1. Scott D. Isaacs, MD, FACP, FACE
Weight Management
Scott D. Isaacs, MD, FACP, FACE
(404)

2. U.S. Prevalence of Overweight and Obesity
Ogden, CL. JAMA. 2014;311(8):

3. Prevalence of Obesity Among U.S. Adults, 2011

4. Prevalence of Obesity Among U.S. Adults, 2012

5. Prevalence of Obesity Among U.S. Adults, 2013

6. Prevalence of Obesity Among U.S. Adults, 2014

7. Definition of Obesity
Weight Category BMI (kg/m2) Underweight < 18.5 Healthy weight > 18.5 and < 25 Overweight > 25 and < 30 Obesity > 30 Obesity class I > 30 and < 35 Obesity class II > 35 and < 40 Obesity class III > 40

8. Stigma: Obesity is Not a Disease Because it is Behavior Induced
Behavior induced diseases:
Alcoholic liver disease
Sexually transmitted disease
Lung cancer
Fractures
Addiction

9. Why is Obesity a Disease?
Physical changes (adiposity)
Metabolic changes (adiposopathy)
Psychological changes

10. Obesity is a Disease
Cleveland Clinic 10th Annual Obesity Summit

11. Medical Complications of Obesity
Biomechanical Complications
Other Complications
Sleep Apnea
Pi-Sunyer X. The medical risks of obesity. Postgrad Med Nov;121(6):21-33.
Depression
Dyslipidemia
Hypertension
Osteoarthritis
Cancer
Prediabetes
Stress
Incontinence
Asthma
NAFLD
PCOS
Diabetes
Gallbladder Disease
GERD
Immobility/
Disability
Cardiovascular disease
Metabolic Complications

12. Therapeutic Weight Loss

13. Obesity Results from Energy Imbalance

14. Obesity is a Complex and Multifactorial Disease

15. The Hypothalamus Plays a Key Role in Appetite Regulation

16. Multiple Hormones Influence Hypothalamic Neurons and Appetite Regulation

17. Gut Hormones Play a Key Role in Hunger and Satiety

18. Physiologic and Metabolic Response to Weight Loss Drives Weight Regain

19. Long-Term Persistence of Hormonal Adaptations to Weight Loss
Sumithran. New Engl J Med 2011; 365:

20. Metabolic Response Defends the Set-point
Maintenance of body weight loss is met with a disproportionate decrease in metabolic rate (decreased energy expenditure and increased muscle efficiency)
Following a 10% weight loss:
24 hour energy expenditure decreases by > 20%
Non-resting energy expenditure decreases by > 30%
Skeletal muscle work efficiency increases by > 20%
Sumithran. New Engl J Med 2011; 365:

21. Biggest Loser Study

22. Biggest Loser Study

23. Biggest Loser Study Danny Cahill 46 years old Now, 295 pounds
Metabolic rate: now burns fewer calories a day than would be expected for a man his size.
New York Times, May 7,
430 pounds
191 pounds

24. Persistent metabolic adaptation 6 years after “The Biggest Loser” competition
Daily body weight changes in the individual subjects (thin lines) and the mean linear weight change (thick line) over the 2 weeks before the follow-up measurements 6 years after “The Biggest Loser” competition.
Obesity. Volume 24, Issue 8, pages , 2 MAY 2016 DOI: /oby
Individual (•) and mean (gray rectangles) changes in (A) body weight, (B) fat‐free mass, and (C) fat mass at the end of “The Biggest Loser” 30‐week weight loss competition and after 6 years. Horizontal bars and corresponding P values indicate comparisons between 30 weeks and 6 years. *P < 0.05 compared with baseline.
IF THIS IMAGE HAS BEEN PROVIDED BY OR IS OWNED BY A THIRD PARTY, AS INDICATED IN THE CAPTION LINE, THEN FURTHER PERMISSION MAY BE NEEDED BEFORE ANY FURTHER USE. PLEASE CONTACT WILEY'S PERMISSIONS DEPARTMENT ON OR USE THE RIGHTSLINK SERVICE BY CLICKING ON THE 'REQUEST PERMISSIONS' LINK ACCOMPANYING THIS ARTICLE. WILEY OR AUTHOR OWNED IMAGES MAY BE USED FOR NON-COMMERCIAL PURPOSES, SUBJECT TO PROPER CITATION OF THE ARTICLE, AUTHOR, AND PUBLISHER.

