Obesity Treatment Abstract: Adult Obesity Is a Common Health Problem Associated with Signiﬁ Cant Adverse Health Outcomes

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Photo by Jose Luis Pelaez Inc./Getty Images © Contemporary approaches to adult Obesity treatment Abstract: Adult obesity is a common health problem associated with signiﬁ cant adverse health outcomes. Evidence-based guidelines support intensive nutrition and behavioral counseling and moderate physical exercise. Pharmacotherapy agents are available for long-term use to enhance weight loss efforts for some patients.

By Jan Meires, EdD, ARNP, and Catherine Christie, PhD, RD, LD/N, FADA

bjects of art have verifi ed the presence of apple- have the safest route to health and longevity while those who shaped human bodies since the dawn of recorded were inactive and obese were more prone to infi rmity and O history. The Venus of Willendorf (24,000 to 22,000 early mortality. He said to his students, “Let thy food be thy BC) is an example of a fi gurine depicting a rotund female medicine and thy medicine be thy food.” He also said “A wise with large breasts, gravid midsection, and fleshy thighs. man should consider that health is the greatest of human Historians believe that ancient civilizations idealized this blessings.” Florence Nightingale (circa 1860) also promoted form, and that obesity was considered a positive attribute, healthy lifestyles related to good nutrition, exercise, rest, and a symbol of health especially during times of famine. limiting exposure to contagion. Hippocrates, the “Father of Medicine” (circa 460 to 370 One of the earliest attempts to give scientifi c basis for BC), posited an opposing view. He noticed that active per- a nutrition recommendation was by a ship surgeon in the sons who took the “right amount nourishment” seemed to British Royal Navy, James Lind (circa 1747). His test was

Key words: adult obesity treatment, pharmacotherapy for obesity, transdisciplinary team approach to obesity management

www.tnpj.com The Nurse Practitioner • September 2011 37

conducted at sea and consisted of two groups of men. One weight adult’s BMI ranges from 25 to 29.9. Class 1 obese group was provided with lemon juice in addition to their adults have BMIs in the 30 to 34.9 range, while Class 2 obese normal rations; the other was not. This test was considered adults have BMIs ranging from 35 to 39.9. Class 3 adults to be the fi rst example of a controlled experiment comparing are morbidly obese with BMIs greater than or equal to 40.2 results on two populations of a factor applied to one group Waist circumference is also used by clinicians to identify and only with all other factors the same. The results of the tests classify obesity. A waist circumference greater than 35 inches conclusively showed that lemons prevented the vitamin C (88 cm) in female adults and greater than 40 inches (102 defi ciency disease, scurvy. Lind published it in 1753. The cm) in male adults indicates excessive body fat in the form British navy did not adopt lemon or lime juice until 1795 as of central obesity. Central obesity is a known risk factor for standard issue at sea. Contemporary thoughts about healthy metabolic syndrome, heart disease, stroke, type 2 diabetes nutrition, healthy body shape, healthy weight, and limiting mellitus, some cancers, and early death.2,3 the adverse effects of adiposity are predicated on the work According to the 2006 to 2008 statistics from the CDC, of Hippocrates, Nightingale, and Lind. the age-adjusted estimated prevalence of obesity overall was Current obesity management uses a transdisciplinary 25.6% among non-Hispanic Blacks, non-Hispanic Whites, approach to encourage patients to make positive changes and Hispanics. Non-Hispanic Blacks had the greatest prevalence of obesity (35.7%), followed by Hispanics (28.7%), and non-Hispanic A healthy adult BMI ranges from 18.5 Whites (23.7%).4 These differences to 24.9 while an overweight adult’s were consistent across all census re- gions and greater among women than BMI ranges from 25 to 29.9. men. Non-Hispanic Black women had the greatest prevalence (39.2%), followed by non-Hispanic black men in lifestyle, diet, and exercise to manage their weight.1 The (31.6%), Hispanic women (29.4%), Hispanic men (27.8%), core team may comprise a physician, physician’s assistant non-Hispanic White men (25.4%), and non-Hispanic (PA), or nurse practitioner (NP), and registered dietitian White women (21.8%).4 (RD) with referral to behavior management specialists and others as needed. Although roles may overlap, each specialty ■ Presentation has individualized roles in care with specifi c outcome in- Obese patients may complain that diets do not work for dicators. For example, the physician, PA, or NP may be the them, they cannot lose weight, or their clothes are too tight. initial contact who conducts a history and physical exam, They may have less obvious complaints related to obesity makes a diagnosis of overweight or obesity, helps the patient including exercise intolerance, shortness of breath, rashes, set goals, reviews the family history for disease risk factors, insomnia, sexual dysfunction, joint pain, abdominal discom- and discusses possible treatments. Based on the informa- fort, and fatigue. As comorbidities associated with obesity tion gathered, the practitioner may then choose to refer are common, it is easy to attribute the symptom to an as- the patient to the RD to determine readiness and provide sociated disease and miss the association to obesity. personalized nutrition assessment and counseling. Further, in cases requiring mental health expertise, a psychologist ■ Diagnosis or other mental health professional may be engaged to Excessive weight and adiposity may be an obvious clue to improve obesity treatment outcomes such as in individuals making the diagnosis of obesity. However, the diagnosis with eating disorders. In addition, research continues into should be made after conducting a complete history and the use of drug therapy as an adjunct to these methods. physical exam, including an assessment of body type, BMI, waist-to-hip ratio and considering differential diagnoses for ■ Defi nition, presentation, and diagnosis of obesity obesity. Although the etiology of obesity is most likely rel- Simply defined, obesity is an excess of adipose tissue in ated to excessive energy intake and decreased energy expen- relation to lean body mass. Practitioners evaluate obesity diture, other causes of obesity must be ruled out. Diseases in adults by calculating the body mass index (BMI) and causing or contributing to obesity include hypothyroidism, obtaining a waist circumference. The BMI closely correlates growth hormone deficiency, hyperinsulinemia, Cushing with excess fat and is calculated by dividing measured body disease, polycystic ovarian disease, hypothalamic states, and weight in kilograms by the height in meters squared. A fl uid retention states associated with kidney disease or heart healthy adult BMI ranges from 18.5 to 24.9 while an over- failure, among others. Medications can also contribute to

