Section 3. How Do We Treat Obesity?

The primary therapeutic goal of obesity management is improvement in adiposity-related complications, not a preset decline in body weight. Lifestyle intervention is a vital component of all weight loss regimens; the choice of whether to implement lifestyle therapy alone or combine it with weight-loss medications or bariatric surgery will depend on the severity of each individual patient’s obesity and related complications.1

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.

3.1 Lifestyle Intervention

Key Points

  • Lifestyle interventions effectively prevent physical and metabolic complications of obesity
    • Lifestyle alone is less effective in populations with more severe obesity
  • Weight loss with lifestyle change is difficult to maintain
    • Behavioral support may need to be intensified to assist with weight loss and maintenance
    • Initial weight loss benefits are sustained even with weight regain
  • Support groups, including healthcare professional teams and community groups, should help patients set realistic goals and encourage adherence to healthy weight loss and maintenance behaviors

AACE/ACE Comprehensive Clinical Practice Guidelines for Medical Care of Patients with Obesity Recommendation1
Overall
  • R64. A structured lifestyle intervention program designed for weight loss (lifestyle therapy) and consisting of a healthy meal plan, physical activity, and behavioral interventions should be available to patients who are being treated for overweight or obesity.

Reduced-Calorie Meal Plan and Macronutrient Composition
  • R65. Reducing total energy (caloric) intake should be the main component of any weight-loss intervention.
  • R66. Even though the macronutrient composition of meals has less impact on weight loss than adherence rates in most patients, in certain patient populations, modifying macronutrient composition may be considered to optimize adherence, eating patterns, weight loss, metabolic profiles, risk factor reduction, and/or clinical outcomes.

Physical Activity
  • R67. Aerobic physical activity training should be prescribed to patients with overweight or obesity as a component of lifestyle intervention; the initial prescription may require a progressive increase in the volume and intensity of exercise, and the ultimate goal should be ≥ 150 min/week of moderate exercise performed during 3 to 5 daily sessions per week.
  • R68. Resistance training should be prescribed to patients with overweight or obesity undergoing weight-loss therapy to help promote fat loss while preserving fat-free mass; the goal should be resistance training 2 to 3 times per week consisting of single-set exercises that use the major muscle groups.
  • R69. An increase in nonexercise and active leisure activity should be encouraged to reduce sedentary behavior in all patients with overweight or obesity.
  • R70. The prescription for physical activity should be individualized to include activities and exercise regimens within the capabilities and preferences of the patient, taking into account health-related and physical limitations.
  • R71. Involvement of an exercise physiologist or certified fitness professional in the care plan should be considered to individualize the physical activity prescription and improve outcomes.

Behavior Interventions
  • R72. Lifestyle therapy in patients with overweight or obesity should include behavioral interventions that enhance adherence to prescriptions for a reduced-calorie meal plan and increased physical activity (behavioral interventions can include: self-monitoring of weight, food intake, and physical activity; clear and reasonable goal-setting; education pertaining to obesity, nutrition, and physical activity; face-to-face and group meetings; stimulus control; systematic approaches for problem solving; stress reduction; cognitive restructuring [i.e., cognitive behavioral therapy], motivational interviewing; behavioral contracting; psychological counseling; and mobilization of social support structures).
  • R73. The behavior intervention package is effectively executed by a multidisciplinary team that includes dietitians, nurses, educators, physical activity trainers or coaches, and clinical psychologists. Psychologists and psychiatrists should participate in the treatment of eating disorders, depression, anxiety, psychoses, and other psychological problems that can impair the effectiveness of lifestyle intervention programs.
  • R74. Behavioral lifestyle intervention and support should be intensified if patients do not achieve a 2.5% weight loss in the first month of treatment, as early weight reduction is a key predictor of long-term weight-loss success. A stepped-care behavior approach should teach skills for problem solving and should evaluate outcomes.
  • R75. Behavioral lifestyle intervention should be tailored to a patient’s ethnic, cultural, socioeconomic, and educational background.

