Evidence-Based Approaches in the Management of Patients With Obesity
In this video, Angela Golden, DNP, FNP-C, discusses evidence-based approaches in the management of patients with obesity, including the use of medications, surgery, and controversies.
TRANSCRIPTION:
Dr Angela Golden: Hi, I am Dr Angela Golden. I'm a family nurse practitioner and I own NPO Obesity Treatment Clinic in Flagstaff, Arizona.
Consultant360: How prevalent is the chronic disease of obesity in the United States?
Dr Golden: The chronic disease of obesity is definitely rising in the US. Right now, the best estimate is around 38% of the adult population has a BMI of 30 or greater. And then, another 30% probably are what we would consider pre-obese or in what the vernacular is overweight category with a BMI of 27 to 30. Really, if they were to have diabetes, hypertension, hyperlipidemia, they actually, by the American Association of Clinical Endocrinologist criteria, would actually have Stage One or Stage Two obesity, even with that lower BMI. Again, I just want to do one quick caveat on that. BMI isn't a way to diagnose obesity but it's how we do it on a population basis, not an individual basis, and it's also a population basis based on White Americans. When we start to get into race and ethnicity, BMI actually lowers when we start to talk about obesity on a population basis.
C360: What are some evidence-based approaches to managing patients with obesity in a primary care setting?
Dr Golden: I think managing obesity from an evidence-based perspective, it's pretty much the same across all the specialties. We're starting to see obesity being managed in many specialties, including women's health, orthopedics, cardiology, but with that many people we talked about the epidemiology, with that many people it's going to have to be treated in primary care. To do that, our primary care colleagues, NPs, PAs, physicians, really need to understand that overeating doesn't cause obesity, obesity causes overeating. That said, we know that having a good eating plan, increasing activity, and behavioral interventions are a basis for treatment just as they are for hypertension, hyperlipidemia, diabetes, all of our cardio-metabolic disorders.
Obesity's not standing out here alone with a need for better eating, more activity, and behavioral interventions as the basis for treatment, all of our cardiometabolics there. Obesity also has a core of medications that can treat the pathophysiology of the disease of obesity and we have surgery that can impact, and the surgery is metabolic bariatric surgery. It's not like the old days where people thought it was just because they made the stomach smaller, we know it's a metabolic surgery, as well. That entails the evidence-based treatment, changing eating, getting a good activity plan, using behavioral interventions to keep those two on track, and then supporting that with medications that treat the pathophysiology of the disease as well as surgery that helps treat the pathophysiology of the disease. All of that comes together to create the evidence-based plan.
C360: What are some real-life examples of the integration of evidence-based approaches in managing patients with obesity?
Dr Golden: I think the easiest way to understand how to treat obesity is from just a case-based scenario. A patient comes in for a well-woman visit in a primary care clinic and the MA does a height, a weight, and you see that the BMI is 32 or 33. That's the screening tool that helps us say, "Okay, we need to find out does this patient actually have obesity? Maybe at that point in your practice the next step is to do a waist measurement so that you can see if the patient has that visceral obesity, that adiposity that's around the middle, that's where the most dangerous fat accumulation can come from. Sure enough, it's a female obviously so we look for a waist circumference greater than 35 inches and hers is 38 so now we've got a diagnosis of obesity. We start to look for obesity-related complications.
It's not the number on the scale, it's not the cosmetics of excess adipose tissue, it's the pathophysiology of what that adipose tissue does to the overall health. Once we know what is it we're trying to prevent or what's already occurred that we're trying to reverse, how is that adiposopathy impacting the patient's quality of life and/or health, and then we start to treat from there. The next step is to ask the patient's permission to talk about their weight. Many of our patients have faced so much bias and stigma in the healthcare environment that this is a disease that it's really important to ask the patient's permission to talk to them, let them know that you have tools to help them with it. And then, once you have their permission, tell them that you would like to make an appointment just to talk about the treatment plan that can be put into place for obesity because it's hard to do that during a well-woman visit or if they're there for follow-up for pre-diabetes or metabolic syndrome or whatever they came into the practice for.
When you get that visit to talk to them about it, you want to do a good history. What does their eating look like? What does their activity look like? Again, you need to do this from a place that's not blame and shame. You're not saying that their obesity was caused by their eating, you need to be able to explain to them that the pathophysiology of obesity creates this endocrine dysfunction that causes higher levels of hunger and less ability to hear satiety, so that they can start to understand how this disease has occurred but that these behavioral interventions can help treat it. And then, start looking at what might be an appropriate medication for them. I don't wait six months of interventions with behavior to see if that worked, just like I don't with diabetes or hyperlipidemia or hypertension. I get in there and find out most patients with obesity have already tried seven to eight times to lose and keep that weight off so there's no reason to give that three to six months.