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obesity including propranolol, contraceptives/hormones, relationship between a person’s food intake and activity nonsteroidal anti-inflammatory drugs, corticosteroids, level. Factors associated with unhealthy weight include low antidepressants, lithium, antipsychotics, and others.5 resting metabolic rate, excessive calorie intake, insuffi cient physical activity, genetics, parental infl uence, environmental ■ Pathophysiology of obesity factors, and stress.9 (See Model of multiple obesity factor The obesity epidemic has generated an intense interest in relationships.) understanding the altered cellular mechanisms regulating Multiple factors are involved in obesity in addition to body weight in overweight and obese persons. Theories the importance of maintaining an adequate and equal bal- about obesity such as the thrifty gene theory have been ance between energy intake and energy expenditure. Thus, postulated based on scientifi c inquiry into the causes of obesity.7 dietary intake from proteins, fats, and carbohydrates must The human genome project provided a much needed per- equal the energy expenditure through physical activity, spective on the genetic causes of obesity and emphasized diet-induced thermogenesis, and basal metabolic rate. In the importance of nutrigenomics.8 To date, more than 340 other words, a “healthy weight” person is much like the genes have been implicated in weight management and one described by Hippocrates, Nightingale, and Lind. This obesity.6 Genetic tests are available to determine a person’s person takes in the required nutrition, is active, and is on risk for obesity, although the clinical and ethical values of a safe course for maintaining health. Scientific inquiry these tests are unknown. has discovered many factors associated with maintaining Obesity has been extensively documented as a com- a healthy weight. For example, the person must have a plex, dynamic, multisystem disease that goes beyond the functional neuroendocrine system. Additionally, the

Model of multiple obesity factor relationships

Cultural and Socioeconomic Factors

Environmental Genetic Factors Factors Access to Nutrition Information

Hormones Access to Foods

Neurotransmitters Neuroendocrine Regulation/ Access to Exercise Inflammatory Response Enzymes

