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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3055_Библиотеки_им_академика_М_И_Перельмана.pdf
171
The measurement of neck circumference may be useful as
part of calculating the STOP-BANG score as a screening tool
for sleep apnea [12]. Please see the chapter on sleep apnea
for more information.
Diagnostic and screening laboratory values such as
lipid panel, hemoglobin A1c, thyroid-stimulating hormone
level, liver function tests, and an EKG should be com-
pleted in addition to any other appropriate evaluations
for associated conditions (listed below) based on history
and exam findings [7, 11].
*prediabetes * metabolic syndrome *type 2 diabetes *dyslipid-
emia *hypertension * cardiovascular disease * nonalcoholic fatty
liver disease *polycystic ovarian syndrome * female infertility
*depression * male hypogonadism * obstructive sleep apnea *
asthma *osteoarthritis *urinary stress incontinence * gastro-
esophageal reflux disease
Who Should Lose Weight?
Results of diagnostic and laboratory testing can be one of the
key factors in determining which patients need to lose weight.
Weight loss is recommended for individuals with a BMI
≥30 kg/m
2
or BMI 25–29.5 kg/m
2
with weight-related compli-
cations (see Fig. 9.1). The Edmonton obesity staging system
may offer clinical guidance in assessing obesity-related risk
and prioritizing treatment [13] (see Table 9.2).
Table 9.2 Edmonton staging system [13]
STAGE
0 1 2 3 4
Clinical
Complications
None Mild Moderate Significant Severe or End-Stage
9. Obesity
172
Treatment
Management of Obesity
Obesity is a complex chronic disease that results in the inter-
action of genetic, environmental, and behavioral determi-
nants. Adipose tissue becomes a dysfunctional endocrine
organ leading to systemic metabolic disease [11]. Therefore,
the cornerstone of management of obesity lies on the impor-
tance of weight loss which has shown to reduce morbidity
(e.g., reduction in the rate of progression to type 2 diabetes,
decrease in blood pressure and plasma lipid levels) and
mortality.
Most guidelines have incorporated a “complications cen-
tric approach” for management of obesity rather than a pre-
set decline in body weight. The therapeutic endpoint is
improvement of obesity-related complications leading to
improved patient health and quality of life [14, 15].
Initial treatment includes lifestyle therapy which is the
cornerstone of all weight-loss interventions (see Fig. 9.1). An
evidence-based comprehensive lifestyle therapy for treat-
ment of obesity includes three components provided by a
trained interventionist (e.g., exercise specialists, registered
dieticians, psychologists, health counselors). The evidence
supporting the efficacy of lifestyle intervention or behavioral
modification is supported by data from two large random-
ized clinical trials which have shown that even modest
weight loss of 5–10% has a significant impact on the meta-
bolic disturbances associated with obesity [16, 17]. The three
main components are:
• Reduced calorie diet
• Physical activity
• Behavior modification to facilitate adherence to diet and
activity
G. Goswami and J.S. Ruddock
173
Diet
To achieve weight loss, an energy deficit is required, and
therefore reducing total energy (caloric) intake (500–750 kcal
daily deficit) should be the main component of any weight-
loss intervention. The meal plan should be individualized
based on personal and cultural preferences. Various types of
diets such as Mediterranean, DASH, low-carb, low-fat, volu-
metric, high–moderate-protein, vegetarian, macronutrient-
targeted, and the AHA-style Step 1 diet have been studied.
Several randomized clinical trials have shown similar weight
loss on diets with different macronutrient composition [18–21].
Diet effectiveness is more related to adherence to the diet
than the diet composition. A very low-calorie diet (≤800 kcal)
is an option in select patients and requires medical supervi-
sion [11].
With dietary intervention in overweight and obese adults,
average weight loss is maximal in 6 months, with smaller
losses maintained for up to 2 years during tapering of treat-
ment and follow-up [22].
Physical Activity
The typical prescription included in a lifestyle intervention is
as follows [11]:
• Aerobic physical activity (such as brisk walking) progress-
ing 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
Higher levels of physical activity, approximately 200–
300 min/week, are recommended to maintain lost weight or
minimize weight gain in the long term (>1 year). A combina-
tion of aerobic and resistance is better than either alone.
