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Update on Office-Based Strategies for the Management of Obesity MICHAEL ERLANDSON, MD; LAURIE C

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Update on Office-Based Strategies for the Management of Obesity MICHAEL ERLANDSON, MD; LAURIE C Editor’s Note: On February 13, 2020, the U.S. Food and Drug Administration (FDA) requested that the manufacturer of Belviq (lorcaserin) voluntarily withdraw this drug from the market because a safety clinical trial showed an increased occur- rence of cancer that outweighed any potential weight loss benefits. See the FDA Drug Safety Communication (https://www. fda.gov/drugs/drug-safety-and-availability/fda-requests-withdrawal-weight-loss-drug-belviq-belviq-xr-lorcaserin-market). Update on Office-Based Strategies for the Management of Obesity MICHAEL ERLANDSON, MD; LAURIE C. IVEY, PsyD; and KATIE SEIKEL, DO, RD Swedish Family Medicine Residency, University of Colorado School of Medicine, Littleton, Colorado Obesity is a common condition that is associated with numerous medical problems such as car- diovascular disease, pulmonary disease, and diabetes mellitus. Primary care physicians have an important role in helping patients develop a successful weight loss plan to improve their overall health. Dietary strategies emphasizing reduced caloric intake, regardless of the nutrient compo- sition, are important for weight loss. Behavioral interventions such as motivational interviewing and encouraging physical activity lead to additional weight loss when combined with dietary changes. Medication regimens for concomitant medical problems should take into account the effect of specific agents on the patient’s weight. Persons with a body mass index of 30 kg per m2 or greater or 27 kg per m2 or greater with comorbidities who do not succeed in losing weight with diet and activity modifications may consider medication to assist with weight loss. Medica- tions approved for long-term treatment of obesity include orlistat, lorcaserin, liraglutide, phen- termine/topiramate, and naltrexone/bupropion. Physicians should consider referring patients for bariatric surgery if they have a body mass index of 40 kg per m2 or greater. For those with obesity-related comorbid conditions, patients should be considered for adjustable gastric band- ing or other bariatric surgical approaches if they have a body mass index of 30 to 39.9 kg per m2. The most commonly performed procedures for weight loss are Roux-en-Y gastric bypass, sleeve gastrectomy, and adjustable gastric banding. Bariatric surgery is the most effective intervention for weight loss in obese patients, and it leads to improvement in multiple obesity-related condi- tions, including remission of diabetes. (Am Fam Physician. 2016;94(5):361-368. Copyright © 2016 American Academy of Family Physicians.) CME This clinical content besity is a pervasive problem EVIDENCE SUMMARY conforms to AAFP criteria confronting patients and their The U.S. Preventive Services Task Force for continuing medical edu- cation (CME). See CME Quiz physicians. From 2011 to 2012, (USPSTF) recommends that all persons Questions on page 346. 69% of U.S. adults were over- 18 years and older be screened for obesity Oweight or obese.1 Many common medical (Table 1 1,3), and that those with a BMI of Author disclosure: No rel- 2 evant financial affiliations. problems, such as diabetes mellitus, pul- 30 kg per m or greater be offered intensive, 2 ▲ monary disease, and cardiovascular disease, multicomponent behavioral interventions. Patient information: A handout on this topic is are related to obesity and can improve with The American Academy of Family Physi- available at http://www. weight loss.2 The management of obesity cians recommends screening for obesity aafp.org/afp/2016/0901/ continues to evolve with the approval of new followed by intensive counseling and behav- p361-s1.html. treatments. This review will provide answers ioral interventions, with at least one session Scan the QR code below to some of the common clinical questions per month for at least three months.4 Waist with your mobile device that physicians encounter when managing circumference may be an acceptable alterna- for easy access to the patient information hand- obesity in the outpatient setting. tive in some persons because BMI may not out on the AFP mobile site. account for the cardiovascular risk of cen- What Is the Family Physician’s Role in tral adiposity. Family physicians can assist Screening for and Managing Obesity? patients in setting weight loss goals, improv- Physicians should screen all patients for obesity ing nutrition, increasing physical activity, with measurement of body mass index (BMI) addressing barriers to change, and develop- or waist