BOSTON — A variety of obesity interventions ranging from lifestyle modification to gastric bypass surgery are available for the approximately 35% of Americans living with the disease; however, the key to success with any approach is early and consistent treatment, according to a speaker at the Cardiometabolic Health Congress.
Caroline M. Apovian
“There’s a long road between diet, exercise and drugs and the higher efficacy treatments, such as bariatric surgery, which in general will give you a 32% or 33% weight loss,” Apovian, also a former vice president for The Obesity Society, said. Bariatric surgery “can roughly translate into about 100 lb to 150 lb (for a patient with obesity) that can be sustained. Compare that to maybe 30 lb (with pharmacotherapy), and you can see that we have a huge treatment gap.”
Recently approved devices, placed endoscopically or surgically, such as the lap band, are now available to help “fill the gap” between results stemming from diet and pharmacotherapy vs. surgery. However, long-term data are not yet available, and it remains unclear what role such devices will play in treatment, Apovian said.
Obesity guidelines, developed jointly in 2013 by the American Heart Association, the American College of Cardiology and The Obesity Society, recommend that physicians use both BMI and waist circumference to identify obesity risk and call for 3% to 5% sustained weight loss in patients with obesity to reduce metabolic risk factors including development of type 2 diabetes. The guidelines also note that there is “no ideal diet,” and that surgery should be considered for adults with obesity who meet the criteria.
However, there are challenges to implementing the guidelines, Apovian said.
“Most (primary care providers) are still not trained in obesity as a disease, and in diagnosis and treatment,” Apovian said. “They’re not trained (in obesity medicine) in medical schools; they’re not trained as residents. The culture still promotes the use of fad diets and supplements, promising a quick and easy fix, and we know that obesity is a chronic and relapsing disease so quick fixes are not going to work.”
Effects of weight loss
The LOOK AHEAD study has shown that 5% to 10% weight loss slows the progression from prediabetes to type 2 diabetes, increases life expectancy, improves glycemic control, BP and improves anatomic complications, such as back, knee and joint pain, Apovian said. Weight loss has also been demonstrated to reduce sleep apnea and the need for certain medications, especially those that promote obesity.
There is an incremental benefit beginning at just 3% weight loss, and initial weight loss predicts ultimate success, Apovian said. Participants in the LOOK AHEAD study who lost at least 10% body weight at 1 year continued to sustain at least 5% weight loss at 4 years, she said.
“Initial weight loss predicts ultimate success,” Apovian said. “This probably has to do with a combination of genetics and motivation for losing weight and keeping it off.”
‘It’s not the diet’
Five meta-analyses conducted from 2012 to 2014 suggest that adherence — not the macronutrient content of a diet — is what will ultimately result in success for any intervention, Apovian said.
“If you put patients on a low-carbohydrate diet, like the Atkins diet ... or The Zone [Diet] or Weight Watchers ... about 25% of the patients that you put on any of these diets are going to lose weight and keep it off at the end of the year,” she said.
However, “does that really mean that there is no benefit when looking at macronutrient content?” Apovian asked. “There probably is benefit. It’s just very difficult to assess the use of different content diets, because people find it very difficult to stay on any one plan for a period of time.”
New evidence has suggested that a low-carbohydrate diet may be better for patients with prediabetes or type 2 diabetes, Apovian said. But long-term data are not yet available.
Evidence also suggests that patients who performed physical activity of at least 300 minutes weekly, expending at least 2,000 kcal per week over 24 months, maintained weight loss nearly three times as great as those who exercised 150 minutes weekly, Apovian said.
Frequency of contact with a PCP predicts weight-loss maintenance, the dietary prescription of a hypocaloric diet, physical activity and behavioral therapy, including weekly weight checks, eating breakfast every morning and consistent meals for structure in the diet.
In 2015, The Endocrine Society published a clinical practice guideline for the pharmacological management of obesity. Medical intervention is recommended for patients with a BMI of at least 27 kg/m² with at least one comorbidity, or patients with a BMI of at least 30 kg/m² with no comorbidities. The guideline recommends medications and dosages based on obesity-related comorbidities, specific recommendations for transitioning patients off drugs that cause weight gain, and shifting from “a paradigm of treating weight last, to treating weight first.”
There are currently six medications available for weight loss.
Lifestyle changes, Apovian said, should be a part of any weight-loss drug therapy, and the risks and side effect profiles should always be considered before initiating any weight-loss medication.
“Even with pharmacotherapy, frequent patient follow-up is key, just like it’s key for bariatric surgery or devices,” Apovian said. She noted that CMS now covers at least 15 visits per year for obesity management. “These drugs work, as long as they are taken.”
A debate continues regarding the role of abnormal nutrient composition in the diet, genetics, and factors like sleep deprivation, stress and lack of physical activity play in the rapidly growing obesity epidemic, according to Apovian.
“We have always had people with large BMIs out there,” Apovian said. “But those numbers have been increasing. These are the people we have to intervene with earlier with bariatric surgery. Those of us who are slowly increasing our weight and increasing our set point by maybe 5% or 10%, perhaps that is more driven by something in our food supply.”
“In the future, we have to engage the government in trying to help us scale down this epidemic,” she said. – by Regina Schaffer
Apovian CM. Lifestyle, Behavioral and Pharmacological Approaches to Obesity Management. Presented at: Cardiometabolic Health Congress; Oct. 5-8, 2016; Boston.
Disclosure: Apovian reports receiving grants, research support or consultant fees from Amlyn, Arena Pharmaceuticals, Aspire Bariatrics, EnteroMedics, Gelesis, GI Dynamics, Johnson & Johnson, Lilly, Merck, Meta Proteomic, MYOS Corporation, Novo Nordisk, Nutrisystem, Orexigen, Pfizer, Sanofi, Scientific Intake, Takeda and Zafgen. Apovian also holds an ownership interest in Science Smart LLC.