Receptors

Resting Metabolic Rate

Total Caloric Intake Energy Energy Thermogenesis Intake Expenditure Composition of the Diet

Physical Activity

Obesity

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members must be aware of the many regulatory systems Feedback mechanism for control of food intake involved in energy homeostasis, appetite, and satiety in order to prescribe appropriate treatments. Pharmacother- apy decisions made by the physician or NP in particular may be dependent upon this knowledge. The central nervous system, hypothalamus, and brain stem are responsible for coordinating and integrating a Hypothalamus – + person’s appetite, eating behaviors, pleasurable sensations – related to eating, and thermogenesis. Signals for satiety arise from the organs in the gut including the pancreas, liver, stomach, peripheral nerves, and adipose tissue. These

Vagus nerve organs send signals to the central nervous system where they are registered and interpreted. The interplay of multiple mechanisms related to a person’s body/brain connections signal’s hunger and satiety in a precise fashion. When a person eats a meal (energy intake), major signals from multiple organs are simultaneously released and carried to the brain Fat cells Ghrelin Stomach through multiple pathways. Key hormones such as leptin, Leptin insulin, amylin, glucagon-like peptide, and peptide PYY 3-36 GLP-1 are affected. Persons with abnormal feedback mechanisms, Insulin Pancreas circuitry, or signaling may overeat, effectively increasing energy intake and weight.9,10 (See Feedback mechanism for Small intestine CCK control of food intake.) The endocannabinoid system plays a major role within Large Ghrelin this hunger/satiety mechanism by helping to maintain intestine energy balance, regulating type and amount of food intake, and determining how much fat is used or stored. This process is accomplished through chemical messengers that bind to cells and activate the cannabinoid (CB 1) receptors. The CB 1 receptors are found in the brain and in some CCK = cholecystokinin, GLP-1 = glucagon-like peptide-1 peripheral tissues of the body such as adipocytes. Adipo- cytes are associated with lipid and glucose metabolism. Source: Porth CM, Matﬁ n, G. Pathophysiology Concepts of Altered Health States. 8th ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & The overweight or obese person may have overactive CB Wilkins; 2009:990. 1 receptors. In the setting of obesity, the overactive CB1 receptors work to promote: person’s environment—where he or she works and lives— • Fat storage in the adipocytes must be healthy to limit toxic exposure to the immune • Insulin resistance system, thereby protecting genes related to healthy weight. • Glucose intolerance In contrast, an overweight or obese person has an imbalance • Elevated triglycerides and lower HDL cholesterol levels. in one or more of these factors. Most of the time, the person Thus, the endocannabinoid system is also overactive with “unhealthy weight” ingests too many calories (energy in persons related to metabolic syndrome, diabetes type intake) related to energy expenditure (activity). Sounds 2, atherosclerotic diseases, and some addictions such as simple, but in reality, the regulation of energy homeostasis nicotine abuse.10 and metabolism is more complex.7 ■ Pharmacotherapy for obesity ■ Regulatory systems involved in obesity Pharmacotherapeutic strategies to combat obesity have been There are many regulatory systems involved in weight man- used in the United States for several decades. Obesity medi- agement. Key areas of interest for the obesity management cations initially focused on increasing energy expenditure team relate to the central/peripheral nervous systems, gut (thermogenics) or reducing energy intake by promoting peptides (cholecystokinin), hormones, fat synthesis, and anorexia. Dinitrophenol was one of the ﬁ rst medications the endocannabinoid system.10 Transdisciplinary team used to treat obesity in the 1930s. The drug caused rapid