circumference. Diet and behavioral ing strategies to maintain long-term life- interventions should be initiated in patients style changes. Behavior modifications can who are obese. lead to clinically important weight loss of SeptemberDownloaded 1, from 2016 the ◆ American Volume Family 94, Number Physician 5 website at www.aafp.org/afp.www.aafp.org/afp Copyright © 2016 American Academy of FamilyAmerican Physicians. Family For the Physician private, noncom 361- mercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Obesity SORT: KEY RECOMMENDATIONS FOR PRACTICE Evidence Clinical recommendation rating References BMI should be calculated for all patients 18 years and older, and those with obesity should be referred for B 2 intensive, multicomponent behavioral interventions. Increased physical activity should be recommended for weight loss in combination with diet and behavioral B 20 modifications. Physicians should consider medications for weight loss in patients with a BMI of 30 kg per m2 or greater, C 26 or 27 kg per m2 or greater who also have comorbidities and have unsuccessfully tried diet and lifestyle modification first. Patients with a BMI of 40 kg per m2 or greater and those with a BMI greater than 35 kg per m2 who also have B 36 obesity-related comorbidities should be referred for consideration of bariatric surgery. Patients with a BMI greater than 30 kg per m2 who also have obesity-related comorbidities may be candidates for adjustable gastric banding. BMI = body mass index. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort. 5%, improved glucose tolerance, and reduction in other EVIDENCE SUMMARY cardiovascular risk factors.2 Various commonly used diet plans result in a similar degree of weight loss, regardless of the specific dietary Which Dietary Approaches Have Been Shown composition of macronutrients (carbohydrate, protein, to Be Most Effective for Weight Loss? and fat).5 Adherence to calorie reduction is the most Adherence to a diet with a deficit of 500 kcal per day, important factor; any diet in which caloric intake is less regardless of macronutrient composition, is most effective than caloric expenditure will lead to weight loss.6 A defi- for weight loss. Simple and realistic diet modifications have cit of at least 500 kcal per day can be achieved with intake the highest likelihood of success. of 1,200 to 1,500 kcal for women and 1,500 to 1,800 kcal for men. Very low-calorie diets (800 kcal or less per day) should be avoided unless the patient is under close supervision with high-intensity lifestyle interventions.7 Table 1. Weight Classifications Diet plans with multiple components can be over- whelming and lead to poor adherence. A simpler Body mass approach using a single dietary adjustment may pro- index (kg Prevalence Waist Classification per m 2) (%) circumference duce weight loss similar to more complex plans. For example, encouraging a patient to increase dietary fiber Underweight < 18.5 NA — intake produces comparable adherence and weight loss Normal weight 18.5 to 24.9 NA Male < 40 in to encouraging compliance with the many goals of (102 cm) the American Heart Association diet. Similarly, more Female < 35 in permissive goals, such as adding more vegetables and (89 cm) standing more, lead to greater improvement in life- Overweight 25 to 29.9 33.6 — Class 1 obesity 30 to 34.9 20.4 Male ≥ 40 in Class 2 obesity 35 to 39.9 8.1 Female ≥ 35 in WHAT IS NEW ON THIS TOPIC: OBESITY Class 3 obesity ≥ 40 6.4 Using a single dietary adjustment may produce weight loss similar to more complex plans. For example, encouraging a NA = not available. patient to increase dietary fiber intake produces comparable adherence and weight loss to encouraging compliance with Information from references 1 and 3. the many goals of the American Heart Association diet. 362 American Family Physician www.aafp.org/afp Volume 94, Number 5 ◆ September 1, 2016 Obesity style behaviors than restrictive approaches that instruct to empower them in the process (Table 2).11,12 Multiple patients to avoid certain foods.8 Although different studies have shown that motivational interviewing can diets with similar caloric intake can result in compa- modestly enhance the effects of a weight-loss program rable weight loss, a higher-quality diet of nutrient-dense (–3.3 lb [–1.5 kg]; 95% confidence interval [CI], –4.4 to foods (e.g., vegetables, fruits, whole grains) that are rich –2.0 lb [–2.0 to –0.9 kg]), and it can be readily used by in fiber, vitamins, and minerals will produce greater primary care physicians.13 This technique can also indi- results.9 The 2015-2020 Dietary Guidelines for Ameri- rectly have beneficial effects on other cardiovascular risk cans reinforce the need to make
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