Update on Office-Based Strategies for the Management of Obesity

 


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Obesity is a common condition that is associated with numerous medical problems such as cardiovascular disease, pulmonary disease, and diabetes mellitus. Primary care physicians have an important role in helping patients develop a successful weight loss plan to improve their overall health. Dietary strategies emphasizing reduced caloric intake, regardless of the nutrient composition, are important for weight loss. Behavioral interventions such as motivational interviewing and encouraging physical activity lead to additional weight loss when combined with dietary changes. Medication regimens for concomitant medical problems should take into account the effect of specific agents on the patient's weight. Persons with a body mass index of 30 kg per m2 or greater or 27 kg per m2 or greater with comorbidities who do not succeed in losing weight with diet and activity modifications may consider medication to assist with weight loss. Medications approved for long-term treatment of obesity include orlistat, lorcaserin, liraglutide, phentermine/topiramate, and naltrexone/bupropion. Physicians should consider referring patients for bariatric surgery if they have a body mass index of 40 kg per m2 or greater. For those with obesity-related comorbid conditions, patients should be considered for adjustable gastric banding or other bariatric surgical approaches if they have a body mass index of 30 to 39.9 kg per m2. The most commonly performed procedures for weight loss are Roux-en-Y gastric bypass, sleeve gastrectomy, and adjustable gastric banding. Bariatric surgery is the most effective intervention for weight loss in obese patients, and it leads to improvement in multiple obesity-related conditions, including remission of diabetes.

Obesity is a pervasive problem confronting patients and their physicians. From 2011 to 2012, 69% of U.S. adults were overweight or obese.1 Many common medical problems, such as diabetes mellitus, pulmonary disease, and cardiovascular disease, are related to obesity and can improve with weight loss.2 The management of obesity continues to evolve with the approval of new treatments. This review will provide answers to some of the common clinical questions that physicians encounter when managing obesity in the outpatient setting.

WHAT IS NEW ON THIS TOPIC: OBESITY

Using a single dietary adjustment may produce weight loss similar to more complex plans. For example, encouraging a patient to increase dietary fiber intake produces comparable adherence and weight loss to encouraging compliance with the many goals of the American Heart Association diet.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

BMI should be calculated for all patients 18 years and older, and those with obesity should be referred for intensive, multicomponent behavioral interventions.

B

2

Increased physical activity should be recommended for weight loss in combination with diet and behavioral modifications.

B

20

Physicians should consider medications for weight loss in patients with a BMI of 30 kg per m2 or greater, or 27 kg per m2 or greater who also have comorbidities and have unsuccessfully tried diet and lifestyle modification first.

C

26

Patients with a BMI of 40 kg per m2 or greater and those with a BMI greater than 35 kg per m2 who also have obesity-related comorbidities should be referred for consideration of bariatric surgery. Patients with a BMI greater than 30 kg per m2 who also have obesity-related comorbidities may be candidates for adjustable gastric banding.

B

36


BMI = body mass index.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

BMI should be calculated for all patients 18 years and older, and those with obesity should be referred for intensive, multicomponent behavioral interventions.

B

2

Increased physical activity should be recommended for weight loss in combination with diet and behavioral modifications.

B

20

Physicians should consider medications for weight loss in patients with a BMI of 30 kg per m2 or greater, or 27 kg per m2 or greater who also have comorbidities and have unsuccessfully tried diet and lifestyle modification first.

C

26

Patients with a BMI of 40 kg per m2 or greater and those with a BMI greater than 35 kg per m2 who also have obesity-related comorbidities should be referred for consideration of bariatric surgery. Patients with a BMI greater than 30 kg per m2 who also have obesity-related comorbidities may be candidates for adjustable gastric banding.

B

36


BMI = body mass index.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual

The Authors

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MICHAEL ERLANDSON, MD, is an assistant clinical professor in the Department of Family Medicine at the Swedish Family Medicine Residency, University of Colorado School of Medicine, Littleton....

LAURIE C. IVEY, PsyD, is director of behavioral health at the Swedish Family Medicine Residency, University of Colorado School of Medicine.

KATIE SEIKEL, DO, RD, is a second-year resident at the Swedish Family Medicine Residency, University of Colorado School of Medicine.

Author disclosure: No relevant financial affiliations.

Address correspondence to Michael Erlandson, MD, Swedish Family Medicine Residency, 191 E. Orchard Rd., Ste. 200, Littleton, CO 80121 (e-mail: michael.erlandson@healthonecares.com). Reprints are not available from the authors.

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