#23 The Obesity Epidemic: The Curbsiders size it up

January 16, 2017 | By Matthew Watto, MD

Obesity is of epidemic proportions in the United States and, unfortunately, many physicians are ill-equipped to tackle this disease.  In this episode, we talk with Dr. Timothy Garvey, MD, FACE, one of the world’s leading experts in obesity research.  We asked the American Association of Clinical Endocrinology to recommend an obesity expert and they gave us the best!

Got feedback? Email thecurbsiders@gmail.com 

Clinical Pearls:

1. Obesity is a DISEASE. Not a lifestyle choice!
2. Obesity is known to be associated with many of the most common preventable diseases and, thus, should be an important component of any treatment program.
3. BMI goals differ between ethnic groups (for example, east Asians developing heart disease with a BMI greater than 23).
4. Weight loss treatment should focus on the disease burden and not on body image.
5. While diet and exercise are independently important, failure to address the underlying sedentary lifestyle will likely prove fruitless.  The American College of Sports Medicine recommends avoiding any sedentary activity greater than 90 minutes at a time and at least 150 minutes of moderate activity weekly.
6. Always ask permission before talking about weight loss; otherwise, you might negatively impact the physician-patient relationship.
7. In order to prevent weight-related complications, aim for approximately 10% weight loss.
8. Weight regain is a REAL problem that should be anticipated (decreased BMR, hormonal implications, and many other issues); weight loss medications help to fight against these pathophysiological mechanisms.
9. Weight loss medications (Orlistat [inhibits fat absorption], Lorcaserine [5HT2C agonist, blunts appetite], Liraglutide [GLP1-RA] at higher dosages [3mg/day], Phentermine/Topiramate [“…most effective?”], Naltrexone/Bupropion) are under-utilized across the board, but before using these medications, the physicians should understand how to use these medications and consider them as part of a weight loss treatment plan that includes lifestyle modifications (i.e. dietary assessment and exercise “prescription”).
10. Liraglutide, Phentermine/Topiramate, and Naltrexone/Bupropion are the most effective medications.
11. If the patient does not lose at least 5% of their weight by three months, stop that specific medication and consider trying another medication.
12. Follow-up with your weight loss patients frequently over the telephone (2 weeks after starting a medication) and in the office (at least monthly).
13. Minimal data supports using weight loss medications in the elderly (>70 years of age)

Dr. Garvey’s “Take-Home” Points:

1. Obesity is a DISEASE not a lifestyle choice!
2. Don’t be afraid to use weight loss medications!
3. Weight loss should be a tool to improve HEALTH, not appearance.

Disclosures:
Dr. Garvey reports several financial disclosures for this talk:

1. Scientific Advisory Board:  Novo Nordisk, Eisai, Janssen, Vivus, Liposcience, Takeda, Astra Zeneca, Alexion, Merck
2. Research Funding (university administered):  Merck, Astra Zeneca, Weight Watchers, Eisai, Sanofi, Pfizer, Novo Nordisk, Lexicon, Elcelyx
3. Stock Ownership (publicly traded):  Eli Lilly, Pfizer, Novartis, Merck, Isis, Bristol-Myers-Squibb, Affymetrix

Learning objectives:
By the end of this podcast listeners will be able to:

1. Understand the impact obesity has on overall health and disease burden.
2. Identify the weight loss medications and which might be appropriate for your patient(s).
3. Have a general understanding of the impact that each individual treatment modality (lifestyle modification, medications, and surgery) has on weight loss.

Links from the show:

1. Dr. Timothy Garvey’s bio (UAB):  https://www.uab.edu/medicine/diabetes/faculty/faculty-bios/111-w-timothy-garvey
2. Dr. Timothy Garvey’s app recommendation, “Lose It,” available from https://www.loseit.com/.
3. Dr. Timothy Garvey’s book recommendation:  “House of God” available https://www.amazon.com/House-God-Samuel-Shem/dp/0425238091/ref=sr_1_1?ie=UTF8&qid=1484443555&sr=8-1&keywords=House+of+God.
4. AACE 2016 Obesity Guidelines:  https://www.aace.com/files/final-appendix.pdf
5. AACE Obesity Treatment Algorithm (highly recommended):  https://www.aace.com/files/guidelines/ObesityAlgorithm.pdf
6. Naltrexone/Bupropion SR for Weight Loss:  Method-of-use study of naltrexone sustained release (SR)/bupropion SR on body weight in individuals with obesity.  Obesity (Silver Spring). 2016 Dec 27. doi: 10.1002/oby.21726.
7. Phentermine/Topiramine for Weight Loss (Review Article):  Combination phentermine and topiramate extended release in the management of obesity.  Expert Opin Pharmacother. 2015 Jun;16(8):1263-74. doi: 10.1517/14656566.2015.1041505.

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