Foreword: Obesity. Preface: Obesity: Guidelines, Best Practices, New Research

Transcription

1 Obesity Foreword: Obesity Anat Ben-Shlomo and Maria Fleseriu xiii Preface: Obesity: Guidelines, Best Practices, New Research Caroline M. Apovian and Nawfal W. Istfan xvii Guidelines for Obesity Management 501 Donna H. Ryan This article addresses current best practices in obesity management, primarily through the discussion of 5 documents guidelines: those sponsored by the US National Institutes of Health and the AHA/ACC/TOS, ENDO, ASBP, AACE, and the United Kingdom s NICE. Common to all of these reports is the emphasis on addressing weight management as a pathway to prevention and optimal management of obesity-associated comorbidities (ie, type 2 diabetes and cardiovascular diseases). No one of these documents fits all needs; all have a place. Furthermore, no one of these documents is final. As knowledge advances, all of the documents will require updating. Regarding Obesity as a Disease: Evolving Policies and Their Implications 511 Theodore K. Kyle, Emily J. Dhurandhar, and David B. Allison In 2013, the American Medical Association recognized obesity as a complex, chronic disease requiring medical attention. Defining obesity as a disease is a very public process, largely driven by expectation of costs and benefits. Although the public has been slow to embrace this definition, evidence is emerging for broader awareness of influencing factors beyond personal choice. This decision seems to be working with other factors to bring more access to care, less blame for people with the condition, and more favorable conditions for research to identify effective strategies for prevention and clinical care to reduce the impact. Pharmacotherapy for Obesity 521 Katherine H. Saunders, Alpana P. Shukla, Leon I. Igel, Rekha B. Kumar, and Louis J. Aronne Successful treatment of obesity requires a multidisciplinary approach including diet, exercise and behavioral modification. As lifestyle changes are not sufficient for some patients, pharmacologic therapies should be considered as adjuncts to lifestyle interventions. In this article, we review clinical indications, mechanisms of action, dosing/administration, side effects, drug interactions and contraindications for the six most widely prescribed obesity medications. We also summarize the efficacy data from

2 viii phase 3 trials which led to drug approval. As multiple agents are sometimes required for clinically significant weight loss, the future of obesity medicine will likely involve combinations of agents in addition to behavioral counseling. Potential Mechanisms Mediating Sustained Weight Loss Following Roux-en-Y Gastric Bypass and Sleeve Gastrectomy 539 Janine M. Makaronidis and Rachel L. Batterham Bariatric surgery is the only effective treatment for severe obesity. Rouxen-Y gastric bypass (RYGB) and sleeve gastrectomy (SG), the most commonly performed procedures, lead to sustained weight loss, improvements in obesity-related comorbidities and reduced mortality. In humans, the main driver for weight loss following RYGB and SG is reduced energy intake. Reduced appetite, changes in subjective taste and food preference, and altered neural response to food cues are thought to drive altered eating behavior. The biological mediators underlying these changes remain incompletely understood, but changes in gut-derived signals, as a consequence of altered nutrient and/or biliary flow, are key candidates. Type 2 Diabetes Treatment in the Patient with Obesity 553 Steven K. Malin and Sangeeta R. Kashyap Lifestyle modification is the cornerstone treatment of type 2 diabetes in the obese patient, and is highly effective at promoting glucose regulation; however, many individuals struggle over time to maintain optimal glycemic control and/or body weight with lifestyle modification. Therefore, additional therapeutic approaches are needed. Pharmacologic interventions have shown promising results for obesity-related diabetes complications. Not surprisingly though lifestyle modification and pharmacology may become ineffective for treating diabetes over time. Bariatric surgery is considered by some, but not all, to be the most effective and durable treatment for combating obesity. In fact many patients with type 2 diabetes have normalized glucose concentrations within days, postoperation. Taken together, treatment of obesity in the patient with type 2 diabetes requires a multi-faceted approach. Behavioral Treatment of the Patient with Obesity 565 Naji Alamuddin and Thomas A. Wadden Advisory panels encourage persons with obesity to lose 5% to 10% of body weight, which can be achieved with dietary change, increased physical activity, and behavioral therapy. Patients participate in weekly individual or group treatment sessions delivered in-person or by telephone. Large-scale trials have demonstrated the effectiveness of this approach, with resulting improvement in cardiovascular disease risk factors. Weight regain is common. Several strategies improve weight loss maintenance, including monthly or more frequent follow-up with an interventionist. Digitally-delivered approaches are promising because they have the potential to reach more individuals.

