The Top 10 Things Every Clinician Should Know About the 2013 Obesity Guidelines

In the United States, nearly 70% of adults are overweight or obese.¹  Excess adipose tissue increases the likelihood of developing sleep apnea, type 2 diabetes mellitus (T2DM), dyslipidemia, and hypertension. The rate of all-cause mortality in obese individuals is higher when compared to normal weight individuals.² Its imperative that we address body weight with all patients in all health care settings – but particularly in primary care settings.

The 2013 American Heart Association/American College of Cardiology/The Obesity Society Guideline for the Management of Overweight and Obesity in Adults were recently published.³ The guidelines, the first in 15 years, do not address every clinical question regarding the treatment of obesity but do provide details regarding which patients will benefit most from weight loss. Here are 10 important things every clinician should know:

1.     Obesity should be managed as a chronic disease. The overall goal in treating overweight and obesity in adults is to decrease cardiovascular disease (CVD) risk and ultimately minimize morbidity and mortality. Every patient should be evaluated for CVD risk factors to determine the need for weight loss therapy. If patients meet criteria for weight loss treatment, both the patient and health care provider discuss and agree upon treatment options and weight loss goals. Once the intervention is implemented, patients should be followed on a regular basis to assess progress. For example, patients may be seen 1-2 times per month for weight evaluation and every 3-6 months for evaluation of CVD risks. Any patient seen in a disease management clinic for diabetes or hypertension would benefit from this strategy.

2.     All patients should have their weight assessed annually. Every patient should have their height, weight, and calculated body mass index (BMI) measured at least yearly.  Patients with a BMI greater than 25 kg/m² should be assessed for CVD risk factors and obesity-related complications. The assessment should include a complete medical history, physical exam, blood pressure, fasting glucose and lipid panels. Patients with at least one CVD risk factor or obesity-related complications are candidates for weight loss therapy.

3.     Being overweight or obese is bad for your health.  Patients with a high BMI are increased risk of type 2 diabetes (T2DM), coronary heart disease, stroke, and all-cause mortality. Current BMI cutpoints are valid and serve as good indicators for the risk of health complications.  Although there are insufficient data to support specific cutpoints based on waist circumference, we also know that health risks increase with increased waist circumference.

4.     The weight loss goal should be 5-10% of body weight in the first 6 months.  While weight loss as low as 3-5% of initial body weight might be “clinically meaningful,” the effects are small. For example, patients with T2DM with a 2-5% weight loss over 1-4 years have a decrease in HbA1c of 0.2-0.3%.  Greater percentage weight loss lead to improvements in low density lipoproteins (LDL) and high density lipoproteins (HDL) cholesterol, lower blood pressure, and a decreased need for medications to control diabetes, dyslipidemias, and hypertension. Although ANY weight loss is beneficial, the benefits increase as the percent increases.

5.     Weight loss = calories expended > calories consumed.  It’s basic math. There are three approaches to designing dietary interventions to achieve weight loss. The first is to prescribe a daily caloric intake that is less than what most people required. For women, that’s 1,200-1,500 kcal/day and for men it’s 1,500-1,800 kcal/day (adjusted for weight and physical activity).  A second approach is to calculate the caloric requirements and reduce it by 500-750 kcal per day or 30% of total.⁴  Lastly, instead of setting specific caloric intake goals, a specific food or group of foods (e.g., high-fat foods, high-carbohydrate foods) can be eliminated which then results in lower caloric intake.

6.     There are many ways to diet and most of them work.  Nearly all diets that have been systematically studied appear to be effective, so long as overall caloric consumption is decreased. For example, a high protein diet (25% total caloric intake) had the same effect in weight loss as a normal protein diet (15% total caloric intake).  The guidelines list a variety of diets to select from when working with patients.  The “best” diet is the one that takes into consideration the patient’s personal preferences, available food, and financial situation. Diets that have proven benefits include the Dietary Approaches to Stop Hypertension (DASH) diet, Therapeutic Lifestyle Changes (TLC) diet, and the Mediterranean diet. Although very low calorie diets (less than 800 kcal/day) lead to weight loss, they require close medical supervision. Patients should be cautioned about starting “fad” diets that haven’t been studied.

