Section 2. Why Do We Treat Obesity?

Obesity prevalence has risen steadily for several decades, and the disease, its complications, and comorbidities place a huge burden on patients and society. Obesity is estimated to add $3,559 annually (adjusted to 2012 dollars) to per-patient medical expenditures as compared to patients who do not have obesity; this includes $1,372 each year for inpatient services, $1,057 for outpatient services, and $1,130 for prescription drugs.1

In the complications-centric approach to obesity management, the primary therapeutic endpoint is improvement in adiposity-related complications, not a preset decline in body weight.2

References
  1. Cawley J, Meyerhoefer C. The medical care costs of obesity: an instrumental variables approach. J Health Econ. 2012;31:219-230.
  2. Garvey WT, Mechanick JL, Brett EM, et al. American Association of Clinical Endocrinologists and American College of Endocrinology Comprehensive Clinical Practice Guidelines for Medical Care of Patients With Obesity. Endocr Pract. 2016;22(suppl 3);1-205.

2.1 Epidemiology

Key Points

  • Obesity is increasing globally
    • Rates of obesity have risen dramatically in the U.S. over the past 4 decades
    • The increase in obesity is strongly associated with the increase in diabetes in the U.S. and worldwide
  • Obesity is costly

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2.2 Metabolic Complications

Key Points

  • Obesity is associated with higher risks of prediabetes and type 2 diabetes (T2D)
  • Weight loss with lifestyle therapy, pharmacotherapy, or bariatric surgery
    • Reduces the risk of progression to T2D
    • Improves glycemic control in patients with T2D
    • Improves features of nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH)
AACE/ACE Comprehensive Clinical Practice Guidelines for Medical Care of Patients with Obesity Recommendations1
Prediabetes and Metabolic Syndrome
  • R30. Patients with overweight or obesity and with either metabolic syndrome or prediabetes, or patients identified to be at high risk of T2D based on validated risk-staging paradigms, should be treated with lifestyle therapy that includes a reduced-calorie healthy meal plan and a physical activity program incorporating both aerobic and resistance exercise to prevent progression to diabetes. The weight-loss goal should be 10%.
  • R31. Medication-assisted weight loss employing phentermine/topiramate ER, liraglutide 3 mg, or orlistat should be considered in patients at risk for future T2D and should be used when needed to achieve 10% weight loss in conjunction with lifestyle therapy.
  • R32. Diabetes medications including metformin, acarbose, and thiazolidinediones can be considered in selected high-risk patients with prediabetes who are not successfully treated with lifestyle and weight-loss medications and who remain glucose intolerant.

Type 2 Diabetes
  • R33. Patients with overweight or obesity and T2D should be treated with lifestyle therapy to achieve 5% to 15% weight loss or more as needed to achieve targeted lowering of A1C. Weight-loss therapy should be considered regardless of the duration or severity of T2D, both in newly diagnosed patients and in patients with longer-term disease on multiple diabetes medications.
  • R34. Weight-loss medications should be considered as an adjunct to lifestyle therapy in all patients with T2D as needed for weight loss sufficient to improve glycemic control, lipids, and blood pressure.
  • R35. Patients with obesity (BMI ≥ 30 kg/m2) and diabetes who have failed to achieve targeted clinical outcomes following treatment with lifestyle therapy and weight-loss medications may be considered for bariatric surgery, preferably Roux-en-Y gastric bypass, sleeve gastrectomy, or biliopancreatic diversion.
  • R36. Diabetes medications that are associated with modest weight loss or are weight-neutral are preferable in patients with obesity and T2D, although clinicians should not refrain from insulin or other medications when needed to achieve A1C targets.

Nonalcoholic Fatty Liver Disease and Nonalcoholic Steatohepatitis
  • R45. Patients with overweight or obesity and NAFLD should be primarily managed with lifestyle interventions, involving calorie restriction and moderate-to-vigorous physical activity, targeting 4% to10% weight loss (a range over which there is a dose-dependent beneficial effect on hepatic steatosis).
  • R46. Weight loss as high as 10% to 40% may be required to decrease hepatic inflammation, hepatocellular injury, and fibrosis. In this regard, weight loss assisted by orlistat, liraglutide, and bariatric surgery may be effective.
  • R47. A Mediterranean dietary pattern or meal plan can have a beneficial effect on hepatic steatosis independent of weight loss.