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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3.2 When to Initiate Pharmacotherapy

Key Points

  • Weight-loss medications should be considered when obesity-related complications can be ameliorated by weight loss.
  • Pharmacotherapy should always be combined with lifestyle therapy, never used alone.
AACE/ACE Comprehensive Clinical Practice Guidelines for Medical Care of Patients with Obesity Recommendation1
  • R76. Pharmacotherapy for overweight and obesity should be used only as an adjunct to lifestyle therapy and not alone.
  • R77. The addition of pharmacotherapy produces greater weight loss and weight-loss maintenance compared with lifestyle therapy alone.
  • R78. The concurrent initiation of lifestyle therapy and pharmacotherapy should be considered in patients with weight-related complications that can be ameliorated by weight loss.
  • R79. Pharmacotherapy should be offered to patients with obesity, when potential benefits outweigh the risks, for the chronic treatment of the disease. Short-term treatment (3 to 6 months) using weight-loss medications has not been demonstrated to produce longer-term health benefits and cannot be generally recommended based on scientific evidence.
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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3.3 Weight Loss Medications

Key Points

  • Older obesity pharmacotherapies are limited by tolerability and dependence issues and are approved only for short-term use (≤12 weeks).
  • Newer weight loss agents are typically better tolerated, have better safety profiles, and are approved for chronic weight management including weight maintenance.
  • Pharmacotherapy for overweight and obesity should be used only as an adjunct to lifestyle therapy and not alone.

AACE/ACE Comprehensive Clinical Practice Guidelines for Medical Care of Patients with Obesity Recommendation1
Short-term Therapy
  • R79. Pharmacotherapy should be offered to patients with obesity, when potential benefits outweigh the risks, for the chronic treatment of the disease. Short-term treatment (3 to 6 months) using weight-loss medications has not been demonstrated to produce longer-term health benefits and cannot be generally recommended based on scientific evidence.

Choice of Weight-Loss Agent
  • R80. In selecting the optimal weight-loss medication for each patient, clinicians should consider differences in efficacy, side effects, cautions, and warnings that characterize medications approved for chronic management of obesity, and the presence of weight-related complications and medical history; these factors are the basis for individualized weight-loss pharmacotherapy; a generalizable hierarchical algorithm for medication preferences that would be applicable to all patients cannot currently be scientifically justified.
  • R81. Clinicians and their patients with obesity should have access to all approved medications to allow for the safe and effective individualization of appropriate pharmacotherapy.

Combinations of Weight-Loss Medications
  • R82. Combinations of FDA-approved weight-loss medications should only be used in a manner approved by the FDA or when sufficient safety and efficacy data are available to assure informed judgment regarding a favorable benefit-to-risk ratio.

Agent Selection for Specific Clinical Conditions
Chronic Kidney Disease
  • R83. Weight-loss medications should not be used in the setting of end-stage renal failure, with the exception that orlistat and liraglutide 3 mg can be considered in selected patients with a high level of caution.
  • R84. The use of naltrexone extended release (ER)/bupropion ER, lorcaserin, or phentermine/topiramate ER is not recommended in patients with severe renal impairment (<30 mL/min).
  • R85. All weight-loss medications can be used with appropriate cautions in patients with mild (50 to 79 mL/min) and moderate (30 to 49 mL/min) renal impairment, except that in moderate renal impairment the dose of naltrexone ER/bupropion ER should not exceed 8 mg/90 mg twice per day, and the daily dose of phentermine/topiramate ER should not exceed 7.5 mg/46 mg.
  • R86. Orlistat should not be used in patients with, or at risk of, oxalate nephropathy. Liraglutide 3 mg should be discontinued if patients develop volume depletion, for example, due to nausea, vomiting, or diarrhea.

Nephrolithiasis
  • R87. Naltrexone ER/bupropion ER, lorcaserin, and liraglutide 3 mg are preferred weight-loss medications in patients with a history, or at risk, of nephrolithiasis. Caution should be exercised in treating patients with phentermine/topiramate ER and orlistat who have a history of nephrolithiasis.

Hepatic Impairment
  • R88. All weight-loss medications should be used with caution in patients with hepatic impairment and should be avoided in severe hepatic impairment (i.e., Child-Pugh score >9).
  • R89. Dose adjustments for some medications are warranted in patients with moderate hepatic impairment specifically, the maximum recommended dose of naltrexone ER/bupropion ER is 1 tablet (8 mg/90 mg) in the morning; the maximum recommended dose of phentermine/ topiramate ER is 7.5 mg/46 mg daily.
  • R90. Clinicians should maintain a high index of suspicion for cholelithiasis in patients undergoing weight-loss therapy, regardless of the treatment modality; in high-risk patients, liraglutide 3 mg should be used with caution; effective preventive measures include a slower rate of weight loss, an increase in dietary fat, or administration of ursodeoxycholic acid.

