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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2866_Библиотеки_им_академика_М_И_Перельмана.pdf
Chapter 10. Obesity
219
Aerobic physical activity (such as brisk walking) progressing to 150 min/week performed on 3–5 separate days per
week.
Resistance exercise single-set repetitions involving major
muscle groups, two to three times per week to maximize fat
loss while preserving lean mass.
Reduction of sedentary behavior to increase overall
energy expenditure.
Higher levels of physical activity, approximately 200–
300 min/week, are recommended to maintain lost weight or
minimize weight gain in the long term (>1year). A combination of aerobic and resistance is better than either alone.
Behavior therapy A structured behavior change program
should be offered, utilizing a multidisciplinary team that
includes any number of the following:
Self-monitoring of food intake, exercise and goal setting,
education (face-to-face individual or group sessions or
remotely, i.e., telephone), problem-solving strategies, stimulus
control, behavior contracting, stress reduction, cognitive
restructuring, motivational interviewing, and psychological
evaluation and counseling with treatment if needed. These
same behaviors are recommended for weight-loss mainte-
nance, with the addition of frequent monitoring of body
weight (weekly or more often). Behaviors that support lifestyle changes help people achieve and sustain weight loss.
Pharmacotherapy
Drugs for overweight and obesity should be used only as an
adjunct to lifestyle therapy and not alone.
Pharmacotherapy can be considered:
• In individuals with a BMI ≥30 kg/m2, without complica-
tions in whom lifestyle therapy fails to achieve weight-loss
goals.
• In individuals with a BMI ≥27 kg/m2, with one or more
complications in whom lifestyle therapy fails to achieve
weight-loss goals.
220
J. S. Ruddock and G. Goswami
Pharmacotherapy is initiated:
• When lifestyle therapy alone fails and the patient progres-
sively gains weight or has no clinical improvement in
weight- related complications.
The addition of pharmacotherapy produces greater weight
loss and weight-loss maintenance compared to lifestyle therapy alone and leads to a longer duration of maintained
weight loss [31]. In selecting the optimal weight-loss medication for each patient, clinicians should consider differences in
efficacy, side effects, cautions, and the presence of weightrelated complications and medical history. Pharmacotherapy
should be offered when potential benefits outweigh the risks
of chronic treatment of the disease. Medications that contribute to weight gain should be discontinued if possible. Weightloss medications should be avoided in women who are
pregnant or planning pregnancy. It is recommended that
weight-loss medications be discontinued after 12 weeks if
weight loss does not exceed 5% of body weight.
Weight-loss medications approved by the Food and Drug
Administration (FDA) for the short-term use (3 month) is
phentermine, while for the long-term use in the treatment of
obesity are orlistat (Xenical Alli), phentermine/topiramate
extended-release combination (Qsymia), naltrexone ER/
bupropion ER (Contrave), liraglutide 3mg (Saxenda), and
semaglutide (Wegovy) which is the most recent addition in
June 2021. Previously approved lorcaserin (Belviq) was voluntarily withdrawn from the market in February 2020 [32].
See Tables 10.3 for specific information about each drug.
Weight-Loss Surgery andProcedures
In obese adults, bariatric surgery is more effective than conventional medical treatment, lifestyle intervention, or medically supervised weight loss. The Swedish Obese Subjects
study followed 2000 patients up to 20 years after surgery
which included banded gastroplasty, gastric banding, and
Roux-en-Y gastric bypass done by open techniques. There
% Total
body
weight loss Side effects Contraindications
Pregnancy, breast feeding,
cardiovascular disease,
Dry mouth,
difficulty in
(7.5mg)
5.5%
uncontrolled hypertension,
glaucoma, hyperthyroidism
sleeping, irritability
(15mg)
6.1%
Chapter 10. Obesity
Pregnancy and
breastfeeding, chronic
malabsorption syndrome,
cholestasis, oxalate
nephrolithiasis
Steatorrhea,
fecal urgency,
incontinence,
flatulence, oily
spotting, frequent
bowel movements,
abdominal pain,
1year—
4.0%
4year—
2.6%
221
(continued)
headache
T . Weight-loss medications: an overview
Medication (dosing) Mechanism of action
Adrenergic agonist
induces weight
loss by release of
norepinephrine leading
to decrease in appetite
Short-term weight loss
Phentermine [40] (schedule
IV-controlled substance)
15–37.5mg daily
Long-term weight loss
Orlistat induces weight
