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Adult Obesity Management in Primary Care

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Northeast Florida Medicine, Vol. 68, No. 2, Summer 2017

Review of Adult Obesity Management in Primary Care

Dept. of Internal Medicine, University of Florida College of Medicine, Jacksonville, FL

Address Correspondence to:

Carmen L. Isache, MD, Ghania Masri, MD
3rd Floor Faculty Clinic, 653 West 8th Street, L21, Jacksonville, FL 32209
Phone: (904) 244-3586
Email: carmen.isache@jax.ufl.edu, ghania.masri@jax.ufl.edu

Date of Release: June 15, 2017
Date Credit Expires: June 15, 2019
Estimated Completion Time: 1 hour
Background:

The Duval County Medical Society (DCMS) is proud to provide its members with free continuing medical education (CME) opportunities in subject areas mandated and suggested by the State of Florida Board of Medicine to obtain and retain medical licensure. The DCMS would like to thank the St. Vincent’s Healthcare Committee on CME for reviewing and accrediting this activity in compliance with the Accreditation Council on Continuing Medical Education (ACCME). This issue of Northeast Florida Medicine includes an article, “Review of Adult Obesity Management in Primary Care” authored by Carmen L. Isache, MD and Ghania Masri, MD, which has been approved for 1 AMA PRA Category 1 credit.TM For a full description of CME requirements for Florida physicians, please visit www.dcmsonline.org.

Faculty/Credentials:

Carmen L. Isache, MD and Ghania Masri, MD, Department of Internal Medicine, University of Florida College of Medicine, Jacksonville, FL.

Needs Assessment:

Obesity is a major global health concern. It imposes a great medical and economic burden on the United States and global healthcare system. Primary Care physicians have a tremendous responsibility for screening, preventing and treating patients with obesity.

Objectives:

1. Define obesity and prevalence in the United States.
2. Understand the role of lifestyle and behavioral changes in preventing and treating obesity.
3. Review the role of pharmacologic agents and bariatric surgery in treating obesity.

CME Credit Eligibility:

A minimum passing grade of 70% must be achieved. Only one re-take opportunity will be granted. If you take your test online, a certificate of credit/completion will be automatically downloaded to your DCMS member profile. If you submit your test by mail, a certificate of credit/completion will be emailed within 4 weeks of submission. If you have any questions, please contact Kristy Williford at 904-355-6561 or kristy@dcmsonline.org. 

Faculty Disclosure:

Carmen L. Isache, MD and Ghania Masri, MD report no significant relations to disclose, financial or otherwise, with an commercial supporter or product manufacturer associated with this activity.

Disclosure of Conflicts of Interest:

St. Vincent’s Healthcare (SVHC) requires speakers, faculty, CME Committee and other individuals who are in a position to control the content of this educational activity to disclose any real or apparent conflict of interest they may have as related to the content of this activity. All identified conflicts of interest are thoroughly evaluated by SVHC for fair balance, scientific objectivity of studies mentioned in the presentation and educational materials used as basis for content, and appropriateness of patient care recommendations.

Joint Sponsorship Accreditation Statement:

This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of St. Vincent’s Healthcare and the Duval County Medical Society. St. Vincent’s Healthcare designates this educational activity for a maximum of 1 AMA PRA Category 1 credit.TM Physicians should only claim credit commensurate with the extent of their participation in the activity.

Obesity is common, serious and costly. As per Centers for Disease Control and Prevention (CDC) data, more than one-third of U.S. adults (34.9 percent or 78.6 million) are obese.1 Obesity is a multifactorial condition, in which excess body fat may put a person at risk of increased mortality and morbidity.2 It imposes a great psychological, medical and economic burden on our nation and the entire world. Obesity represents a complex disorder, involving appetite regulation and energy metabolism, that needs to be appropriately screened for and managed, starting from the primary care physician’s office. Management of adult obesity includes behavioral therapy and lifestyle intervention, pharmacological adjunctive weight loss medication and bariatric surgery. Each weight loss plan is made based on individual, patient-related factors. However, in order for any plan to be successful, the patient needs to be placed in the center of the decision-making process.

