Oct, 12th 2017 6:50 am, Article Recommended by Dr. J. Smith
John B Dixon
It is well recognised that Australia has one of the highest prevalences of overweight and obesity in the developed world, and that this is the greatest contributing factor, along with ageing, to the chronic disease burden in our society. Predictions are confronting; close to 80% of Australian adults are predicted by be obese by the year 2025. The determinants of obesity are multifactorial and are influenced by early life environments as well as genetics. Prevention is failing due to many factors including a poor understanding of these determinants as well as reluctance to act at a government/community level.
This article aims to provide a practical approach to weight management in general practice with a focus on some of the more intensive interventions beyond the first line lifestyle modification advice.
General practitioners are often well placed to identify overweight and obesity. Patient engagement in management is critical, as for any chronic disease. Treatment needs to be evidence based and focused on a broad range of health outcomes, not simply on weight. Intensive interventions to potentiate weight loss may involve use of very low energy diets, pharmacotherapy and bariatric surgery. Referral to specialist weight assessment and management clinics, where available may be appropriate, particularly for complex cases with more severe comorbidity.
Obesity is a complex, chronic, relapsing condition and, along with ageing, is the greatest contributing factor to chronic disease burden in our society. It is well recognised that Australia has one of the highest prevalences of overweight and obesity in the developed world, affecting over 60% of adults and 25% of children and adolescents; this figure is predicted to increase to close to 80% of adults by the year 2025.1,2 One-quarter of Australian adults are considered to be obese (body mass index [BMI] >30 kg/m2), and numbers affected by this more severe form of overweight are rising exponentially.2,3 The economic burden associated with the epidemic proportions of obesity in Australia has been attributed to the overall healthcare cost of $58.2 billion in 2008, with direct healthcare costs in excess of $8 billion per year.4 These figures are only likely to increase, further straining health services.
The major determinants of obesity are multifaceted, surprisingly poorly understood and extend well beyond simplistic explanations about high energy Western diets and obligatory reductions in human movement.5 The interplay between humans and the environment, influenced by genes, epigenetic default metabolic programming, the intrauterine environment and early infant feeding practices set the scene in the early years for weight trajectory throughout life.6 The list of comorbidities associated with both excess weight and the metabolic consequences of obesity is extensive and encompasses chronic disease, as well as functional and psychosocial disability (Table 1).7 Furthermore, it is well established that increasing levels of obesity are associated with poor overall quality of life and increased morbidity and mortality.8
Prevention of obesity is failing for many reasons including: a poor understanding of the obesity determinants and evidence regarding what influences them, political inertia associated with a modern market economy, and philosophical views of personal responsibility versus regulation and whole of community involvement. Treatment strategies for obesity should ideally follow a chronic disease model of care with a patient centred focus and initial use of lifestyle and micro-environmental interventions, with escalation to more intensive interventions as dictated by the severity of disease and response to therapy.9,10 Treatment needs to be evidence based and focused on a broad range of health outcomes, not simply on weight. Excellent management of medical, psychological and physical co-morbidity are critical to engaging patients in weight loss interventions, improving function and quality-of-life, and reducing morbidity and mortality. It is also important to note that not all methods to treat obesity are equally effective. This article addresses first-line treatment with lifestyle modification in general practice and then focusses on appropriate use of more intensive treatments to support weight loss as well as identifying indications for referral to specialist weight management clinics.