Hypertension
  • R91. In patients with existing hypertension, orlistat, lorcaserin, phentermine/topiramate ER, and liraglutide 3 mg are preferred weight-loss medications. Heart rate should be carefully monitored in patients receiving liraglutide 3 mg and phentermine/topiramate ER. Naltrexone ER/bupropion ER should be avoided if other weight-loss medications can be used because weight loss assisted by naltrexone ER/bupropion ER cannot be expected to reduce blood pressure, and the drug is contraindicated in uncontrolled hypertension.

Cardiovascular Disease and Cardiac Arrhythmia
  • R94. In patients with established atherosclerotic cardiovascular disease, orlistat and lorcaserin are preferred weight-loss medications. Liraglutide 3 mg, phentermine/topiramate ER, and naltrexone ER/bupropion ER are reasonable to use with caution, and to continue if weight-loss goals are met, with careful monitoring of heart rate and blood pressure. Cardiovascular outcome trials are planned or ongoing for all weight-loss medications except orlistat.
  • R95. Orlistat and lorcaserin are preferred weight-loss medications in patients with a history or risk of cardiac arrhythmia. Naltrexone ER/bupropion ER, liraglutide 3 mg, and phentermine/topiramate ER are not contraindicated but should be used cautiously with careful monitoring of heart rate and rhythm.

Depression With or Without Selective Serotonin Reuptake Inhibitor Therapy
  • R96. All patients undergoing weight-loss therapy should be monitored for mood disorders, depression, and suicidal ideation.
  • R97. Orlistat, liraglutide 3 mg, and phentermine/topiramate ER at initiation (3.75 mg/23 mg) and low treatment (7.5 mg/46 mg) doses may be considered in patients with obesity and depression.
  • R98. Lorcaserin and naltrexone ER/bupropion ER should be used with caution in patients with obesity and depression or avoided if patients are taking medications for depression.

Anxiety
  • R99. Maximal dose (15 mg/92 mg) phentermine/topiramate ER should be used with caution in patients with obesity and anxiety disorders.

Psychotic Disorders With or Without Medications
  • R100. Patients with psychotic disorders being treated with antipsychotic medications (lithium, atypical antipsychotics, monoamine oxidase inhibitors) should be treated with a structured lifestyle intervention to promote weight loss or prevent weight gain.

  • R101. Treatment with metformin may be beneficial in promoting modest weight loss and metabolic improvement in individuals with psychotic disorders who are taking antipsychotic medications.
  • R102. Caution must be exercised in using any weight-loss medication in patients with obesity and a psychotic disorder due to insufficient current evidence assessing safety and efficacy.

Eating Disorders Including Binge Eating Disorder
  • R104. Patients with overweight or obesity who have binge eating disorder should be treated with a structured behavioral/lifestyle program in conjunction with cognitive behavioral therapy or other psychological interventions.
  • R105. In patients with overweight or obesity and binge eating disorder, treatment with orlistat or approved medications containing topiramate or bupropion may be considered in conjunction with structured lifestyle therapy, cognitive behavioral therapy, and/or other psychological interventions.
  • R106. Structured lifestyle therapy and/or selective serotonin reuptake inhibitor therapy may be considered in patients with obesity and night eating syndrome.

Glaucoma
  • R107. Liraglutide 3 mg, orlistat, and lorcaserin are preferred weight-loss medications in patients with a history, or at risk of, glaucoma. Phentermine/topiramate ER should be avoided and naltrexone ER/bupropion ER used with caution in patients with glaucoma.

Seizure Disorder
  • R108. Phentermine/topiramate, lorcaserin, liraglutide, and orlistat are preferred weight-loss medications in patients with a history, or at risk, of seizure/epilepsy. The use of naltrexone ER/bupropion ER should be avoided in these patients.
  • R109. All patients with obesity should be monitored for typical symptoms of pancreatitis (e.g., abdominal pain or gastrointestinal [GI] distress) due to a proven association between these diseases.
  • R110. Patients receiving glyburide, orlistat, or incretin-based therapies (glucagon-like peptide-1 receptor agonists or dipeptidyl peptidase 4 inhibitors) should be monitored for the development of pancreatitis. Glyburide, orlistat, and incretin-based therapies should be withheld in cases of prior or current pancreatitis; otherwise there are insufficient data to recommend withholding glyburide for glycemic control, orlistat for weight loss, or incretin-based therapies for glycemic control or weight loss due to concerns regarding pancreatitis.

