On 2016 Oct 27, James Yeh commented:

Editor's Comment Obesity and Management of Weight Loss — Polling Results

James Yeh, M.D., M.P.H., and Edward W. Campion, M.D.

Obesity is increasingly prevalent worldwide, and about 40% of Americans meet the diagnostic criteria for obesity.[1] The goal of weight loss is to reduce the mortality and morbidity risks associated with obesity. Patients with a body-mass index (BMI) in the range that defines obesity (>30) have a risk of death that is more than twice that of persons with a normal BMI.[2] Obesity is also associated with increased risks of cardiovascular disease, diabetes, and several cancers. A recent study suggests that being overweight or obese during adolescence is strongly associated with increased cardiovascular mortality in adulthood.[3] Studies suggest that even a 5% weight loss may reduce the complications associated with obesity.[4]

In September 2016, we presented the case of Ms. Chatham, a 29-year-old woman with class I obesity (BMI, 32) who leads a fairly sedentary lifestyle, with frequent reliance on takeout foods and with infrequent physical activity.[5] Readers were invited to vote on whether to recommend initiating treatment with one of the FDA-approved drugs for weight loss along with lifestyle modifications or to recommend only nonpharmacologic therapies and maximizing lifestyle changes. The patient has no coexisting medical conditions, but her blood pressure is slightly elevated (144/81 mm Hg). In the past, Ms. Chatham has tried to lose weight using various diets, each time losing 10 to 15 lb (4.5 to 6.8 kg), but she has never been able to successfully maintain weight loss.

Over 85,000 readers viewed the Clinical Decisions vignette during the polling period, and 905 readers from 91 countries voted in the informal poll. The largest group of respondents (366) was from the United States or Canada, representing nearly 40% of the votes. A large majority of the readers (80%) voted against prescribing one of the FDA-approved medications for weight loss and instead recommended maximizing lifestyle modification and nonpharmacologic therapies first.

A substantial proportion of the 64 Journal readers who submitted comments expressed concern about the absence of efficacy data on long-term follow-up and about the side effects associated with current FDA-approved medications for weight loss. Some suggested that simply treating obesity with a prescription medication is shortsighted and that it is important to uncover patients’ motivations for existing lifestyle choices and for weight loss. The commenters emphasized the need for a multifaceted approach to obesity management that includes nutritional and psychological support, as well as stress management, with the goal of long-lasting improvement in exercise and eating habits that will lead to weight reduction and maintenance of a healthier weight.

Some commenters, noting the difficulty of lifestyle changes, felt that pharmacotherapy can be a complementary and reasonable part of a multidisciplinary treatment plan. Some wrote that obesity should be managed as a chronic disease is managed and that an inability to lose weight should not be seen as a disciplinary issue, especially given the importance of genetic and physiological factors. These commenters argued that the use of pharmacotherapy as part of the treatment plan to achieve weight loss should not be stigmatized.

Overall, the results of this informal Clinical Decisions poll indicate that a majority of the respondents think physicians should not initially recommend the use of an FDA-approved drug as part of a weight-loss strategy, at least not for a patient such as Ms. Chatham, and that many respondents were troubled by the current uncertainties about the long-term efficacy and safety of weight-loss drugs.

REFERENCES 1. Flegal KM, Kruzon-Moran D, Carroll MD, Fryar CD, Ogden CL. Trends in obesity among adults in the United States, 2005 to 2014. JAMA 2016;315:2284-91. 2. Global BMI Mortality Collaboration. Body-mass index and all-cause mortality: individual-participant-data meta-analysis of 239 prospective studies in four continents. Lancet 2016;388:776-86. 3. Twig G, Yaniv G, Levine H, et al. Body-mass index in 2.3 million adolescents and cardiovascular death in adulthood. N Engl J Med 2016;374:2430-40. 4. Kushner RF, Ryan DH. Assessment and lifestyle management of patients with obesity: clinical recommendations from systematic reviews. JAMA 2014;312:943-52. 5. Yeh JS, Kushner RF, Schiff GD. Obesity and management of weight loss. N Engl J Med 2016;375;1187-9.