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weight loss by increasing metabolic rate through uncou- signifi cant and sustained weight loss. The drug was linked pling mitochondrial oxidative phosphorylation, but its use to pulmonary hypertension and valvular heart disease in was discontinued due to multiorgan toxicity and increased 1997 and both fenfluramine and dexfenfluramine were mortality. Thyroxine (T4) was also used during this time removed from the market.10,12-14 Over-the-counter (OTC) frame as it increased basal metabolic rate and enhanced medications and supplements such as phenylpropanol- weight loss. Similar to dinitrophenol, it had serious adren- amine and ephedra have been used for weight loss and ergic adverse reactions and toxicity issues. In the late 1930s, were later removed from the U.S. market due to signifi cant amphetamines were used to induce anorexia and increase adverse reactions.5,15 sympathetic activity. During this era physicians treating Currently, pharmacotherapy for nonorganic causes obesity also prescribed a combination of amphetamines, of obesity treatment is limited to a few medications. The thyroid, digitalis, and diuretics known as the “Rainbow Nurse Practitioner Prescribing Reference16 includes only fi ve Pills.” This therapy was available until the mid 1960s when medications under the heading of “Obesity.” Three of these use was discontinued due to its addictive nature and inc- medications are sympathomimetics with the generic names reased risk for death. of phentermine HCl, phendimetrazine tartrate, and benz- In the early 1990s a combination of the anorectic ser- phetamine HCl. All of these medications are indicated for otoninergic drug fenfl uramine and the sympathomimetic short-term use (see Currently available medications for adult agent phentermine (“fen phen”) was used by millions for obesity treatment in the United States).16

Currently available medications for adult obesity treatment in the United States16

(Consult complete prescribing reference prior to use.) Generic name Trade name Classiﬁ cation Therapy duration Schedule Implications Phentermine HCl Adipex-P Sympathomimetic Short-term CIV Limit use. Use lowest dose monotherapy; 3 possible for shortest time. months or less BMI 30 or greater or 27 or with concurrent greater with risk factors. Not diet and exercise recommended for children prescriptions the elderly, pregnant or nursing mothers. Avoid late evening dosing. Phendimetrazine Bontril PDM Sympathomimetic Short-term CIII Limit use. Use lowest dose tartrate monotherapy; 3 possible for shortest time. months or less Not recommended for chil- with concurrent dren the elderly, pregnant, diet and exercise or nursing mothers. Avoid prescriptions late evening dosing or abrupt cessation after prolonged high doses. Abuse and dependence potential. Benzphetamine Didrex Sympathomimetic Short-term CIII Refer to physician for evalua- HCl monotherapy; 2 tion prior to prescribing. Limit to 4 weeks or less use. Use lowest dose pos- with concurrent sible for shortest time. Not diet and exercise recommended in children, the prescriptions elderly, pregnant (Category X), or nursing mothers. Abuse and dependence potential. Orlistat Xenical Lipase inhibitor Long-term with None BMI 30 or greater or 27 or concurrent diet greater with risk factors. May and exercise pre- decrease absorption of fat scriptions soluble vitamins. Signiﬁ cant GI adverse reactions. Recent evidence/outcome data are available. www.tnpj.com The Nurse Practitioner • September 2011 41