General practitioners are often the first healthcare providers to identify overweight or obesity. Treatment should be individualised with careful consideration given to the severity of the problem and associated complications using the 5As approach for weight management: Ask and Assess, Advise, Assist and Arrange (Table 2).7
Establish a therapeutic relationship, communicate and provide care in a way that is person centred, culturally sensitive, non-directive and non-judgemental
It is important to assess the level of obesity by BMI, distribution of weight (waist circumference), and the extent of co-morbidity, in order to provide effective treatment and assess level of disease risk (Table 3).7,11,12 Patient engagement as a central agent in management is fundamental. The therapeutic partnership is critical in delivering long term health outcomes as for any other chronic disease.9
Obese class I
Obese class II
Obese class III
* Disease risk for type 2 diabetes, hypertension and cardiovascular disease Increased WC can also be a marker for increased risk even in persons of normal weight Reproduced from the Scottish Intercollegiate Guidelines Network (SIGN). Management of obesity. A national clinical guideline. Edinburgh: SIGN; Year. (SIGN publication no. 115). [cited 10 July 2013]. Available from URL: http://www.sign.ac.uk
Optimal management of obesity in time poor general practice requires a team care approach involving those specifically trained and experienced in obesity management. These may include dieticians, practice nurses, commercial weight management programs, exercise physiologists and psychologists.7 General practitioners are encouraged to identify, engage and regularly communicate with local weight management providers and to refer those with resistant severe complex obesity for specialised assessment and management recommendations.7 The evidence demonstrating the benefits of weight loss is well documented. Modest weight loss of 510% of starting weight can result in significant health benefits, with substantial weight loss offering even greater improvements in obesity related comorbidities. Weight loss for most isnt easy. Regulation of body weight is carefully controlled by a range of highly efficient homeostatic mechanisms that work to prevent weight loss rather than to protect against weight gain.1315 In addition, factors predisposing an obese patient to weight gain such as certain medications, smoking status, a patients weight history and readiness to change can significantly impact on weight loss success.7 These factors and mechanisms challenge successful weight loss and long term weight maintenance for the obese patient and should be taken into careful consideration, especially when planning interventions.
Despite these difficulties, lifestyle interventions remain the first line treatment for overweight and obesity. General practitioners should make patients aware of the health risks associated with increases in BMI and the benefits that can be derived from lifestyle change, even when independent of weight loss.7 The initial approach to weight loss and lifestyle change should include an emphasis on healthy eating with a subsequent reduction in energy intake, in line with the Australian Dietary Guidelines 2013.16 Increasing levels of physical activity and reductions in sedentary behaviour should also be encouraged.7,12,16,17 Psychological therapies to support behaviour change may also be of assistance.
Intensive interventions to potentiate weight loss may involve use of very low energy diets (VLEDs), pharmacotherapy and bariatric surgery. A summary of the weight loss effects of each weight management intervention is shown in Figure 1.
Figure 1. Average weight loss of subjects completing a minimum 1 year weight management intervention; based on review of 80 studies (N=26 455; 18 199 completers [69%])26
VLEDs (30 or BMI >27 with obesity related comorbidities. When used under the medical supervision of a GP and dietician, VLEDs are able to induce rapid weight loss and have been shown to achieve an average weight loss of 1820% with better sustained weight reduction.18 In addition to weight loss effects, the rapid weight loss offered by VLEDs has been shown to improve glycaemic control in patients with type 2 diabetes, improve blood pressure and reduce total cholesterol. VLEDs involve replacing all meals with a specific meal replacement formula (additional food can be carefully added) during the intensive early phase. These high protein-low carbohydrate diets induce fat burning and mild ketosis, which results in suppression of hunger and promotion of satiety. Treatment duration with a VLED is generally 812 weeks, however, safe year-long use under strict medical supervision has been reported.19 In addition, VLEDs are safe and effective when used to assist with long term weight maintenance in either an intermittent or on-demand fashion.20
VLEDs may not be suitable for use for all obese patients and it is important to consider the costs associated with purchasing suitable nutritionally complete meal replacements. VLEDs are contraindicated for use in pregnant or lactating women, infants, children, adolescents (under 18 years), elderly (over 65 years), patients with a history of psychological disturbances, alcohol misuse or drug abuse, in the presence of porphyria, recent myocardial infarction or unstable angina.7 Monitoring and support of patients on VLEDs is required for success (Table 4). Training on the use of VLEDs is available and should be sought by practices wanting to effectively utilise this intensive intervention with suitable overweight or obese patients.
