Download
1 / 52
E N D
Management of obesity Professor / Mohammed Ahmed Bamashmos (MD) Professor of Internal Medicine and Endocrinology Faculty of Medicine , Sanaa University
قال تعالى: ﴿ وَكُلُوا وَاشْرَبُوا وَلَا تُسْرِفُوا إِنَّهُ لَا يُحِبُّ الْمُسْرِفِينَ ﴾ صدق الله العظيمعن جعدة بن خالد أن رسول الله صلى اللهعليه وسلم رأى رجل عظيم البطن فأشار بإصبعه إلى بطنه قائلاً: (ما هذا يا هذا لو كان هذا في غير المكان هذا لكان خير لك) صدق رسول الله
Definition • Obesity is a health condition in which excess body fat gets accumulated below the skin and around the visceral organs. A person is considered obese or overweight when his or her body weight is about 20% more than the ideal body weight. Also, if your Body Mass Index (BMI) is 30 or more, you can be considered obese. Obesity can cause many diseases like heart disease, cancer, arthritis, PCOD, depression, sleep disorder, and type 2 diabetes. Go for a health checkup if you are obese or overweight because obesity is a cause of many health conditions and hence it is best to stay aware of your health and detect diseases at an early stage
risk factors • 1- not getting enough sleep • 2- sitting to much • 3- eating large protein • 4- drinking sugary beverages • 5- eating processed food • 6- feeling stressed all the time • 7- lack of exercise • 8- watching lots of television • 9- skipping meals • 10- eating because of emotion • 11- drinking heaheavily
Assessment of overweight and obesity • 1- clinical assessment
Indication of drugs • accordance with a clinicians judgment and knowledge of the patient, treatment may be informed by the AACE clinical practice guidelines,3 which indicate that the use of pharmacotherapy should only be employed as an adjunct to and initiated concurrently with lifestyle therapy for obesity management in order to promote greater weight loss and improved weight-loss maintenance. Weight loss medications are prescribed for patients with a BMI > 30 kg/m2 or with a BMI > 27 kg/m2 when there is at least one ABCD-related comorbidity. • Patients deemed at elevated risk for obesity-related disease should be evaluated for clinical comorbidities and then assessed for the severity of any complications, including but not limited to hypertension, diabetes, or dyslipidemia (see Table
What are the therapeutic targets of medication-assisted weight loss? • Therapeutic targets for weight loss are best determined by the stage of comorbid involvement with the express goal of reversing clinical complications to improve the patient’s outcomes.3 • There are three scenarios to guide initiation of pharmacotherapy after lifestyle therapy has been trialed: • In patients who present with progressive weight gain or worsening of comorbid complications in which lifestyle therapy has been deemed insufficient. • To lessen or reverse tendency toward weight regain following initial weight loss success. • To promote greater weight loss in order to lessen weight-related complications.
Improvements in type 2 diabetes, hypertension, and dyslipidemia, for example, may be achieved in some patients with as little as 3 to 5% weight loss whereas other patients may require greater than a 15% loss of initial weight to reach desired therapeutic improvements in comorbid complications, and other conditions such as polycystic ovary syndrome, fatty liver disease, and sleep apnea, may require closer to a minimum of 10-15% weight loss to improve outcome(s).
Which medications should be used? • Currently, there are eight medications approved by the Food and Drug Administration (FDA) for use in supporting weight loss: • phentermine (Adipex-P®, Suprenza®)* • benzphetamine (Regimex®, Didrex®)* • orlistat (Xenical®, alli®)† • phentermine-topiramate ER (Qsymia®)† • liraglutide injection (Saxenda®)† • lorcaserin HCL (BELVIQ®)† • naltrexone HCl and bupropion HCl (CONTRAVE®)† • phendimetrazine (Bontril®)**Approved for short-term use; †Approved for long-term (chronic) use
Targeted Weight Loss Rx for Specific Comorbidities1 • Prediabetes—The recommended preferences for pharmacotherapy in patients with concurrent obesity and prediabetes is: phentermine/topiramate ER or liraglutide (3 mg) and secondarily: Orlistat or lorcaserin, which have been deemed moderately effective in achieving a reduction in diabetes risk of 36-45% and improvement in the patient’s lipid profile. • Obstructive sleep apnea—recommended first-line therapy is phentermine/topiramate ER, and second-line therapy to consider is liraglutide, which has been moderately effective.
