Exploring psychotherapeutic issues and agents in clinical practice
Obesity rates in the United States are at an all-time high. No state in the country has an obesity rate among adults <20%; in fact, four states exceed 35% and one half have an obesity rate of 30% to 35% (Behavioral Risk Factor Surveillance System, 2015). Childhood obesity is also a serious concern, affecting 17% of children and adolescents (approximately 13 million) ages 2 to 19. Approximately 9% of preschool age children, 17.5% of 6- to 11-year-old children, and 20.5% of 12- to 19-year-old children are considered obese in the United States (Ogden, Carroll, Fryar, & Flegal, 2015).
Obesity rates among women are higher (40.4%) than among men (35%), with women being twice as likely (9.9%) to be extremely obese compared to men (5.5%) (Flegal, Kruszon-Moran, Carroll, Fryar, & Ogden, 2016). Among children and adolescents, obesity disproportionately affects those from low-income families, with 14.5% of Women, Infants, and Children (WIC) participants aged 2 to 4 years experiencing obesity (Pan et al., 2016). The prevalence of childhood obesity was found to be higher among Hispanic (17.3%) and American Indian/Alaska Native (18%) populations than non-Hispanic White (12.2%), non-Hispanic Black (11.9%), or Asian/Pacific Islander (11.1%) populations (Pan et al., 2016).
Obesity in children and adults is a complex and potentially detrimental health issue, which can be influenced by various behaviors, such as eating foods with low nutritional and high caloric values, not getting enough physical activity, and poor sleep routine—issues nurses understand as lifestyle concerns. Some illnesses, such as polycystic ovarian syndrome and Cushing's disease, may contribute to obesity in children and adults. Certain medications, such as steroid and antipsychotic agents, may also contribute to weight gain. For children and adults, obesity can contribute to many health consequences. Hypertension, cardiac disease, type 2 diabetes, pulmonary issues and sleep apnea, bodily aches and pains, depression and other mental illness, and even stroke or death may occur as a consequence of obesity (Centers for Disease Control and Prevention [CDC], 2015b). With such devastating effects of obesity, how can we, as nurses, aid our patients in developing healthier weights in addition to recommending and sustaining behavioral modifications and healthy lifestyle habits?
Many patients who struggle with obesity and weight gain have used over-the-counter (OTC) diet pills or herbal supplements, enrolled in any of the numerous weight loss programs, opted for bariatric surgery, and/or purchased any of the multitude of programs or supplements available on the internet and touted as “natural or holistic.” Few OTC medications are proven to be effective for weight loss, and dietary supplements/herbal medications have not been adequately studied for safety or effectiveness (Anderson, 2016). Although patients lose weight with these options, prescription medication-assisted weight loss is another means to assist patients in their pursuit of weight reduction and health when prescribed and monitored by a health care professional and used in combination with a nutritionally sound meal plan and less sedentary lifestyle.
Who Is a Candidate for Medication-Assisted Weight Loss?
Prescription weight loss medications are generally reserved for individuals who have been unable to lose weight through diet and exercise and/or who have serious health problems due to their excess weight (Mayo Clinic Staff, 2015). Obesity is typically defined as a measure of one's body mass index (BMI), which is calculated by a formula using height and weight. BMI is calculated by dividing weight in pounds by height in inches squared and multiplying by a conversion factor of 703 (CDC, 2015a). For children and teens, BMI is also based on age and sex at birth (i.e., girl or boy) and uses the BMI-for-age percentile growth charts (CDC, 2015a) (Table 1).
The universally accepted criteria for mediation-assisted weight loss is a BMI >30 or >27 with medical complications due to obesity, such as diabetes, hypertension, sleep apnea, and hyperlipidemia, among others. It is anticipated that over the course of 1 year, patients using medications to assist their weight loss efforts, in conjunction with a sound nutritional plan and exercise, may lose 5% to 10% of their initial weight (Anderson, 2016). This 5% to 10% loss is the “magic number” for clinically meaningful weight loss, which lowers the risk of life-threatening obesity-related illnesses (Burgess, 2017).
