Obesity Management in Adults

Abstract

ImportanceObesity affects approximately 42% of US adults and is associated with increased rates of type 2 diabetes, hypertension, cardiovascular disease, sleep disorders, osteoarthritis, and premature death.ObservationsA body mass index (BMI) of 25 or greater is commonly used to define overweight, and a BMI of 30 or greater to define obesity, with lower thresholds for Asian populations (BMI ≥25-27.5), although use of BMI alone is not recommended to determine individual risk. Individuals with obesity have higher rates of incident cardiovascular disease. In men with a BMI of 30 to 39, cardiovascular event rates are 20.21 per 1000 person-years compared with 13.72 per 1000 person-years in men with a normal BMI. In women with a BMI of 30 to 39.9, cardiovascular event rates are 9.97 per 1000 person-years compared with 6.37 per 1000 person-years in women with a normal BMI. Among people with obesity, 5% to 10% weight loss improves systolic blood pressure by about 3 mm Hg for those with hypertension, and may decrease hemoglobin A1c by 0.6% to 1% for those with type 2 diabetes. Evidence-based obesity treatment includes interventions addressing 5 major categories: behavioral interventions, nutrition, physical activity, pharmacotherapy, and metabolic/bariatric procedures. Comprehensive obesity care plans combine appropriate interventions for individual patients. Multicomponent behavioral interventions, ideally consisting of at least 14 sessions in 6 months to promote lifestyle changes, including components such as weight self-monitoring, dietary and physical activity counseling, and problem solving, often produce 5% to 10% weight loss, although weight regain occurs in 25% or more of participants at 2-year follow-up. Effective nutritional approaches focus on reducing total caloric intake and dietary strategies based on patient preferences. Physical activity without calorie reduction typically causes less weight loss (2-3 kg) but is important for weight-loss maintenance. Commonly prescribed medications such as antidepressants (eg, mirtazapine, amitriptyline) and antihyperglycemics such as glyburide or insulin cause weight gain, and clinicians should review and consider alternatives. Antiobesity medications are recommended for nonpregnant patients with obesity or overweight and weight-related comorbidities in conjunction with lifestyle modifications. Six medications are currently approved by the US Food and Drug Administration for long-term use: glucagon-like peptide receptor 1 (GLP-1) agonists (semaglutide and liraglutide only), tirzepatide (a glucose-dependent insulinotropic polypeptide/GLP-1 agonist), phentermine-topiramate, naltrexone-bupropion, and orlistat. Of these, tirzepatide has the greatest effect, with mean weight loss of 21% at 72 weeks. Endoscopic procedures (ie, intragastric balloon and endoscopic sleeve gastroplasty) can attain 10% to 13% weight loss at 6 months. Weight loss from metabolic and bariatric surgeries (ie, laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass) ranges from 25% to 30% at 12 months. Maintaining long-term weight loss is difficult, and clinical guidelines support the use of long-term antiobesity medications when weight maintenance is inadequate with lifestyle interventions alone.Conclusion and RelevanceObesity affects approximately 42% of adults in the US. Behavioral interventions can attain approximately 5% to 10% weight loss, GLP-1 agonists and glucose-dependent insulinotropic polypeptide/GLP-1 receptor agonists can attain approximately 8% to 21% weight loss, and bariatric surgery can attain approximately 25% to 30% weight loss. Comprehensive, evidence-based obesity treatment combines behavioral interventions, nutrition, physical activity, pharmacotherapy, and metabolic/bariatric procedures as appropriate for individual patients.

Racial and Ethnic Differences in Obesity Treatment in the Veterans Affairs Healthcare System

“…While MOVE! and similar lifestyle counseling interventions are evidence-based avenues to weight loss, medications and surgery produce substantially more weight loss on average (12,37). Thus, this set of results indicating lower access to more intensive, more effective treatments among minoritized patients is troubling, even if access to MOVE!…”

“…Incretin-based injectable medications join the existing arsenal of evidence-based, guidelinerecommended obesity treatments, including behavioral weight loss programs, older anti-obesity medications, and bariatric surgery (8)(9)(10)(11)(12), all of which were underutilized in the era prior to incretinbased therapy (13)(14)(15)(16)(17)(18)(19). As marginalized populations frequently receive healthcare innovations slower and later than more resource-rich counterparts (20,21)-and given inequities in use of existing obesity treatments (18,19,(22)(23)(24)(25)-it is far from certain that these next-generation medications are diffusing equitably.…”

Alcohol use disorder and body mass index show genetic pleiotropy and shared neural associations

“…Interest in this putative overlap has been heightened by recent reports that GLP-1 receptor agonists (GLP-1RAs)—approved for treating type 2 diabetes and obesity—may represent potential new pharmacotherapies for AUD (Leggio et al, 2023). Similarly, medications used to treat AUD reduce weight in individuals with obesity (Elmaleh-Sachs et al, 2023). For example, topiramate, recommended as an off-label treatment for AUD (Perry et al, 2022; Reus et al, 2018), is approved in combination with phentermine as a weight loss medication.…”

“…Similarly, medications used to treat AUD reduce weight in individuals with obesity (Elmaleh-Sachs et al, 2023). For example, topiramate, recommended as an off-label treatment for AUD (Perry et al, 2022;Reus et al, 2018), is approved in combination with phentermine as a weight loss medication.…”

Successful dietary changes correlate with weight‐loss outcomes in a new dietary weight‐loss program

“… 1 , 2 , 3 , 4 , 5 However, available dietary weight‐loss programs, including commercialized diets, very‐low‐calorie diets, and academia‐developed programs, are insufficient in the magnitude of weight loss and sustainability of lost weight. 6 , 7 , 8 , 9 To the best knowledge of the Individualized Diet Improvement Program (iDip) group, only one study demonstrated the major reversal of type 2 diabetes lasting for 2 years using a ketogenic diet. 10 , 11 Outcomes of behavioral weight loss are similar to dietary weight loss in magnitude and sustainability.…”