In morning report on July 19 we reviewed an outpatient approach to obesity with a focus on management. See the learning points below.
Why are we talking about this?
- Obesity is a prevalent chronic disease worldwide, affecting 650 million adults
- Obesity and it’s complications (eg: cardiovascular disease, diabetes), are major contributors to global morbidity and mortality.
- Treatments that result in substantial weight loss may improve outcomes for people living with obesity
- An approach to and understanding of obesity is relevant to all specialties and to all levels of training!
Approach to Obesity (from CMAJ):
Historically the approach to obesity focused almost exclusively on lifestyle measures. We now know that lifestyle measures alone fail for most people. Evidence suggests that diet and exercise prompt physiologic counter regulatory mechanisms that limit weight reduction and impede weight maintenance. Obesity is a complex multicomponent chronic disease of energy homeostasis involving central and peripheral mechanisms. When present, these mechanisms make returning to a lower weight difficult.
Management of obesity has 3 main pillars: psychological, pharmacologic, surgery
Psychological:
- Implement multicomponent behavior modification
- Manage sleep, time, stress
- Cognitive behavioral therapy should be provided to patients if appropriate
Pharmacologic:
- Indications:
- BMI
30 or BMI
- BMI
- Pharmacotherapy may be used to maintain weight loss that has been achieved by health behavior changes, and to prevent weight regain
- Three approved medications for obesity management in Canada:
- Liraglutide
- Naltrexone/bupropion
- Orlistat
- Semaglutide is not officially in the guidelines, but clinicians are using it for obesity management
Surgery:
- Procedure should be decided by surgeon in discussion with the patient
- Sleeve gastrectomy
- Roux-en-Y
- Biliopancreatic diversion with/without duodenal stretch
- Indications:
- BMI
- BMI 35-40 with adiposity related complication
- BMI
- BMI
Final Pearls:
Too much of a good thing?
- Be mindful of patients who are losing too much weight with pharmacologic therapies
- Can be part of disordered eating and body dysmorphia
- Always important to have psych considerations as part of your approach in management
Documentation:
- So important! We need to be patient centered in our language to reduce stigma associated with weight.
- At many sites, patients will have access to the EMR and will be able to read your notes – how would you feel if your doctor was writing ”xyz” about you?
- Some examples of patient centered language:
- “elevated BMI” may be more patient centered than “obese”
- Patients are people living with medical conditions, they should not be defined by their medical conditions
- “29 year old obese female referred to my clinic…. “
- vs: “Emily is a 29 year old resident doctor living with an elevated BMI who I saw in clinic to discuss…”
References:
1. Wilding, J. P. H. et al. Once-Weekly Semaglutide in Adults with Overweight or Obesity. N. Engl. J. Med. 384, 989–1002 (2021).
2. Pedersen, S. D. & Wharton, S. Canadian Adult Obesity Clinical Practice Guidelines 1 KEY MESSAGES FOR HEALTHCARE PROVIDERS Pharmacotherapy in Obesity Management.
3. Wharton, S. et al. Obesity in adults: A clinical practice guideline. CMAJ 192, E875–E891 (2020).
4. Jastreboff, A. M. et al. Tirzepatide Once Weekly for the Treatment of Obesity. N. Engl. J. Med. (2022). doi:10.1056/NEJMOA2206038/SUPPL_FILE/NEJMOA2206038_DATA-SHARING.PDF
5. Rosen, C. J. & Ingelfinger, J. R. Shifting Tides Offer New Hope For Obesity. https://doi.org/10.1056/NEJMe2206939 (2022). doi:10.1056/NEJME2206939
6. Frías, J. P. et al. Tirzepatide versus Semaglutide Once Weekly in Patients with Type 2 Diabetes. N. Engl. J. Med. 385, 503–515 (2021).
7. Tuttle, K. R. Breaking New Ground with Incretin Therapy in Diabetes. N. Engl. J. Med. 385, 560–561 (2021).