Pharmacotherapy for the treatment of obesity should be considered for use as an adjunct to lifestyle intervention in patients with a BMI >30 or BMI >27 with obesity related comorbidities.21 Weight loss medications used in the treatment of obesity can act centrally to increase levels of satiety or act on the gastrointestinal tract to restrict nutrient absorption. Table 5 describes the pharmacological agents that may be used to treat obesity.7,17 Care, consideration and close monitoring is essential when prescribing these medications. The United States Food and Drug Administration (FDA) has recently approved two new medications: lorcaserin and phentermine-topiramate.
Without diabetes treated with atypical anti-psychotics: 4.8% body weight (CI: 8.01.6) following 1214 weeks treatment29
With diabetes:2.8 kg (CI: 3.42.3) following minimum 20 weeks treatment31
15 mg phentermine plus 92 mg topiramate: 10.2 kg (CI: 10.49.3) following 56 weeks treatment33
These medicines are not yet approved for use by the Therapeutic Goods Administration (TGA) in Australia.21 It is important to note that the safety and efficacy of co-administration of lorcaserin or phentermine-topiramate with other products for weight loss, and the effects of these medications on cardiovascular morbidity and mortality, have not yet been established.
Bariatric surgery should be considered for patients with a BMI >40 or with a BMI >35 with obesity related comorbidities.22 Bariatric surgery is the most effective available treatment for obesity in terms of achieving and maintaining substantial weight loss long term.23 The three most commonly performed procedures in Australia include laparoscopic adjustable gastric banding (LAGB), Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). We are now starting to learn about how alterations to the gastrointestinal tract, induced by bariatric surgery, reduce hunger, increase satiety and confer other metabolic benefits as well as sustained weight loss.24,25
To date, the long term safety of LAGB and RYGB has been documented, however evidence on long term safety is lacking for the SG. Each procedure is accompanied by its own advantages and disadvantages, and these need to be taken into consideration when assessing a patients suitability for surgery (Table 6). Current medical and psychological comorbidities, as well as ability to provide informed consent, will all influence a patients suitability for undergoing a particular procedure.7 Patients considering bariatric surgery should be made aware of the commitment to indefinite post-surgical care and long term monitoring from an experienced team.
Unfortunately, specialist weight assessment and management clinics for complex severe obesity are not broadly available, but with the emergence of new drugs, devices and surgical procedures, as well as ever increasing patient numbers; assessment by teams skilled in this area is becoming more necessary. Some major hospitals offer outpatient specialist weight management or metabolic clinics; however, access is often impeded by very long waiting lists. Medicare Locals may provide a forum for exploring delivery gaps in regional areas particularly. Specialised weight management services would provide advice to the GP similar to that expected from cardiac or diabetes referrals such as an evaluation of the patients, advice regarding the treatment options and a proposal for ongoing shared care. Severe obesity is a serious complex chronic disease and requires this level of expertise and support to optimise health outcomes.
General practitioners are in a key position to provide support, advocacy and coordinate management for obese patients. The use of intensive interventions should be considered and utilised within the general practice setting and, where indicated, complex obese patients should be referred to specialist weight assessment and management clinics.
Competing interests: John B Dixon is a board member of Nestle Australia and has received payment for consultancy from Allergan Inc and Bariatric Advantage. John B Dixon has received payments for lectures from iNova Pharmaceuticals and Merck Sharp & Dohme and for development of educational presentations from iNova Pharmaceuticals, and travel expenses from GI Dynamics.Provenance and peer review: Commissioned; externally peer reviewed.
Files on the website can be opened or downloaded and saved to your computer or device.
To open click on the link, your computer or device will try and open the file using compatible software.
To save the file right click or option-click the link and choose “Save As…”. Follow the prompts to chose a location.
PDF Most of the documents on the RACGP website are in Portable Document Format (PDF). These files will have “PDF” in brackets along with the filesize of the download. To open a PDF file you will need compatible software such as Adobe Reader. If you do not have it you can download Adobe Reader free of charge.
DOC Some documents on this site are in Microsoft Word format. These will have “DOC” in brackets along with the filesize of the download. To view these documents you will need software that can read Microsoft Word format. If you don’t have anything you can download the MS Word Viewer free of charge.
MP3 Most web browsers will play the MP3 audio within the browser
The rest is here:
RACGP – Obesity recommendations for management in …