Reference
  1. Garvey WT, Mechanick JL, Brett EM, et al. American Association of Clinical Endocrinologists and American College of Endocrinology Comprehensive Clinical Practice Guidelines for Medical Care of Patients with Obesity. Endocr Pract. 2016;22(suppl 3);1-205.

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2.3 Cardiovascular Complications

Key Points

  • Obesity is associated with increased cardiovascular risk
  • Weight loss by means of lifestyle therapy, pharmacotherapy, or bariatric surgery positively affects cardiovascular risk markers
AACE/ACE Comprehensive Clinical Practice Guidelines for Medical Care of Patients with Obesity Recommendations1
Dyslipidemia
  • R37. Patients with overweight or obesity and dyslipidemia (elevated triglycerides and reduced HDL-C) should be treated with lifestyle therapy to achieve 5% to 10% weight loss or more as needed to achieve therapeutic targets. The lifestyle intervention should include a physical activity program and a reduced-calorie healthy meal plan that minimizes sugars and refined carbohydrates, avoids trans fats, limits alcohol use, and emphasizes fiber.
  • R38. Patients with overweight or obesity and dyslipidemia should be considered for treatment with a weight-loss medication combined with lifestyle therapy when necessary to achieve sufficient improvements in lipids (i.e., elevated triglycerides and reduced HDL-C).

Hypertension
  • R39. Patients with overweight or obesity and elevated blood pressure or hypertension should be treated with lifestyle therapy to achieve 5% to 15% weight loss or more as necessary to achieve blood pressure reduction goals in a program that includes caloric restriction and regular physical activity.
  • R40. Patients with overweight or obesity and elevated blood pressure or hypertension should be considered for treatment with a weight-loss medication combined with lifestyle therapy when necessary to achieve sufficient weight loss for blood pressure reduction.
  • R41. Patients with hypertension considering bariatric surgery should be recommended for Roux-en-Y gastric bypass or sleeve gastrectomy, unless contraindicated, due to greater long-term weight reduction and better remission of hypertension than with laparoscopic adjustable gastric banding.
  • R92. Renin-angiotensin system inhibition therapy (angiotensin receptor blocker or angiotensin converting enzyme inhibitor) should be used as the first-line drug for blood pressure control in patients with obesity.
  • R93. Combination antihypertension therapy with calcium channel blockers may be considered as second-tier treatment. Beta blockers and thiazide diuretics may also be considered in some patients but can have adverse effects on metabolism; beta-blockers and alpha-blockers can promote weight gain.

Cardiovascular Disease (CVD)
  • R42. Weight-loss therapy is not recommended based on available data for the expressed and sole purpose of preventing CVD events or to extend life, although evidence suggests that the degree of weight loss achieved by bariatric surgery can reduce mortality. Cardiovascular outcome trials assessing medication-assisted weight loss are currently ongoing or being planned.
  • R43. Weight-loss therapy is not recommended based on available data for the expressed and sole purpose of preventing CVD events or to extend life in patients with diabetes. Cardiovascular outcome trials assessing medication-assisted weight loss are currently ongoing or being planned.

Congestive Heart Failure
  • R44. Weight-loss therapy is not recommended based on available data for the expressed purpose of preventing CVD events or to extend life in patients with congestive heart failure, although evidence suggests that weight loss can improve myocardial function and congestive heart failure symptomatology in the short term.

Reference
  1. Garvey WT, Mechanick JL, Brett EM, et al. American Association of Clinical Endocrinologists and American College of Endocrinology Comprehensive Clinical Practice Guidelines for Medical Care of Patients With Obesity. Endocr Pract. 2016;22(suppl 3);1-205.

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2.4 Organ-Specific, Hormonal, and Biomechanical Complications

Key Points

  • Numerous organ-specific and biomechanical complications accompany obesity
  • Weight loss ameliorates all of these conditions

AACE/ACE Comprehensive Clinical Practice Guidelines for Medical Care of Patients with Obesity Recommendations1
Sex Hormone–Related Disorders
Polycystic Ovary Syndrome (PCOS)
  • R48. Women with overweight or obesity and PCOS should be treated with lifestyle therapy with the goal of achieving 5% to 15% weight loss or more to improve hyperandrogenism, oligomenorrhea, anovulation, insulin resistance, and hyperlipidemia; clinical efficacy can vary among individual patients.
  • R49. Patients with overweight or obesity and PCOS should be considered for treatment with orlistat, metformin, or liraglutide, alone or in combination, because these medications can be effective in decreasing weight or improving PCOS manifestations, including insulin resistance, glucose tolerance, dyslipidemia, hyperandrogenemia, oligomenorrhea, and anovulation.
  • R50. Selected patients with obesity and PCOS should be considered for laparoscopic Roux-en- Y gastric bypass to improve symptomatology, including restoration of menses and ovulation.