Sibutramine, classified as a mixed neurotransmitter (such as, attention-deficit hyperactivity disorder drugs, reuptake inhibitor, was indicated for long-term use and signifi cant caffeine intake), or guanethidine.16 originally designed to treat depression before being pulled Patients on this class of medications need to be seen from the market in October 2010.17 regularly to monitor weight loss and to identify new symp- Another medication for long-term use is the lipase toms including physical or psychological dependence. These inhibitor, orlistat. Orlistat is available in prescription strength medications should be discontinued if patients develop de- and a lower dose, OTC version. Orlistat is relatively safe pendence or cardiovascular/pulmonary symptoms such as and effective for modest weight loss. However, there have chest pain, palpitations, hypertension, valvular disorders, been rare post marketing reports of severe liver injury in edema, pulmonary hypertension, dyspnea, and seizures.16 patients treated with orlistat. Information can be found on Practitioners should educate patients to report adverse the FDA website: http://www.fda.gov/Drugs/DrugSafety/ reactions including central nervous system overstimula- PostmarketDrugSafetyInformationforPatientsandProvid- tion, impaired coordination, dizziness, palpitations, el- ers/ucm213038.htm. Most prescribers exert greater caution evated BP, psychosis, dry mouth, constipation, urticaria, and impotence. Blood glucose levels should be monitored in patients with Prescriptions for sympathomimetics should diabetes. Additionally, the relationship be written for a short period of time with a between reduced food intake and possible changes in antidiabetic medications low number and no refi lls. should be discussed. Practitioners may need to reinforce the signs and symptoms of hypo- and hyperglycemia. when prescribing the sympathomimetics as these drugs are Sympathomimetic medications tend to lose effi cacy controlled (scheduled) and have the potential for serious quickly and have the potential for adverse drug effects. They adverse events and signifi cant drug-to-drug interactions.16 should only be prescribed when the patient has failed to lose Prior to prescribing these medications, the practitioner weight after successfully complying with lifestyle changes should conduct a history and physical exam to rule out or- for approximately 6 months. Prescriptions should be writ- ganic causes of obesity, as well as to determine the presence ten for a short period of time, with a low number, and no of factors that may contraindicate or preclude the medica- refi lls. Prescribers of these drugs should consider placing tion. The history and exam should be suffi cient to determine their patients under contract. Implementing these strategies which patients might experience adverse reactions or drug- requires the patient to follow up with the team regularly to-drug interactions. The practitioner and the patient both and decreases the chance for serious adverse events, abuse, should understand that when the medication is stopped, the and overdose.16 amount of weight lost (and more) may be regained. Last but NPs may be required to have additional qualifi cations not least, a transdisciplinary approach should be adopted as related to licensure prior to prescribing scheduled medica- team members can enhance successful weight loss by rein- tions. Those who have not received additional education and forcing the patient’s improved lifestyle, nutrition, fi tness pre- supervision by experts in weight loss management pharma- scriptions, and sleep recommendations (7 to 8 hours/night). cotherapy (all classes) should seek this knowledge prior to considering these medications for treatment.16 ■ Sympathomimetics Simply put, sympathomimetics work by central nervous ■ Lipase inhibitors system stimulation and by suppressing the appetite center Orlistat works by effectively limiting calorie intake by enh- in the brain. They are indicated as monotherapy for short- ancing vagal-dependent satiety and limiting the absorption term use in obese, nonpregnant, non-nursing adults. These of fat in the intestine. The medication should to be taken medications are contraindicated in patients with athero- with meals and needs to be ingested with approximately sclerosis, hypertension and other cardiovascular diseases, 30% of the meals calories from fat. It is contraindicated in hyperthyroidism, glaucoma, extreme nervousness, agitation, those with chronic malabsorption states, as well as in pa- and drug or alcohol use. These medications are also not tients with cholestasis. The drug should be used cautiously recommended for use in the elderly, patients with anorexia in patients with hyperoxaluria, calcium oxalate nephro- or bulimia, and patients taking antidepressants (such as, lithiasis, and in those receiving antidiabetic medications current or recent monoamine oxidase inhibitor, current (monitor blood glucose). This drug should not be used in selective serotonin reuptake inhibitor [SSRI]), stimulants nursing mothers . Although the pregnancy category is B, the

