The global epidemic of overweight and obesity is linked to negative health outcomes, including type 2 diabetes, hypertension, cardiovascular disease, and other comorbidities. While lifestyle interventions such as diet and exercise are always the first approach, they have been unsuccessful in a large number of people, leading obesity experts to call for more aggressive treatment with bariatric surgery and new weight loss medications. We asked practicing clinicians how they have responded to that message.
The Medscape Obesity Treatment Survey was completed by 1414 US medical professionals between December 17, 2015 and January 19, 2016. The sample comprised 265 family medicine physicians (19%), 230 internal medicine physicians (16%), 136 endocrinologists (10%), 281 ob/gyns (20%), 250 nurse practitioners (18%), and 252 physician assistants (18%). All were practicing medicine in the United States and treating patients who are overweight (defined as BMI between 27 and 29.9) or obese (BMI equal to or greater than 30).
As has been reported frequently in the literature, practitioners also reported a significant relationship between their overweight and obese patients and related comorbidities, including type 2 diabetes, hypertension, and lipid disorders. Again, the strongest association was seen with endocrinologists' patients, some of whom probably were referred because of their disease complexity.
Less than two thirds of respondents—59%—said they prescribe weight loss medications to any of their patients who are obese or overweight with comorbid conditions. That means that 41% of medical practitioners never offer these drugs to patients who might stand to benefit from them.
Endocrinologists are much more likely to prescribe weight loss medications, with 85% of respondents saying they do offer these drugs to some of their patients. Ob/gyns are the least likely to prescribe these agents, with 60% saying they never prescribe them. Among primary care providers, physicians are more likely to prescribe these drugs than are nurse practitioners or physician assistants.
Healthcare providers who say they are willing to prescribe weight loss medications—59% of the original survey sample—only write such prescriptions for a fraction of their obese and overweight patients. The preferred management approach across all specialties and professions is still diet and exercise, while prescriptions are written for 24%-30% of those patients.
The success rate of overweight/obese patients fully meeting their weight loss goals is typically about 20% or lower. About half of these patients do not meet their weight goals, while the remaining patients are only able to achieve part of their goals. Although these rates are discouraging to many clinicians, the other part of the story is that half of patients either partially or fully meet their goals.
Most respondents who prescribe weight loss drugs said they initiate pharmacologic treatment only after diet and exercise fail to achieve desired results. Only 1 in 5 said they will do so at the request of the patient (only 7% among endocrinologists), while a similar proportion will start prescription treatment if a patient develops a new comorbid condition or surpasses a predetermined BMI threshold despite recommended lifestyle changes.
When asked to name the biggest problem in managing obesity, respondents cited patients' lack of willingness to follow their weight loss plan. A lack of effective treatments is the next biggest challenge, followed by patients' ability to pay for treatments.
According to clinical guidelines, bariatric surgery may be appropriate in obese patients with type 2 diabetes who cannot be managed adequately with medication. In this survey, prescribers of weight loss medications said they referred about 13% of their obese patients for bariatric surgery. That figure was nearly the same across specialties and professions.
Generic phentermine and bupropion are currently prescribed more than other weight loss agents. The newest option on the market, Saxenda® (liraglutide), is being prescribed by almost one third of prescribers and was identified by 76% as a drug they intended to prescribe more in the next 6 months. Orlistat is the only drug available over the counter, sold as alli®.
Generic phentermine is used by the largest proportion of prescribers, with the exception of endocrinologists, who have a greater propensity to prescribe Qsymia® (phentermine-topiramate) or Saxenda. The latter drug is used in a lower dose (liraglutide formulated as Victoza®) to treat type 2 diabetes, so endocrinologists are probably more familiar with it.
Healthcare providers who said they never prescribe weight loss medications to obese and overweight patients explained their reasons for that stance. More than two thirds expressed a preference for focusing on nonpharmaceutical approaches such as diet and exercise. Other reasons included safety and side-effect concerns. More than one third said they don't know enough about available medications.
Respondents who said they do not prescribe weight loss medications were asked what might persuade them to change that position. They clearly are looking for solid information to guide their prescribing, citing clinical trials showing a drug to be safe and effective; prescribing guidelines; and information on managing risk factors and side effects.
Obesity is a medical condition associated with serious comorbidities requiring appropriate medical treatment. Despite the arrival of several new medications to treat obesity, healthcare providers are prescribing mostly older drugs and to only a fraction of eligible patients, probably because they are not confident that available medications are effective, safe, and affordable.