loss by blocking
dietary absorption of
fat
Orlistat (Xenical) 120mg PO TID
before meals
Over-the-counter 60mg PO TID
before meals
222
J. S. Ruddock and G. Goswami
Pregnancy and
breastfeeding (topiramate
teratogenicity)
Concomitant monoamine
oxidase inhibitor
Headache,
paresthesia,
insomnia
Decreased
bicarbonate,
% Total
body
weight loss Side effects Contraindications
1year—
6.6–7.5%
(MAOI) use within
14days, hyperthyroidism,
glaucoma, cardiovascular
disease or history
Pregnancy and
xerostomia,
anxiety, depression,
constipation,
dizziness, nausea
Nausea, headache,
1year—
breastfeeding, uncontrolled
hypertension, seizure
disorder, concomitant
insomnia, vomiting,
constipation,
diarrhea, dizziness,
4.2–5.2%
MAOI (within 14days),
long-term opioid or
opiate agonists use or
acute opiate withdrawal,
anorexia nervosa
anxiety, xerostomia
T . (continued)
Medication (dosing) Mechanism of action
Topiramate is an
anticonvulsant, which
has been shown to
increase weight loss in
obese patients
Phentermine/topiramate ER
(Qsymia)
Starting dose: 3.75/23mg PO QD
for 2weeks
Recommended dose:7.5/46mg PO QDEscalation dose: 11.25/69mg PO QDMaximum dose: 15/92mg PO QD
Phentermine is a
norepinephrine-
releasing agent
Bupropion is a mild
Naltrexone ER/bupropion ER
reuptake inhibitor
of dopamine and
norepinephrine
Naltrexone, an opioid
antagonist
(Contrave)
Dose titration:
Week 1:
1 tablet (8/90mg) PO QAM
Week 2:
1 tablet (8/90mg) PO BID
Week 3:
2 tabs (total 16/180mg) QAM
and 1 table (8/90mg) Q HS
Week 4:
2 tabs (total 16/180mg) PO QHS
Pregnancy and
breastfeeding, personal or
family history of medullary
thyroid cancer, pancreatitis,
acute gall bladder disease,
gastroparesis
Pregnancy and
Nausea, vomiting,
diarrhea,
constipation,
headache,
dyspepsia, increased
heart rate
Increased risk
1year—
5.6%
Lost
Chapter 10. Obesity
breastfeeding, personal or
family history of medullary
thyroid cancer, pancreatitis,
acute gall bladder disease,
gastroparesis
of diabetic
retinopathy nausea,
vomiting, diarrhea,
constipation,
headache,
dyspepsia, increased
heart rate
12.4%—
68weeks
223
Long-acting GLP-1
(glucagon-like peptide)
analog
Liraglutide 3mg—(Saxenda)
Titrate dose weekly by 0.6mg as
tolerated up to a maximum dose
of 3mg subcutaneously daily
Long-acting GLP-1
(glucagon-like peptide)
Semaglutide 2.4mg (Wegovy)
[41–44]
analog
2.4mg per week
224
J. S. Ruddock and G. Goswami
was a 24% reduction in overall mortality, obesity-related
morbidity (e.g., decreased incident rates of diabetes, hypertension, dyslipidemia), and improvements in quality of life in
the bariatric surgery group compared with the conventionally
treated group [33]. Recent studies in US populations also
support the enduring nature of these outcomes long term
[34]. However, despite the growing prevalence of obesity and
demonstrated efficacy and safety of bariatric surgery, only
~0.5% of eligible patients receive this treatment [2]. While
the internist does not perform surgery, primary care physicians play an important role in terms of identifying patients
who may benefit from surgery, advising them to consider this
option and referring to a skilled bariatric surgery team for
evaluation if deemed appropriate [35].
Surgical intervention is indicated and consistently covered
by insurance carriers for patients with the following:
• BMI of ≥40kg/m2 who have failed comprehensive lifestyle
therapy and pharmacological means
• BMI of ≥35kg/m2 with one or more severe obesity-related
complications (who have not met weight-loss goals) if the
anticipated benefits outweigh the risks, side effects, and
cost of the surgical procedure
Consensus guidelines now also recognize the following
additional indications for surgery though not yet widely covered by medical insurance carriers [36]:
• Patients with diabetes or metabolic syndrome with a BMI
of 30–34.9kg/m2 with inadequate glycemic control despite
optimal lifestyle and medical therapy [2, 13]
• Patients with a BMI >27kg/m2 in persons of Asian descent
with comorbid diabetes mellitus
• Patients at any weight, to achieve optimal health and qual-
ity of life when the amount of weight loss needed to pre-
vent or treat clinically significant obesity-related
complications cannot be obtained using nonsurgical
therapy
Chapter 10. Obesity
The procedures that are commonly used include the
following:
• Laparoscopic adjustable gastric banding
• Laparoscopic sleeve gastrectomy
• Roux-en-Y gastric bypass
Laparoscopic sleeve gastrectomy comprises 70% of currently performed procedures, followed by laparoscopic gastric bypass (25%), adjustable gastric banding (3%), and
duodenal switch (2%) [36]. See Tables 10.4 for more informa-
tion about common surgical options.