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medication should not be used during pregnancy unless the ■ Other medications benefi ts of weight loss are very high. Other medications including antidepressants, antidiabetics, Patients taking this medication may require a mul- and others are currently under investigation for their use tivitamin/mineral supplementation as orlistat interferes in obesity treatment. with absorption of fat-soluble vitamins (A, D, E, K) and Antidepressants. Fluoxetine (Prozac) is a SSRI that was beta carotene. Guidelines recommend monitoring patients initially used for the treatment of depression and later app- receiving warfarin and cyclosporine. Many patients stop tak- roved for bulimia. The medication has been studied for use ing this medication because of gastrointestinal (GI) adverse in obesity and in obesity with type 2 diabetes (60 mg/day) reactions including increased defecation, stool incontinence, combined with a reduced calorie diet. Weight loss effi cacy fatty/oily stools and evacuation, increased fl atus, and fecal is most apparent during the fi rst 4 to 6 months of use and urgency. These effects need to be reviewed prior to initiat- may wane at 12 months. The medication also improves ing orlistat.16 insulin sensitivity in type 2 diabetics. The higher doses of this medication may increase the chance for adverse reac- ■ Evidence related to effi cacy/safety tions including serotonin syndrome.20 The evidence from recent, double-blind, randomized con- Antidiabetics. Metformin (Glucophage), a biguanide, trol trials in adults related to orlistat is positive. Sixteen may be helpful for obesity and is undergoing analysis for clinical trials (n = 10,631 participants) revealed that orlistat use along with lifestyle modifi cation in the treatment of (when compared to placebo) reduced weight on average adolescent obesity. Amylin, a beta cell hormone co-secreted by 2.9 kg (95% CI), range 2.5 to 3.2 kg. Additionally, this with insulin in response to meals, was found to reduce food medication decreased the incidence of diabetes, improved intake and body weight in rodents. Synthetic amylin, pram- glycemic control in persons with diabetes, and improved lintide (Symlin), is a diabetes medication that has been used total cholesterol and BP levels. The medication slightly in obesity studies. Greater initial weight loss and sustained lowered concentrations of high-density lipoprotein (HDL) weight loss were achieved with lifestyle modifi cations in levels. The study documented increased rates of GI adverse adults taking pramlintide (Symlin, synthetic Amylin) for reactions in the medication group.18 1 year.21 Participants receiving active medication were signifi - cantly more likely to lose 5% to 10% of weight loss thresh- ■ Medications on the horizon olds. However, the attrition rates in studies measuring the The CB 1 blockers are a new class of medications that show effects of medications ranged from 30% to 40%. Similar promise. Rimonabant is approved for use in Europe but was fi ndings were published for other clinical trials, and were denied FDA approval in the United States due to signifi cant not included in the meta-analysis.19 mood-related adverse reactions. The medication has been Evidence for the effi cacy for the sympathomimetics studied in placebo-controlled trials and has been found to medications is variable. The risk of treatment often out- reduce weight, decrease waist circumference, improve lipid weighs the benefi t of treatment. Because of this fact, use of profi les, and lower BP. The CB 1 blocker medications require these medications is limited and practitioners are ethically further study but may be useful in treating other obesity- bound to consider other options. related diseases as well.22-24

Obesity therapeutic options by BMI and weight classiﬁ cation6

BMI Weight classiﬁ cation Diet, exercise, and sleep Pharmacotherapy Bariatric surgery recommendations

18.5 to 24.9 Healthy weight Individualized as needed No No

25 to 29.9 Overweight Yes Should be considered for No BMI greater than 27 with comorbidities

30 to 34.9 Class 1 Obese Yes Yes Yes, with comorbidities

35 to 35.9 Class 2 Obese Yes Yes Yes

≥40 Class 3 Obese Yes Yes Yes www.tnpj.com The Nurse Practitioner • September 2011 43

As obesity rates rise and weight maintenance statistics Behaviors identified in individuals who successfully continue to be marginal, the market for weight loss medica- maintained weight loss include: tions is unlimited. A medication that offers safety, longevity • High levels of physical activity without adverse reactions, effectiveness in reducing food • Low dietary fat and high dietary carbohydrate intake intake or appetite, and/or sustained weight loss has yet to • Regularly self-monitoring weight. be found. On the horizon are over 150 molecules in various Other behavioral attributes of people with long-term stages of research. Several medications are currently under weight maintenance include: investigation, which target neural pathways, fat cells, hor- • Less binge-eating behavior mones such as leptin, metabolism and GI system inhibi- • Less loss of intake control while eating tors such as ghrelin, and other GI modiﬁ ers. Examples are • Higher long-term physical activity tesofensine,25 liraglutide,26 and topiramate.27 Additionally, • Less depression when compared to those who regained multidrug therapy for treatment of obesity is under inves- lost weight.33 tigation. Examples include pramlintide/metreleptin28 and In addition, subjects who began regaining weight early bupropion/naltrexone.29 after weight loss had less long-term success.31