25. Persistent metabolic adaptation 6 years after “The Biggest Loser” competition
Obesity. Volume 24, Issue 8, pages , 2 MAY 2016 DOI: /oby
Individual (•) and mean (gray rectangles) changes in (A) resting metabolic rate and (B) metabolic adaptation at the end of “The Biggest Loser” 30‐week weight loss competition and after 6 years. Horizontal bars and corresponding P values indicate comparisons between 30 weeks and 6 years. *P < compared with baseline.
IF THIS IMAGE HAS BEEN PROVIDED BY OR IS OWNED BY A THIRD PARTY, AS INDICATED IN THE CAPTION LINE, THEN FURTHER PERMISSION MAY BE NEEDED BEFORE ANY FURTHER USE. PLEASE CONTACT WILEY'S PERMISSIONS DEPARTMENT ON OR USE THE RIGHTSLINK SERVICE BY CLICKING ON THE 'REQUEST PERMISSIONS' LINK ACCOMPANYING THIS ARTICLE. WILEY OR AUTHOR OWNED IMAGES MAY BE USED FOR NON-COMMERCIAL PURPOSES, SUBJECT TO PROPER CITATION OF THE ARTICLE, AUTHOR, AND PUBLISHER.

26. Biology Defends the Set Point

27. Treatment of Obesity

28. Management of Obesity Step therapy:
Energy deficit meal plan
Increased physical activity
Behavioral modification
Anti-obesity medications & supplements
Devices
Surgery
Therapeutic lifestyle changes combined with any treatment modality enhances weight loss

29. Patient Expectations for Weight Loss
Dream weight -37%
Happy weight %
Acceptable weight -24%
Disappointed weight -15%
Foster & Wadden et al. J Consult Clin Psychol Feb;65(1):79-85.

30. Efficacy of Currently Available Treatments
Dream weight 37%
Improvement in comorbidities 5-10% 0% 5%
10%
15%
20%
25%
30%
35%
Meds + Lifestyle
Lifestyle
Surgery

31. Risks and Efficacy Lower risk Lower efficacy Higher efficacy
Diets
VLCD
Pharma
Devices*
Lower efficacy
Higher efficacy
Lap
band
Sleeve
Endoluminal gastric sleeve, gastric balloon, and vagal stimulator
VLCD = very low calorie diet
Jensen MD, J Am Coll Cardiol. 2013;pii:S (13) print/368664
Roux-en-Y bypass
BPD-DS
Higher risk

33. Therapeutic Lifestyle Change (aka Behavior Modification)
Set realistic achievable goals
Individualized
5-10% of body weight in 4-6 months
Specific behavior goals (e.g. I will walk at lunch 3 times a week)
Help patients gradually make changes to dietary patterns that are harmful to their health
Communication should focus on a healthy lifestyle
Encourage “physical activity” over “exercise”

34. Physical Activity
Physical activity alone is rarely effective for weight loss
Getting to and staying at a healthy weight requires a long term PA plan
Physical activity is necessary for long term weight loss and maintenance
>150 minutes/week moderate intensity PA or >75 minutes/week vigorous intensity PA for weight maintenance (more is better)
Devices can be helpful (pedometer, FitBit, Apple watch, etc.)

35. Sitting Less Lowers Mortality

36. Macronutrient Content Does Not Influence Weight Loss

37. Macronutrient Content Does Not Influence Weight Loss

40. Healthier “Meal Pattern”
dairy

43. Rationale for Treatment of Obesity With Medications
Obesity is a chronic disease
Most chronic diseases are treated with medications (ie. diabetes, HTN, hyperlipidemia)
The biochemistry of people with obesity is different than that of lean people
When people with obesity lose weight their biochemistry does not become the same as lean people
Medications change biochemistry

44. Criteria for Using Anti-obesity Medications
BMI > 27 kg/m2 with at least one comorbidity
BMI > 30 kg/m2 with or without comorbidity
Always as an adjunct to an energy-deficit meal plan, increased physical activity and behavior modification.