Obesity is a multifactorial condition, in which excess body fat may put a person at risk of increased mortality and morbidity.2 The CDC defines overweight and obesity as a weight that is higher than what is considered to be a healthy weight for a given height.1 Body Mass Index, or BMI, is used as a screening tool for overweight or obesity. Overweight is defined as a BMI of 25 kg/m² to 29.9 kg/m² and obesity as a BMI of >30 kg/m². An increase in obesity rates has led to worsening health outcomes and an explosion of health care costs. Being overweight or obese significantly increases a patient’s risk of developing more than twenty other different diseases and health conditions, including type 2 diabetes, hypertension, metabolic syndrome, cardiovascular disease, specific cancers and osteoarthritis.3

It is estimated that obesity accounts for 9.1 percent of annual health care spending in the United States (U.S.), costing our nation up to $147 billion dollars in 2008.4 Obesity imposes a great psychological, medical and economic burden; therefore, efforts to reduce its incidence need to become a priority. There is no single or simple solution to the obesity epidemic. It’s a complex problem and there has to be a multifaceted approach. Policy makers, state and local organizations, business, community and school leaders, healthcare professionals and individuals must work together to create an environment that supports a healthy lifestyle. Primary care providers should screen all their patients for obesity and determine who is in need of further counseling and management.

Prevalence in United States of America

According to data gathered by the CDC between 2011 and 2014, more than one-third  of U.S. adults are obese.1 The prevalence of obesity was reported to be slightly higher in women compared to men (38.3 percent versus 34.3 percent) and was also shown to be more prevalent among certain ethnic groups such as non-Hispanic blacks who have the highest age-adjusted rates of obesity (48.1 percent), followed by Hispanics (42.5 percent), non-Hispanic whites (34.5 percent), and non-Hispanic Asians (11.7 percent). Obesity is higher among middle aged adults, age 40-59 years (40.2 percent) and older adults, age 60 and over (37.0 percent) than among younger adults.5

As far as relation between obesity and socioeconomic status, the CDC reports that among men, obesity prevalence is generally similar at all income levels. However, higher income women were less likely to be obese when compared to lower income women. Also, those with college degrees were less likely to be obese when compared with less educated women. There was no significant trend between obesity and education among men.6

Obesity, defined as having a body-mass index (BMI) greater than 30 kg/m², was finally recognized by the American Medical Association as a chronic disease in 2013. (Table 1)

Table 1: Weight classification by BMI

Since obesity is associated with multiple other comorbidities, primary care physicians have an enormous responsibility to screen adults for obesity and offer patients effective counseling and guidance.

There is increasing evidence to suggest that obesity is not just a simple problem of will power or self-control but a complex disorder involving appetite regulation and energy metabolism, associated with various comorbid conditions.2,3,7 Although the etiology of obesity has not been firmly established, genetic, metabolic, biochemical, cultural and psychosocial factors contribute to obesity. Some individuals may become overweight or obese partly because they have a genetic or biologic predisposition to gain weight, however, in most cases, the increasing prevalence of overweight and obese individuals reflects changes in society and behaviors over the past 20 to 30 years. Lifestyle patterns are influenced by an overabundance of energy-dense food choices and decreased opportunities and motivation for physical activity.7 According to the U.S. Surgeon General, approximately 25 percent of American adults are completely sedentary, and more than 60 percent are not regularly active at the recommended level of 30 minutes per day.8 An estimated 300,000 preventable deaths occur each year in the U.S. because of unhealthy diet and physical inactivity,9 which are known contributors to obesity.

