#324: Obesity Medicine FAQ with Dr. Fatima Cody Stanford 

February 28, 2022 | By Matthew Watto, MD

Video

Obesity treatment has been around since the 1950s but we’ve been underutilizing it for far too long! Not only that, we’ve been thinking about obesity the wrong way for decades. Join us with Dr. Fatima Cody Stanford (@AskDrFatima) of Massachusetts General Hospital as we reframe our approach to this disease and learn tips on prescribing  older,  but still very effective, medications used to treat obesity.

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Credits

• Producer, Writer, Show Notes, Infographics, Cover Art: Isabel Valdez, PA-C
• Show Notes, Infographics: Maddison McLellan
• Hosts: Matthew Watto MD, FACP; Paul Williams MD, FACP   
• Reviewer: Monee Amin, MD
• Executive Producer: Beth Garbitelli
• Showrunner: Matthew Watto MD, FACP
• Editor: Clair Morgan of nodderly.com
• Guest: Fatima Cody Stanford, MD 

CME Partner: VCU Health CE

The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit. See info sheet for further directions. Note: A free VCU Health CloudCME account is required in order to seek credit.

Show Segments

• Intro, disclaimer, guest bio
• Guest one-liner by Dr. Fatima Cody Stanford
• Case from Kashlak 
• Guidelines for treatment 
• Getting the history and discussing weight goals
• The Care Team:  Dietician, Behavioral Specialist, Provider
• Medications: Phentermine, Topiramate, Bupropion, Naltrexone
• Obesity treatment in pregnancy
• Referring to bariatric surgery
• Take home points
• Outro

Obesity Medicine Pearls

1. Obesity is a disease that can and needs to be treated with either surgery or medications. Obesity is NOT the patient’s fault.
2. Help the patient determine a goal weight based on what they feel is their healthy point. Ask them the heaviest weight they’ve been; do not assume the weight they’re at during your visit is the heaviest. 
3. Some patients may already be very well-versed in managing a healthful diet so you might not always need to refer to dieticians
4. Screen your patients for eating disorders. While the patient may be in remission from these disorders, their condition could recur while undergoing treatment.
5. Studies show bupropion may elevate blood pressure and heart rate more often than phentermine.
6. Monitor patient blood pressure and heart pulse while on medical treatment and especially if being treated with phentermine or bupropion.
7. Topiramate can be used to help both weight loss and reduce night time cravings and should be dosed in the evenings.
8. Naltrexone is known to cause nausea as a side effect and should be uptitrated weekly, or even monthly, to help reduce the incidence of nausea.  
9. Metformin is the only medication that could be used in pregnancy or breastfeeding as of the recording of this episode. 
10. Weight loss medications can be used in patients who’ve had bariatric/metabolic surgery if their weight loss plateaus or if they regain weight.
11. BMI has historically been a skewed assessment of weight and obesity. Waist circumference measurements have a more direct impact on patient outcomes. 
12. Bottom line: weight loss is an individual journey. Medications and surgical intervention have different impacts in different patients.

Obesity Medicine FAQ

Obesity is a Disease

The Basics 

Our guest, Dr. Fatima Cody Stanford, offered us a wealth of information both on and off air.  We have included drug information and other resources that she recommends which may have been cut from the final audio. 

Our expert is a strong advocate for treating obesity as the disease that it is; it is not something that occurred to the patient at their fault. The primary guidelines used in the treatment of obesity were a collaborative effort from the American College of Cardiology, the American Heart Association, and the Obesity Society. 

Major obesity-related conditions include diabetes, obstructive sleep apnea, and heart disease. Gather the history by asking the patient what their weight has been and learning about their past weight struggles. Ask the patient about the weight loss strategies they have used that have failed. 

