(For the rest of us)
Obesity rates in the United States are staggering. It is estimated that by the
year 2030, 86.3% of adults will be overweight or obese, and by 2048
all American adults will be overweight or obese (Kanaya, Vaisse, 2011).
With these statistics and the common knowledge that exercise and proper diet
are necessary to maintain weight, yet are blatantly disregarded, what can
primary care providers do pharmacologically to reduce obesity?
Before we start…
We can’t begin the discussion of weight loss without talking about exercise and diet. All pharmacologic interventions, as recommended by the drug manufacturers and providers, always include a lifestyle change of exercise and diet. Make no mistake, just the lifestyle change can effect a loss of weight with food portion control being the most important factor. However, though exercise alone cannot be credited with a big impact on weight loss, it can impact heart health. It is very important to have a serious discussion with your primary care provider about diet and exercise prior to considering a trial of medication.
According to Kanaya & Vaisse, 2011, weight loss and control of weight occur when physical activity is 60 minutes a day for most of the week. Heart disease prevention occurs with activity of 30 minutes a day with moderate intensity physical activity for most days of the week.
The key to dieting and weight loss includes eating a low-calorie, low-fat diet, eating breakfast regularly, and maintaining a consistent eating pattern throughout the week (Kanaya & Vaisse, 2011). To lose weight with dieting, calories expended must exceed calories taken in.
At what weight can I begin medication for weight loss?
The Clinical Guideline recommended by The National Heart, Lung, and Blood Institute suggests that FDA approved medication can be started for people with a Body Mass Index of 30 and no obesity related conditions (Usatine, Smith, Chumley, Mayeaux, 2013). If you have obesity related conditions (e.g. Diabetes, high blood pressure, or hyperlipidemia), medication can even be implemented at a BMI of 27.
So how do we determine BMI?
BMI means body fat based on height and weight, so for the first step, calculate your BMI:
Next, plug your BMI level into the below table:
- If your BMI is 27-29.9 and you have an obese related medical condition (e.g. diabetes, hypertension, or hyperlipidemia as an example) you may be able to begin medical therapy for weight loss.
- If your BMI is >30 and you have no obese related medical conditions, you should be clear to start medical therapy.
- >40 you could even be a candidate for surgery (talk with your doctor).
Medications for weight loss
Let’s consider 3 of the popular medications and talk about benefits vs. side effects.
Before we begin, pregnancy or even the possibility of pregnancy are always contraindicated with pharmacologic weight loss. If there is a possibility of conception or pregnancy, be prepared to start an oral contraceptive if you aren’t already taking one.
Lorcaserin is showing promise. If you’re taking an SSRI/SNRI (e.g. Prozac or Lexapro, or other depression medication) this medication might be contraindicated. This drug is pretty new to the market, so use of it must be carefully monitored.
Phentermine is the oldest medication approved by the FDA for weight loss and, in conjunction with a lifestyle intervention, has been shown to have a modest effect on weight loss with an average of seven pound weight loss compared with placebo. There are possible side effects such as heart palpitations, rapid heart rate, and elevated blood pressure. (Moldovan, Weldon, Daher, Schneider, Bellinger, Berk, Hermé, Aréchiga, Davis, and Peters (2016)
Saxenda is a promising drug in a class called GLP-1 receptor agonists. In non-diabetic obese patients, when combined with diet and exercise, Saxenda showed an average 4.5% weight loss in 1 year.
Positive weight outcomes at 56 weeks occurred in 80.1% of patients on Saxenda, the highest success rate of all the combinations studied (Jancin, 2016).
Early responders also averaged a 10.5-cm (4.13 inches) shrinkage in waist circumference at 56 weeks, and 50% of these patients had a 10% or greater weight loss at 56 weeks.
“Good cholesterol” levels often rise and systolic blood pressure levels often decrease on this medication.
Side effects of Saxenda include an absolute contraindication for people with multiple endocrine neoplasia, or MEN syndromes, which are genetically inherited disorders that manifest as tumors occurring in multiple endocrine organs, such as the thyroid, kidneys, brain and pancreas.
The resulting co-morbidities from obesity are so vast and well documented that in 2013 the American Medical Association officially named it as a disease. While fighting this disease was once an elusive diet and exercise only club, medical science has now arrived with a bang.
Diseases associated with obesity include high blood pressure, diabetes, elevated cholesterol and sleep apnea. They are often discovered too late leading to the number one cause of death in men and women, cardiovascular disease (Barnes et. al, 2017).
Your primary care provider is the best resource to direct and coordinate efforts to lead you on your journey toward improving your health by weight reduction with lifestyle changes and, possibly, medication. However, they may suggest additional interventions such as referral to UTMB’s Center for Obesity and Metabolic Surgery which offers comprehensive health care resources only an academic health center can provide.
Beginning with primary care, your provider can now begin alleviating the core issue of many current and future health problems. With diligence, exercise, diet and now pharmacologic means, the future of obesity is looking brighter, one pound at a time.
Come see us today to discuss pharmacologic therapy for weight loss and let us get you on the road to health and wellness.
UTMB Adult Primary Care, Webster
17448 Highway 3, Suite 200 Webster, TX 77598
Barnes A, Rogers M, Tran C. Obesity as a Clinical and Social Problem. In: King TE, Wheeler MB. eds. Medical Management of Vulnerable and Underserved Patients: Principles, Practice, and Populations, 2e New York, NY: McGraw-Hill; http://accessmedicine.mhmedical.com/content.aspx?bookid=1768§ionid=119151960. Accessed March 16, 2017.
Baron RB. Obesity. In: Feldman MD, Christensen JF, Satterfield JM. eds.Behavioral Medicine: A Guide for Clinical Practice, 4e New York, NY: McGraw-Hill; 2014. http://accessmedicine.mhmedical.com/content.aspx?bookid=1116§ionid=62688607. Accessed March 03, 2017.
Grajo JR, Paspulati RM, Sahani DV, Kambadakone A. The Radiologic clinics of North America: Multiple Endocrine Neoplasia Syndromes. WB Saunders Company; 05/01/2016;54:441.
Jancin, Bruce. “An enlightened approach to weight loss using liraglutide.” Family Practice News, 15 Nov. 2016, p. 3+. Health Reference Center Academic, go.galegroup.com/ps/i.do?p=HRCA&sw=w&u=txshracd2618&v=2.1&id=GALE%7CA474714845&it=r&asid=bc93b71e6bc82aabd71e47a82447992b. Accessed 6 Mar. 2017.
Kanaya AM, Vaisse C. Chapter 20. Obesity. In: Gardner DG, Shoback D. eds.Greenspan’s Basic & Clinical Endocrinology, 9e New York, NY: McGraw-Hill; 2011. http://accessmedicine.mhmedical.com/content.aspx?bookid=380§ionid=39744060. Accessed March 03, 2017.
Moldovan, C. P., Weldon, A. J., Daher, N. S., Schneider, L. E., Bellinger, D. L., Berk, L. S., Hermé, A. C., Aréchiga, A. L., Davis, W. L. and Peters, W. R. (2016), Effects of a meal replacement system alone or in combination with phentermine on weight loss and food cravings. Obesity, 24: 2344–2350. doi:10.1002/oby.21649