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3 Medical Management of Obesity

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Abstract

Obesity is a major health problem and its prevalence continues to increase worldwide. Data from the National Center for Health Statistics, National Health and Nutrition Examination Survey (2009–2010), showed that the prevalence of obesity (body mass index (BMI) >30 kg/m2) in the USA had significantly increased over the last two decades of the twentieth century (NCHS Data Brief (82), 1–8, 2012). More than two thirds of the population was overweight (BMI 25–29.9 kg/m2), and the percentage of obese US adults was 35.7 % in 2009–2010, and approximately 6 % (one in 16) had a BMI >40 kg/m2 (http://www.ncbi.nlm.nih.gov/books/NBK44660/pdf/TOC.pdf), whereas 16.9 % of US children and adolescents were obese. In real numbers, this equates to 78 million obese adults and 12.5 million obese children and adolescents.

In Europe, although the problem of obesity is not as dramatic, its rate of growth is dangerously approaching these US figures. Over the past 20 years, the rate of obesity has risen threefold and is more than 30 % in some European countries. About 50 % of all adults in Europe are classified as overweight (BMC Public Health 8, 200, 2008). In England, morbid obesity in women increased 180 % while rising threefold among men in less than a decade (https://catalogue.ic.nhs.uk/publications/public-health/surveys/heal-surv-eng-2011/HSE2011-Sum-bklet.pdf). In Spain, in hardly two decades, the percentage of obese children has increased from 5 to 16 %, and it is the second European country in the rate of childhood obesity (Obes Rev 13(4), 388–92, 2012).

Obesity is considered a key risk factor for coronary artery disease (CAD), stroke, hypertension (HTA), type 2 diabetes mellitus (T2DM), obstructive sleep apnea (OSA), depression, stroke (N Engl J Med 341(15), 1097–105, 1999; Arch Intern Med 161(13), 1581, 2001; Stroke 41(5), e418–26, 2010; Arch Intern Med 167(16), 1720–8, 2007; Diabetes 52(5), 1210–4, 2003), and certain types of cancer (Lancet 371(9612), 569–78, 2008). In addition, obese people are at a higher risk of having a metabolic dyslipidemic state with low high-density lipoprotein (HDL), high triglycerides (TG), and increased levels of small dense low-density lipoprotein (LDL) (Arteriosclerosis 10(4), 497–511, 1990). Individuals who had a more central localization of fat were at a higher risk for diabetes and dyslipidemia compared to people who had a more peripheral distribution of fat.

The Framingham Heart Study ranked body weight as the third most important predictor of CAD among males (Circulation 67(5), 968–77, 1983). Many experts feel that measurements of central adiposity such as waist circumference and waist-hip ratio might be better predictors of CVD risk (Hypertension 58, 991–3, 2011). Individuals who are obese have also an increased risk of mortality. The Nurse’s Health Study clearly showed that there was an almost linear, continuous relationship between obesity and mortality (N Engl J Med 333(11), 677–85, 1995). In individuals who are severely obese (BMI > 40 kg/m2), the risk of obesity-associated morbidities and mortality is even greater. Obesity contributes to about 112,000 preventable deaths every year in the USA (http://www.ncbi.nlm.nih.gov/books/NBK44660/pdf/TOC.pdf). Absolute rates of obesity tend to be higher in those with low incomes and low education levels. In some minorities, the percentage of individuals with a BMI > 40 exceeds 10 % (http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2007.pdf.). The percentage of black women with morbid obesity has doubled in less than a decade to a very concerning 15 %. Unfortunately, the future does not appear more promising, and it is expected that more than 50 % of Americans will be obese in the year 2025.

Morbid obesity is also a social and economic problem. The National Health Expenditure Accounts (NHEA) estimated that the annual medical burden of obesity could be as high as $147 billion per year (in 2008 dollars) (Health Aff 28(5), w822–31, 2009). In addition being obese is associated with a worse quality of life, compared to that caused by the use of tobacco, alcohol or based on certain parameters, such as poverty. People with morbid obesity have in many cases inability to ambulate, stress incontinence, difficulty with personal hygiene, and limited selection in clothing. A direct consequence of social bias is economic disadvantage with decreased monetary and educational/employment opportunities (Obes Surg 12(1), 14–8, 2002).

Our understanding of the mechanisms that regulate weight and body composition has greatly advanced in recent years, and new hormones and regulatory pathways have been discovered over the last few years. However, the current management of obesity continues to be one of the greatest challenges in our daily clinical practice. Many physicians feel frustrated with the current approach to obesity therapy. Few hospitals have interdisciplinary programs which include dieticians, exercise physiologists, and psychologists specialized in the treatment of obesity, and the current drug armamentarium to treat obesity continues to be very limited. Furthermore if weight loss is accomplished, we lack effective long-term programs to help patients to keep the weight off.