In 2000, the World Health Organization (WHO) published a technical report in which researchers addressed the increased risk for other medical conditions in patients with obesity.  The chronic, life-threatening health problems associated with obesity fall into the following categories: cardiovascular problems, conditions associated with insulin resistance, certain types of cancers (e.g. hormonally related and large bowel cancers) and gallbladder disease. The risks of developing these medical conditions were categorized based on severity: greatly increased risk (relative risk > 3) for non-insulin dependent diabetes mellitus, gallbladder disease, dyslipidemia and sleep apnea, moderately increased risk (relative risk of 2-3) for coronary artery disease, osteoarthritis of knees, gout and hypertension, slightly increased risk (relative risk of 1-2) for cancer (breast cancer in postmenopausal women, endometrial cancer, colon cancer), reproductive hormone abnormalities, impaired fertility, polycystic ovary syndrome, low back pain and fetal defects associated with maternal obesity.10

Screening for Obesity

The United States Preventive Service Task Force and the National Institute of Health recommend screening all adults for obesity by calculating BMI and measuring waist circumference.11 Men with a waist circumference of more than 40 inches and women with a waist circumference of more than 35 inches are at increased risk for metabolic syndrome, diabetes, dyslipidemia and hypertension.12

Patients diagnosed with obesity should be assessed prudently for other health risk factors with complete history, physical exam and laboratory tests. The primary care physician needs to share the obesity diagnosis with their patient and also discuss the other potential health risks associated with diagnosis. 

Management of Obesity

In 2013, the American College of Cardiology, American Heart Association Task Force on Practice Guidelines and The Obesity Society updated the guidelines for management of overweight and obese adults in order to help primary care physicians better manage this category of patients.13 The main goal is to decrease obesity-related cardiovascular disease by identifying patients who are obese or overweight and offering those patients comprehensive counseling regarding lifestyle intervention, alone or in conjunction with pharmacological weight loss therapy. This enormous task starts with assessing the patient’s readiness to make the needed changes in order to achieve their weight loss goal and also to identify any possible barriers to success.

The American Association of Clinical Endocrinologists and the American College of Endocrinology have also published clinical practice guidelines for medical care of patients with obesity.14 In these guidelines, one of the issues addressed is prevention. Prevention is categorized as primary, secondary and tertiary. Primary prevention is defined as preventing the development of overweight and obesity. This can be done by educating the public and promoting healthy eating and regular exercise. Secondary prevention is defined as preventing future weight gain and the development of weight-related complications in overweight and obese patients. This is done by screening and diagnosing using BMI, evaluating for possible complications and starting treatment with behavioral/lifestyle modifications and optional use of adjunctive weight-loss medication. Tertiary prevention refers to using weight-loss therapy to eliminate or ameliorate weight-related complications and prevent disease progression. This includes behavioral and lifestyle modifications, weight-loss medications and potentially bariatric surgery. 

 

Behavioral therapy and lifestyle intervention

There is no doubt that counseling patients on lifestyle changes represents a major challenge and a time-consuming activity that most primary care physicians have difficulties with, especially due to the lack of reimbursement and resources.

There is evidence to support behavioral changes being effective in helping obese and overweight patients lose weight resulting in a decreased risk of obesity-associated comorbidities such as diabetes mellitus and cardiovascular disease. The Diabetes Prevention Program Outcomes Study was one of the landmark trials, conducted over 15 years, which showed that intense lifestyle changes surpass the use of Metformin, an oral hypoglycemic agent, in preventing type 2 diabetes mellitus in overweight patients (27 percent versus 18 percent reduction in diabetes incidence, respectively).15 It is essential to educate primary care providers on counseling strategies for weight loss. Assessing a patient’s history of weight gain or loss, dietary habits, physical activity and sleep history are very important. A primary care physician should discuss with their patient realistic goals of weight loss and emphasize that 10 percent of body weight loss has a positive effect on their overall health and mortality. The patient and their physician should together develop a weight loss program to include a diet compatible with the patient’s taste that can be maintained for at least one year. The patient needs to understand that the main core of weight loss is to keep a negative calorie-energy balance. Multiple studies confirmed there is no difference in weight loss rate between different diet plans.16 The best diet is the one to which the patient will adhere the most. The key factor is to achieve an average of 500 calories deficit per day in order to achieve a four-pound weight loss in a month.16

Physicians should empower their patients by making them an essential part of a patient-centered decision-making process on a weight loss program. The patient needs to be encouraged to feel in control with the plan, to self-monitor their weight, to keep a food dairy and to participate in a type of physical activity that fits their lifestyle.