U.S. Food and Drug Administration–Approved Weight Loss Medications
Health care professionals are aware that there is no “magic pill” that will help patients shed weight and maintain the weight loss. Weight loss and maintenance require persistence and hard work to make the lasting behavioral and lifestyle changes with regard to nutrition and exercise. The U.S. Food and Drug Administration (FDA) requires that medications marketed for weight loss meet the following standards: (a) over a 1-year period, they must produce a loss that is ≥5% of the loss experienced by individuals taking a placebo or (b) they must demonstrate that >35% of individuals achieved >5% weight loss and that this loss was statistically significant compared to the control/placebo group; and (c) standards a and b must show improvements in lipid, blood pressure, and blood glucose profiles (Burgess, 2017). These stringent guidelines have limited the number of FDA-approved weight loss medications available in the United States. In addition, due to the relatively limited amount of weight loss achieved through medication assistance, the question arises: do the benefits outweigh the risks and side effects? The answer is yes, given that a weight loss of 5% to 10% can dramatically lower disease risks (Burgess, 2017), especially for cardiac-, metabolic-, glycemic-, and insulin-related illnesses.
There are various mechanisms of actions contributing to the overall weight loss properties of the FDA-approved agents. The most common types of prescription weight loss medications are appetite suppressing anorectics. In these medications, the lipase inhibitors block fat absorption in the intestines; the selective serotonin (5HT-2C) receptor agonists contribute to satiety or a feeling of fullness; glucagon-like peptide 1 (GLP-1) agonists regulate the area of the brain involved with appetite; and other agents increase metabolism and affect the brain's reward center (Anderson, 2016). Table 2 presents FDA-approved weight loss medications.
U.S. Food and Drug Administration–Approved Weight Loss Medications
Mechanisms of Action Side Effects of Weight Loss Medications
Appetite suppressing anorectics (i.e., phentermine, phendimetrazine, methamphetamine, benzphetamine, and diethylpropion) are categorized by the FDA as controlled dangerous substances (CDS). These agents are only approved for short-term (generally less than 12 weeks) use due to their potential for abuse; in fact, methamphetamine has a black box warning for high abuse potential and dependency (Rantini, 2016). Although FDA-approved weight loss drugs are deemed safe if used as directed and monitored by a health care professional, the short-term agents are contraindicated for use in individuals with hypertension, cardiac disease, and hyperthyroidism (Mayo Clinic Staff, 2015). The most common side effects related to appetite suppressant agents include: increased blood pressure and heart rate, anxiety, restlessness, insomnia, dry mouth, and constipation. Although none of the appetite suppressing anorectic medications are FDA approved for use in individuals younger than 18, many of the short-term agents have been used in individuals as young as 12.
Most of the long-term agents are only approved for use in individuals older than 18. The drugs approved for long-term use include orlistat, liraglutide, locaserin, phentermine/topiramate combination, and naltrexone/bupropion combination. Orlistat is the age exception, as it is the only FDA-approved weight loss medication for individuals 12 and older (Burgess, 2017). Many of the long-term agents do not have the risk for abuse and dependence and are not considered CDS. These medications have unique mechanisms of action, which contribute to their varied potential to aid patients in achieving their weight loss goals, as well as more varied side effects than short-term agents.
Orlistat, and its OTC half-strength formulation, Alli®, blocks the absorption of fat in the intestine and eliminates the excess fat through bowel movements. Orlistat can interfere with the absorption of other medications and fat-soluble vitamins such as A, D, E, and K and beta-carotene. Given the mechanism of action, the side effects of orlistat include bowel-related issues including: diarrhea, oily stools, fecal spotting, urgency, flatulence, bloating, and recurrent pain in the upper abdomen. The side effects may be more prominent if a high-fat meal is consumed or the overall dietary fat exceeds 30% (MedlinePlus, 2016b).
Locaserin works by increasing the feelings of fullness to decrease the amount of food consumed. Locaserin is a CDS Schedule IV and may contribute to abuse. As this medication works as a selective serotonin receptor 2C agonist, caution should be used if the patient is prescribed other agents working on the serotonin system, which might include: psychotropic medications, drugs to treat diabetes, agents used to treat migraine headaches, some cough medications, some pain medications, and many herbal and nutritional supplements. The most common side effects related to locaserin include: constipation, dry mouth, fatigue, muscular pain, headache, insomnia, and anxiety (MedlinePlus, 2017a).
Liraglutide is a daily injectable medication delivered subcutaneously to control blood sugar, insulin levels, and digestion. This medication is believed to act as a GLP-1 agonist, regulating the appetite center in the brain. Because it is similar to many medications used to treat type 2 diabetes, it is contraindicated if the patient is prescribed such agents. Liraglutide is also contraindicated in patients with a personal or family history of endocrine tumors or thyroid cancers. The most common side effects of liraglutide include: headache, constipation, heartburn, fatigue, difficulty urinating, and injection site reactions (MedlinePlus, 2016a).