9. Obesity
174
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 life-
style 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/m
2
, without complica-
tions in whom lifestyle therapy fails to achieve weight-loss
goals
• In individuals with a BMI ≥27 kg/m
2
, with one or more
complications in whom lifestyle therapy fails to achieve
weight-loss goals
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 [23]. In selecting the optimal
weight-loss medication for each patient, clinicians should
consider differences in efficacy, side effects, cautions, and
the presence of weight-related complications and medical
history. Pharmacotherapy should be offered when poten-
tial benefits outweigh the risks of chronic treatment of the
disease. Medications that contribute to weight gain should
be discontinued if possible. Weight-loss medications
G. Goswami and J.S. Ruddock
175
should be avoided in women who are planning pregnancy.
It is recommended that weight-loss medications be dis-
continued after 12 weeks if weight loss does not exceed
5% of body weight.
Weight-loss medications approved by the FDA for the use
in the treatment of obesity are orlistat (Xenical Alli): phentermine/
topiramate extended release combination (Qsymia), lorcase-
rin (Belviq), naltrexone ER/bupropion ER (Contrave), and
liraglutide 3 mg (Saxenda).
See chart 1 for specific information about each drug.
Weight-Loss Surgery
In obese adults, bariatric surgery is more effective than con-
ventional medical treatment, lifestyle intervention, or medi-
cally 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
was a 24% reduction in overall mortality, obesity-related
morbidity (e.g., decreased incident rates of diabetes, hyper-
tension, dyslipidemia), and improvements in quality of life in
the bariatric surgery group compared with the conventionally
treated group [24].
Surgical intervention is indicated for patients with:
• BMI of ≥40 kg/m
2
who have failed comprehensive lifestyle
therapy and pharmacological means
• BMI of ≥35 kg/m
2
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
Though evidence is limited, there may be benefit from
surgical interventions for patients with diabetes or metabolic
syndrome with a BMI of 30–34.9 kg/m
2
[11].
The procedures that are commonly used include:
9. Obesity
176
• Laparoscopic adjustable gastric banding
• Laparoscopic sleeve gastrectomy
• Roux-en-Y gastric bypass
See chart 2 for more information about common surgical
options.
Long-term follow-up after uncomplicated bariatric surgery:
Patents who have undergone bariatric surgery need lifelong
follow-up visits. Follow-up with a multidisciplinary team
consisting of the bariatric surgeon, nurses, registered dieti-
cian, 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 [25].
Clinical Pearls
1. Undesirable terms such as “heaviness,” “fat,” “large size,”
“excess fat,” and “fatness” should be avoided when
addressing issues regarding weight.
2. Lifestyle modification is the foundation of all treatment
algorithms.
3. 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.
4. Obesity is a chronic disease and requires ongoing treat-
ment. Patients will have varying motivation and adherence
and will need ongoing encouragement.
5. 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 clinically
significant and may take 6 months or more to accomplish.
G. Goswami and J.S. Ruddock
177
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 be sensitive and non-
judgmental in your approach to all conversations regarding
weight management.
Medications are FDA approved for the chronic long-term
treatment of obesity and can be prescribed in the appropriate
patient.
Surgery is effective and safe in appropriately selected
patients (Tables 9.3 and 9.4).
1. Measure height, weight and BMI
Measure waist circumference for
patients with BMI 25 to <35 kg/m
2
Thorough history and physical exam
Laboratory evaluation
25 – 29.9 – overweight
30 – 34.9 – Class I Obesity
35 – 34.9 – Class II Obesity
≥ 40 – Class III Obesity
BMI ≥ 30 kg/m
2
or
BMI ≥ 40 kg/m
2
or
BMI ≥ 27 kg/m
2
+ Obesity
Men ≥ 40 in/102 cm , Women ≥ 35 in/88 cm
BMI – Body mass index in kg/m
2
BMI ≥ 35 kg/m
2
+ Obesity related
complications
related complications
Recommendations for waist circumference cut-offs values may vary based on ethnicity
Stratify BMI Category
TREATMENT OPTIONS
PHARMACOTHERAPY
BARIATRIC SURGERY
COMPREHENSIVE
LIFESTYLE
INTERVENTION
2.
3.
4.