Weight regain following weight loss remains a major challenge. The maximum weight loss usually occurs in the first six months and then weight may plateau by the end of the following six months.13 This may discourage patients to continue with their lifestyle changes, therefore the primary care physician needs to encourage them to continue adhering to the long-term weight loss program, including regular exercise and weekly weight self-monitoring. Behavioral intervention has a higher chance of success when attempted through a multidisciplinary approach. Dieticians, nurses, educators, physical activity trainers and clinical psychologists play an important role, in addition to the primary care provider, in helping the patient adhere to the weight loss plan.  

In 2011, the Centers for Medicare and Medicaid Services approved payment for an intensive behavioral therapy program provided by primary care physicians.17 This program offers patients 14 visits face-to-face with their primary care physician, once a week for the first two months, then every other week for the following four months. Patients who lose 3 kg in the first six months can be qualified for another 6-12 months of service. Each visit should last for at least 15 minutes with average reimbursement of $26.00. Unfortunately, due to this low compensation, less than one percent of Medicare beneficiaries have received this benefit.

Pharmacological adjunctive weight loss medication

In the past few years, the U.S. Food and Drug Administration (FDA) has approved several new long-term medications to be used in conjunction with behavioral therapy for weight loss. These medications are indicated for patients with a BMI above 30 or for patients with BMI above 27 with comorbidities. They are designed to help patients adhere to low calorie diets and maintain weight loss. Primary care physicians should discuss with their patients the risks and potential side effects of these medications and help the patient determine if the benefits outweigh the risks.

Phentermine has been on the market for a long time. It is a sympathomimetic weight loss drug approved for up to only 12 weeks of use. The greater appetite suppression effect and weight loss usually occur in the first four weeks. Phentermine is a stimulant and common side effects include tachycardia, increase in blood pressure, feeling jittery and insomnia. This drug should be avoided in the elderly or patients with coronary artery disease.18

Orlistat is a lipase inhibitor which decreases absorption of approximately one third of the dietary fat. This drug was approved in 1999 as a prescription drug, dosed 120 mg three times a day, with meals. In 2007, the FDA approved Orlistat at 60 mg three times a day, as a nonprescription drug.19 The four-year XENDOS double-blinded prospective study randomized 3305 Swedish patients to placebo versus Orlistat, both in conjunction with lifestyle changes. At the end of the study, the Orlistat group had significant lower incidence of type 2 diabetes mellitus (18.8 percent vs 28.8 percent) and a significantly higher number of patients had a loss of 10 percent of body weight (26 percent vs 16 percent).20

Lorcaserin is a selective serotonin 5-HT2C receptor agonist which stimulates receptors in the appetite nervous center, promoting satiety. The BLOOM trial demonstrated the safety of lorcaserin use and an average loss of 8 percent of body weight at one year. Patients on lorcaserin were also noted to have an improvement in blood pressure control and a decrease in their hemoglobin A1c, low-density lipoproteins (LDL) and triglycerides levels.21 Weight loss at 12 weeks is usually predictive of weight loss at 52 weeks. Patients are expected to lose more than 5 percent of their body weight by 12 weeks of lorcaserin use. As far as side effect profile, lorcaserin was shown to cause no increase in incidence of valvulopathy, a finding that supports the hypothesis that valvulopathy is not associated with activation of the 5-HT2C receptors, as opposed to prior weight-loss drugs such as fenfluramine which activated the 5-HT2B receptor in cardiac valvular interstitial cells, thought to cause serotonin-associated valvulopathy.22

The Phentermine-topiramate controlled-release tablet combines phentermine, a sympathomimetic amine that decreases appetite, with topiramate which increases gamma-aminobutyric acid activity in the brain and induces prolonged satiety. Primary care physicians should monitor patients closely for weight loss and possible side effects, with a goal of more than 3 percent of body weight loss in the first 12 weeks and more than 5 percent of body weight loss at 24 weeks. The SEQUEL trial, a placebo-controlled, double-blind study that included 676 overweight and obese patients with more than two weight-related comorbidities, demonstrated drug safety at 108 weeks of use with average weight loss significantly greater compared to placebo, at two years. Other secondary benefits included improvement of lipid profile and hemoglobin A1c.23

