What is new in the medical management of obesity?: Dr. SK Wangnoo & Dr. P Kiran Kumar
M3 India Newsdesk Dec 06, 2020
This Sunday, we bring to you from our archives, an article by Dr. SK Wangnoo and Dr. P Kiran Kumar, as part of an exclusive Endocrinology series. They turn the spotlight on obesity and new management strategies, both pharmacological and non-pharmacological.
Management begins with evaluation of obesity for both endogenous, predisposing factors like genetic, epigenetic, familial along with endocrine causes and exogenous factors like bad lifestyle, eating behaviours, junk food, physical inactivity, smoking, depression, and hypersomnia as causes of obesity.
Obesity is a growing problem nowadays in developing nations like India. According to the ICMR-INDIAB study (2015), prevalence rate of obesity and central obesity varies from 11.8 to 31.3% and 16.9 to 36.3% respectively. As obesity is associated with many comorbid conditions like diabetes, metabolic syndrome, coronary heart disease, non-alcoholic fatty liver disease, management of obesity has acquired an important role in treating such diseases.
The principal goals in the management of obesity are to prevent or treat comorbidities, fight against stigmatisation, positive body image, and self-esteem along with weight loss which forms the crux of the management. The treatment is individualised to the patient based on his following comorbid conditions and the following table guides on how to set target goals for patients.
| Condition | Target weight loss | Improved symptoms |
| Metabolic syndrome | 10 | Prevent diabetes |
| T2DM | 5-15 | Reduce glycated Hb |
| Dyslipidaemia | 5-15 | Low triglyceride |
| Hypertension | 5-15 | Low BP |
| NAFLD | 10-40 | Reduce inflammation |
| PCOS | 5-15 | Ovulation |
| Sleep apnoea | 7-11 | Decrease apnea |
| Asthma | 7-8 | Improve FEV1 |
| GERD | 10 or more | Reduce symptoms |
Medical management
The medical management can be broadly divided into lifestyle changes which involve diet and physical activity, psychological therapy, pharmacotherapy. BMI and waist circumference will guide the therapy to be individualised to the patient as follows:
| BMI |
Waist circumference Men <94 cm; Women <80 cm |
Waist circumference Men >94 cm; Women >80 cm |
Comorbidities |
| 25 to 29.9 | L | L | L+-D |
| 30 to 34.9 | L | L+-D | L+-D+-S |
| 35 to 39.9 | L+-D | L+-D | L+-D+-S |
| More than 40 | L+-D+-S | L+-D+-S | L+-D+-S |
L- Lifestyle intervention, D- Drugs, S- Surgery
Lifestyle changes
The goal should focus on lifestyle changes, body composition, decreasing waist circumference than on weight loss per se. Patient education is an important component in obesity treatment. It improves the therapeutic efficacy and patient motivation to change in the long term.
Nutrition and eating behaviour
Most of the obese patients no longer recognise physiological sensation of hunger and satiety. Instead, they eat because it is time to eat food as an emotional compensation. So it is advised that the patient should be encouraged to eat food after they feel the sensation of hunger though waiting for hunger for too long may be counterproductive in the form of consumption of more calories.
A balanced diet should be prescribed. Mediterranean diet which has a high content of vegetables, fruits, legumes, foods rich in omega 3 fatty acids should be promoted.
Physical activity
About 300 minutes/week of endurance activity at moderate intensity or 150 minutes at higher intensity mobilises visceral fat and it can be divided into multiple shorter segments of 10 minutes minimum so that it has an impact on the metabolism. Walking remains the best over any sporting activity due to compliance. Asking patients to wear a pedometer or an accelerometer to monitor total accumulation of steps as part of activities of daily living is a useful strategy. Step counts are highly correlated with activity level.
ADA advises to plan more than 16 sessions of high intensity in 6 months and to achieve 500-700 kcal/day energy deficit. To achieve weight loss of more than 5%, short term (in 3 months) interventions that use very low calorie diets (less than 800 kcal/day) and total meal replacement may be prescribed in selected patients.
Psychological therapy
Cognitive behavioural therapy can be used to reinforce new dietary and physical activity behaviours. It strongly influences the success of treatment. Strategies include self-monitoring techniques (journaling, weighing) stress management, stimulus control (using smaller plates, not eating in front of the television or in the car).
The patient should be advised to keep a record of anticipated behavioural changes which can be reviewed frequently by the physician. Eating compulsions, stressful conditions, emotional relationship with food should be discussed with the patient and addressed. Psychotherapy is important in treating depression and anxiety. Body image, self-esteem, and self-confidence can be improved by psychotherapy.
