ENDO 2018: 100th Endocrine Society Annual Meeting :

Overcoming Clinical Indifference to Obesity is a Public Health Imperative

The impact of obesity on disease outcomes and health prospects is profound.1  Adults with obesity experience per capita medical costs that are 42% higher than healthy weight peers, and are twice as likely to die before 70 years old,2 according to research appearing in the journal Obesity.

For patients whose health mandates a reduction in adiposity choosing between behavioral interventions, pharmacotherapy, and gastric surgery,  all proven to support clinically significant improvements in weight status.Yet, clinicians are not recommending these interventions to patients who would benefit from the health outcomes achieved.

Despite an understandable, albeit, problematic clinical indifference to the challenge of obesity, it is no coincidence that several sessions at ENDO 2018 focused on the diagnosis and management of obesity.3-5

We can no longer settle for an “eat less, move more” mantra. After all, the evidence is irrefutable—obesity is a complex disease, arising from an interplay between metabolic, individual, psychophysiological, genetic, and environmental factors,3 said Robert F. Kushner, MD, professor of medicine, and medical director of the Center for Lifestyle Medicine at Northwestern University Feinberg School of Medicine in Chicago, opening a session focused on practical strategies to improve obesity care, “in addition to compelling societal norms, learned behaviors, and cultural factors; and just like smoking, change will take a long time.”

Obesity is a multifaceted disease, requiring an individualized approach to care.

We have a Medical Imperative to Treat Obesity

Evidence-based guidelines for obesity management recognized as a medical condition,6 according to the American Association of Clinical Endocrinologists. Defined as a complex, adiposity-based chronic disease, obesity management is essential in order to address a myriad of weight-related complications to optimize health and quality of life.

“Regardless of your competency and interest, take a better [weight] history,” Dr. Kushner said, because before you can help your patients, you need to know how they got to weight they are in your office, and you need to have an understanding of the biology of weight loss and maintenance.

There is an urgency in all of this is that obesity must be addressed before it turns into diabetes.

“We have fallen into a comfortable message of pushing patients to lose just 5-10% of their body weight to improve health parameters, “but 5% is just not enough!, said Holly Wyatt, MD, associate professor of medicine at the University of Colorado School of Medicine in Aurora, Colorado, “We can do better!”

Can No Longer Settle for 5% Weight Loss as Healthy  

The game changer is a need to appeal to what is perceived as more important--achieving happiness; health has proven to be a poor motivator.4

Most patients feel that they are a failure because they haven’t been able to maintain their lost weight, yet they are quick to say, “just help me lose,” Dr. Wyatt said, “So listen to them.”

Start by making this the goal, and separate out weight loss, which is finite, from weight maintenance, which will be a completely different focus for later.“By approaching clinical care as a two-step process: first weight loss, then weight maintenance, we'll have a better chance at keeping our patients on the right track since each step requires a distinct method to assure successful outcomes are achieved,” Dr. Wyatt told EndocrineWeb.

“The sweet spot is six months because patients can adhere to a temporary diet plan that is solely meant to promote weight loss, and then they need to work at maintaining that lost weight,” she said. This is critical because weight loss creates an energy gap—the more a patient loses, the greater the energy gap, prompting physiological efficiencies to develop. Our job is to help our patients fill the gap so that the desired balance can occur.4

“After all, what works for weight loss is a short-term commitment to reduce energy intake to promote meaningful weight loss. And, we know that the cornerstone of a healthy lifestyle begins with diet and exercise,” said Dr. Wyatt.

Recalibrating the Approach to Achieve a Lower Body Weight

Will you be good a delivering a lifestyle modification, or should you consider identifying a member of your team to provide this critical service to patients at risk for diabetes or who present with an upward trend in weight gain—something to think about,4,5 

What are the behaviors that need to be in place to fill that gap? If we are to have a chance to be effective—Rather than focus on weight loss as a means to weight maintenance—the old paradigm—we will give our patients will a better chance of successful weight control if we approach these as two distinct strategies,5 according to Caroline Apovian, MD, professor of medicine and pediatrics at Boston University School of Medicine, and director of the Center for Nutrition and Weight Management at Boston Medical Center, in Massachusetts.

Obesity is all about early imprinting, endocrine-disruptors, lack of exercise, too much sugar, genetics, weight-promoting medications, stress, poor sleep, and not enough time in the day.“All of these factors remind us that the phenotype of obesity is complicated, met with a myriad of interactions that vary individually,” said Dr. Apovian.

We’ve learned from some 11,000 individuals in the National Weight Loss Registry (NWLR) that there are key strategies that have helped them keep off an average of 66 pounds and for more than 5.5 years, to date.5  The changes reported from the NWLR are:

  • Eat breakfast every day.
  • Increase in daily physical activity; most walk 1 hour/day  
  • Permanent dietary changes (ie, more vegetables, fewer starches)
  • Weigh in at least once a week

"Despite advances in all aspects of obesity management: lifestyle intervention, pharmacotherapy and bariatric surgery,7,8 the use of these options have been rejected by patients and ignored by the majority of clinicians," said Dr. Apovian.

It’s Time for New Game Plan

“If we are being honest with ourselves, lifestyle modification will not be enough for the majority of our patients,” said Dr. Apovian. How are we going to move the field forward, to have the necessary impact on our patients’ waists in the long-term?

Despite the known benefits of bariatric surgery, only about 1% of patients who are eligible for weight management procedures get it. Similarly, there are six approved medications for weight control yet too few patients are using these tools,8 according to Dr. Apovian.

As it is, patients need medication just to help them achieve even a 5-10% weight loss and keep it off. It must be acknowledged that most patients who need a prescribed appetite suppressant will need to stay on the medication, just as they do to manage hypertension, hyperlipidemia, and other chronic diseases.

“While these meds won’t solve the problem, they should be viewed as a necessary part of obesity medical management,” Dr. Apovian said.

Utilizing the Full Armamentarium to Achieve a Healthier Weight

“Pills and surgery are an important and underutilized adjunct but the cornerstone of weight management is and will always be behavior modification and lifestyle management,” she said, “However, the approach must be individualized, and the patients should understand that they will require lifelong care.”

One of the biggest hurdles is medical reimbursement. Most appetite suppressants are not covered by health insurance. Yet, there is great value in prescribing the right medication to our patients.

  • For severe food cravings or binge eating/drinking, naltrexone/bupropion SR has proven effective in conjunction with behavior modification and has led to double the amount weight loss in comparison to patients on no medication.
  • Liraglutide (Victoza), an injectable, taken at twice the dose prescribed for diabetes management, induces satiety and reduces cardiometabolic risks, but the price is high.
  • A new medication, semaglutide, is coming and is anticipated to promote double weight loss.
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