■ Dietary supplements ■ The National Weight Control Registry (NWCR) Many patients use OTC dietary supplements as part of their The NWCR is a research study that obtains data and in- weight loss efforts. Although there are many products on formation from people who have successfully lost weight the market, the evidence for their benefi ts in weight loss and kept it off.34 Inclusion in the registry includes persons and weight loss maintenance is poor. There are numerous meeting the following criteria: 18 years of age or older, lost at least 30 pounds, and maintained a weight loss of at least 30 pounds for 1 Greater initial and sustained weight loss year or more. Enrollees in the NWCR were achieved with lifestyle modifi cations frequently complete surveys regarding their success at losing weight, current in adults taking pramlintide for 1 year. weight maintenance strategies, and other health-related behaviors. The current registry sample is 80% methods to treat and manage obesity in adults including female and 20% male. The mean age is 45 years for women behavioral weight treatment, medical nutritional therapy, and 49 years for men. The mean weight for women is 145 cognitive behavioral therapy, exercise prescription, or some lb and for men 190 lb. The mean total weight lost for all combination of these in addition to pharmacotherapy and registry members is 66 lb with a mean time weight has been bariatric surgery. Current evidence suggests that a compre- successfully maintained being 5.5 years. Forty-fi ve percent hensive treatment approach to manage adult obesity, which of registry participants lost the weight on their own and the benefi ts from the breadth of knowledge and expertise across other 55% lost weight with the help of some type of program. disciplines, is most effective in the treatment and manage- Ninety-eight percent of NWCR participants report that ment of adult obesity.30 (see Obesity therapeutic options by they modifi ed their food intake in some way to lose weight. BMI and weight classifi cation). Ninety-four percent increased their physical activity, walking was the most frequently reported form of activity. There is vari- ■ Weight loss maintenance ety in how NWCR members successfully maintain their weight While there is evidence to suggest what components are loss. Weight maintenance success is refl ected in the fi ndings necessary for successful weight loss treatment, there are less that a large majority of registry members report continuing data regarding successful weight loss maintenance. In most to maintain a low-calorie, low-fat diet and doing high levels of clinical studies, only a small number of individuals are able activity. In addition, 78% eat breakfast every day, 75% weigh to keep weight they have lost off over time.30 A recent article themselves at least once a week, 62% watch less than 10 hours of on obesity treatment and management in the United States TV per week, and 90% exercise for an average of 1 hour/day.34 indicated that weight loss management programs are un- A recent study of the NWCR participants described successful long-term, as most individuals who intentionally how eating and exercise habits changed from 1995 to 2003.35 lost greater than 10% of body weight, will regain 2/3 of the The results of this study found that the daily percentage weight within a year. Additionally, most individuals regain of calories from fat increased from 23.8% to 29.4%; and all of the lost weight within 5 years.31 calories from carbohydrate decreased from 56% to 49.3%,

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A transdisciplinary approach to adult obesity1

Screen to rule out organic causes and make appropriate referrals – NP/MD Assess anthropometrics – RD Pituitary dysfunction Waist-to-hip ratio Thyroid disease Waist circumference Polycystic ovary disease Assess comorbid Height and weight Hypothalamic disorders conditions – NP/MD Calculate BMI Genetic disorders Hypertension Frame Size Others Dyslipidemia CVD Hyperinsulinemia Diabetes Assess health risk – NP/MD/RD Metabolic syndrome BMI Risk-adjusted comorbidities Sleep apnea (If one or more applies) GERD <25 Minimal Low Osteoarthritis 25-<27 Low Moderate Breast, endometrial, 27-<30 Moderate High and/or colon cancer 30-<35 High Very high Depression 35-<40 Very high Extremely high Others >40 Extremely high Extremely high

R/O weight loss contraindications – NP/MD Pregnancy/lactation Medical/mental conditions such as: If Yes Recommend weight Eating disorders, psychosis, bipolar disorder, severe stability depression

Assess readiness for weight loss – RD/NP/MD If No Discuss prevention of Is client ready? further weight gain Reevaluate readiness at future visits

Discuss treatment options – RD/NP/MD

Implement weight loss protocol – Goal is to lose 5%-10% body weight Individualized lifestyle changes including sleep recommendations – RD/NP/MD 500 calorie deficit below calculated need to result in one pound weight loss/week– Personalized meal plan – RD Self-management training – RD/NP/MD Exercise prescription – NP/MD Reinforce Physical Activity – RD/NP/MD

When goal weight is achieved, Implement weight maintenance protocol When goal weight is not achieved, Personalized meal plan – RD Discuss possible adjunctive therapy – NP/MD Self-Management Training – RD/NP/MD Exercise prescription – NP