The drug phentermine/topiramate extended release (ER) combines two older medications with weight loss properties into one convenient agent. Phentermine is an appetite suppressing anorectic; topiramate ER is an anticonvulsant agent that contributes to feelings of fullness, thereby decreasing appetite. This drug is classified as a CDS Schedule IV and may be habit forming. Women who are or may become pregnant should not use phentermine/topiramate ER due to the risk of cleft lip and cleft palate in the developing fetus. In addition, this combination weight loss drug is contraindicated in patients with glaucoma or those who have had a heart attack or stroke in the past 6 months. It is recommended that fluids be increased during treatment with this medication. The most common side effects include: headache and dizziness; numbness or tingling in the face and extremities; decreased attention, concentration, and ability to recall recent events; fatigue; dry mouth and excessive thirst; tachycardia; eye pain; and generalized pain (MedlinePlus, 2017b).
The drug naltrexone/bupropion ER is a combination of the opioid antagonist, naltrexone, and the dopamine-norepinephrine reuptake inhibitor antidepressant, bupropion ER. These agents are hypothetically thought to reduce appetite and curb hunger and food cravings by working on the brain's reward system. This agent is contraindicated in patients who are prescribed or are abusing opioid-related medications, as they may be subject to precipitated withdrawal. Naltrexone/bupropion ER is also contraindicated in patients with seizure disorders and should not be taken with a high-fat meal, as this may precipitate seizures. Caution should be used when prescribing to individuals with liver disease, epilepsy, visual concerns, hypertension, and mental health issues. The most common side effects include: constipation, headache, insomnia, anxiety, increased blood pressure, blurred vision, and fatigue (Drugs.com, 2017).
Nurses offer patients a holistic perspective on their health. In working with patients who struggle with their weight, whether obesity or being overweight with medical complications, nurses provide education regarding the various behavioral modifications needed to lead a healthier lifestyle. These modifications include dietary changes to enhance the consumption of foods with high nutritional value; replacing sugary beverages with water; reducing the use of drugs, alcohol, and tobacco; and increasing exercise to improve health and longevity.
However, for many challenged with the task to lose significant amounts of weight, making lifestyle changes may not be enough. Although prescription weight loss medications are not “miracle pills,” they may enhance patients' efforts. Although some agents may be used for long-term weight loss and maintenance, generally, if 3% to 5% of the patient's baseline weight is not lost within the first 12 weeks of starting a medication, the individual is unlikely to benefit from that particular agent (Burgess, 2017). Finally, although medication-assisted weight loss is not a “miracle cure,” the prescribing of weight loss medications may provide patients with the ability to maximize their potential to engage in the changes necessary to enhance their weight reduction efforts, if only by the 5% to 10% that is known to improve the comorbidities associated with obesity. For some, the disease of obesity is a chronic, recurrent illness, which may require long-term medication assistance to sustain weight loss and reduce comorbidities. Nurses must consider these factors and add weight loss medications to the toolkit of potential treatment options for those trying to manage the disease of obesity.
- Anderson, L. (2016). Prescription weight loss/diet pills: What are the options. Retrieved from https://www.drugs.com/article/prescription-weight-loss-drugs.html
- Behavioral Risk Factor Surveillance System. (2015). Prevalence of self-reported obesity among U.S. adults by state and territory. Retrieved from https://www.cdc.gov/obesity/data/prevalence-maps.html
- Burgess, K. (2017). Diet pills: A research summary. Retrieved from http://www.consumersearch.com/diet-pills