Newer procedures that have been FDA approved include
aspiration therapy and space-occupying gastric devices. FDA
trials of gastric emptying devices are underway [36]. These
novel procedures are considered as possibly suitable for
patients being bridged to surgery or for those who have failed
non-invasive interventions and are too high risk for surgical
intervention [37]. Non-surgical procedures may be considered in patients who may benefit from short-term interventions with high chance of maintaining lifestyle changes for
sustained weight loss [36].
225
Long-Term Follow-Up After Uncomplicated Bariatric Surgery
Patients who have undergone bariatric surgery need lifelong
follow-up visits. Follow-up with a multidisciplinary team consisting of the bariatric surgeon, medical obesity specialists,
endoscopists, nurses, registered dietician, psychologists, exercise physiologists, and support groups is important to optimize results post-surgery. Obesity-related complications
should be reviewed and medications adjusted as needed during follow-up. Metabolic deficiencies commonly seen with
RYGB (e.g., serum calcium, iron, B12, vitamin D, folate, and
thiamine) should be assessed at 3 and 6 months and then
annually after surgery [36]. It is now estimated that 25–35%
J. S. Ruddock and G. Goswami
226
Long-term
complications >30days
Weight
T . Surgical techniques and outcomes [26, 27]
post- surgery Comorbidity remission outcome (estimates in % from RCT)
loss
Mortality ≤30days—0.08% (0.01–0.30), n=934
Mortality >30days—0.39% (0.01–0.86), n=954
Complication rates—21(12–33), n=649
Dumping syndrome
Marginal or
gastrojejunal ulcers
60–
85%
Gastric
bypass
Diabetes remission rates—95.15 (88.38–98.80), n=152
Hypertension remission rates—80.98 (68.2–91.5), n=183
Dyslipidemia remission rates—80.16 (61.6–94.1), n=147
Nephrolithiasis
Depression
Cholelithiasis Mortality ≤30days—0.11 (0.01–0.50), n=743
Cholelithiasis
45–
Adjustable
Mortality >30days—0.14 (0.00–0.55), n=613
Complication rates—13 (5.2–26), n=855
Diabetes remission rates—73.8 (36.0–96.1), n=35
Hypertension remission rates—53.55 (12.5–89.6), n=27
55%
gastric band
Dyslipidemia remission rates—39.9 (4.69–87.0), n=132
Mortality ≤30days—0.50 (0.01–3.88), n=40
Mortality >30days—6.00 (0.00–100.00), n=40
Complication rates—13 (0.7–44), n=137
Stenosis leading
to gastric outlet
obstruction
55–
80%
Sleeve
gastrectomy
Diabetes remission rate—NAaHypertension remission rate—NAaDyslipidemia remission rate—NA
a
Cholelithiasis
Not enough long-term data was available for sleeve gastrectomy remission rates in the analysis
a
Chapter 10. Obesity
227
of patients experience weight regain after bariatric surgery,
and therefore it is important to monitor patients closely and
consistently to help in preventing and managing weight
regain [38]. There is also a growing body of evidence supporting an increased risk of alcohol use disorder (AUD) after
bariatric surgery procedures, so this should be discussed with
patients prior to surgery. The incidence seems to be highest
2 years after surgery, so physicians should continue to vigilantly screen and counsel patients regarding the increased
risk at their follow-up visits [36, 39].
Clinical Pearls
• Undesirable terms such as “heaviness,” “fat,” “large size,”
“excess fat,” and “fatness” and even the term “obese”
should be avoided when addressing issues regarding
weight.
• Lifestyle modification is the foundation of all treatment
algorithms.
• Weight-loss medications should not be prescribed to
women who are pregnant or breastfeeding. Women of
reproductive age should be using a reliable contraceptive
method.
• Obesity is a chronic disease and requires ongoing treat-
ment. Patients will have varying motivation and adherence
and will need ongoing encouragement.
• Patients and sometimes physicians have unrealistic
weight- loss goals, and it is important to establish realistic
and achievable goals. A 5–10% weight reduction is clini-
cally significant and may take 6 months or more to
accomplish.
Don’t Miss This!
• Even a brief conversation with their primary care provider
can make a difference in patient’s perceptions of excess
weight as a medical issue. Remember to ask patients per-
mission before initiating conversations about their weight.
Be sensitive and nonjudgmental in your approach to all
conversations regarding weight management.
228
J. S. Ruddock and G. Goswami
• Medications are FDA approved for the chronic long-term
treatment of obesity and can be prescribed in the appro-
priate patient.
• Surgery is effective and safe in appropriately selected
patients (Tables 10.3 and 10.4).
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