New Guidelines Urge Docs to Focus on Obesity
ATLANTA — Doctors should diagnose and treat obesity at every clinic visit, the way they would any other chronic disease, according to new national guidelines. But some experts disagree.
“It’s an enormous shift,” Donna Ryan, MD, co-chair of the guideline committee, toldMedPage Today during an interview at Obesity Week here. “The current way [primary care clinicians] engage obese patients, if at all, is to tell them to lose weight. They recommend weight loss, but they don’t own weight management.”
“They don’t really engage in helping patients achieve weight loss, either through referral or providing counseling or prescribing,” said Ryan, a professor emeritus at Pennington Biomedical Research Center in Louisiana. “They have been reluctant to do that. But that is changing.”
The obesity guidance is one of four updated guidelines on cardiovascular preventioncommissioned by the National Heart, Lung, and Blood Institute and developed by the American Heart Association and the American College of Cardiology. The Obesity Society partnered with those two institutions to develop the obesity-specific guidelines — which hadn’t been updated since 1998.
Ryan said the guidelines are geared toward primary care clinicians and offer an algorithm for managing obesity. They focus on identifying at-risk patients and prescribing appropriate interventions.
The first step, she said, is assessing who needs to lose weight, and current body mass index (BMI) cutpoints are a good place to start.
Those who have a BMI of 30 and up need treatment, no questions asked. Those who fall into the overweight category — a BMI of 25 to 30 — should be treated if they have other risk factors, including an elevated waist circumference of 35 inches and up for women or 40 inches and up for men.
Although there’s been some debate about the utility of BMI as a screening tool, Ryan said the research shows “very clearly that as BMI increases, the risk for cardiovascular disease, diabetes, and cancer all go up.”
As far as how much weight patients need to lose, the guidelines urge that even a minimal amount brings health benefits.
“Weight loss as little as 3% to 5% can produce health benefits, but what we’re really aiming for is 5% to 10% weight loss,” Ryan said. “That’s where we can get a lot of health benefits.”
“The message is not 3%, 5% or 10%,” Ryan added. “The message is that you don’t have to go down to a normal weight. You don’t have to hit a BMI of 25 to achieve a lot of health benefits.”
Which diet should doctors prescribe? That depends on the patient, the guidelines say.
Ryan said the group reviewed 17 diets, and not surprisingly, found that “there is no magic diet.”
Instead, clinicians should prescribe a diet based on patients’ other risk factors. Someone with hypertension, for instance, may benefit from the DASH diet, while those with other cardiovascular risks might try a Mediterranean diet.
“As long as you’re creating a negative energy balance, usually 500 to 1,000 calories per day, you’re going to get weight loss, regardless of the diet,” Ryan said.
And that diet should be part of a comprehensive lifestyle intervention that includes physical activity and behavioral changes — which should be delivered by a trained interventionist. The guidelines recommend that patients meet with this counsellor 14 times in the first 6 months, and follow up for at least a year.
Even though that may not be widely covered by all insurances, Ryan urged that “we have the evidence to support its efficacy and we’re very much hoping that it will be covered.”
The guidelines do not make specific references to obesity medications because there was only one available — orlistat (Alli, Xenical) — when the committee was reviewing the evidence. Since then, two new diet drugs have been approved by the FDA: lorcaserin (Belviq) and phentermine/topiramate (Qnexa).
The drugs could fit into an overall lifestyle intervention plan, but aren’t likely to help all on their own, Ryan said when pressed about whether an increased focus on treating obesity could lead to more liberal writing of scripts for obesity drugs.
“These medications work by reducing hunger and increasing satiety, and you’re only going to get that if you’re trying to diet,” Ryan said. “You’ll get minimal weight loss if you just write the prescription. But if you combine it with a diet and lifestyle intervention, you will achieve and sustain much better weight loss. It’s a much better business model than just writing prescriptions.”
She said the drugs are “used as an intensification approach. When patients can’t do it on their own, they may need biological reinforcers to achieve behavioral change.”
The fifth and final recommendation in the obesity guidance focuses on bariatric surgery for weight loss. It maintains recommendations to refer patients with a BMI of 40 and up, or 35 plus at least one obesity-related comorbidity, to bariatric surgery when other interventions fail.
“It’s not a change in recommendation, but it’s a much stronger endorsement of surgery,” Ryan said. “Doctors should actively consider surgery and refer patients who might benefit from it, because the efficacy and safety evidence is strong.”
Not all groups, however, agree with the guidance. Jeffrey Mechanick, MD, of Mount Sinai Icahn School of Medicine in New York, and president of the American Association of Clinical Endocrinologists, said his organization reviewed the guidelines and did not endorse them.
Alan Garber, MD, of Baylor College of Medicine, and a former past-president of AACE, said the guidelines don’t accurately reflect the literature.
“It’s a very narrow slice of a highly pre-specified kind of evidence base, which doesn’t necessarily extrapolate to the whole of the at-risk population and therefore leaves many patients untreated or at residual risk,” Garber said. “To be blunt, it’s inadequate.”