Principles of Medical Practice for Overweight, Obesity, and Adiposopathy
Presented by J. Michael Gonzalez-Campoy, MD, PhD, FACE
Principles of medical practice for overweight, obesity and adiposopathy were published by Dr. Gonzalez-Campoy and colleagues in a review article in the International Journal of Endocrinology.
- Principle 1—Overweight and Obesity Are a Continuum, and Together Represent a Chronic, Biological, Preventable, and Treatable Disease
Adipose tissue helps regulate metabolism. The accumulation of excess fat mass may cause physical changes and adipose tissue dysfunction. Many complications of overweight and obesity in turn are obstacles to effective weight loss. Overweight and obesity are also linked to psychiatric diseases including depression. On the basis of the physical, metabolic, and psychological complications—overweight and obesity meet the definition of a chronic disease.
While body mass index (BMI) is typically used to define overweight and obesity, there are many people with an elevated BMI due to increased lean mass, and many others with metabolic diseases at a lean BMI. Newer tools, such as DXA body composition analysis that are better to differentiate between lean and fat mass, may be more clinically useful.
Metabolic risk may be assessed by simple biometrics, including body weight, waist circumference, and waist-to-hip ratio monitored over time.
- Principle 2—Every Patient Who Has Overweight or Obesity Should Be Initially Evaluated for Causes and Complications of Weight Gain, Including Adiposopathy
All patients with overweight or obesity should be evaluated for underlying causes or complications of weight gain. The evaluation should include a complete history, physical examination, and laboratory testing. Consideration should be made to substitute medications associated with weight gain (eg, select antipsychotics, antiepileptics, and antidepressants) whenever possible.
Laboratory findings associated with adiposopathy include increased leptin, tumor necrosis factor alpha, C-reactive protein, free fatty acids, and triglycerides; decreased adiponectic, HDL cholesterol; hyperinsulinemia/ hyperglycemia; activation of renin-angiotensin-aldosterone; and hypoandrogenemia in men or hyperandrogenemia in women.
Adiposopathy is characterized by an enlargement of fat cells, accumulation of visceral fat, growth of adipose tissue that exceeds its blood vessel supply leading to ischemia and inflammation, increase in immune cells in adipose tissue, and ectopic fat deposition (eg, fatty liver).
- Principle 3—Every Patient Who Has Overweight or Obesity Should Have Periodic Risk Restratification
Since BMI is not a perfect predictor of adiposopathy and metabolic diseases, it is recommended that practitioners re-evaluate the risk for these disorders yearly in patients who have overweight or obesity.
- Principle 4—There Are No Short-Term Solutions to a Chronic Medical Problem: Overweight and Obesity Should Be Treated with the Same Model of Chronic Disease Management That We Use for Other Chronic Diseases
A change in perspective has occurred over the past 5 years, with a number of leading medical organizations calling for treatment of obesity as a chronic disease. Thus, patients with overweight and obesity should receive long-term treatment, just as any other chronic disease would be managed.
- Principle 5—Effective Behavior Modification to Achieve a Negative Energy
Balance Is the Primary Long-Term Goal of the Medical Treatment of Overweight and Obesity
Patients should be taught how to reduce their caloric intake and increase physical activity. Strategies to achieve these goals include increasing the number foods with low-caloric density; drinking water instead of juice or sugary drinks; using smaller plates; eating 10 servings of fresh fruit or vegetables each day; having physical activity 2-minutes every hour for a total of 30 daily minutes; using tools to measure physical activity such as a pedometer; and being physically active when feeling hungry.
- Principle 6—The Team Approach to Overweight and Obesity Should Be Offered to All Patients to Provide Nutrition Education and Physical Activity Coaching
A comprehensive team approach to care is important and should include a range of health care professionals including nurse educators, dietitians, behavioral counselors, mental health professionals, and physical therapists. Patient education should include a variety of options, including electronic and/or print media, audiovisual resources, web-based education, and group classes. Offices should be equipped with supplies (scales, gowns, chairs, blood pressure cuffs) that accommodate larger sizes and make patients feel comfortable.
- Principle 7—Pharmacotherapy Should Be Used Indefinitely in the Management of Overweight and Obesity
Pharmacotherapy may augment the benefits of improved nutrition and increased physical activity. Some available options include the following:
- Phentermine—This adrenergic agent is indicated for short-term use, but is commonly used "off label" since it is the most affordable obesity medication. Patients taking this agent should be monitored for blood pressure.
- Orlistat—This pancreatic lipase inhibitor prevents fat from breaking down during digestion, decreasing its absorption. Steatorrhea is the most common side effect.
- Lorcaserin—This agent is a selective 5-hydroxytryptamine T2c receptor agonist that causes early satiety.
- Phentermine-topiramate—This is a combination of two medications with different mechanisms of action, each of which leads to early satiety. Because topiramate is associated with cleft-palate defects, contraception is strongly recommended for women of reproductive age.
- Buproprion-naltrexone—The early satiety of bupropion is coupled with naltrexone, which takes away from the pleasurable sensations associated with eating. This combination is associated with nausea, and therefore has to be titrated from a low starting dose.
- Benzphetamine, phendimetrazine, and diethylpropion—These centrally acting hyperadrenergic medications cause early satiety, are approved for the treatment of obesity, and are similar to phentermine in terms of side effects.
All these agents are contraindicated in pregnant women.
Many other agents, including selected antidepressants, GLP-1 agonists, SGLT-2 blockers, metformin, pramlintide, and topiramate may be used off-label for management of obesity.