7.     A weight loss program should include a calorie restricted diet, physical activity, behavioral therapy, and regular face-to-face visits with the intervention team.  Engaging in physical activity most days totalling at least 150 minutes of aerobic exercise every week will augment weight loss.  A structured behavioral program emphasizing self-monitoring of food intake, weight, and physical activity will also help. Programs that include individual or group visits of moderate (e.g., 1-2 times per month) or high (e.g., >14 sessions) intensity for at least 6 months do the best. Weight regain after the initial loss is common and lifestyle changes must be maintained to key the weight off. For weight maintenance, physical activity requirements are higher, 200-300 minutes/week. Face-to-face or telephone follow-up one to two times per month for up to 2.5 years may be needed to maintain weight loss.

8.     Comprehensive lifestyle modification results in more weight loss than diet alone. When the three components (calorie restriction, physical activity, and behavior therapy) are offered simultaneously, a mean 8 kg weight loss at 6 months has been reported. Those who participate in a comprehensive weight loss program for up to 2 years often maintain a loss of more than 5% of their initial body weight.

9.     Drugs and surgery may be helpful for some. Patients that do not reach weight loss goals and are motivated to lose weight may benefit from pharmacologic therapy or bariatric surgery as an adjunct to lifestyle modifications.  As with any medication, the risks and benefits must be weighed in each patient taking into consideration comorbid conditions and safety profile.^5,6 A 20-35% weight reduction is commonly achieved with bariatric surgery.  This degree of weight loss often leads to lower fasting glucose and serum insulin concentratons, a lower incidence of type 2 diabetes, improved blood pressure and lipid profile. Bariatric surgery results vary by type of surgery.

10.  Don’t stop treatment after the weight loss goal is achieved!  As with any chronic disease, once a therapeutic goal is met, continued treatment and monitoring is necessary to maintain efficacy. Weight regain is common with any weight loss strategy including diet, exercise, pharmacotherapy, and bariatric surgery. Equally important is a continued re-evaluation of CVD risks to evaluate the need for intensified or adjunctive therapy for weight loss or other conditions.                      

Final thoughts …

Although the guidelines provide extensive data to support nonpharmacologic recommendations, they have minimal information regarding medication management.  At the time when the 2013 guideline was developed, only orlistat was FDA approved for long-term weight loss.  Since that time, locaserin and a phentermine /topiramate combination product have been approved.   Several older agents are available for short-term weight loss (i.e., phentermine benzphetamine,  diethylpropion, phendimetrazine) and some drugs are routinely used off-label (e.g., metformin, exenatide, liraglutide). Numerous herbal products and supplements are marketed for weight loss.  The American Society of Bariatric Physicians (ASBP) developed an Obesity Algorithm that provides far more detailed guidance about the use of pharmacotherapy strategies.  You can find the ASBP treatment algorithm and position statements on their website.⁷

Also neglected in 2013 Obesity Guidelines was cognitive behavioral therapy (CBT). The guidelines focus on behavioral activities to monitor weight loss and food intake, but do not discuss identifying other causes of weight gain such as stress. Identifying and treating the underlying psychological reasons for weight gain are also important. The National Weight Control Registry (NWCR) has a research resource webpage with various behavioral interventions including many publications on CBT.

Lastly, the role of the pharmacist as part of the interprofessional team is not mentioned. Admittedly, other health care professionals – dietician, psychologist, exercise specialist, and health counselors – are only briefly discussed.  Pharmacists can and do play an important role by assessing each patient’s weight and CVD risk factor, gauging readiness for change, applying motivational interviewing techniques, monitoring progress, and recommending adjunctive treatment when appropriate.  Research regarding the impact of pharmacists involved in comprehensive weight management programs are sorely needed.