Obesity Management Update
A recent issue of The Lancet features a short review article on obesity management by George Bray and colleagues.
The paper summarizes the general approach including behavioural (lifestyle), medical and surgical treatments.
While the section on behavioural interventions focuses much on the experience of the Look AHEAD trial (of which several of the authors were co-investigators), it adds little to what is already known on this. As I often say, “lifestyle” treatments for obesity are no more important or effective in real life than “lifestyle” treatments for other chronic conditions including diabetes, hypertension or dyslipidemia – without medications, the vast majority of patients with these issues will be “uncontrolled”.
Thus, the only real new change in obesity management is the increasing number of anti-obesity drugs available in the US (and hopefully soon elsewhere). The paper gives a nice review over the various medications that have been approved as well as several that are in development.
As for obesity treatment with medication, the authors note,
“Several guiding principles should be followed when prescribing drugs for weight loss.First, effective lifestyle support for weight loss should be provided during their use. These medications work to reinforce the patient’s attempts to change eating behaviours and produce an energy deficit. Second, the prescriber and patient should be familiar with the drug and its potential side-effects. Third, unless clinically meaningful weight loss occurs after 3 to 4 months, (generally defined as loss of more than 4–5% of total bodyweight in patients without diabetes; in patients with obesity and diabetes, loss of more than 3% of total bodyweight can be considered satisfactory) a new treatment plan should be implemented. No one medication is effective in every patient just as not every patient is appropriate for every medication.”
All of the above is correct and could be said about using medications for any other chronic condition – medications for hypertension, diabetes, or dyslipidemia work best when combined with “lifestyle” interventions, both prescribers and patients need to be familiar with the drugs for these conditions and their potential side effects. Obviously, when patients do not respond to or tolerate these drugs, they should be discontinued. Also, for these indications, no one medication is effective for every patient and not every patient is appropriate for every medication.
Thus, in summary, medical management of obesity is beginning to look pretty much the same as management of other chronic medical diseases – the only difference is that it is still far less accepted and access to such treatments are still limited by lack of professional education and barriers to access including coverage for these treatments.
Fortunately, I expect this to change in the coming years.