Lifestyle medicine foundation for treating people with obesity
Key takeaways:
- Intensive lifestyle medicine should be the foundation of care for all people with obesity.
- Anti-obesity medications and bariatric surgery can be used as adjunctive therapies for indicated patients.
DENVER — Lifestyle medicine is a central component of obesity treatment, including for adults who receive anti-obesity medications or undergo bariatric surgery, according to three speakers at the Lifestyle Medicine Conference.
“Whether you’re treating obesity with surgery, whether you’re thinking of treating obesity with medications, lifestyle medicine is really the foundation,” Deepa Sannidhi, MD, DipABLM, DipABOM, associate clinical professor in the department of family medicine at University of California, San Diego (UCSD), associate program director for the UCSD/San Diego State University general preventive medicine residency, clinical director of the UCSD Center for Integrative Medicine Supervised Lifestyle and Integrative Medicine program and the UCSD Center for Advanced Weight Management, and general concentration lead at the Herbert Wertheim School of Public Health, said during a presentation. “Chronic disease guidelines for every single condition, including obesity, promote lifestyle intervention as the first treatment.”
Lifestyle intervention induces weight loss
Sannidhi outlined six pillars of lifestyle medicine as defined by the American College of Lifestyle Medicine: regular physical activity, whole foods, restorative sleep, stress management, positive social connection and avoidance of risky substances. She said providers must consider each person’s circumstances, such as the home they live in or the societal environment, which may be promoting weight gain.
According to a statement from the U.S. Preventive Services Task Force published in 2018, people with obesity should be engaging in high-intensity, multicomponent lifestyle intervention. The statement goes on to state that interventions are often not “adequately dosed” for success. With proper lifestyle intervention, Sannidhi said, people with obesity can expect to lose 5% to 10% of their body weight.
At Sannidhi’s institution, intensive lifestyle intervention is provided through a shared medical appointment model, where participants attend a medical visit in a group setting. Following three intake sessions, participants attend 12 sessions over 4 to 6 months. The sessions focus on the six pillars of lifestyle therapy and include time for meditation, sharing of experiences, learning about a healthy lifestyle topic, interactive topic-specific discussion and the creation of action plans.
“The idea is to create a program that other clinicians can easily replicate,” Sannidhi said.
Incorporating medications into care
Anti-obesity medications may be used as an adjunctive therapy for some people who need to lose weight, according to Michelle Hauser, MD, MS, MPA, FACP, FACLM, clinical associate professor of surgery and medicine at Stanford University School of Medicine, obesity medical director at the Stanford Lifestyle and Medical Weight Management Center, and the obesity medication attending physician for Move Time at the Palo Alto VA Health Care System. Hauser said anti-obesity medications should be used as a tool in combination with healthy eating and physical activity. People who may be prescribed anti-obesity medications include those with a BMI of 30 kg/m2 or higher or people with a BMI of 27 kg/m2 to 29 kg/m2 who have comorbidities and were unable to lose at least 5% of their body weight in 3 to 6 months with comprehensive lifestyle intervention.
“Lifestyle is the first treatment for anyone with obesity,” Hauser said during a presentation. “I like to describe it as part of the ingredients in a recipe. For a lot of people once they see me, a lot of people have tried lifestyle changes, and they haven’t led to sustainable weight loss. We want to tune [lifestyle intervention] up, but it’s also adding [anti-obesity medication].”
Before prescribing anti-obesity medications, providers should analyze what medications a person is already taking. Hauser said there are numerous types of medications that may cause weight gain, and providers should look to switch people with obesity to an alternative medication within the same class that is weight neutral or weight-loss promoting.
Hauser said anti-obesity medications can confer a weight loss of 3% to 20%, depending on the class of agent used. Providers should discontinue or change the medication if weight loss is not achieved at 12 weeks of the maximum-tolerated dose. After starting an anti-obesity medication, providers may also need to change blood pressure or diabetes medications the person may be on. While a person is receiving an anti-obesity medication, providers need to monitor mood, weight, heart rate, BP and glucose.
Hauser said the best approach for providers treating people with obesity is to add pharmacotherapy to intensive lifestyle intervention.
“The results I was seeing with lifestyle medicine alone and obesity medicine alone really paled compared with combining the two,” Hauser said.
Lifestyle medicine and bariatric surgery
For people undergoing bariatric surgery, lifestyle medicine should be incorporated throughout the process, according to Kelley Hagerich, MD, MPH, FACP, DABOM, DipABLM, national lead physician champion for the VA Health Care System and medical director of the VA VISN21 bariatric surgery program. Before surgery, a multidisciplinary assessment should be conducted and include a medical evaluation by a bariatric surgeon, a nutritional assessment by a registered nutritionist, a physical activity assessment by a physical therapist or exercise kinesiologist, and a psychological evaluation by a psychologist or another mental health provider.
“We need to meet patients where they are on their weight-loss journey, even if we are not necessarily recommending bariatric surgery to them,” Hagerich said during a presentation. “We want to be able to have an informed discussion about weight-loss options with them and be able to discuss the risks and benefits of surgeries.”
For the nutrition assessment, Hagerich said providers should look at a chronological weight history and review eating behaviors, prior weight-loss attempts, life-changing circumstances and whether the person is using obesogenic medications. Body composition and energy requirements should be reviewed to provide a baseline for adiposity distribution, and nutritional status should be assessed.
People who are undergoing bariatric surgery should undergo a presurgical preparation intervention to improve postoperative outcomes. This intervention should last 4 to 12 weeks and include nutrition, pulmonary and exercise aspects. The exercise portion should focus on strength and aerobics and be optimized to a person’s starting functional capacity.
“After any major abdominal surgery, there’s a decrease of 20% to 40% in a patient’s functional capacity in the postoperative period, even in the absence of complications from the surgery,” Hagerich said. “The lower preoperative functional capacity can lead to increase morbidity and mortality, and a prolonged postoperative recovery period.”
For the presurgical psychosocial evaluation, providers can identify possible contraindications to the procedure and identify strengths and weakness to enhance surgical outcomes. The medical evaluation before surgery is multifactorial, according to Hagerich, and includes an evaluation of substance use, including smoking, marijuana and alcohol.
After surgery, Hagerich said some people may regain weight or may have lost an insufficient amount of weight. In these cases, lifestyle interventions can be incorporated. Providers should ask about dietary patterns, physical activity, psychological disorders and motivation, and provide them with knowledge or skills to make changes.
“We need a lot more research to be done to know how to prevent weight regain, address insufficient weight loss and how to treat these conditions,” Hagerich said.
Reference:
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Sannidhi D, et al. Evidence-based lifestyle medicine treatment of adults with obesity: Essential skills for lifestyle medicine clinicians. Presented at: LM2023 Lifestyle Medicine Conference; Oct. 29-Nov. 1, 2023; Denver (hybrid meeting).