Pharmacotherapy Bariatric Surgery (BMI > 27 with high health risk and (BMI > 30 with comorbidities) no contraindications) Medical surveillance required – NP/MD Medical surveillance required – NP/MD Preoperative lifestyle change – NP/MD Personalized meal plan and lifestyle Postoperative personalized meal plan change – RD and lifestyle change – RD

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refl ecting a trend toward lower carbohydrate consumption 13. Sachdev M, Miler WC, Ryan T, Jollis GJ. Effect of fenfl uramine-derivative diet pills on cardiac valves: a meta-analysis of observational studies. Am Heart J. in popular diets of the time. 2002;144(6):1065-1073. The proportion who consumed less than 90 grams of 14. Haddock CK, Poston WSC, Dill PL, Foreyt JP, Ericsson M. Pharmacotherapy for obesity: a quantitative analysis of four decades of published randomized carbohydrate (generally considered a low carbohydrate diet) clinical trials. Int J Obes Relat Metab Disord. 2002;26(2):262-273. increased from 5.9% to 17.1%. Weight regain over a 1-year 15. Alraei RG. Herbal and dietary supplements for weight loss. Top Clin Nutr. 2010; period was related to higher caloric, fast food and fat intake, 25(2):136-150. 16. Obesity in Nurse Practitioners’ Prescribing Reference. Winter 2011;17(4);2439-245. and lower levels of physical activity. 17. U.S. Department of Health and Human Services: U.S. Food and Drug Patient education should address the environmental Administration. Meridia (sibutramine): Market withdrawal due to risk of serious cardiovascular events. 2010. http://www.fda.gov/Safety/MedWatch/ changes that have contributed to the increase in obesity. SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm228830.htm. Instruction should include caloric reduction, frequency of 18. Nkansah N, Garala M, Agness C, et al. Orlistat for the prevention of cardiovascular disease in overweight or obese individuals. Cochrane Database fast food consumption, reduction of fat and sugar intake, Syst Rev. 2007;3:1-20. increased nutrient-rich and high-fi ber carbohydrates, label 19. Rucker D, Padwai R, Li SK, Curioni C, Lau DC. Long term pharmacotherapy for reading, grocery shopping recommendations, and methods obesity and overweight: updated meta-analysis. BMJ. 2007;335(7631):1194-1199. 20. Aponte JC, Ballesteros B, Deantonio R. Fluoxetine for overweight and obesity. to increase physical activity and reduce screen time (see A Cochrane Database Syst Rev. 2008;3:1-14. transdisciplinary approach to adult obesity). 21. Smith SR, Aronne LJ, Burns CM, et al. Sustained weight loss following 12-month pramlintide treatment as an adjunct to lifestyle intervention in obesity. Diabetes Care. 2008;31(9):1816-1823. ■ Summary 22. Curioni C, Andre C. Rimonabant for overweight or obesity. Cochrane Database Interventions for overweight and obesity should be delivered Syst Rev. 2006;(4):CD006162. 23. Christensen R, Kristensen PK, Bartels EM, Bliddal H, Astrup A. Effi cacy and and reinforced by a transdisciplinary healthcare team. The safety of the weight-loss drug rimonabant: a meta analysis of randomized most effective approaches include both diet and physical trials. Lancet. 2007;370(9600):1706-1713. 24. Chaput JP, Tremblay A. Current and novel approaches to the drug therapy of activity recommendations with frequent monitoring and obesity. Eur J Clin Pharmacol. 2006;62(10):793-803. behavioral counseling.36 25. Astrup A, Madsbad S, Breum L, Jensen TJ, Kroustrup JP, Larsen TM. Effect of tesofensine on body weight loss, body composition, and quality of life in Currently, the safest and most effective medication for obese patients: a randomized, double blind placebo controlled trial. Lancet. weight loss and weight loss maintenance is orlistat.18 In the 2008;372(9653):1906-1913. 26. Astrup A, Rössner S, Van Gaal L, et al. Effects of liraglutide in the treatment future, as new medications become available, combination of obesity: a randomized, double-blind, placebo controlled study. Lancet. therapy may be more prevalent and potentially more effective. 2009;374(9701):1606-1616. 27. Rosenstock J, Hollander P, Gadde KM, et al. 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