November 6, 2023
5 minutes of reading
Key takeaways:
- Intensive lifestyle medicine should be the basis of care for all people with obesity.
- Anti-obesity medications and bariatric surgery may be used as adjunctive therapies for indicated patients.
DENVER — Lifestyle medicine is a central part of obesity treatment, including for adults who receive anti-obesity medications or undergo bariatric surgery, according to three speakers at the Lifestyle Medicine Conference.
“Whether you treat obesity with surgery, whether you consider treating obesity with medication, lifestyle medicine is really the basis”, Deepa Sannidhi, MD, DipABLM, DipABOM, associate clinical professor in the Department of Family Medicine at the University of California, San Diego (UCSD), associate director of the UCSD/San Diego State University General Preventive Medicine Residency Program, clinical director of the Center for Integrative Medicine Supervised Lifestyle and Integrative Medicine of the UCSD program and the UCSD Center for Advanced Weight Management, and general concentration lead at the Herbert Wertheim School of Public Health, said during a presentation. “Chronic disease guidelines for every condition, including obesity, encourage lifestyle intervention as the first treatment. »
Lifestyle intervention induces weight loss
Sannidhi described six pillars of lifestyle medicine as defined by the American College of Lifestyle Medicine: regular physical activity, whole foodss, restful sleep, stress management, positive social connection and avoidance of risky substances. She said providers need to consider each person’s circumstances, such as the home they live in or the societal environment, which may contribute to weight gain.
According to a statement from the U.S. Preventive Services Task Force released in 2018, people with obesity should engage in a high-intensity, multicomponent lifestyle intervention. The statement goes on to say that interventions are often not “adequately dosed” to be successful. With proper lifestyle intervention, Sannidhi said, obese people can expect to lose 5 to 10 percent of their body weight.
At Sannidhi Institution, intensive lifestyle intervention is delivered through a shared medical appointment model, where participants attend a group medical visit. After three intake sessions, participants attend 12 sessions over 4 to 6 months. Sessions focus on the six pillars of lifestyle therapy and include time for meditation, sharing experiences, learning about a healthy living topic, interactive discussion on a topic specific and the creation of action plans.
“The idea is to create a program that other clinicians can easily replicate,” Sannidhi said.
Integrate medications into care
Anti-obesity medications may be used as an adjunctive treatment for some people who need to lose weight, according to Michelle Hauser, MD, MS, MPA, FACP, FACLM, clinical associate professor of surgery and medicine at Stanford University School of Medicine, medical director of obesity at the Stanford Lifestyle and Medical Weight Management Center, and obesity medication physician for Move Time at the Palo Alto VA Health Care System. Hauser said anti-obesity drugs should be used as a tool in combination with a healthy diet and physical activity. People who may be prescribed anti-obesity medications include those with a BMI of 30 kg/m2 or more or people with a BMI of 27 kg/m2 at 29 kg/m2 who have comorbidities and have failed to lose at least 5% of their body weight in 3-6 months with comprehensive lifestyle intervention.
“Lifestyle is the first treatment for anyone with obesity,” Hauser said during a presentation. “I like to describe it as part of the ingredients in a recipe. For many people, once they saw me, they tried to change their lifestyle, but it didn’t result in lasting weight loss. We want to improve (lifestyle intervention), but that also means adding (anti-obesity medications).
Before prescribing anti-obesity medications, providers should analyze what medications a person is already taking. Hauser said there are many types of medications that can cause weight gain, and providers should seek to switch obese people to an alternative medication in the same class that is weight-neutral or loss-promoting. weight.
Hauser said anti-obesity drugs can confer 3 to 20 percent weight loss, depending on the class of agent used. Providers should discontinue or change the medication if weight loss is not achieved after 12 weeks of maximum tolerated dose. After starting anti-obesity treatment, providers may also need to change the blood pressure or diabetes medications the person is taking. While a person is receiving obesity medication, providers must monitor their mood, weight, heart rate, blood pressure and blood sugar.
Hauser said the best approach for providers treating people with obesity is to add drug therapy to intensive lifestyle intervention.
“The results I was seeing with lifestyle medicine alone and obesity medicine alone really paled in comparison to the combination of the two,” Hauser said.
Lifestyle Medicine and Bariatric Surgery
For people undergoing bariatric surgery, lifestyle medicine should be integrated throughout the process, according to Kelley Hagerich, MD, MPH, FACP, DABOM, DipABLM, VA Health Care System National Physician Champion and Medical Director of the VA VISN21 Bariatric Surgery Program. Before surgery, a multidisciplinary evaluation should be performed and includes a medical evaluation by a bariatric surgeon, a nutritional evaluation by a registered nutritionist, a physical activity evaluation by a physical therapist or exercise kinesiologist, and a psychological evaluation by a psychologist or other mental health specialist. supplier.
“We need to meet patients where they are in their weight loss journey, even if we don’t necessarily recommend bariatric surgery,” Hagerich said during a presentation. “We want to be able to have an informed discussion with them about weight loss options and be able to discuss the risks and benefits of surgical procedures.”
For nutritional assessment, Hagerich said providers should look at chronological weight history and examine eating behaviors, previous weight loss attempts, life-changing circumstances and whether the person is using obesogenic medications. Body composition and energy requirements should be examined to provide a baseline for adiposity distribution, and nutritional status should be assessed.
People undergoing bariatric surgery should undergo a presurgical preparation procedure to improve postoperative outcomes. This intervention should last 4 to 12 weeks and include nutritional, pulmonary and exercise aspects. The exercise portion should focus on strength and aerobics and be optimized based on a person’s initial functional capacity.
“After any major abdominal surgery, there is a 20 to 40 percent decrease in the patient’s functional capacity in the postoperative period, even in the absence of complications related to the operation,” Hagerich said. “Lower preoperative functional capacity may result in increased morbidity and mortality as well as a prolonged postoperative recovery period.”
For presurgical psychosocial assessment, providers can identify possible contraindications to the procedure and identify strengths and weaknesses to improve surgical outcomes. The medical evaluation before surgery is multifactorial, according to Hagerich, and includes an assessment of substance use, including smoking, marijuana and alcohol.
After surgery, Hagerich said some people may gain weight back or have lost an insufficient amount of weight. In these cases, lifestyle interventions can be incorporated. Providers should ask questions about dietary habits, physical activity, psychological disorders, and motivation, and provide them with the knowledge or skills needed to make changes.
“We need to do a lot more research on how to prevent weight regain, remedy insufficient weight loss and how to treat these conditions,” Hagerich said.
Reference:
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Sannidhi D, et al. Evidence-based lifestyle medicine treatment for adults with obesity: essential skills for lifestyle medicine clinicians. Presented at: LM2023 Lifestyle Medicine Conference; October 29-Nov. 1, 2023; Denver (hybrid meeting).
Disclosures: Hagerich reports having been a speaker for the CASPR group. Hauser and Sannidhi report no relevant financial disclosures.
American College of Lifestyle Medicine