Let's get in there and find out what the problem is and start matching them to an appropriate anti-obesity medication. Or, the situation I gave you was a patient with a BMI of 32, but if that BMI is greater than 35 and they have obesity-related complications, of which there are 236, then we might want to be considering a referral for bariatric and metabolic surgery. All of that can happen inside a primary care visit. Many people think, "Oh, I don't have that kind of time," but our Canadian colleagues have demonstrated that obesity can be treated in primary care in about a 5-to 10-minute portion of a primary care visit and done very effectively. Their research has been beautifully done to show us that we can do this. We just do it in smaller pieces than what I might do in my obesity practice where that's the primary thing I'm seeing the patient for. I think that's just an example of how I'd go about moving forward in treating the patient.
C360: What are your views on the use of diabetes medications in the management of patients with obesity? Are there benefits? Pitfalls?
Dr Golden: People ask a lot about, probably because of social media, about diabetes medications being used to treat obesity, and the one that's being talked about the most right now is semaglutide. Well, semaglutide is a molecule that has been used to treat diabetes but it has also been used to treat obesity, it's just a different dose. For me, it's hard to say that I'm using a diabetes medication to treat obesity, it is the same exact molecule. I might be using a lower dose to treat obesity, which people then say, "Well, that's a diabetes medicine." I'm not really sure how you differentiate where in the concrete is the line drawn based on a dosage, between one indication and another. The second piece of that, which I won't get on my soapbox too hard about, is we treat using medications off-label every single day so I don't know why this has gotten such publicity around it, but it has. At the end of the day, I guess what I would say is one of the biggest obesity-related complications, meaning obesity causes it, is type II diabetes.
If I've got a medication that can prevent type II diabetes from occurring by treating obesity, then I'm going to use it. If somebody wants to tell me the label on that medication is diabetes instead of obesity, then so it, let it be there. Now, I hear all the time, and recently from a pharmacist, who was going to refuse to fill a prescription for semaglutide 2.0 for a patient that didn't have type II diabetes but had obesity. And so, we had to have a lengthy discussion about how I have the authority to use off-label medications. In fact, to me it's not really off-label, it's the same exact molecule, it's just a lower dose. When we had that discussion that way, he kind of went, "Oh." I said, "Yeah, oh." And he filled the prescription.
I think it's just there's so much hype around it right now and it is part of the bias and stigma of this disease. For someone to tell me that they don't want to do it because they want to hold onto their stock for people who have diabetes tells me they think obesity deserves less treatment than diabetes does when, in reality, if I treat the obesity I'm treating the diabetes.
I think that there's no real downside, in my mind, of using any medication that might help patients reduce their adipose tissue burden and, therefore, the adiposopathy of this chronic disease of obesity.
C360: How does the use of these medications compare with other treatment options?
Dr Golden: As we look at the whole evidence-based package that we have to treat obesity, we know that lifestyle interventions can help patients lose about five to 8% of their body weight, and that impacts many of the obesity-related complications. It will help lower hemoglobin A1C, it will help lower blood pressure. It starts to help with non-alcoholic fatty liver disease. But when we start to do combination therapy, so we have lifestyle interventions and we put medication with that, we start to see higher numbers in the ability to remove adipose tissue or weight loss. Medication alone, right now, as we have right now in our toolbox, the medications we have alone, give us somewhere between five and 15% weight loss. But when we do that as a combination therapy, intensive lifestyle intervention plus pharmacotherapy, it is very clear in the evidence that we increase the amount of weight loss but, more importantly, we have better maintenance in the weight that does get lost.
Lifestyle alone, rarely do patients find that that second hit of obesity where they lose weight and then they get increased levels of grow and hunger hormone, decreased levels of the satiety hormone so they don't fill as full, and they get an increase in weight. It's called metabolic adaptation. The medications help offset that metabolic adaptation so when we put the two together we get more weight loss and we get more sustainable weight loss when we have the medications with them. And then, if the patient has opted, because it's an appropriate treatment for them to go with metabolic bariatric surgery, then we start to see that in a fair number of those patients, and the literature's anywhere from 50 to 60%, there starts to be weight regain about nine to 12 months. Those patients often need medication support because of metabolic adaptation. I think that we've got the same kind of situation, even with bariatric surgery, that we have to have a combination of therapies available to patients and chronic care follow-up. It's a chronic disease and it needs chronic care follow-up. That's, I think, another big key take home.
C360: What are the overall take-home messages from our conversation today?
Dr Golden: I hope as people are listening or viewing this video that what they're taking home is that obesity is a chronic disease with real endocrine pathophysiology and that it's more than just telling people to eat less and move more. It's about putting together a full evidence-based treatment plan that does include a good eating plan, an increase in activity, supported by medications and/or surgery that impact the pathophysiology of this chronic disease.