Binge Eating or Nighttime Cravings—the best data point to naltrexone ER/bupropion ER and lorcaserin, however, naltrexone/bupropion are contraindicated in patients with bulimia (purging disorder). • Concomitant psychiatric disorders—liraglutide or orlistat are the best pharmacotherapy options. • To best determine whether the current pharmacology regime is working for the patient, Dr. Garvey told EndocrineWeb that clinicians "key in on the health benefits that have been achieved as a result of weight loss."
APPETITE-SUPPRESSANT MEDICATIONS • Most appetite suppressants work primarily by increasing the availability of anorexigenic neurotransmitters — notably, norepinephrine, serotonin, dopamine, or some combination of these neurotransmitters — in the central nervous system.
Noradrenergic Agents • Noradrenergic drugs available in the United States include phentermine, diethylpropion, phendimetrazine, and benzphetamine (Table 1). Amphetamines are no longer recommended (and are not approved for use) for weight loss because of the potential for their abuse. Benzphetamine and phendimetrazine, which are classified as Schedule III drugs by the Drug Enforcement Administration (DEA), are considered by the DEA to have substantially greater potential for abuse than those on Schedule IV. • All of the above medications are approved by the Food and Drug Administration (FDA) for use of “a few weeks” only (generally presumed to be 12 weeks or less) for the treatment of obesity.
All of the above medications are approved by the Food and Drug Administration (FDA) for use of “a few weeks” only (generally presumed to be 12 weeks or less) for the treatment of obesity.7 Few studies of their safety and efficacy have extended to six months or beyond.28 Such studies show a consistent but moderate difference in weight loss (a difference of 2 to 10 kg) in comparisons with placebo.32-37 Side effects of noradrenergic medications include insomnia, dry mouth, constipation, euphoria, palpitations, and hypertension.7 Although the most widely used of these compounds, phentermine, was used in combination with fenfluramine, it has not been independently associated with valvular heart disease.38 The only over-the-counter appetite-suppressant medication approved for the treatment of obesity, phenylpropanolamine, was recently withdrawn from the market because of concern about an association with hemorrhagic stroke in women.39
Serotonergic Agents • Serotonergic agents act by increasing the release of serotonin, inhibiting its reuptake, or both. Fenfluramine (Pondimin) and dexfenfluramine (Redux), medications that both stimulated serotonin release and inhibited its reuptake, were withdrawn from the market in the United States in 1997 because of associations with valvular heart disease and pulmonary hypertension. Their efficacy in controlled studies appeared similar to that of the noradrenergic agents.28,40
Selective serotonin-reuptake inhibitors are currently approved for a number of indications that are not related to obesity, including depression and obsessive–compulsive disorder. Some selective serotonin-reuptake inhibitors have induced weight loss in short-term studies, and fluoxetine (Prozac) (at a dose of 60 mg) has undergone considerable evaluation to determine its efficacy for weight loss.41,42 Unfortunately, although patients who received fluoxetine for six months lost more weight than those who received placebo, steady regain occurred during the next six months despite the continuation of medication, eroding any difference between the treatment groups.28 Sertraline (Zoloft), evaluated as an adjunct for weight maintenance after a very-low-calorie diet, showed a similar lack of long-term efficacy.43
Mixed Noradrenergic–Serotonergic Agents • Mechanisms of Action of Sibutramine.Sibutramine (Meridia), an inhibitor of both norepinephrine reuptake and serotonin reuptake that also weakly inhibits dopamine reuptake (Figure 1), is approved by the FDA for weight loss and weight maintenance in conjunction with a reduced-calorie diet.7 Sibutramine is given in a dose of 10 to 15 mg once daily and may be given in a 5-mg dose to patients who do not tolerate the 10-mg dose. Unlike fenfluramine and dexfenfluramine, it does not induce serotonin release, and has not been implicated in the development of valvular heart disease.44,45 Over a six-month period, subjects who follow a reduced-calorie diet and receive sibutramine typically lose 5 to 8 percent of their preintervention body weight, as compared with 1 to 4 percent among subjects who receive placebo.46-49
