Disclosures Behavioral and Medical Approaches for Obesity Treatment Scott Kahan, MD, MPH Director, National Center for Weight and Wellness Clinical Director, Strategies To Overcome and Prevent (STOP) Obesity Alliance George Washington University kahan@gwu.edu I have served on advisory boards, consulted to, spoken for, or received research funding from: Vivus Eisai Novo Nordisk Takeda Board of Directors: American Board of Obesity Medicine Book royalties: Johns Hopkins University Press, Lippincott, Williams & Wilkins, Wolters-Kluwer Agenda Provider behaviors Start the conversation Redefine success Address expectations Attention to weight gain as medication effect Patient behavioral strategies Self monitoring Meal replacement options Ongoing interaction Pharmacotherapy options Start the Conversation Most physicians don t counsel about obesity 1999: 41% advised to lose weight 211: 66% told they had excess weight Most patients don t consider approaching their physicians for help with weight/obesity Galuska DA, et al. JAMA 1999;282:176-8. Post RE, et al. Arch Intern Med. 211;171:316-21. 1
Redefine Success 3234 adults with obesity and pre-diabetes Placebo Metformin Lifestyle Knowler WC, et al. NEJM 22. Address Expectations Consider Weight Gain as Medication Adverse Effect 1 99. (33% loss) (31% loss) (2% loss) (17% loss) Mean Weight (kg) 7 2 66. 68 74.2 81.9 Starting weight Current Goal "Happy" "Acceptable" "Disappointed" Foster GD, et al. J Consult Clin Psychol. 1997;6:79-8. Kushner RF, Kahan S. Ob Consults 214;2(1):7 2
Patient Behavioral Strategies Self-monitoring Meal replacement products Ongoing interaction and support Multimodal behavioral trial: Look AHEAD Self-Monitoring Weight Loss (lbs) 3 Records Kept 1 to 2 Records Kept 2 2 1 1 3 to 4 Records Kept + Records Kept Month 3 Month 6 Month 9 Month 12 Steinberg DM, et al. Obesity 213;21(9):1789-97. JADA, 1991. Meal Replacements vs Low Calorie Diet Ongoing Guidance and Support 2 2 Weight Loss (lbs) 1 1 Reduced Calorie Diet Meal Replacements Weight Loss (%) 4 6 8 1 12 14 No maintenance visits Maintenance visits 3 months 12 months 16 18 Months 1 1 Heymsfeld, et al. Int J Obesity 23, 27, 37-49. Perri, et al. JCCP 1988;6:29-34. 3
Look AHEAD Trial Look AHEAD Trial Counseling, support, and guidance Individual counseling and group classes Weekly initially, reduced thereafter Self-monitoring Calorie-reduced diet 12-1 kcal/day if <2 lb 1-18 kcal/day if >2 lb Portion-controlled meal replacements 3/day in months 1-4, reduced thereafter Physical activity Gradual escalation to 17 min/week and 1, steps/day Look AHEAD Research Group. Diab Care 27;3:1374-83.. Look Ahead Research Group. Arch Intern Med 21;17(17):166-7. Louisiana Obese Subjects Study FDA-Approved Obesity Pharmacotherapy Options Phentermine (and other noradrenergic agents) Orlistat(Xenical/Alli) Lorcaserin (Belviq) Phentermine/topiramate ER (Qsymia) Bupropion SR/naltrexone SR (Contrave) Ryan DH, et al. Arch Intern Med, 21. 4
Newer Pharmacotherapy Options Lorcaserin Selective HT2c receptor agonist Increases satiety Schedule IV Single FDAapproved dose BID dosing Phentermine- Topiramate ER Phentermine: NE release; blunts appetite Topiramate: Carbonic anhydrase inhibitor, GABA, other; prolongs satiety Schedule IV 3.7/23 mg fixeddose increments Bupropion SR- Naltrexone SR Bupropion: DA/NE reuptake inhibitor; activates POMC neurons, leading to decreased appetite Naltrexone: opioid receptor antagonist; blocks autoinhibition of POMC to amplify bupropion effect 8/9 mg increments Pharmacotherapy Key Points Each has average of -1+% weight loss, depending on population, analysis, etc Each leads to intermediate outcome improvements Each has distinct responders and non-responders Improved outcomes with combination treatment Chronic use is standard All pregnancy category X Outcomes by Responder Status Combination Therapy Placebo alone Medication alone Lifestyle modification alone Combined therapy Smith SR, et al. Obesity. 214; Jul 18. doi: 1.12/oby.2841. Adapted from Wadden, et al. NEJM, 2.
Thank you kahan@gwu.edu www.abom.org 6