Experts offer optimism on overcoming obesity
ACP and Annals of Internal Medicine hosted a forum on managing the epidemic levels of obesity in America.
The statistics were dire, but the outlook was bright during ACP's and Annals of Internal Medicine's virtual live event, “Overweight and Obesity: Current Clinical Challenges.”
Moderator Christina C. Wee, MD, MPH, FACP, began by noting that the March 8 forum was not such a departure from its predecessors, which have primarily focused on COVID-19.
“The rise in obesity over the last several decades has been characterized as being epidemic-like, and in fact, recent data from the CDC suggests that more than 40% of all U.S. adults meet the criteria for being obese,” said Dr. Wee, who is Senior Deputy Editor of Annals, ACP Vice President, and an associate professor of medicine at Harvard Medical School and Beth Israel Deaconess Medical Center in Boston.
To help physicians optimize their treatment of this common issue, the forum gathered experts to discuss the latest in the field, including new medical treatments for obesity. (More information on obesity is also available in ACP's Obesity Management Learning Hub).
“I'm the most optimistic that I've ever been in treating patients with obesity, and I've been doing it now for over 15 years,” said Sharon J. Herring, MD, MPH, associate professor of medicine and director of the Program for Maternal Health Equity at the Center for Urban Bioethics at the Lewis Katz School of Medicine at Temple University in Philadelphia.
One reason for that optimism is semaglutide, a glucagon-like peptide 1 (GLP-1) receptor agonist, which both the panelists and the virtual audience chose as the preferred treatment for the first case presented: a 42-year-old man with a body mass index (BMI) of 43 kg/m2.
“It's tolerated by most patients, although side effects in the beginning can be quite strong,” said Melanie R. Jay, MD, MS. “And it can lead to up to 15% or 16% weight loss on average … a really good medication we don't worry about. It's been shown to be safe in people with diabetes and heart failure.”
The drug can be difficult for some patients to access, noted Dr. Jay, who is an associate professor in the departments of medicine and population health at the NYU Grossman School of Medicine and Veterans Affairs (VA) New York Harbor Healthcare System in New York City.
“Where I practice at the VA, they require that before we give GLP-1 agonists, because they're expensive, that they fail another medication,” she said. Orlistat, a lipase inhibitor that has been shown to cause about 5% weight loss, is the drug she usually tries first.
Metformin would be another inexpensive option, said Dr. Herring. “I don't think we push metformin enough. It is such a benign drug, so I do think that we could get some benefit in some patients with metformin.” Naltrexone-bupropion is another approved option, Dr. Kay noted, adding that the choice of medication should be based on patients' comorbidities as well as access.
A question that arose during the group discussion was the appropriate duration of therapy. “Something that patients ask all the time: ‘Am I going to have to be on this forever?’” said Dr. Herring. “Obesity is a chronic disease just like diabetes, just like high blood pressure. When you get your blood pressure controlled on your medication, you don't immediately stop your medication. Otherwise your blood pressure would go back up.”
That said, she thinks it's reasonable for patients who have successfully achieved weight loss on a drug to try a holiday from it to see if they can maintain their weight.
The patient in the case posed to the panel had expressed lack of interest in surgery, but it's worthwhile to offer a referral to a surgeon even if patients aren't sure they want surgery, according to Anita P. Courcoulas, MD, MPH, Anthony M. Harrison Chair and Professor of Surgery and chief of minimally invasive bariatric and general surgery at the University of Pittsburgh.
“To learn about surgery should be a part of the initial evaluation,” she said. “We reassure patients that the literature in bariatric surgery has exploded in the last 15 years and the procedures now are less invasive and much safer. Hospital stays are a day to a day and a half. Perioperative mortality is under one-half of 1%.”
Dr. Courcoulas noted that even if a patient is inclined toward surgery, the procedure is not going to happen right away. “You have to go through a five- or six-month physician-supervised diet before most insurance companies will approve surgery, so that's a convenient time to maybe try some lifestyle counseling, if they haven't had that, and add medications.”
Bariatric, or metabolic, surgery is being increasingly seen as a treatment for conditions besides obesity, or even diabetes, she noted. “There's a lot of promotion of these operations … as a bridge to be able to undergo other necessary procedures,” Dr. Courcoulas said. “You can't have egg retrievals. You can't have a knee replacement in most settings if your BMI is over 35 to 40.”
Patients who do choose surgery will need to decide between gastric sleeve and gastric bypass. “There's about 13 randomized trials comparing sleeve and bypass head-to-head which show that there's slightly better weight loss with bypass compared to sleeve, and when you look at the details of glycemic control, there's better glycemic control in the long run after gastric bypass,” she said. “In terms of different health conditions, people that start with very bad acid reflux disease or a hiatal hernia are not good candidates for sleeve.”
An important concern for internal medicine physicians is what happens to patients after surgery, noted Dr. Herring. “What we're seeing more and more in clinical practice, at least among the internists who do this, is some weight regain after surgery that people are seeking medications for,” she said. “Will they have increased side effects because of these surgical procedures? Thus far, it doesn't appear that they do.”
It's common to regain weight two years or more after surgery, agreed Dr. Courcoulas. “And the earlier studies have shown that intervening [to treat regain] earlier is better. You can even intervene if they're not falling on the best trajectory,” she said. “I think we will see some studies emerging looking at medications as adjunctive therapy.”
She called on her primary care colleagues to keep a close eye on these patients. “People post-bariatric surgery need a lot of support and a lot of help for the rest of their lives in terms of maintaining their weight and then looking for red flags,” she said. “Patients who undergo bariatric surgery have a higher risk of suicidal ideation, suicidal attempts after surgery, as well as higher risks of substance and alcohol use disorders after surgery.”
The panelists also discussed prevention of obesity, tackling the case of a 24-year-old woman with a BMI of 26 kg/m2 who is concerned about her risk of obesity in the future after gaining weight during her pregnancy two years earlier.
Diet options to consider included keto, Mediterranean, and whichever diet she could most easily adhere to. The audience, and Dr. Herring, chose the last of those. “Telling her that the best diet is one that she can stick to while monitoring her caloric intake is the approach that I would take,” she said. “Overall, when it comes to weight loss effects, there really hasn't been data that has shown that one is superior to another.”
The experts also discussed the role of exercise for this patient and others. “General recommendations for most people are 30 minutes of moderate to vigorous activity most days of the week, but for weight loss, it's even more, so you're going for 60 to 90 minutes. And a lot of people can't get to that,” said Dr. Kay.
Physical activity is beneficial to overall health and weight maintenance but “On average, we don't think of that as being as important as dietary change for weight loss,” she said. That can actually be good news for some patients. “Most patients feel like ‘Oh, I can't lose weight because I can't do physical activity,’” Dr. Kay said.
The experts encouraged physicians to be positive both about patients' ability to lose weight and about their bodies as they are. “We all want people to feel good about themselves,” said Dr. Herring. “There's no reason not to feel good about yourself at any size. That doesn't mean that you're still not going to make some changes to feel better when you're walking up stairs or to help with your high blood pressure or help with mechanical strain on your knees.”
“It's not something that's the patient's fault,” added Dr. Kay. “If we treat it like we do other chronic diseases, I think the outcomes are going to be better. Patients will want to stay in care and we can temper their expectations and think about being on medication long term, about escalating care.”
In her final contribution to the forum, she noted that many more medications for weight loss are currently in the pipeline. “I also am really excited about this new era,” Dr. Kay said.