HealthAugust 23, 2022

Overcoming script-writing hesitations in obesity management 

A patient-first approach to obesity management and treatment is crucial for clinicians and family practitioners. 

Like diabetes or heart disease, obesity is a chronic disease — and it should be approached as one. Rather than being curative, destination-based or marked by a specific goal weight, obesity management is a lifelong process. And while diet plays an important role, medication and surgical interventions should be considered as well

To make the most of obesity treatment strategies, some clinicians may need a shift in mindset to break through certain long-standing stigmas. Such stigmas have driven a historical underutilization of weight management medications, despite evidence showing the long-term efficacy and safety of pharmacologic strategies.

That’s the perspective of Jonathan Q. Purnell, MD, Professor of Medicine and Medical Director of the Interdisciplinary Weight Management Program at Oregon Health Sciences University. In his recent lecture “Medical Management of Obesity,” now available for CME credit on AudioDigest®, Dr. Purnell provides his take on the medical management of obesity, discussing the pathophysiology of weight regulation along with key medications to try.

At a time when more than 40 percent of Americans are obese — and amid mounting evidence that biological signals drive obesity behaviors outside of patients’ control — Dr. Purnell’s insights on the complexities of this chronic disease are worth the listen. We’ve summarized his talk below, but you’ll want to tune in to the full 37-minute lecture and Q&A session to learn more about this and other AudioDigest® internal medicine topics.

A patient-first approach to obesity management

Establishing a patient-centric care plan is critical. This includes not just using people-first language when talking to patients — such as saying “person with obesity” instead of “obese person” — but also gathering as much information as possible for the patient’s file.

This extra context can help identify the circumstances surrounding weight gain, such as pregnancy, menopause, or the onset of new medications or diseases. Clinicians should note the patient’s lifetime maximum weight in their file. This way, you’ll always have a reference point for comparison.

Just be careful not to make incorrect correlations that can impact care planning, Dr. Purnell cautions. For example, clinicians sometimes consider depression as a cause of obesity, when it may be the other way around.

The biological drivers of uncontrollable weight gain

Underpinning Dr. Purnell’s lecture is this central point: Weight-gain behaviors are driven by internal biological signals. We can’t control them. They control us.

That point becomes clear as he describes the pathophysiology of weight regulation. In a typical response, you eat a meal. Once your body has taken in calories, your gastrointestinal system secretes gut hormones that convey fullness and satisfaction. These satiety hormones, such as glucagon-like peptide 1, signal the brain to tell us when to stop eating.

But some people experience less secretion of these satiety hormones and decreased suppression of the hunger hormone ghrelin, even when they have consumed enough calories. When that “I’m full” signal never makes it to the brain, patients feel the need to eat more often, leading to weight gain.

Obesity management medications to consider

Weight management medications counteract these biological drivers by amplifying the fullness signal, but not changing the hormones that give off that signal. With stronger satiety, the patient’s appetite becomes more normalized and weight loss more achievable. Because of these mechanics, there can be an effectiveness plateau around 6 to 10 percent below the initial weight. Still, medications are best used long-term.

Patients meet criteria for medication when their body mass index (BMI) is at least 27 with a weight-related comorbidity, especially hypertension, dyslipidemia, or diabetes. If they have no other comorbidities, the BMI threshold goes up to 30.

Currently, four medications have been approved by the U.S. Food and Drug Administration (FDA). These include tetrahydrolipstatin, phentermine plus topiramate, bupropion plus naltrexone, and liraglutide.

Best practices and barriers to obesity treatments

As a general practice, Dr. Purcell recommends starting with lifestyle changes and supporting those behaviors during treatment. Importantly, clinicians should approach medication as a long-term strategy, discontinuing it only for adverse events or for people who are (or want to become) pregnant.

Even so, these recommendations can go against a clinician’s gut instincts — perhaps because of some mistaken perceptions. Dr. Purcell considered these misperceptions a barrier to effective treatment, such as the belief that phentermine alone has the same safety concerns of fenfluramine/phentermine or “fen-phen” (it doesn’t) or that there’s a perceived need for frequent follow-up that can overburden a general or family practice (research suggests otherwise).

Dr. Purcell busts these myths and more in his full audio lecture, pointing to the positive effect that scripts can play in obesity management.

Read More About Managing Obesity With Medications On AudioDigest
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