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Obesity: A threat to public health that requires appropriate treatment

BOSTON — Experts at the ACP Internal Medicine Meeting urged physicians to recognize obesity as a disease state, especially as it becomes more prevalent in the United States.

According to Fatima Cody Stanford, MD, MPH, obesity medicine and nutrition fellow at Massachusetts General Hospital, Harvard Medical School and Harvard Kennedy School of Government, obesity affects more of the population than nonalcoholic steatohepatitis, diabetes, seasonal allergies, and all cancers. It is a multifactorial disease order, Stanford said, and the various components leading to obesity should be analyzed carefully, especially as they relate to genetics, the environment and behavior.

Treatment guidelines, options

Guidelines for the treatment of obesity are based on BMI: class 1 obesity is categorized as BMI of 30-35; class 2 as BMI of 35-40; and class 3 as BMI of 40 and greater. According to Stanford, diet, physical activity and behavioral therapy are indicated among patients who are overweight (BMI 25-30), or have class 1, 2 or 3 obesity, regardless of comorbidities. Patients who are overweight with comorbidities are also eligible for pharmacotherapy, as are those with class 1, 2 or 3 disease. However, Stanford pointed out that only patients who do not lose 1 pound. per week after 6 months of combined diet, physical activity and behavioral therapy should be considered for pharmacotherapy. Weight loss surgery is indicated among patients with class 1, 2 or 3 disease with comorbidities.

Among patients who may be unable to lose weight due to weight-promoting medications such as antipsychotics, antidepressants, sleep agents, beta blockers, steroids, insulin and hypoglycemic agents, Stanford suggested that clinicians identify the agent causing weight gain and discontinue it where appropriate. In instances where medication cessation is not appropriate, such as with beta blockers, Stanford recommended an anti-obesity medication be considered in conjunction with lifestyle changes. Some FDA-approved pharmacologic options include CNS stimulants/anorexiants, antidepressants/dopamine reuptake inhibitors/opioid antagonists, gastrointestinal agents and medications like liraglutide, a GLP-1 agonist.

Overall, Stanford recommended using targeted strategies for each individual to determine what option is most appropriate, and to be patient.

Bariatric surgery

Bruce Schirmer, MD, Stephen H. Watts Professor of Surgery, department of surgery at the University of Virginia, discussed available surgical treatment options for obesity and how to prepare patients for their consultation.

According to Schirmer, it is important that primary care physicians evaluate and treat obesity-related diseases. Those often overlooked include obstructive sleep apnea, substance abuse, cholelithiasis, depression, hyperlipidemia, coronary artery disease and pulmonary hypertension. Schirmer also emphasized the importance of communication between the PCP and bariatric surgeon. Surgeons rely on PCPs to refer appropriate patients, and often the PCP is the first point of contact when patients present with postoperative complications.  

In terms of options, Schirmer said sleeve gastrectomy has become the most popular surgery in the U.S., accounting for 46% of all surgeries, in the last year and a half. Gastric banding, on the other hand, seems to be on its way out, he said. Overall, bariatric surgery has many benefits, including its ability to increase lifespan, improve quality of life, improve or eliminate obesity-related diseases and transform patients. Regarding risk, bariatric surgery is slightly more risky than cholecystectomy, but is less risky than appendectomy, colon surgery, small bowel surgery, gastric surgery, pancreatic, and hepatic or esophageal surgery, he said. 

“Once [patients] decide they need help, I would hope that you would, for the folks that are appropriate, at least think about surgery as a very effective, durable and relatively safe way for them to achieve good weight loss.” – by Stacey L. Adams

For more information:

Stanford FC, et al. Clinical Triad: The experts weigh in on obesity. Presented at: ACP Internal Medicine Meeting; April 30-May 2, 2015; Boston.

Disclosures: Schirmer reports a consultant relationship with Allurion. Stanford reports no relevant financial disclosures.