Management of Obesity

We hosted a Continuing Medical Education (CME) webinar led by Dr. Angela Fitch (MD, FACP, FOMA), Associate Director of Mass General Weight Center and Vice President of the Obesity Medicine Association. She was kind enough to educate webinar attendees on the evaluation of a patient with obesity, share information about different treatment options for obesity, and discuss the manifestations of obesity-related disease in the primary care setting.

We summarized Dr. Fitch's insights below - be sure to watch the webinar here for the key details and tips shared:


1. What is obesity & what is state of obesity in the U.S.? Why is it important to acknowledge?

Obesity is defined as a disease in which excess body fat has accumulated to a level that may have an adverse effect on health with three classes that act as a marker for different stages for types of treatments:

  • Class 1: BMI 30 - 34.9
  • Class 2: BMI 35 - 39.9
  • Class 3: BMI ≥ 40

Obesity is a chronic treatable disease, but is currently undertreated and overlooked. It is estimated that by 2030 over 50% of the adult population will struggle with obesity. Adult obesity is a pediatric disease and there are significant disparities in obesity, particularly in Hispanic and Black populations who have higher rates than the white population. It should be noted that the majority of obesity is driven by genetics, biology, and environmental factors. Furthermore, currently:

  • 65% of patients believe obesity is a disease 
  • 80% of healthcare professionals believe obesity is a disease 
  • 82% of people with obesity 
2. How does a PCP approach a patient regarding obesity?

Dr. Fitch suggested applying the 5As of Obesity Management: Asking, Assessing, Assisting, Agreeing & Advising.

Asking a patient, in a thoughtful, non-stigmatic manner, "I'm concerned by how your weight may be affecting your overall health - have you thought about that as well?" Based on the level of readiness of this response, Dr. Fitch usually asks the patient to track their daily habits and food plan to better assess and assist the patient on the best next steps for a clinical workup (follow-up appointment) and determining the patient's health status and the appropriate treatment.

3. Where should a PCP start to access the best obesity treatment options for their patients?

Dr. Fitch's rule of thumb for a "good body fat percentage" for men and women is < 30% (men are a little bit leaner because of their testosterone levels). She also shared that "for every 10 lb of weight that is lost, you can expect 7 lbs of fat lost  and 3 lbs of lean muscle mass lost." Measuring body fat can be done through different technologies, such as the Bioimpedance mechanism, the most practical, and the DEXA, the gold standard scale.

  • Anti-obesity medications' objectives:
    • Treat disease
    • Adiposopathy or sick fat disease (SFD) → metabolic syndrome created by the excess storage of fat
    • Fat mass disease (FMD)
    • Facilitate management of eating behavior
    • Slow progression of weight gain/regain
    • Improve the health, quality of life, and body weight of the patient with overweight 

Dr. Fitch has found that the combination of medication, behavior modification and meal replacements have the greatest effect on weight loss, while medication alone has the smallest effect on weight loss.

4. How should a PCP access for treatment goals?
What people want from a goal standpoint is either appearance change or remission of disease.
  • > 5% weight loss for diabetes prevention
  • >10% weight loss for NAFLD resolution
  • >15-20% weight loss for diabetes remission
5. What are the different obesity phenotypes?

Dr. Fitch emphasized that Behavioral, Medical and Societal are the three key phenotypes for obesity assessment:

  • Behavioral
    • Depressed emotional eating
    • Binge eating/all or nothing thinking
    • ADHD
    • Addictive eating
    • Chaotic eating
    • Anxious/PTSD comfort eating
    • Decreased physical activity
    • Poor sleep
    • Poor self care
  • Medical
    • Diabetes
    • Insulin resistance
    • Testosterone deficiency
    • Insomnia/OSA
    • Medication side effects
    • Orthopedic issues
  • Societal
    • Low income
    • Lack of knowledge
    • Cultural habits and norms

Dr. Fitch advises PCPs to discuss these Set Point Factors with their patients to create a realistic weight management treatment plan:

  • processed diets irregular eating pattern
  • inadequate physical activity
  • inadequate sleep
  • stress
  • weight increasing medications
  • life changes (aging, pregnancy, menopause)

While it is not always linear, Dr. Fitch discussed that there is an Obesity Treatment Pyramid to follow to properly guide and evaluate patients. As health risks and BMI increases, the level of treatment increases, going from lowest health risk to highest health risk of the pyramid: lifestyle modifications for the lowest risk group to prescriptive nutritional intervention to pharmacotherapy to endoscopic procedures and finally, to surgery for the highest risk group.

To learn more about the specific medication and surgical options that Dr. Fitch recommended, watch this webinar.

For full access to this webinar, as well as past CME webinars, please visit rubiconmd.com/cme.

Sources:

  1. Kaplan LM, Golden A, Jinnett K, et al. Perceptions of Barriers to Effective Obesity Care: Results from the National ACTION Study. Obesity. 2017. doi:10.1002/oby.22054.

  2. Scott Kahan, MD, MPH; JoAnn E. Manson, MD, DrPH. Obesity Treatment, Beyond the Guidelines Practical Suggestions for Clinical Practice. 2019. doi:10.1001/jama.2019.2352.

  3. Gelesis100 [Instructions for Use]. Boston, MA: Gelesis; 2019. 2. Greenway FL, et al. Obesity. 2019;27:205-216.