TREAT: Lifestyle therapy, pharmacotherapy and bariatric surgery

The principal goals in obesity management are to prevent complications by trying to keep the patient metabolically healthy (if possible), to prevent or to treat complications if they are already present, to reduce stigmatisation and to restore wellbeing, positive body image and self-esteem.1

There are multiple guidelines available for obesity management, which include recommendations on the below three categories of intervention. Each category can offer different levels of weight loss:2

  • Lifestyle therapy – In various studies, lifestyle modifications, including low calorie diets, have shown to reduce weight by between 5-8%.3 However, these interventions are not always sufficient to maintain weight loss4,5
  • Pharmacotherapy – Pharmacological options have different mode of actions and across the different classes they can provide 3-9% weight loss6
  • Bariatric surgery – There are a number of different types of weight loss surgery, with each option providing different weight loss efficacies ranging between 7-38%7,8

Lifestyle therapy modifications are the cornerstone of all obesity treatment and should be the first line intervention in all individuals with a BMI ≥25 kg/m2. Importantly, lifestyle modifications must be included as part of any weight loss intervention.1 However, these interventions are not always sufficient to maintain weight loss.4,5

For more guidance on Lifestyle Therapy Modifications see page 91: AACE/ACE Guidelines 2016.

Pharmacological treatment should be considered as part of a comprehensive strategy of disease management.9 Pharmacotherapy can help patients to maintain compliance, reduce obesity-related health risks and improve quality of life. It can also help to prevent the development of obesity complications (e.g. cardiovascular diseases and type 2 diabetes).9 Pharmacotherapy can be considered in patients with a BMI of ≥30 kg/m2, or ≥27 kg/m2 with obesity-related complications if lifestyle therapy does not provide sufficient clinical benefit for individuals.2

Anti-obesity medications can act directly on the central nervous system, inducing weight loss by reducing appetite, or act peripherally and induce weight loss by interfering with fat absorption from the gastrointestinal tract.10

There is also a role for pharmacotherapy post-bariatric surgery. 10-20% of all patients will regain the weight lost following bariatric surgery.11 In these cases, pharmacotherapy is recommended for patients with a partial weight loss response or who have experienced weight regain after bariatric surgery.12

For more guidance on Pharmacological Treatment Options, see page 102: AACE/ACE Guidelines 2016.

Bariatric surgery is the third-line and currently most efficient intervention for obesity management. In patients with a BMI ≥40 kg/m2, more than 45kg overweight or with a BMI ≥35 kg/m2 and at least one or more obesity-related complication.13 It is intended to manage excess weight that is severe and/or associated with severe weight-related complications.2,13

For more guidance on Bariatric Surgery, see page 131: AACE/ACE Guidelines 2016.

Reprinted from Endocrine Practice, Vol 22, Garvey et al., "Treatment Goals Based on Diagnosis in the Medical Management of Patients with Obesity", 1-203, Copyright (2016), with permission from the American Association of Clinical Endocrinologists. Available at https://journals.aace/doi/10.4158/EP161365.GL

References

1.     Durrer Schutz D, Busetto L, Dicker D, et al. European Practical and Patient-Centred Guidelines for Adult Obesity Management in Primary Care. Obes Facts. 2019;12:40–66.

2.     Garvey WT, Mechanick JI, 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):1–203.

3.     Johns D, Hartmann-Boyce J, Jebb SA, et al. Diet or Exercise Interventions vs Combined Behavioral Weight Management Programs: A Systematic Review and Meta-Analysis of Direct Comparisons. J Acad Nutr Diet. 2014;114:1557–1568.

4.     Mann T, Tomiyama AJ, Westling E, et al. Medicare's search for effective obesity treatments: diets are not the answer. Am Psychol. 2007;62:220–233.

5.     Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. Circulation. 2014;129:S102–138.

6.     Kushner R. Weight Loss Strategies for Treatment of Obesity: Lifestyle Management and Pharmacotherapy. Prog Cardiovasc Dis. 2018;61:246­–252.

7.     Courcoulas A, Christian N, Belle S, et al. Weight change and health outcomes at 3 years after bariatric surgery among individuals with severe obesity. JAMA. 2013;310:2416–25.

8.     Berry M, Urrutia, Lamoza P, et al. Sleeve Gastrectomy Outcomes in Patients with BMI Between 30 and 35–3 Years of Follow-Up. Obes Surg. 2018;28:649–55.

9.     Yumuk V, Tsigos C, Fried M, et al. European Guidelines for Obesity Management in Adults. Obesity Facts. 2015;8:402–424.

10.  Li M and Cheung BM. Pharmacotherapy for obesity. Br J Clin Pharmacol. 2009;68:804–810.

11.  Rye P, Modi R, Cawsey S, et al. Efficacy of high-dose liraglutide as an adjunct for weight loss in patients with prior bariatric surgery. Obesity Surgery. 2018;28:3553–3558.

12.  Busetto L, Dicker D, Azran C, et al. Practical Recommendations of the Obesity Management Task Force of the European Association for the Study of Obesity for the Post-Bariatric Surgery Medical Management. Obesity Facts. 2017;10:597–632.

13. American Society for Metabolic and Bariatric Surgery (ASMBS) website. Bariatric surgery procedures. Available at: https://asmbs.org/patients/bariatric-surgery-procedures. Last accessed: October 2020.

HQ20OB00140, Approval date: December 2020

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