Opioid Use
  • R111. In patients requiring chronic administration of opioid or opiate medications, phentermine/topiramate ER, lorcaserin, liraglutide 3 mg, and orlistat are preferred weight-loss medications, while naltrexone ER/bupropion ER should not be used.

Women of Reproductive Potential
  • R112. Weight-loss medications must not be used in pregnancy.
  • R113. All weight-loss medications should be used in conjunction with appropriate forms of contraception in women of reproductive potential.
  • R114. Weight-loss medications should not be used in women who are lactating and breast-feeding.

The Elderly, ≥65 years
  • R115. Elderly patients (≥65 years) should be selected for weight-loss therapy involving structured lifestyle interventions that include reduced-calorie meal plans and exercise, with clear health-related goals in mind that include prevention of type 2 diabetes (T2D) in high-risk patients with prediabetes, blood pressure lowering, and improvements in osteoarthritis, mobility, and physical function.
  • R116. Elderly patients with overweight or obesity being considered for weight-loss therapy should be evaluated for osteopenia and sarcopenia.
  • R117. Weight-loss medications should be used with extra caution in elderly patients with overweight or obesity; additional studies are needed to assess efficacy and safety of weight-loss medications in the elderly.

Addiction/Alcoholism
  • R118. In patients with obesity and alcohol or other addictions, consider using orlistat or liraglutide 3 mg. Lorcaserin (abuse potential due to euphoria at suprapharmacologic doses) and naltrexone ER/bupropion ER (lowers seizure threshold) should be avoided in patients with alcohol abuse, and naltrexone ER/bupropion ER is contraindicated during alcohol withdrawal.

Post-Bariatric Surgery
  • R119. Patients that have undergone bariatric surgery should continue to be treated with an intensive lifestyle intervention. Patients that have regained excess weight (≥25% of the lost weight), have not responded to intensive lifestyle intervention, and are not candidates for reoperation may be considered for treatment with liraglutide (1.8 to 3.0 mg) or phentermine/topiramate ER; the safety and efficacy of other weight-loss medications have not been assessed in these patients.

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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3.4 Bariatric Surgery

Key Points

  • Four weight-loss surgical options are available
    • Laparoscopic adjustable gastric band (LAGB)
    • Laparscopic sleeve gastrectomy (LSG)
    • Biliopancreatic diversion with or without duodenal switch (BPD-DS) and with or without LSG (staged BPD)
    • Roux-en-Y gastric bypass (RYGB)
  • BPD-DS and RYGB yield greater weight loss but more post-surgical morbidity than LSG or LAGB
  • Surgical candidates should be selected carefully with consideration of psychosocial as well as medical factors
  • Nutritional and metabolic follow-up are vital to ensure positive outcomes

AACE/ACE Comprehensive Clinical Practice Guidelines for Medical Care of Patients with Obesity Recommendation1
  • R120. Patients with a body mass index (BMI) of ≥40 kg/m2 without coexisting medical problems and for whom the procedure would not be associated with excessive risk should be eligible for bariatric surgery.
  • R121. Patients with a BMI of ≥35 kg/m2 and 1 or more severe obesity-related complications, including type 2 diabetes (T2D), hypertension, obstructive sleep apnea, obesity-hypoventilation syndrome, Pickwickian syndrome, nonalcoholic fatty liver disease or nonalcoholic steatohepatitis, pseudotumor cerebri, gastroesophageal reflux disease, asthma, venous stasis disease, severe urinary incontinence, debilitating arthritis, or considerably impaired quality of life may also be considered for a bariatric surgery procedure. Patients with BMI of 30 to 34.9 kg/m2 with diabetes or metabolic syndrome may also be considered for a bariatric procedure, although current evidence is limited by the number of patients studied and lack of long-term data demonstrating net benefit.
  • R122. Independent of BMI criteria, there is insufficient evidence for recommending a bariatric surgical procedure specifically for glycemic control alone, lipid lowering alone, or cardiovascular disease (CVD) risk reduction alone.
  • R123. All patients should undergo pre-operative evaluation for weight-related complications and causes of obesity, with special attention directed to factors that could affect a recommendation for bariatric surgery or be ameliorated by weight loss resulting from the procedure.

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.

DOWNLOAD SLIDES (PDF)