Fig. 9.1 Evaluation of a patient with increased weight
9. Obesity
Table 9.3 Weight-loss medications: An overview
Medication (dosing) Mechanism of action
% Total body
weight loss Side effects Contraindications
Orlistat (Xenical) 120 mg
PO TID before meals
Over-the-counter 60 mg
PO TID before meals
Orlistat induces weight
loss by blocking dietary
absorption of fat
1 year—
4.0%
4 year—
2.6%
Steatorrhea, fecal
urgency, incontinence,
flatulence, oily spotting,
frequent bowel
movements, abdominal
pain, headache
Pregnancy and
breastfeeding, chronic
malabsorption syndrome,
cholestasis, oxalate
nephrolithiasis
Phentermine/topiramate ER
(Qsymia)
Starting dose: 3.75/23 mg
PO QD for 2 weeks
Recommended dose:7.5/46 mg
PO QD
Escalation dose: 11.25/69 mg
PO QD
Maximum dose: 15/92 mg
PO QD
Topiramate is an
anticonvulsant, which
has been shown to
increase weight loss in
obese patients
Phentermine is a
norepinephrine-
releasing agent
1 year—
6.6–7.5%
Headache, paresthesia,
insomnia
Decreased bicarbonate,
xerostomia, anxiety,
depression, constipation,
dizziness, nausea
Pregnancy and
breastfeeding (topiramate
teratogenicity)
Concomitant monoamine
oxidase inhibitor
(MAOI) use within
14 days, hyperthyroidism,
glaucoma, cardiovascular
disease or history
Lorcaserin (Belviq) 10 mg
PO BID
Decreases food intake
and promote satiety
by acting as a selective
agonist to the serotonin
5HT2C receptors on the
proopiomelanocortin
neurons of the
hypothalamus
1 year—
3–3.6%
2 years—
3.1%
Headache, nausea,
dizziness, fatigue,
xerostomia, dry
eye, constipation,
diarrhea, back pain,
nasopharyngitis,
hyperprolactinemia
Pregnancy and
breastfeeding
Creatinine clearance <30
History of depression
Naltrexone ER/bupropion ER
(Contrave)
Dose titration:
Week 1:
1 table (8/90 mg) PO QAM
Week 2:
1 table (8/90 mg) PO BID
Week 3:
2 tabs (total 16/180 mg) QAM
and 1 tab (8/90 mg) Q HS
Week 4:
2 tabs (total 16/180 mg) PO QHS
Bupropion is a mild
reuptake inhibitor
of dopamine and
norepinephrine
Naltrexone, an opioid
antagonist
1 year—
4.2–5.2%
Nausea, headache,
insomnia, vomiting,
constipation, diarrhea,
dizziness, anxiety,
xerostomia
Pregnancy and
breastfeeding, uncontrolled
hypertension, seizure
disorder, concomitant
MAOI (within 14 days),
long-term opioid or
opiate agonists use or
acute opiate withdrawal,
anorexia nervosa
Liraglutide 3 mg—Saxenda
Titrate dose weekly by 0.6 mg as
tolerated up to a maximum dose
of 3 mg subcutaneously daily
Long-acting GLP-1
(glucagon-like peptide)
analog
1 year—
5.6%
Nausea, vomiting,
diarrhea, constipation,
headache, dyspepsia,
increased heart rate
Pregnancy and
breastfeeding, personal or
family history of medullary
thyroid cancer, pancreatitis,
acute gall bladder disease,
gastroparesis
180
Table 9.4 Surgical techniques and outcomes [26, 27]
Weight
loss
Long-term complications
>30 days post-surgery
Comorbidity remission outcome
(estimates in % from RCT)
Gastric
bypass
60–85% Dumping syndrome
Marginal or gastrojejunal
ulcers
Cholelithiasis
Nephrolithiasis
Depression
Mortality ≤30 days—0.08% (0.01–0.30), n = 934
Mortality >30 days—0.39% (0.01–0.86), n = 954
Complication rates—21(12–33), n = 649
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
Adjustable
gastric band
45–55% Cholelithiasis Mortality ≤30 days—0.11 (0.01–0.50), n = 743
Mortality >30 days—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
Dyslipidemia remission rates—39.9 (4.69–87.0), n = 132
Sleeve
gastrectomy
55–80% Stenosis leading to gastric
outlet obstruction
Cholelithiasis
Mortality ≤30 days—0.50 (0.01–3.88), n = 40
Mortality >30 days—6.00 (0.00–100.00), n = 40
Complication rates—13 (0.7–44), n = 137
a
Diabetes remission rate—NA
a
Hypertension remission rate—NA
a
Dyslipidemia remission rate—NA
a
Not enough long-term data was available for sleeve gastrectomy remission rates in the analysis
G. Goswami and J.S. Ruddock