- Centers for Disease Control and Prevention. (2015a). About adult BMI. Retrieved from https://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html#
- Centers for Disease Control and Prevention. (2015b). The health effects of overweight and obesity. Retrieved from https://www.cdc.gov/healthyweight/effects/index.html
- Drugs.com. (2017). Contrave. Retrieved from https://www.drugs.com/contrave.html
- Flegal, K.M., Kruszon-Moran, D., Carroll, M.D., Fryar, C.D. & Ogden, C.L. (2016). Trends in obesity among adults in the United States, 2005 to 2014. JAMA, 315, 2284–2291. doi:10.1001/jama.2016.6458 [CrossRef]
- Mayo Clinic Staff. (2015). Prescription weight-loss drugs. Retrieved from http://www.mayoclinic.org/healthy-lifestyle/weight-loss/in-depth/weight-loss-drugs/art-20044832
- MedlinePlus. (2016a). Liraglutide injection. Retrieved from https://medlineplus.gov/druginfo/meds/a611003.html
- MedlinePlus. (2016b). Orlistat. Retrieved from https://medlineplus.gov/druginfo/meds/a601244.html
- MedlinePlus. (2017a). Locaserin. Retrieved from https://medlineplus.gov/druginfo/meds/a613014.html
- MedlinePlus. (2017b). Phentermine and topiramate. Retrieved from https://medlineplus.gov/druginfo/meds/a612037.html
- Ogden, C.L., Carroll, M.D., Fryar, C.D. & Flegal, K.M. (2015). Prevalence of obesity among adults and youth: United States, 2011–2014. Retrieved from https://www.cdc.gov/nchs/products/databriefs/db219.htm
- Pan, L., Freedman, D.S., Sharma, A.J., Castellanos-Brown, K., Park, S., Smith, R.B. & Blanck, H.M. (2016). Trends in obesity among participants aged 2–4 years in the special supplemental nutrition program for women, infants and children—United States, 2000–2014. Retrieved from https://www.cdc.gov/mmwr/volumes/65/wr/mm6545a2.htm?s_cid=mm6545a2_w
- Rantini, M. (2016). Prescription weight loss drugs. Retrieved from http://www.webmd.com/diet/obesity/weight-loss-prescription-weight-loss-medicine#1
Body Mass Index (BMI) Formulas and Weight Status Categories (Centers for Disease Control and Prevention, 2015a)
|Adult BMI Formula: Weight (lb)/Height (in)2× 703|
| Example: Weight = 150 lb, Height = 5′5″ (65 in)|
| Calculation: [150 ÷ (65)2] × 703 = 24.96|
|Adult BMI Calculatora|
|BMI||Weight Status Category|
|18.6 to 24.9||Healthy weight|
|25.0 to 29.9||Overweight|
|Child and Teen BMI FormulaUse the adult BMI formula with the following exceptions:|
| 1) Measure weight to the nearest 1/4 (0.25) lb (8 oz = 1/2 lb)|
| 2) Measure height to the nearest 1/8 in (12 in = 1 ft)|
| 3) Child/teen BMI also accounts for age and sex at birth (i.e., boy or girl)|
| 4) Use the BMI-for-Age Percentile Growth Charts (access https://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/about_childrens_bmi.html)|
|Child/Teen BMI Calculator|
|Percentile Range||Weight Status Category|
|5th to <85th percentile||Healthy weight|
|85th to <95th percentile||Overweight|
U.S. Food and Drug Administration–Approved Weight Loss Medications
|Type/Generic Name||Brand Name||Available Strengths and Maximum Dosing||CDS Schedule||Treatment Term, Age for Use (Years)|
| Phentermine||Adipex-P®Suprenza®||15, 30, and 37.5 mg capsule, 37.5 mg tablet
Max dose = 37.5 mg daily||IV||Short-term, >16|
| Phendimetrazine||Bontril PDM®Bontril SR®||35 mg PDM tablet and 150 mg SR capsule
Max dose = 70 mg TID||III||Short-term, off label >17|
| Methamphetamine||Desoxyn®||5 mg tabletsMax dose = 5 mg TID||II||Short-term, off label >12|
| Benzphetamine||Didrex®Regimex®||25 and 50 mg tablets
Max dose = 50 mg daily||III||Short-term, >12|
| Diethylpropion||Tenuate®||25 mg tablet and 75 mg ER tablet
Max dose = 25 mg TID or 75 mg ER daily||IV||Short-term, >16|
| Orlistat||Zenical®Alli®(OTC non-Rx)||120 mg capsules
Max dose = 120 mg TID||No||Long-term, >12|
|Selective Serotonin 2C Receptor Agonist|
| Locaserin||Belviq®Belviq XR®||10 mg tablets and 20 mg ER tablet
Max dose = 10 mg BID or 20 mg ER daily||IV||Long-term, >18|
| Liraglutide||Saxenda®||6 mg/mL injectable pen
Max dose = 3 mg SC injection daily||No||Long-term, >18|
| Phentermine and topiramate ER||Qsymia®||3.75 mg/23 mg, 7.5 mg/46 mg, 11.25 mg/69 mg, 15 mg/92 mg ER capsules
Max dose = 15 mg/92 mg daily||IV||Long-term, >18|
| Naltrexone HCl and bupropion HCl ER||Contrave®||8 mg/90 mg ER tablet
Max dose = 2 tablets BID||No||Long-term, >18|