45. Role of Medications in Weight Loss
They do not work on their own
Medications amplify the effects of behavioral changes to produce consumption of fewer calories
Addition of a medication to a comprehensive weight loss program produces an additive effect

46. Should Pharmacotherapy be Used as an Adjunct to Lifestyle Intervention?
Yes, if patients have a history of struggling to achieve and sustain weight loss.
Yes, if patients meet indications.
Yes, always with lifestyle intervention, because the medications don’t work on their own.

47. The Meds Don’t Work on Their Own It is important to use medication as an adjunct to lifestyle counseling: here’s why
Wadden TA, et al. N Engl J Med 2005;353:2111–2120.
The interventions for the four treatment groups in this 1-year study were:
Sibutramine alone: Sibutramine 5 mg qd titrated to 15 mg qd over 6 weeks, with eight minute visits with their PCP over the course of the study.
Lifestyle modification alone: attended about twenty-nine 90-minute psychologist-led group meetings based on the LEARN (Lifestyle, Exercise,
Attitudes, Relationships, and Nutrition) program over the course of the study
Sibutramine + brief therapy: same as sibutramine alone, plus two treatment manuals, homework assignments, and food-intake and activity records
Combined therapy: combined the interventions described for the Sibutramine alone and Lifestyle alone group. The LEARN program was modified to include sibutramine.

49. Medications Approved for Chronic Weight Management and How They Work
ER: extended release / SR: sustained release / 5HT: serotonin / GABA: Gamma aminobutyric acid / GLP-1: Glucagon-like peptide 1

50. Placebo-subtracted Weight Loss in Patients With and Without T2DM
Naltrexone/ bupropion3,4
32/360 mg ER QD
56 weeks
Orlistat1, mg TID 52 weeks
Lorcaserin5,6 10 mg BID 52 weeks
Liraglutide7,8 3.0 mg QD
56 weeks
PHEN/TPM9,10 7.5/46 mg ER QD
56 weeks
Values are placebo-subtracted and approximated from kg weight reductions where applicable
1. Torgerson et al. Diabetes Care 2004;27:155–61; 2. Berne et al. Diabet Med 2005;22:612–8; 3. Smith et al. N Engl J Med 2010;363:245–56; 4. O’Neil et al. Obesity 2012;20:1426–36; 5. Apovian et al. Obesity (Silver Spring) 2013;21:935–43; 6. Hollander et al. Diabetes Care 2013;36:4022–9; 7. Pi-Sunyer et al. Diabetologia 2014;57:73-OR; 8. Davies et al. Diabetologia 2014;57:39-OR; 9. Gadde et al. Lancet 2011;377:1341–52; 10. Garvey et al. Diabetes Care online September, 2014
Percent weight loss at one year
First, make the point that we always see less weight loss, on average, with diabetics. To be approved, all these drugs had to approach 5% placebo subtracted with loss. The combinations seem to do a bit better. Ricky, ask: Are you surprised Orlistat? Orlistat CAN work. In this study they gave it with a very strong DPP like intervention. This is an important concept. Then show them the categorical data.

52. hCG

53. Supplements for Weight Loss
Myth: products are natural and don’t have side effects
No standardized formulations
Limited studies
No long term studies
No long term outcomes
Safety concerns
No standardized outcomes
Use at your own risk!

54. Devices for Weight Loss
Gastric band
AspireAssist
Gastric balloons
Vagal stimulator

55. Intragastric Balloons
Orbera®
Endoscopic outpatient procedure
Relatively easy to perform
Removed after 6 months
Modest weight loss (~10%)
Reshape

56. Vagal Blockade (VBLOC)
“Pacemaker” for the stomach
Difficult surgery, need expertise
Neuroregulator implanted subcutaneously
Modest weight loss

57. Bariatric Surgery Procedures
(Indication BMI >40 or BMI >35 with comorbidity)

58. Weight Management Obesity is a chronic disease Step therapy includes:
Nutritional changes
Physical activity
Behavioral changes
Anti-obesity medications and supplements
Devices
Surgery
Therapeutic lifestyle changes combined with any treatment modality enhances weight loss

59. Scott D. Isaacs, MD, FACP, FACE
Questions