For a comprehensive guide for managing obesity in the primary care setting, our guest recommends the Weight Can’t Wait guide from the Strategies to Overcome and Prevent (STOP) Obesity Alliance that was developed by a number of medical professional associations.  She also uses the video linked below to teach patients about obesity medicine because the content in this video is tailored for individuals without medical professional knowledge: Obesity: It’s More Complex than You Think | Fatima Cody Stanford || Radcliffe Institute

Talking about Weight: Setting a Target Weight… or Not

Our expert does not believe in setting target weights and aims to shift the patients away from thinking about a set number on the scale.  She has seen patients feel as if they failed because the target weight loss goal was not met even though the patients have lost a meaningful amount of weight.  Instead, she believes helping patients reach the weight at which they feel they are at their happiest and healthiest.  Dr. Stanford reminds us that the number on the scale does not represent adiposity alone.   

Weight History

Dr. Stanford often sees how weight bias can lead us into poor outcomes. We can be mindful in our approach to gathering weight history by asking for permission to talk about weight, especially if this is not the primary reason for the visit.  We should ask the patients what was the heaviest weight they have been; the weight they have in the appointment might not be the heaviest they have been.  Dr. Stanford asks patients if they have lost weight successfully in the past and she recommends using a graph to show the history of their past weights to illustrate their weight changes. 

When to Weigh-in

Dr. Stanford suggests each patient’s comfort level with weigh ins is different and to follow his/her lead. Further, she suggests even more important than weigh-ins is to measure waist circumference with a goal of women 35 inches (88.9 cm) or less and men 45 inches (114.3 cm) or less (Dagan 2013). Regarding BMI, she suggests target weights should not be set by BMI as they differ based on age, sex and race/ethicity (Davis 2013). BMI is not based on medicine and is an indirect measure of adiposity (Rothman 2008). Dr. Stanford suggests that older adults may have an advantage with slightly higher BMI (due to metabolic demands of illness) (Nair 2021, Kalantar-Zadeh 2005). Dr. Stanford adds that while BMI metrics are helpful for overall trends, obesity medicine is individualized. Lastly, she emphasizes the importance of giving patients a percentage of excess body mass lost and total body weight loss at each visit but also making a note how the patient feels. 

The Treatment Care Team 

Dr. Stanford begins the conversation about treatment for weight by gauging what interests the patient:  lifestyle modifications, behavioral therapy, medications, devices, or surgery. Their interests or experiences can be used to connect the patient to the right care team member which include the physician/provider, dietician, and behavioral psychologist. For example, seeing as how patients with obesity may have good fundamental knowledge about diet, it may not be entirely necessary to refer every patient to dieticians.  

Behavioral Psychologist Referral

Dr. Stanford recommends looking for red flags suggestive of eating disorders to determine if a referral to a behavioral psychologist is warranted. Patients may be in remission of eating disorders, but these can recur and interfere with the progress they are making with obesity treatment. Eating disorders can be detected by asking the following questions:

• Do you ever get up at night to eat?
  • Night eating syndrome applies to the patient who wakes up in the middle of the night to eat.
• Have you noticed food crumbs in your bed when you wake up?
  • Night-related eating disorder refers to the patients who have no recollection of eating at night. 
• Do you feel loss of control in eating?
  • Ask if the patient has been diagnosed with an eating disorder such as anorexia, bulimia, or binge eating disorder. 

Medications: The expert approach

Dr. Stanford has been using multiple weight loss medications for years before the advent of GLP-1 receptor agonists.  The main focus of our discussion centered around medications that have been in use since before GLP-1 RA. She generally starts with just one drug and uptitrates it. She will add a second agent based on the patient’s experience. Dr. Stanford emphasizes that each person has a different response to each medication and trial and error is important in the medication approach to treating obesity. Her other best practice recommendation, particularly with phentermine and bupropion:  have the patient check blood pressure and heart rate Monday morning, Wednesday midday, and Friday evening and ask the patient to send these measurements in on a weekly basis. She will stop the medication if there is a significant increase in either the blood pressure or heart rate. 

“We are not reticent to consider medication for any other chronic disease whether it be diabetes or hypertension…but only about 1% of individuals that meet criteria for medications[…] are actually on medications for the treatment of obesity”

–Dr. Fatima Cody Stanford (Claridy 2021)

Phentermine

Phentermine was the first drug approved for weight loss in 1959 and has a high level of efficacy. Because this medication is a stimulant, Dr. Stanford recommends dosing this treatment first thing in the morning and has even used it instead of ADD/ADHD medications for the mild, dual benefit of focus and attention (Poultron et al 2016).  To dose phentermine, Dr. Stanford suggests starting with phentermine 15mg one pill in the morning for approximately three months before increasing to phentermine 30mg one pill in the morning. She reminds us to monitor the blood pressure and heart rate before increasing it to 30mg.  In her expert opinion, there is not much of an added benefit in increasing to phentermine 37.5mg.  

