Obesity Treatment Requires More Than Lifestyle Modification

Miriam E Tucker

February 13, 2015

Obesity is a complex medical problem that requires a multimodal approach beyond merely advising patients to go on a diet and exercise, four obesity experts say in a new opinion piece.

"When treating obesity, mere recommendations for lifestyle change are most likely insufficient," the lead author, psychiatrist Christopher N Ochner, PhD, from the Icahn School of Medicine at Mount Sinai, New York, told Medscape Medical News.

Instead, he said, "implement a multimodal strategy — as opposed to just insisting they diet — which may include the use of medications or vagal-nerve blockade or surgery as appropriate."

The paper also advises clinicians to formulate lifestyle-based strategies for prevention of obesity among people who are already overweight. "Don't wait until patients have obesity in order to address proper nutrition and exercise," Dr Ochner advised.

The authors also recommend the creation of strategies for the maintenance of weight loss, "which is far more difficult than weight loss."

Also important, Dr Ochner said, "Don't blame patients who are not able to maintain significant weight losses achieved via diet and exercise....Unfortunately, many of us still assume that the individual with obesity should have made it successful and, therefore, lacks adequate willpower. This view is incorrect and potentially damaging."

Dr Ochner and coauthors — internist Adam G Tsai, MD, from the University of Colorado, Denver; chair of the American Board of Obesity Medicine Robert F Kushner, MD, from the Center for Lifestyle Medicine, Chicago, Illinois; and Thomas A Wadden, PhD, from the Center for Weight and Eating Disorders at the University of Pennsylvania, Philadelphia — express their opinions in a comment published online February 12, 2015 in Lancet Diabetes & Endocrinology.

Asked for his thoughts on the piece, Craig Primack, MD, from the Scottsdale Weight Loss Center, Arizona, said he agrees with many of the conclusions.

"Since the beginning of time with weight, people have been saying you have to do more diet and exercise, and we're not getting anywhere. People take it as a personal failing.…A lot of times we start diets in January, but by February we're off. This is a hormonal problem. Some of the weight-loss medications can 'reset' the hypothalamus."

But chair of the United Kingdom's National Obesity Forum, Dr David Haslam, from Luton & Dunstable Hospital, Bedford, stressed, "Nutritional changes and increases in physical activity underpin each and every weight-loss attempt.

"Medications to reduce weight are a bonus but only work effectively in the context of sound nutrition and activity advice, and weight loss can be maintained only in that context," he added.

"More Biologically Based Interventions Are Likely to Be Needed"

The paper represents the opinions of the authors and not of any organization — although all four are members of the US Obesity Society.

The idea for the piece came from some members of that society's public affairs committee, who expressed concern that many clinicians still believe " 'just eat less and move more' should be sufficient to treat chronic obesity, and it's the patient's fault if it is not," Dr Ochner told Medscape Medical News.

He and his coauthors explain that caloric restriction triggers biological adaptations in the human body that were originally intended to prevent starvation but that now undermine the long-term effectiveness of lifestyle modification by promoting excess calorie consumption and fat storage.

"Because sustained obesity is in large part a biologically mediated disease, more biologically based interventions are likely to be needed to counter the compensatory adaptations that maintain an individual's highest lifetime body weight," they write.

Antiobesity drugs, bariatric surgery, and the newly approved intra-abdominal vagal-nerve–blockade device can all accomplish that to varying degrees, they note.

The authors provide tips for obesity prevention among overweight individuals and for the treatment of obesity. For prevention, they advise that clinicians address the importance of proper nutrition and physical activity, and for those who have lost weight, ensure they provide resources for weight-loss maintenance.

With regard to treatment, they recommend the implementation of a multifaceted individualized strategy, potentially including "highly structured diets, a high-protein diet, increases in physical activity, drugs, and bariatric surgery," noting that bariatric surgery is "the only effective long-term treatment for obesity available" and should be "recommended when appropriate."

They also advise, "Inform patients that powerful biological mechanisms encourage weight regain and use of biologically based treatments [such as] drugs is not a reflection of weak will."

Clinical Approach

Dr Primack told Medscape Medical News that he offers weight-loss medications to patients at the outset along with lifestyle counseling, although he doesn't push the drugs if the patient doesn't want to take them. However, "If they struggle at all, or have slow weight loss — and the more diets they've already been on — it becomes a stronger and stronger recommendation."

Dr Haslam's emphasis differs slightly. "Just as blood-pressure–lowering drugs reduce the burden of stroke, weight-loss drugs do likewise with regard to stroke, diabetes, sleep apnea, fatty liver, cardiovascular disease, and much more. So in my opinion, they should be promoted, but only in the context of good behavioral advice. My personal practice is to ensure lifestyle changes first but not to be shy of the (limited) weight-loss pharmacopoeia we have in the UK," he said.

Dr Ochner acknowledged, "The science is not precise enough yet to be able to tell exactly which patients will respond best to which of these treatments. This is something that is being explored but has a long way to go.…We have only limited initial data on the vagal-blockage intervention, but the weight loss appears to be significantly less than that achieved through modern bariatric techniques."

Moreover, he told Medscape Medical News, "reimbursement factors in quite heavily regardless of whether we feel it should. Those most in need generally cannot afford validated treatments out of pocket. We are desperately fighting for more third-party payers to reimburse for obesity treatments [in the United States].

"Hopefully, this piece will help spread the message that we are dealing with a disease that is in large part biological and deserves to have the same reimbursement policies as other diseases," he concluded.

Dr Ochner has received grants from Accera and nonfinancial support from ProBar. Dr Tsai has received nonfinancial support from Nutrisystem. Dr Kushner reports personal fees from Vivus, Takeda, and Novo Nordisk and grants from Weight Watchers. Dr Wadden reports personal fees from Nutrisystem, Orexigen Pharmaceutical, Novo Nordisk, Boehringer Ingelheim, Guilford Press, and Shire Pharmaceutical and grants from Novo Nordisk, Weight Watchers, and NutriSystem. Dr Primack is a speaker for Vivus, Novo Nordisk, Eisai and Takeda. Dr Haslam has no relevant financial disclosures.

Lancet Diabetes & Endocrinol. Published online February 12, 2015. Abstract

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