Obesity management in the clinic: Look beyond BMI
CHICAGO — Selecting an appropriate intervention, prescribing new pharmacotherapies and incorporating guidelines into patient care are some ways in which clinicians can manage obesity in clinical practice, researchers said here at the ADA Scientific Sessions.
“Obesity is a disease with genetic, environmental and behavioral determinants like any other chronic disease,” Caroline M. Apovian, MD, associate professor of medicine at the Boston University School of Medicine, director of the Center for Nutrition and Weight Management and co-director of the Nutrition Support Service at Boston Medical Center, and director of clinical research for the Obesity Research Center, said during a presentation.
Caroline M. Apovian
Apovian spoke about how clinicians should grade obesity levels for an appropriate intervention. She said multiple studies have shown that while BMI is semi-accurate, it only explains about 11% of individual variability in insulin sensitivity.
“BMI doesn’t tell us everything we need to know about the patient,” she added. “A complication-centric, rather than a BMI-centric, model will help target more intensive interventions.”
She cited the American Association of Clinical Endocrinologists’ new diabetes algorithm as a potential resource for clinicians. “It is a great schematic, showing you how to go through a complications model for care,” she said.
Additionally, she said advances in lifestyle interventions, new weight loss medications and refined bariatric surgery options help create a more robust model of care for the management of obesity.
According to Thomas A. Wadden, PhD, the Albert J. Stunkard professor of psychology in psychiatry, and director of the Center for Weight and Eating Disorders at the Perelman School of Medicine, University of Pennsylvania, lifestyle modifications are the first steps toward a goal for all patients.
He suggested that clinicians have patients begin by writing down everything they’ve eaten in a typical week or 2, followed by their portion sizes, caloric intake, time and place of food intake, activity, thoughts and moods. Eventually, he said that clinicians should encourage patients to alter their diet by increasing fruits, vegetables, olive oil and almonds. Of course, clinicians should set realistic goals for their patients, he added.
“Patients should meet weekly in group or individual sessions to receive feedback from an interventionalist. The most successful individuals are going to have instruction on a weekly basis,” Wadden said. “Physical activity is critical to weight loss.”
He added that digital interventions are becoming more popular; however, the most effective method of electronic interventions is telephone counseling for individuals or group counseling. “I think this is going to be the wave of the future,” he said, adding that the critical value is going to be keeping patients engaged in the interventions.
Michelle Look, MD, FAAFP, a clinician in private practice at the San Diego Sports Medicine and Family Health Center, cited various data on the latest FDA-approved obesity drugs lorcaserin (Belviq, Arena Pharmaceuticals) and phentermine/topiramate extended-release (Qsymia, Vivus).
“The weight-regulating mechanism is very complex,” Look said. “Evolution has created multiple feedback loops to address hunger, satiety and appetite. This is what has made weight loss so difficult for our patients. Recently, several compounds have made significant strides showing significant weight loss. Numbers — some up to the double digits — correlate with the Look AHEAD trial and DPP, to effect CV factors.”
She also cited a study conducted by herself and colleagues. The 2-year sustained weight loss and metabolic benefits with controlled-release phentermine/topiramate in obese and overweight adults (SEQUEL) trial was a randomized, placebo-controlled, phase 3 extension study.
She and colleagues ultimately found that phentermine/topiramate extended-release in conjunction with lifestyle modification was well-tolerated and an effective treatment option for the continued treatment of obesity complicated by cardiometabolic disease, according to data.
Look said patients with and without diabetes could benefit from these new therapies.
“Now we have two agents to fill the gap in obesity management, but it is still so important to continue lifestyle interventions.” – by Samantha Costa
For more information:
Eckel RH. Symposium: Obesity Management for the Practicing Clinician. Presented at: ADA Scientific Sessions; June 21-25, 2013; Chicago.
Disclosure: Apovian reports being on advisory panels for Abbott, Allergan, Amylin, Arena, Johnson & Johnson, Merck, Novo Nordisk, Orexigen, Sanofi, and Zafgen. She has received research support from Amylin, Dr. Robert C. and Veronic Atkins Foundation, Eli Lilly and Company, MetaProteomics, Orexigen, Pfizer, and Sanofi. Other researchers report no relevant financial disclosures.