On 2016 Oct 27, James Yeh commented:

Editor's Comment Obesity and Management of Weight Loss — Polling Results

James Yeh, M.D., M.P.H., and Edward W. Campion, M.D.

Obesity is increasingly prevalent worldwide, and about 40% of Americans meet the diagnostic criteria for obesity.[1] The goal of weight loss is to reduce the mortality and morbidity risks associated with obesity. Patients with a body-mass index (BMI) in the range that defines obesity (>30) have a risk of death that is more than twice that of persons with a normal BMI.[2] Obesity is also associated with increased risks of cardiovascular disease, diabetes, and several cancers. A recent study suggests that being overweight or obese during adolescence is strongly associated with increased cardiovascular mortality in adulthood.[3] Studies suggest that even a 5% weight loss may reduce the complications associated with obesity.[4]

In September 2016, we presented the case of Ms. Chatham, a 29-year-old woman with class I obesity (BMI, 32) who leads a fairly sedentary lifestyle, with frequent reliance on takeout foods and with infrequent physical activity.[5] Readers were invited to vote on whether to recommend initiating treatment with one of the FDA-approved drugs for weight loss along with lifestyle modifications or to recommend only nonpharmacologic therapies and maximizing lifestyle changes. The patient has no coexisting medical conditions, but her blood pressure is slightly elevated (144/81 mm Hg). In the past, Ms. Chatham has tried to lose weight using various diets, each time losing 10 to 15 lb (4.5 to 6.8 kg), but she has never been able to successfully maintain weight loss.

Over 85,000 readers viewed the Clinical Decisions vignette during the polling period, and 905 readers from 91 countries voted in the informal poll. The largest group of respondents (366) was from the United States or Canada, representing nearly 40% of the votes. A large majority of the readers (80%) voted against prescribing one of the FDA-approved medications for weight loss and instead recommended maximizing lifestyle modification and nonpharmacologic therapies first.

A substantial proportion of the 64 Journal readers who submitted comments expressed concern about the absence of efficacy data on long-term follow-up and about the side effects associated with current FDA-approved medications for weight loss. Some suggested that simply treating obesity with a prescription medication is shortsighted and that it is important to uncover patients’ motivations for existing lifestyle choices and for weight loss. The commenters emphasized the need for a multifaceted approach to obesity management that includes nutritional and psychological support, as well as stress management, with the goal of long-lasting improvement in exercise and eating habits that will lead to weight reduction and maintenance of a healthier weight.

Some commenters, noting the difficulty of lifestyle changes, felt that pharmacotherapy can be a complementary and reasonable part of a multidisciplinary treatment plan. Some wrote that obesity should be managed as a chronic disease is managed and that an inability to lose weight should not be seen as a disciplinary issue, especially given the importance of genetic and physiological factors. These commenters argued that the use of pharmacotherapy as part of the treatment plan to achieve weight loss should not be stigmatized.

Overall, the results of this informal Clinical Decisions poll indicate that a majority of the respondents think physicians should not initially recommend the use of an FDA-approved drug as part of a weight-loss strategy, at least not for a patient such as Ms. Chatham, and that many respondents were troubled by the current uncertainties about the long-term efficacy and safety of weight-loss drugs.

REFERENCES 1. Flegal KM, Kruzon-Moran D, Carroll MD, Fryar CD, Ogden CL. Trends in obesity among adults in the United States, 2005 to 2014. JAMA 2016;315:2284-91. 2. Global BMI Mortality Collaboration. Body-mass index and all-cause mortality: individual-participant-data meta-analysis of 239 prospective studies in four continents. Lancet 2016;388:776-86. 3. Twig G, Yaniv G, Levine H, et al. Body-mass index in 2.3 million adolescents and cardiovascular death in adulthood. N Engl J Med 2016;374:2430-40. 4. Kushner RF, Ryan DH. Assessment and lifestyle management of patients with obesity: clinical recommendations from systematic reviews. JAMA 2014;312:943-52. 5. Yeh JS, Kushner RF, Schiff GD. Obesity and management of weight loss. N Engl J Med 2016;375;1187-9.