Fenfluramine/phentermine, also known as the fen-phen, was a combination drug used for the treatment of obesity but it is now banned. 

Ohio and Florida prescribers, did you know you could not prescribe phentermine for long-term use as of the date of our recording? Dr. Stanford advises to check state licensing board for any future updates and details on the limitations of prescribing phentermine.  Some practitioners prescribe three-months of treatment, hold the treatment for one month then re-prescribe for another three months to work around the limitations while still offering treatment for the patients. 

Topiramate

In Dr. Stanford’s opinion, topiramate, an anti-seizure drug that slows brain wave activity,  should be prescribed in the evenings due to its side effect of somnolence. This strategy could also help reduce the nighttime cravings (Nourredine 2021).  She recommends dosing topiramate at dinner or bedtime, starting at the 25mg dose and titrating up to 100mg if needed.   Her aim is to use the lowest effective dose and maintain the patient at said dose.  Due to concern for side effects including cognitive issues, paresthesias, or word-finding difficulties, she rarely goes over 150mg.  

Bupropion and Naltrexone 

Dr. Stanford suggests the use of bupropion in patients in whom the goal is to treat both depression and obesity. However, she reminds us that bupropion is more likely to elevate blood pressures and heart rate than phentermine (Roose 1991, Thase 2008, Siebenhofer 2009) . The aim in using bupropion is to mimic the dosing used in the bupropion/naltrexone combination pill.  To dose bupropion as monotherapy, Dr. Stanford starts with bupropion sustained-release (SR)150mg oral twice a day and titrates to  bupropion sustained-release (SR) 200mg twice a day.  Consider increasing to a total daily of 450mg by prescribing  bupropion sustained-release (SR) 150mg TWO tablets together in the morning followed by  bupropion sustained-release (SR) 150mg in the evenings. When adding naltrexone, start by prescribing a quarter of a tablet of naltrexone 50mg for a total of 12.5mg in the morning for one week followed by adding another quarter of a tablet of naltrexone 50mg for a total of 12.5mg in the evenings for another week. Increase to half of a tablet of naltrexone 50mg for a total of 25mg in the morning with a quarter of a tablet of naltrexone 50mg for a total of 12.5mg in the evening for an additional week. Lastly, titrate to a half of a tablet of naltrexone 50mg for a total of 25mg twice a day.  The most common side effect of naltrexone is nausea and if the patient were to experience this, Dr. Stanford suggests slowing down the titration from weekly dose increases to monthly dose increases. 

GLP-1 Agonists

GLP-1 Agonists are commonly used and Dr. Stanford calls them the “golden children of obesity treatment.” For instance, semaglutide 2.4mg was noted to contribute to 14.9% weight loss (Wilding et al., 2021).   However, patient access to these medications differs widely based on insurance coverage, and like many other medications, they will not work for everyone. 

For more practice changing knowledge from past episodes on GLP-1 receptor agonists, check out our episodes #243 Diabetes Triple Distilled and #296 Diabetes FAQ.

Orlistat, Metformin, and New Novel Therapies

Orlistat is available over the counter at low doses and as a prescription at higher strengths. It is less commonly used, which Dr. Stanford suggests may be due to its smaller degree of weight loss and has some unwanted patient side effects (Filippatos 2008). Dr. Stanford relates anecdotal and successful experiences with using metformin for weight loss treatment, though it is not a typical weight loss medication. Lastly,  there is  a novel therapy involving scheduled consumption of cellulose and citric acid capsules (brand name Plenity)  The proposed mechanism involves giving patients a sensation of satiety, thus contributing to a decrease in total body weight loss (Giruzzi 2020). Given its newness, Dr. Stanford cites limited patient access with a large out-of-pocket cost and it is not available over the counter. 

