Tuesday, January 27, 2015

Canadian Clinical Practice Guidelines For Obesity: We Need More Than Diet and Exercise

sharma-obesity-doctor-kidYesterday, saw the release of new Clinical Practice Guidelines from the Canadian Task Force on Preventive Health Care to help prevent and manage obesity in adult patients in primary care.

Similarly to the Endocrine Society’s Guidelines for the pharmacological treatment of obesity (see yesterday’s post), the authors use a GRADE system to rank and rate their recommendations.

Key recommendations are summarized as follows:

  • Body mass index should be calculated at primary health care visits to help prevent and manage obesity.
  • For normal weight adults, primary care practitioners should not offer formal structured programs to prevent weight gain.
  • For overweight and obese adults health care practitioners should offer structured programs to change behaviour to help with weight loss, especially to those at high risk of diabetes.
  • Medications should not routinely be offered to help people lose weight.

Virtually all of these recommendations are supported by evidence that is rated between moderate to very low, which essentially leaves wide room for practitioners to either do nothing or whatever they feel is appropriate for a given patient.

The guidelines do not discuss the role of bariatric surgery (arguably the most effective treatment for severe obesity) and make no recommendations for when this should be discussed with patients.

The rather subdued recommendations for the use of medications is understandable, given that the only prescription medication available for obesity in Canada is orlistat (why the authors chose to also discuss metformin, which is not indicated for obesity treatment, is anyone’s guess).

Overall, the reader could easily come away from these guidelines with a sense that obesity management in primary care is rather hopeless, given that behavioural interventions are modestly effective at best (which is probably why the authors recommend that these not be routinely offered to patients at risk of weight gain).

Indeed, it is hard to see how primary care practitioners can get more enthusiastic about obesity management given this rather limited range of treatment options currently available to Canadians.

If there is anything to take away from these guidelines, it is probably the simple fact that we desperately need more effective treatments for Canadians living with obesity.

@DrSharma
Edmonton, AB

The whole document is available here

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Monday, January 26, 2015

Endocrine Society Clinical Practice Guidelines For The Pharmacological Treatment of Obesity

sharma-obesity-medications6Last week, the US Endocrine Society released a rather comprehensive set of evidence-based clinical practice guidelines for the pharmacological management of obesity, published in the Journal of Clinical Endocrinology and Metabolism.

The recommendations in the 21-page document follow the rather rigorous Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) group (from 0 to 4 stars) and goes beyond just evaluating the evidence in favour of pharmacological treatment of obesity itself but also for the pharmacological treatment of overweight and obese individuals presenting other medical conditions.

Here are the (in my opinion) most important recommendations from this document:

1) While diet, exercise and behavioural interventions are recommended in all patients with obesity,

“Drugs may amplify adherence to behavior change and may improve physical functioning such that increased physical activity is easier in those who cannot exercise initially. Patients who have a history of being unable to successfully lose and maintain weight and who meet label indications are candidates for weight loss medications.(****)”

2) “If a patient’s response to a weight loss medication is deemed effective (weight loss > 5% of body weight at 3 mo) and safe, we recommend that the medication be continued. If deemed ineffective (weight loss < 5% at 3 mo) or if there are safety or tolerability issues at any time, we recommend that the medication be discontinued and alternative medications or referral for alternative treatment approaches be considered. (****)”

3) “If medication for chronic obesity management is prescribed as adjunctive therapy to comprehensive life- style intervention, we suggest initiating therapy with dose escalation based on efficacy and tolerability to the recommended dose and not exceeding the upper approved dose boundaries. (**)”

The guidelines also make specific recommendations for the pharmacological treatment of overweight and obese individuals presenting with a wide range of other medical issues, including 2 diabetes mellitus (T2DM), cardiovascular disease, psychiatric illness, epilepsy, rheumatoid arthritis, COPD, HIV/AIDS and allergies.

For example:

“In patients with T2DM who are overweight or obese, we suggest the use of antidiabetic medications that have additional actions to promote weight loss (such as glucagon-like peptide-1 [GLP-1] analogs or sodium-glu- cose-linked transporter-2 [SGLT-2] inhibitors), in addi- tion to the first-line agent for T2DM and obesity, metformin. (***)”

The guidelines also discuss the pros and cons of the anti-obesity medications currently available in the US (phentermine, orlistat, phentermine/topiramate, lorcaserin, buproprion/naltrexone, and liraglutide), which we can only hope will soon also become available to patients outside the US.

The entire document is available here.