The Naltrexone-bupropion sustained-release tablet is a fixed combination of two active ingredients with a unique action on the hypothalamus, leading to decreased appetite, ability to control food preference and increased metabolism. The COR-II phase III trial was a double-blind, placebo-controlled study that included 1,496 overweight or obese participants, randomized 2:1 to receive combined naltrexone plus bupropion or placebo for up to 56 weeks. This clinical trial determined the safety of this drug at 56 weeks and also showed that the participants who received naltrexone-bupropion achieved more than 5 percent of body weight loss at 28 weeks and at 56 weeks, in significantly higher numbers compared to the placebo group. Along with the weight loss, this medication also had positive effects on cardiovascular risk factors by improving lipid profile and hemoglobin A1c.24 This medication is contraindicated however in patients with seizure disorder, uncontrolled hypertension and opiate dependence.

Liraglutide is one of the latest drugs approved by the FDA for treating obesity. This drug has been on the market prior, for treatment of diabetes. Liraglutide is a glucagon-like-peptide-1 (GLP-1) analogue that has been shown to contribute to weight loss by regulating appetite and caloric intake. A randomized double-blind trial conducted in obese patients who did not have type 2 diabetes mellitus concluded that patients treated with liraglutide, as an adjunct to diet and exercise, lost approximately 8 percent of their body weight at 56 weeks.25

Bariatric Surgery

Bariatric surgery is indicated for patients with a BMI greater than 40 or greater than 35 with comorbidities, who are motivated to lose weight and did not respond to behavioral therapy with or without adjunctive pharmacological treatment.26

Bariatric surgery has a long term sustained weight loss benefit. Even though it may carry upfront risks, it has a positive effect on comorbidities, quality of life and it has been shown to decrease mortality up to five years after procedure.27

Primary care physicians have a tremendous responsibility for screening, preventing and treating patients with obesity. Diet, exercise, and behavioral modification continue to be the cornerstone of obesity management. Pharmacotherapy is an adjunctive tool to lifestyle changes and it may help adherence to behavioral modification and improve weight loss maintenance. There is no one-size-fits-all solution. However, placing the patient in the center of the decision-making process will result in the greatest chance of leading to a successful weight loss plan. Establishing a medical home care model and improving reimbursement for coordination of care by the primary care physicians may also aid significantly in prevention and management of obesity.

1. Centers for Disease Control and Prevention. Overweight and Obesity [Internet]. Atlanta (GA): U.S. Department of Health & Human Services; 2016 Sep [cited 2017 May 12]. Available from: https://www.cdc.gov/obesity/index.html.

2. Lyznicki JM, Young DC, Riggs JA, et al. Obesity: Assessment and Management in Primary Care. Am Fam Physician. 2001 Jun 1;63(11):2185-97.

3. National Heart, Lung, and Blood Institute. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. National Institute of Health; 1998 Sep. 262 p. Report No.: 98-4083.

4. Finkelstein EA, Trogdon JG, Cohen JW, et al. Annual Medical Spending Attributable to Obesity: Payer- and Service-Specific Estimates. Health Affairs. 2009 Sep-Oct;28:w822-831.

5. Ogden CL, Carroll MD, Fryar CD, et al. Prevalence of Obesity Among Adults and Youth: United States, 2011–2014. NCHS Data Brief. 2015 Nov;(219):1-8.

6. Ogden CL, Lamb MM, Carroll MD, et al. Obesity and Socioeconomic Status in Adults: United States, 2005–2008. NCHS Data Brief. 2010 Dec;(50):1-8.

7. Institute of Medicine (US) Committee to Develop Criteria for Evaluating the Outcomes of Approaches to Prevent and Treat Obesity; Thomas PR, editor. Weighing the options: criteria for evaluating weight-management programs. Washington (DC): National Academy Press (US); 1995.

8. U.S. Department of Health and Human Services. Physical activity and health: a report of the Surgeon General. Atlanta (GA): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion; 1996. 292 p.