3 ix The Role of Macronutrient Content in the Diet for Weight Management 581 George A. Bray and Patty W. Siri-Tarino Diets to treat obesity have been in existence since Hippocrates treated obesity some 2500 years ago. There are currently a wide variety of diets and a common misconception that a single magical diet can cure overweight and obesity. Systematic reviews and meta-analyses indicate that all diets work when adhered to and that initial weight loss can predict the amount of weight lost and maintained for up to 4 years. Individual preferences are thus key in selecting a diet. There are emerging data pinpointing genetic variability in the metabolic responses to variation in macronutrient intake. Brown and Beige Adipose Tissue: Therapy for Obesity and Its Comorbidities? 605 Anny Mulya and John P. Kirwan Overweight and obesity are global health problems placing an everincreasing demand on health care systems. Brown adipose tissue (BAT) is present in significant amounts in adults. BAT has potential as a fuel for oxidation and dissipation as heat production, which makes it an attractive target for obesity therapy. BAT activation results in increased energy expenditure via thermogenesis. The role of BAT/beige adipocyte activation on whole body energy homeostasis, body weight management/regulation, and whole body glucose and lipid homeostasis remains unproven. This paper reviews knowledge on brown/beige adipocytes in energy expenditure and how it may impact obesity therapy and its comorbidities. Genetics of Bariatric Surgery Outcomes 623 Olivier F. Noel, Christopher D. Still, and Glenn S. Gerhard Outcomes after bariatric surgery can vary widely and seem to have a significant genetic component. Only a small number of candidate gene and genome-wide association studies have analyzed bariatric surgery outcomes. The role of bile acids in mediating the beneficial effects of bariatric surgery implicate genes regulated by the farnesoid X receptor transcription factor. Leptin and Hormones: Energy Homeostasis 633 Georgios A. Triantafyllou, Stavroula A. Paschou, and Christos S. Mantzoros Leptin, a 167 amino acid adipokine, plays a major role in human energy homeostasis. Its actions are mediated through binding to a leptin receptor and activating the JAK-STAT3 signal transduction pathway. It is expressed mainly in adipocytes, and its circulating levels reflect the body s energy stores in adipose tissue. Recombinant methionyl human leptin has been FDA approved for patients with generalized non-hiv lipodystrophy and for compassionate use in subjects with congenital leptin deficiency. The purpose of this review is to outline the role of leptin in energy homeostasis, as well as its interaction with other hormones.

4 x Bariatric Surgery: Overview of Procedures and Outcomes 647 Dan E. Azagury and John Magaña Morton Bariatric surgery is the most efficient and long-lasting weight loss therapy available. Its safety has improved more than tenfold over the last decade. With the advent of laparoscopy, mortality rates of are now under 1 per 1400 cases in accredited centers. Gastric bypass reduces diabetesrelated mortality by 92% over 7 years and long lasting remission has been demonstrated in observational studies covering >10,000 patients and multiple randomized control trials. The benefit of bariatric surgery on diabetes is so substantial that these procedures should be considered in all type 2 diabetic patients with a BMI > 35 kg/m 2. Medical Devices in the Treatment of Obesity 657 Julietta Chang and Stacy Brethauer Obesity continues to be a growing epidemic worldwide. Although bariatric surgery remains the most effective and durable treatment of obesity and its comorbidities, there is a need for less invasive yet efficacious weight loss therapies. Currently the Food and Drug Administration has approved two endoscopically placed intragastric balloon devices and a surgically placed vagal blockade device. Another device that holds promise, particularly for the treatment of type 2 diabetes, is the endoscopically placed duodenojejunal bypass sleeve. This article reviews the indications and current data regarding results for these devices. Update on Adolescent Bariatric Surgery 667 Nirav K. Desai, Mark L. Wulkan, and Thomas H. Inge Childhood obesity remains a significant public health issue. Approximately 8% of adolescent girls and 7% of adolescent boys have severe (class 2) obesity. Adolescent severe obesity is associated with numerous comorbidities, and persists into adulthood. Bariatric surgery is the most effective treatment available, resulting in major weight loss and resolution of important comorbid conditions. Clinical practice guidelines for pediatric obesity treatment recommend consideration of surgery after failure of behavioral approaches. Careful screening and post-operative management of patients by a multidisciplinary team is required. Long-term studies are needed to assess the impact of adolescent bariatric surgery. The Psychosocial Burden of Obesity 677 David B. Sarwer and Heather M. Polonsky Obesity is associated with several comorbidities, including cardiovascular disease, type 2 diabetes, sleep apnea, osteoarthritis, and several forms of cancer. Obesity and its comorbidities also come with a significant psychosocial burden, impacting numerous areas of psychosocial functioning. The evaluation of psychosocial functioning is an important part of the assessment and treatment planning for the patient with obesity. This article provides an overview of the psychosocial burden of obesity. It also describes the psychological changes typically seen with weight loss. A particular focus is on the psychosocial functioning of individuals with extreme obesity who present for and undergo bariatric surgery.

5 xi Energy and Nutrient Timing for Weight Control Does Timing of Ingestion Matter? 689 Megan A. McCrory, Ayla C. Shaw, and Joy A. Lee Over the past 40 years, meal skipping and snacking in adults in the United States has increased, and currently most eating occasions occur later in the day than previously. Whether these changes have played a causal role in the obesity epidemic is poorly understood. Observational studies are largely inconclusive due to methodological limitations. Experimental evidence does not support a causal role for eating frequency, or breakfast skipping in weight control. Emerging evidence suggests that eating irregularity and eating later in the day may be detrimental for weight control, but more studies are needed. This article summarizes studies and highlights areas needing attention. Index 719