The Sibutramine Trial of Obesity Reduction and Maintenance followed 605 European adults who took 10 mg of sibutramine daily for 6 months, after which 467 participants who had lost more than 5 percent of their preintervention body weight were randomly assigned to continue to receive sibutramine or to receive placebo for 18 months.51 Although weight was regained in both groups during the second year of follow-up, weight losses were significantly greater among those who received sibutramine for the full two years of the trial. More than 25 percent of those who continued to take sibutramine maintained their reduced weight for the entire observation period. As in most studies of weight-loss medications, the large numbers of dropouts in both the study-drug group and the placebo group limit the generalizability of the findings.51 By the end of the study, the dose of sibutramine had been increased to 20 mg, a dose higher than is approved in the United States, in 52 percent of the subjects taking the medication. However, 86 percent of the subjects who did not regain any of the weight they had lost were taking no more than 15 mg of sibutramine daily. Sibutramine may also increase weight loss and improve maintenance of reduced weight in subjects who have previously lost weight with a very-low-calorie diet.52
MEDICATIONS THAT REDUCE NUTRIENT ABSORPTION • Inhibition of Fat Absorption by Orlistat.The only FDA-approved medication for obesity that reduces nutrient absorption is orlistat (Xenical), which acts by binding to gastrointestinal lipases in the lumen of the gut, preventing hydrolysis of dietary fat (triglycerides) into absorbable free fatty acids and monoacylglycerols (Figure 2). Patients who take 120 mg of orlistat with or up to one hour after meals excrete in the stool approximately one third of the dietary fat they ingest, thereby reducing calorie and fat intake. In double-blind, placebo-controlled trials, orlistat had moderate efficacy for weight loss in adults. Orlistat-treated subjects who completed trials lasting one year lost approximately 9 percent of their preintervention body weight, as compared with 5.8 percent among those who took placebo
Orlistat has also been found to slow the rate of regain of weight during a second year of use; orlistat-treated subjects regained less weight during the second year than placebo-treated subjects did (a regain of 35.2 percent vs. 62.4 percent, a difference of about 2.5 kg).55-57 In these long-term studies, orlistat-treated patients also had moderate decreases in diastolic blood pressure, insulin levels while fasting, and total cholesterol and low-density lipoprotein cholesterol, with a small cholesterol-lowering effect that was independent of weight loss. Orlistat induced small reductions in body weight in patients with type 2 diabetes that were nevertheless significantly greater than those that occurred in such patients who received placebo (losses of 6.2 kg vs. 4.3 kg); orlistat also led to improvement in glycosylated hemoglobin values and a decreased requirement for sulfonylurea drugs.58 Orlistat appears to have similar efficacy regardless of whether it is prescribed in a primary care or a specialized treatment setting.59
Treatment conversation Initiating the conversation Either a patient or an HCP can initiate the conversation regarding the need to lose weight. The situation is generally easier to handle when a patient expresses a desire to lose weight. She has already acknowledged existence of the disease—that is, the obesity—and is seeking treatment for it on her own. However, in many cases, the HCP must broach the topic, usually after a patient has come in for a routine visit and the findings from her history, physical examination, and laboratory tests indicate that steps must be taken to lower her risk for experiencing obesity-related complications—or to treat the complications that already exist. To avoid discomfiting a patient in this situation, a panel of nurse practitioners convened by the American Nurse Practitioner Foundation
Foundation (ANPF) recommends that the HCP show her objective data reflecting her disease and her risk for future complications—with an emphasis that obesity is a health problem—and then assess her motivation and readiness for change.7 In this context, the HCP and the patient need to synchronize their expectations and goals for weight loss therapy. HCPs now have reliable tools to help patients lose 5%-10% of their body weight. This weight loss may not produce the desired cosmetic outcome but will no doubt result in clinical benefits. The emphasis is on improving the health of the patient. To inspire a patient with obesity to want to lose weight and to commit to follow a weight-loss treatment plan, the HCP can help her identify at least one compelling reason to lose weight.7
To inspire a patient with obesity to want to lose weight and to commit to follow a weight-loss treatment plan, the HCP can help her identify at least one compelling reason to lose weight.7 Common patient-centered reasons include (1) decreasing the risk of having a complicated pregnancy; (2) being able to play with children or grandchildren; (3) walking without becoming short of breath; (4) preventing other chronic diseases such as T2DM; and (5) improving existing weight-related complications such as sleep apnea or T2DM. Of note, some patients may not be aware of the health risks posed by obesity and will be motivated to lose weight once educated about the risks