Treatment Concerns in Pregnancy and Breastfeeding

None of the medications discussed can be used in patients who are trying to get pregnant or who are breastfeeding. Though off-label, metformin may be an option for obesity management in patients with reproductive potential, who are pregnant, or those who are breastfeeding (Newman and Dunne, 2021). Patients should stop any of the aforementioned medications immediately when they become pregnant.  Dr. Stanford reminds us that GLP-1 agonists are contraindicated in pregnancy and she recommends it be stopped at least two months before conception (Sacks 2018, Alexopoulos et al 2019). 

The place of weight loss surgery

Bariatric/Metabolic Surgery Referral: When You Need a Snow Plow

Anecdotally, Dr. Stanford mentions that patients often start the treatment discussion by stating they do not want surgery though this may be the best treatment modality. Dr. Stanford uses the analogy of selecting the right tool, such as a spoon or snow plow, for shoveling several inches of snow.  When trying to select the best tool for weight loss, a spoon is to lifestyle modifications as a snow plow is to bariatric surgery.

When to Refer 

As noted by the NIH Consensus panel in 1991 and the AACE/TOS/ASMBS/OMA/ASA clinical practice guidelines updated in 2019, metabolic/bariatric surgery can and should be considered in patients with moderate obesity plus major obesity-related conditions or persons with a BMI ≥ 40 regardless of whether they have major obesity related conditions. Metabolic/bariatric surgery can resolve diabetes and sleep apnea (Schauer 2003; Buchwald H 2004). 

The Rule of Twos

Dr. Stanford notes that a common weight loss surgery patients undergo is sleeve gastrectomy. She has adopted her own “Rules of 2s” when discussing recovering from this surgery with her patients: 2 hours of surgery time, 2 days in the hospital, 2 weeks of recovery. Even after surgery and regardless of patient outcome, Dr. Stanford suggests annual labs and routine monitoring post operatively. If patients do not lose weight post surgery, plateau or regain weight, she suggests weight loss medication can be prescribed, even if these medications were not efficacious before surgery (Stanford 2017; Stanford, 2019). Your Curbsiders team, along with Dr. Vivian Sanchez, curated an episode on bariatric surgery and a how-to for the care of patients after bariatric/metabolic surgery (Curbsiders #275: Bariatric Surgery for the Internist).

Take Home Points

• Obesity is a disease and requires chronic care and treatment. This is not a disease that is characterized by willpower or moral failing of a patient. 
• Our language matters. Eliminate the words obese or morbid. Patients have the disease of obesity, they are not obese persons. 
• We have evidence-based treatment modalities that are underutilized for the treatment of obesity, both pharmacotherapy and surgical interventions.

Links*

Weight Can’t Wait: Guide for the Management of Obesity in the Primary Care Setting by (Guide)

2. NBS: The Truth About Fat by Nova: Check your local Public Broadcasting Station

*The Curbsiders participates in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising commissions by linking to Amazon. Simply put, if you click on our Amazon.com links and buy something we earn a (very) small commission, yet you don’t pay any extra.

Goal

Listeners will develop a framework to approach the management of obesity, utilizing medication, surgical intervention and a multidisciplinary team, keeping the individualized nature of obesity medicine in mind and recognizing it as a chronic disease.

Learning objectives

After listening to this episode listeners will…  

1. Recognize obesity is an illness and its implications on other chronic diseases.
2. Develop a strategy to help patients set realistic goals.
3. Individualize the medical treatment of obesity according to the patient’s needs.
4. Manage medical weight loss with medications which may be cost effective as monotherapy or combination therapy.

Recognize instances when medication needs to be adjusted or changed based on side effects or response to treatment.

Disclosures

Dr. Stanford is an advisor for Calibrate, a weight loss program that features telemedicine consults, coaching, and endorses medical weight loss medications as those discussed in this program. The Curbsiders report no relevant financial disclosures. 

Citation

Valdez I, McLellan M, Stanford FC, Williams PN, Watto MF. “#324: Obesity Medicine FAQ with Dr. Fatima Stanford”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list  February 28, 2022.