In this chapter we will review some of the scientific evidence to support the use of lifestyle interventions and medications (nonsurgical approach) to help obese patients to lose weight.

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Authors and Affiliations

  1. Research Unit, Division of Endocrinology, IUNICS, Hospital Universitario Son Espases, Ctra. Valldemossa 79, Palma de Mallorca, 07010, Spain

    Bartolome Burguera M.D., Ph.D. & Joan Tur B.S., M.H.S., Ph.D.

Authors
  1. Bartolome Burguera M.D., Ph.D.
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  2. Joan Tur B.S., M.H.S., Ph.D.
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Corresponding author

Correspondence to Bartolome Burguera M.D., Ph.D. .

Editor information

Editors and Affiliations

  1. Cleveland Clinic Lerner College of Medicine, Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, Ohio, USA

    Stacy A. Brethauer

  2. Cleveland Clinic Lerner College of Medicine, Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, Ohio, USA

    Philip R. Schauer

  3. Department of Surgery, Health Sciences Center, University of Virginia Health System, Charlottesville, Virginia, USA

    Bruce D. Schirmer

Review Questions and Answers

Review Questions and Answers

  1. 1.

    It is very important to set realistic expectations before starting medical treatments of obesity. What would be a realistic weight loss goal known to reduce the cardiovascular risk of patients?

    1. (a)

      5–15 %

    2. (b)

      3–10 %

    3. (c)

      5–7 %

    4. (d)

      None of the above

    CORRECT ANSWER (A): A −5 to −15% weight loss reduces obesity-related health risks significantly. There are a substantial number of patients who respond to weight loss interventions with important changes in their lifestyle, which translates in long-term weight loss.

  2. 2.

    Which of the following sentences would be false when we speak of the benefits of physical activity?

    1. (a)

      Reduced risk of premature death of any cause.

    2. (b)

      Reduced risk of diabetes mellitus.

    3. (c)

      Weight loss (without caloric restriction).

    4. (d)

      In elderly people there is strong evidence supporting the improvement of cognitive function in people who are physically active.

    CORRECT ANSWER (A): The benefits of physical activity include reduced risk of premature death of any cause, cerebrovascular disease, diabetes mellitus, some cancers (breast cancer and colon cancer), depression, prevention of weight gain, weight loss (in combination with caloric restriction), improvement of physical fitness, and musculoskeletal fitness. Inactivity and low cardiorespiratory fitness are as important as overweight and obesity as mortality predictors.

    In elderly people there is strong evidence supporting the improvement of cognitive function in people who are physically active and moderate evidence in regard to overall improvement in well-being, functional health, reduction of abdominal obesity, reduced risk of developing hip fracture, risk reduction of lung cancer, and weight loss maintenance.

  3. 3.

    Which of the following sentences is false when we speak of lifestyle modifications?

    1. (a)

      Changes in dietary behavior, the stimulation of physical activity, and emotional support continue to be the mainstays for the management of obesity in adults, children, and adolescents.

    2. (b)

      Lifestyle interventions alone result in long-term weight loss and the majority of dieters do not return to baseline weight within 3–5 years.

    3. (c)

      The improvements described in morbidly obese patients using behavioral therapy as an element of an intensive lifestyle intervention could benefit a huge number of people.

    4. (d)

      Lifestyle interventions can be provided at the hospital or primary care setting

    CORRECT ANSWER (B): Lifestyle interventions alone rarely result in long-term weight loss and the majority of dieters return to baseline weight within 3–5 years.

  4. 4.

    Which of the following sentences is correct?

    1. (a)

      Phentermine is an approved anti-obesity drug for short-term therapy.

    2. (b)

      GLP-1 analogues are effective weight loss drugs.

    3. (c)

      Topiramate is an antiepileptic drug with a weight loss side effect.

    4. (d)

      Lorcaserin, in addition to a reduced-calorie diet and exercise, could be a potential useful drug to treat obesity.

    5. (e)

      All of the above.

    CORRECT ANSWER (E).

  5. 5.

    Which of the following sentences is correct?

    1. (a)

      Bydureon is an exenatide long-acting release without weight loss effect.

    2. (b)

      Naltrexone is a dopamine reuptake inhibitor with weight loss effect.

    3. (c)

      Topiramate in combination with bupropion extended release is effective in causing weight loss.

    4. (d)

      Bupropion is an effective smoking cessation tool.

    5. (e)

      Cetilistat has central as well as gastrointestinal weight loss mechanism.

    CORRECT ANSWER (D). Bupropion is a dopamine and norepinephrine reuptake inhibitor that was first approved for the treatment of depression [139] and later for smoking cessation [140].

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Burguera, B., Tur, J. (2015). 3 Medical Management of Obesity. In: Brethauer, S., Schauer, P., Schirmer, B. (eds) Minimally Invasive Bariatric Surgery. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-1637-5_3

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