Pharmacotherapy
It complements the lifestyle and behavioural therapy. They are indicated in patients with BMI more than 30 or 27 with comorbidities. The goal of weight loss on anti-obesity drugs must be 5% in non-diabetic and 3% in diabetic patients within 3 months of therapy. If the weight is not achieved as per the above goals, the drugs are withheld.
The most common drugs available nowadays are Orlistat, Liraglutide, Bupropion-Naltrexone sustained release and Lorcasein, Phentermaine Topiramate extende- release used for long-term management and Phentermine used for short-term management.
Liraglutide
It is a glucagon-like peptide 1 analogue secreted by the ileum in response to a meal. It increases satiety through activating GLP-1 receptors in arcuate nucleus in hypothalamus and increases insulin in response to a meal. It is injectable at a dose of 3 mg per day and is used to treat diabetes where as the dose is very less in diabetic management.
It should be used with caution in cholelithiasis patients. Black box warning conditions include thyroid C cell tumors and acute pancreatitis. It should be discontinued if at least 4 percent weight loss is not observed.
Orlistat
It is a potent and selective inhibitor of pancreatic lipase and reduces intestinal absorption of fat. Available at 60 mg and 120 mg, it can be given before a fatty meal. Fatty diarrhoea with faecal fat loss and gastrointestinal symptoms are common. Multivitamin supplements are added in view of decreased absorption of fat-soluble vitamins like A,D,E, and K and care needs to be taken, as absorption could be decreased for medications like Cyclosporine, thyroid hormones, anticonvulsants.
Cholelithiasis and nephrolithiasis are other side effects along with rare incidence of severe liver injury. Maximum weight loss of 5 to 10 percent is usually observed and it is available as an OTC (over-the-counter) drug.
Bupropion/Naltrexone
These are two centrally-acting drugs. Bupropion is a non-selective inhibitor of dopamine and norepinephrine transporters and used as an anti-depressive drug and to stop habitual smoking. Naltrexone is an opioid receptor antagonist used to treat alcohol and opioid dependence. The combination drugs act in consort: Bupropion stimulates secretion of alpha MSH from POMC whereas Naltrexone blocks the feedback inhibitory effects of opioid receptors activated by the beta endorphin released in the hypothalamus thus allowing the inhibitory effects of MSH to reduce food intake.
The recommended doe is 16/180 mg a day with expected weight loss of 5% in three months. Common adverse events include nausea, constipation, headache, vomiting, dizziness, diarrhoea, insomnia, and dry mouth are seen. These are contraindicated in uncontrolled hypertension, seizure disorders, chronic opioid therapy and acute angle closure glaucoma.
Lorcaserin
It is a selective 5HT2c receptor agonist and acts through POMC neurons. 10 mg twice a day is advised. It should be discontinued if the patient has not lost at least 5% of body weight. The most common adverse events experienced are headache, dizziness, and nausea. Modest statistical improvements are seen in cardiovascular and metabolic outcome measurements.
The serious side effect valvulopathy which is observed with other serotonergic drugs (due to action on 5HT2b) is not seen with Lorcaserin as the action is through a different receptor.
Note: Recently, the US FDA has requested the withdrawal of the drug Lorcaserin from the market due to its mitogenic potential.
Phentermine/Topiramate
The combination drug contains a catecholamine releaser and anti-convulsant. The mechanism of action is uncertain but it is thought to be mediated by modulation of GABA receptors, inhibition of carbonic anhydrase, and glutamate antagonism.
The most common adverse events seen are paresthesia, dry mouth, constipation, insomnia. Women of child-bearing age should avoid these drugs because of increased risk of congenital foetal oral cleft formation because of Topiramate.
Medical devices
Gastric balloon devices have been recently added to the weigh loss armamentarium. The two FDA approved devises are RESHAPE which has two silicone balloons attached to a central silicone shaft and ORBERA, a single balloon device placed in the stomach endoscopically. Both systems are placed in the stomach for 6 months use only in patients with BMI of 30 to 40 kg/m2 with adverse events like nausea, vomiting and abdominal pain.
Primary prevention of obesity is essential as treatment of obesity is complex, difficult, and costly. The longer a patient suffers from obesity, the more difficult it is to treat. The management approach should be patient-centred with a multidisciplinary team comprising of a nutritionist, psychologist, physical trainers, and clinicians.
This article was originally published on February 17, 2020.
Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.
The writer, Dr. Subhash Kumar Wangnoo is a Senior Consultant Endocrinologist and Diabetologist at Apollo Centre for Obesity, Diabetes and Endocrinology (ACODE) in New Delhi.
The write, Dr. P. Kiran Kumar is an Endocrine Fellow at Apollo Centre for Obesity, Diabetes and Endocrinology (ACODE) in New Delhi.
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