9. McGinnis JM, Foege WH. Actual causes of death in the United Sates. JAMA. 1993 Nov 10; 270(18):2207–12.

10. World Health Organization. Obesity: preventing and managing the global epidemic. Report of a WHO Consultation. Geneva (Switzerland): WHO Consultation on Obesity; 1999 [cited 2017 May 12]. 253 p. Report No: 894.

11. U.S. Preventive Services Task Force. Final Recommendation Statement - Obesity in Adults: Screening and Management [Internet]. 2012 Jun [cited 2017 May 12]. Available from: https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/obesity-in-adults-screening-and-management.

12. U.S Department of Health and Human Services – National Institutes of Health. Assessing your weight and health risk [Internet]. Cited 2017 May 12. Available from: https://www.nhlbi.nih.gov/health/educational/lose_wt/risk.htm.

13. Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults - A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. J Am Coll Cardiol. 2014 Jul 1;63(25 Pt B):2985-3023.

14. Garvey WT, Mechanick JI, Brett EM, et al. American Association of Clinical Endocrinologists and American College of Endocrinology Comprehensive Clinical Practice Guidelines for Medical Care of Patients with Obesity. Endocrine Pract. 2016 Jul;22(7):842-84.

15. Diabetes Prevention Program Research Group. Long-term Effects of Lifestyle Intervention or Metformin on Diabetes Development and Microvascular Complications: the DPP Outcomes Study. Lancet Diabetes Endocrinol. 2015 Nov;3(11):866–75.

16. Van Horn L. A Diet by Any Other Name Is Still About Energy (Editorial). JAMA. 2014 Sep 3;312(9):900-1.

17. Wadden TA, Butryn ML, Hong PS, et al. Behavioral Treatment of Obesity in Patients Encountered in Primary Care Settings - A Systematic Review. JAMA. 2014 Nov 5;312(17):1779-91.

18. Phentermine – Highlights of prescribing information [Internet]. Cited 2017 May 12. Available from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/085128s065lbl.pdf.

19. U.S. Department of Health and Human Services – U.S. Food and Drug Administration. FDA Approved Drug Products [Internet]. Cited 2017 May 12. Available from: https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm?event=overview.process&applno=021887.

20. Sjöström L. Analysis of the XENDOS Study (XENICAL in the Prevention of Diabetes in Obese Subjects). Endocrine Practice. 2006 Jan;12(1):31-3.

21. Smith SR, Weissman NJ, Anderson CM, et al. Multicenter, Placebo-Controlled Trial of Lorcaserin for Weight Management. N Engl J Med. 2010 Jul 15;363(3):245-56.

22. Centers for Disease Control and Prevention (CDC). Cardiac valvulopathy associated with exposure to fenfluramine or dexfenfluramine: U.S. Department of Health and Human Services interim public health recommendations, November 1997. MMWR Morb Mortal Wkly Rep. 1997 Nov 14;46(45):1061-106.

23. Garvey WT, Ryan DH, Look M, et al. Two-year sustained weight loss and metabolic benefits with controlled-release phentermine/topiramate in obese and overweight adults (SEQUEL): a randomized, placebo-controlled, phase 3 extension study. Am J Clin Nutr. 2012 Feb;95(2):297-308.

24. Apovian CM, Aronne L, Rubino D, et al. A randomized, phase 3 trial of naltrexone SR/bupropion SR on weight and obesity-related risk factors (COR-II). Obesity (Silver Spring). 2013 May;21(5):935–43.

25. Pi-Sunyer X, Astrup A, Fujioka K, et al. A Randomized, Controlled Trial of 3.0 mg of Liraglutide in Weight Management. N Engl J Med. 2015 Jul 2;373:11-22.

26. Pentin PL, Nashelsky J. What are the indications for bariatric surgery? J Fam Pract. 2005 Jul;54(7):633-4.

27. Christou NV, Sampalis JS, Liberman M, et al. Surgery Decreases Long-term Mortality, Morbidity, and Health Care Use in Morbidly Obese Patients. Ann Surg. 2004 Sep;240(3):416-24.