Female Infertility
  • R51. Weight loss is effective to treat infertility in women with overweight and obesity and should be considered as part of the initial treatment to improve fertility; weight loss of ≥ 10% should be targeted to augment the likelihood of conception and live birth.

Male Hypogonadism
  • R52. Treatment of hypogonadism in men with increased waist circumference or obesity should include weight-loss therapy. Weight loss of more than 5% to 10% is needed for significant improvement in serum testosterone.
  • R53. Bariatric surgery should be considered as a treatment approach that improves hypogonadism in most patients with obesity, including patients with severe obesity (body mass index [BMI] >50 kg/m2) and type 2 diabetes (T2D).
  • R54. Men with true hypogonadism and obesity who are not seeking fertility should be considered for testosterone therapy in addition to lifestyle intervention because testosterone in these patients results in weight loss, decreased waist circumference, and improvements in metabolic parameters (glucose, A1C, lipids, and blood pressure).

Pulmonary Disorders: Obstructive Sleep Apnea (OSA) and Asthma
  • R55. Patients with overweight or obesity and obstructive sleep apnea should be treated with weight-loss therapy including lifestyle interventions and additional modalities as needed, including phentermine/topiramate extended release (ER) or bariatric surgery; the weight-loss goal should be at least 7% to 11% or more.
  • R56. Patients with overweight or obesity and asthma should be treated with weight loss using lifestyle interventions; additional treatment modalities may be considered as needed including bariatric surgery; the weight-loss goal should be at least 7% to 8%.
Biomechanical Disorders
Osteoarthritis (OA)
  • R57. Patients with overweight or obesity and OA involving weight-bearing joints, particularly the knee, should be treated with weight-loss therapy for symptomatic and functional improvement and reduction in compressive forces during ambulation; the weight-loss goal should be ≥ 10% of body weight. A physical activity program should also be recommended in this setting because the combination of weight-loss therapy achieving 5% to 10% loss of body weight combined with physical activity can effectively improve symptoms and function.
  • R58. Patients with overweight or obesity and OA should undergo weight-loss therapy before and after total knee replacement.
Urinary Stress Incontinence
  • R59. Women with overweight or obesity and stress urinary incontinence should be treated with weight-loss therapy; the weight-loss goal should be 5% to 10% of body weight or greater.
Gastroesophageal Reflux Disease (GERD)
  • R60. Patients with overweight or obesity and gastroesophageal reflux should be treated using weight loss; the weight-loss goal should be 10% of body weight or greater.
  • R61. Proton pump inhibitor (PPI) therapy should be administered as medical therapy in patients with overweight or obesity and persistent gastroesophageal reflux symptoms during weight-loss interventions.
  • R62. Roux-en-Y gastric bypass should be considered as the bariatric surgery procedure of choice for patients with obesity and moderate to severe gastroesophageal reflux symptoms, hiatal hernia, esophagitis, or Barrett’s esophagus. Intragastric balloon for weight loss may increase gastroesophageal reflux symptoms and should not be used for weight loss in patients with established gastroesophageal reflux.
Reference
  1. Garvey WT, Mechanick JL, Brett EM, et al. American Association of Clinical Endocrinologists and American College of Endocrinology Comprehensive Clinical Practice Guidelines for Medical Care of Patients With Obesity. Endocr Pract. 2016;22(suppl 3);1-205.

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2.5 Psychological Complications (Coming Soon)

Key Points
  • Depression, anxiety, eating disorders, and other psychological conditions frequently are associated with obesity
  • Weight loss may positively affect the psychological complications of obesity.
AACE/ACE Comprehensive Clinical Practice Guidelines for Medical Care of Patients with Obesity Recommendation1
  • R63. Patients with overweight or obesity and depression interested in losing weight should be offered a structured lifestyle intervention.
Reference
  1. Garvey WT, Mechanick JL, Brett EM, et al. American Association of Clinical Endocrinologists and American College of Endocrinology Comprehensive Clinical Practice Guidelines for Medical Care of Patients With Obesity. Endocr Pract. 2016;22(suppl 3);1-205.