Family Medicine Vital Signs

   By: Jessica L. Jones, MD, MSPH

The American Medical Association, Council of the Obesity Society and American Association of Clinical Endocrinologists have classified obesity as a chronic disease.  With our pervasive cultural habits of inactivity and excess calorie consumption, obesity is an epidemic in the US! Given the significant costs, both physical and financial, associated with the diagnosis of obesity, it is time to start treating obesity with an evidence based approach, similar to the manner in which we approach other chronic diseases.

The treatment modalities of lifestyle modification, pharmacotherapy, and surgery has been shown to be effective in addressing obesity. The timing of the progression through these interventions may need to be adjusted depending upon an individual’s circumstances.

Figure 1: Paradigm for Treating Obesity^{1, 2}

 

Lifestyle modification

Lifestyle modification or behavior change strategies are created as a unique approach for each individual. Strategies include calorie reduction, exercise and self-monitoring. Consulting a dietician and exercise specialist can be helpful for planning and jumping into action. Calorie reduction should be prioritized for weight loss, while exercise is required for maintenance of lost weight. ¹

 

Pharmacotherapy

Currently, three prescription drugs are approved by the FDA for clinical use:

• Lorcaserin hydrochloride (Belviq): Lorcaserin works by activating the serotonin 2C receptor in the brain which may help a person eat less and feel full after eating smaller amounts of food.
• Phentermine with topiramate (Qysmia): Phentermine is a central nervous system stimulant and topiramate is an anti-seizure medication.
• Bupropion with naltrexone (Contrave): Bupropion is an antidepressant and naltrexone blocks the effects of narcotics and alcohol.³

Starting in the 1930s, amphetamine derivatives were the first appetite suppressants used widely; however, they lost favor due to addictive and euphoric side effects.  In the 1990s and early 2000s, fenfluramine, dexfenfluramine, and subutramine were other stimulants that were introduced, and then taken off the market, primarily due to their adverse cardiovascular effects.^1 ,4  Phentermine is currently the most commonly prescribed anorexia inducing agent, but studies offer limited support for long-term use.¹

Lorcaserin is a derivative of fenfluramine and dexfenfluramine with greater receptor selectivity. Thus, it has fewer adverse effects. It was approved for use in the US in 2012.^1,4

The use of medication combinations is becoming more common. In 2012, the combination of phentermine with topiramate was approved for use in the US.  This combination of medications produces an anorexic effect, though the mechanism of action has not been established. ¹

Neurobehavioral medications have also been shown to yield weight loss.  Buproprion is an antidepressant medication that affects dopamine and norepinephrine receptors.  In the US is it also approved for smoking cessation.  In combination with Naltrexone, an opioid antagonist, Buproprion’s anorectic effects can be useful for weight loss. ^{2, 4}

Orlistat is an over the counter weight loss medication.  A synthetic form of the natural lipstatin, Orlistat was the first lipase inhibitor approved in the US in 1999.^1, 2  In 2003, it was approved for use in adolescents.²  Subsequently, Orlistat was made available over the counter at half the prescription dose (2007). ¹

A number of the medications used to treat Type 2 Diabetes Mellitus have been shown to produce weight loss. However, none of these are currently approved for obesity treatment.

Metformin, Pramlintide, Glucagon-like peptide-1 (GLP-1) and the associated derivatives (Exenatide and Liraglutide) have been shown to induce weight loss. However, none of these are currently approved by the FDA for the treatment of obesity.  ^4, 5

Pharmacotherapy is a great option to augment weight loss lifestyle modifications.  If individuals have not lost 5% of their body weight after 3 months of pharmacotherapy, the medication should be discontinued. ¹

 

Surgery

If lifestyle modification and pharmacotherapy trials have failed to provide effective weight loss, individuals can consider bariatric surgical procedures.  Candidates for bariatric surgery include those with BMI>40, or those with a BMI>35 and other comorbidities such as hypertension, dyslipidemia, osteoarthritis, etc.  Three categories of bariatric surgery are widely used:

1. Restrictive (i.e. banding, vagal stimulation and balloon),
2. Malabsorptive (i.e. bypass), and
3. Combined Restrictive and Malabsorptive.

Restrictive or banding procedures decrease the size of the gastric opening.  Malabsorptive procedures reroute the gastrointestinal system to reduce the digestion and absorption of nutrients.  Bariatric procedures also alter gastrointestinal hormones and adipose metabolism, resulting in weight loss. ¹

Currently, there are four FDA-approved devices on the market designed to treat obesity:

• Lap-Band Gastric Banding System,
• Realize Gastric Band,
• The Maestro Rechargable System, and
• ReShape Integrated Dual Balloon System.

The Maestro Rechargable System and the ReShape Integrated Dual Balloon System are the newest weight loss devices.

The FDA approved an electronic vagus nerve blockade device, Maestro Rechargable System, in January 2015.⁶  The vagus nerve stimulates gastric and pancreatic secretions to digest food, and transmits signals that alter the sensations of hunger and satiety.  Studies indicate that intermittent vagus nerve blockade can assist with weight loss.^7,8 

In July 2015, the FDA approved use of the ReShape Integrated Dual Balloon System. This object is inserted into the stomach during an endoscopy. Once inflated it induces feelings of satiety to augment weight loss efforts.  The device should be removed after 6 months. ⁹

Investigators continue to research new programs and devices.  There is no single right answer, and providers must adapt weight loss recommendations to individual circumstances.  New techniques will continue to be developed as tools for our use in addressing this complex and challenging chronic health issue.

additional resources 1, 2, 3, 4

Jessica Jones MD, MSPH is an Assistant Professor with the University of Utah Division of Public Health.