) are meal plans or liquid for- mulations that provide an energy level between 200 Side effects of these long-term agents vary and, and 800 kcal/day [32]. These meal plans are designed along with typical dosing and weight-loss efficacy, are to produce rapid weight loss in patients with BMI > 30 included in Table 1 [38,43,44]. kg/m2 who have other significant comorbidities or have Orlistat is both available with or without a prescrip- failed other approaches [33]. Long term outcomes com- tion and has modest weight loss maintenance over a paring VLCMPs and LCMPs do not clearly distinguish 1-year period [42]. There is no indication that currently which dietary strategy works better 34[ ,35]. available anti-obesity medications are associated with Exercise pulmonary hypertension, valvular dysfunction or other cardiovascular abnormalities associated with earlier an- Exercise and physical activity is the other part of the ti-obesity medications [38,42]. foundation for weight loss management. Numerous studies confirm that regular exercise and physical activ- Table 2 below summarizes findings from a 2015 me- ity assist in weight loss, simply by burning more ener- ta-analysis which examined common medications asso- gy than consuming [16]. Exercise also improves many ciated with secondary weight change [45]. Insulin ther- other aspects
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