@DrSharma
Edmonton, AB

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Friday, January 23, 2015

GLP-1 Analogue Liraglutide For Obesity Gets Positive Vote In Europe

novo_nordiskJust one month after the GLP-1 analogue liraglutide 3 mg received approval for obesity treatment by the US-FDA, liraglutide 3 mg, yesterday, also got a positive nod from the Committee for Medicinal Products for Human Use (CHMP) under the European Medicines Agency (EMA).

Here is how the Novo Nordisk press release describes the mode of action and indication for liraglutide 3 mg:

Saxenda®, the intended brand name of liraglutide 3 mg, is a once-daily glucagon-like peptide-1 (GLP-1) analogue, with 97% homology to naturally occurring human GLP-1, a hormone involved in appetite regulation. The CHMP positive opinion recommends that Saxenda® will be indicated as an adjunct to a reduced-calorie diet and increased physical activity for weight management in adult patients with an initial Body Mass Index (BMI) of >=30 kg/m2 (obese), or >= 27 kg/m² to < 30 kg/m² (overweight) in the presence of at least one weight-related comorbidity such as dysglycaemia (pre-diabetes or type 2 diabetes mellitus), hypertension, dyslipidaemia or obstructive sleep apnoea.”

Regular readers will be aware of the role that the incretin GLP-1 plays in the  regulation of glucose metabolism as well as satiety and appetite.

Data for this approval come from the Phase 3 SCALE trial program involving over 5,000 patients with overweight and obesity, the majority of who also had related comorbidities.

Given that this is an injectable drug that will be available only with a  doctor’s prescription and, as any anti-obesity medication, will need to be used in the long-term, it will be interesting to see how this new approach to obesity treatment will be accepted by doctors and their patients.

Although liraglutide 3 mg may not work for or be tolerated by everyone, I am confident that this much-needed addition to the obesity treatment tool-box will provide a new treatment option to some patients – especially those with obesity related health problems.

@DrSharma
Edmonton, AB

Disclaimer: I have received honoraria for consulting and speaking from Novo Nordisk

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Thursday, January 22, 2015

Pregnancy Weight Gain Study

Enrich logoToday’s post is for health professionals who provide care to pregnant women in their practice?

Researchers from the University of Alberta are conducting a short online survey to get a better understanding of the barriers and challenges you may experience related to gestational weight gain, and about what may help and support them to help women achieve healthy weights during pregnancy.

The researchers are also asking you to assess the strengths and limitations of the 5As of Healthy Pregnancy Weight Gain, a new resource from the Canadian Obesity Network.

This information will help to inform the development of universal strategies that promote healthy dietary intake and appropriate weight management in pregnancy and postpartum.

Your participation in this short survey is much appreciated.

Click here to take the survey.

@DrSharma
Edmonton, AB

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Wednesday, January 21, 2015

Activity Trumps Weight Loss For Health?

Despite the sharma-obesity-exercise2The fact that it is better to be fit and fat than skinny and unfit is not new – indeed, I would regard the evidence on this as pretty conclusive.

Nevertheless, for those, who still harbour any remaining doubts, the study by Ulf Ekelund on behalf of the EPIC Investigators, recently published in the American Journal of Clinical Nutrition should drive this message home.

This analysis looks at the relationship between physical activity and all-cause mortality in 334,161 European men and women followed for about 12.4 y (corresponding to 4,154,915 person-years).

No matter how the researchers looked at the data, activity levels appeared a better predictor of mortality than BMI or waist circumference.

Thus the authors calculated that while avoiding all inactivity would theoretcally reduce all-cause mortality by 7.35%, trying to maintain a “normal weight” (or rather a BMI less than 30) would reduce mortality by only 3.66% (although avoiding obesity AND inactivity did have the greatest effect).

Despite the limitations of these type of cross-sectional analyses, which as a rule, tend to overestimate the potential benefits of an actual intervention, the message is clear – it appears that even small increases in physical activity in inactive individuals can have substantially greater benefits to health than obsessing about losing a few pounds.

This is indeed useful information, as we have long known that increasing physical activity in most cases does surprisingly little in terms of weight loss but rather a lot in terms of increasing health and fitness.

So do not despair if the hours your patients are putting in at the gym are not changing those numbers on the scale – the health benefits are still worth the effort.

@DrSharma
Reykjavik, Iceland

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In The News

Diabetics in most need of bariatric surgery, university study finds

Oct. 18, 2013 – Ottawa Citizen: "Encouraging more men to consider bariatric surgery is also important, since it's the best treatment and can stop diabetic patients from needing insulin, said Dr. Arya Sharma, chair in obesity research and management at the University of Alberta." Read article

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