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Looking Beyond Lifestyle: A Comprehensive Approach to the Treatment of Obesity in the Primary Care Setting
The Journal for Nurse Practitioners xxx (xxxx) xxx
Contents lists available at ScienceDirect
The Journal for Nurse Practitioners journal homepage: www.npjournal.org
Looking Beyond Lifestyle: A Comprehensive Approach to the Treatment of Obesity in the Primary Care Setting Jayme Taylor, MSN, FNP-BC a b s t r a c t Keywords: lifestyle behaviors obesity obesity as a chronic disease obesogenic diseases obesogenic medications pharmacologic treatment of obesity primary care
Obesity is a growing public health concern due to its increased health risks and comorbidities. Currently, the number of those affected is the highest ever seen in United States history. Obesity treatment in the primary care setting is generally focused on the very basic lifestyle modifications of diet and exercise; however, obesity is a complex chronic disease that is often multifactorial and requires modification to areas other than lifestyle behaviors alone. Primary care clinicians often see obesity as too difficult or time consuming to treat in the primary care setting, and due to factors including lack of comfort or familiarity in treatment, low patient adherence, and time constraints, providers often choose to avoid treatment altogether. This report challenges providers to look beyond lifestyle in the assessment and treatment of obesity, and recommendations are given for comprehensive management of obesity in the primary care setting. © 2019 Elsevier Inc. All rights reserved.
Introduction Health care reform is tasking providers to increase focus on the wellness of populations through health maintenance and disease prevention. As a result, issues such as obesity, behavioral health, and substance abuse have become major public health concerns. With the current mode of health care delivery, focusing on these issues can be a somewhat difficult and time-consuming process. This is especially true of obesity itself because this is often an integration of all these public health concerns into a single disease process. Many would argue that obesity is one of the greatest health care concerns affecting Americans today. Therefore, obesity needs to be viewed as a treatable chronic disease process, and there needs to be a greater focus on treatment in the primary care setting. This report aims to provide practical recommendations regarding assessment and treatment of obesity, including lifestyle modifications, treatment beyond lifestyle modifications, and an exploration of common barriers to treatment. Obesity as a Disease Current data indicate that the combined prevalence of overweight and obesity in the United States is 69.2%.1 Many obesity recommendations also apply to those who are classified as overweight; however, for the purpose of this report, I will focus on obesity alone. Obesity is defined by Centers for Disease Control and Prevention as a weight that is higher than what is considered a healthy weight given height. A healthy weight is determined by https://doi.org/10.1016/j.nurpra.2019.09.021 1555-4155/© 2019 Elsevier Inc. All rights reserved.
calculating the body mass index (BMI) as kg/m2. Obesity is defined as a BMI measurement greater than 30 kg/m2. However, this is often broken down further into classes 1 to 3 (Table 1).2e4 These categories are important when discussing treatment, because as with any disease process, the aggressiveness in which to treat obesity should be directed by the severity of the disease. National Health and Nutrition Examination Survey data for 2015 to 2016 reported that nationally, 39.6% of adults and 18.5% of children had a BMI that met criteria for diagnosis of obesity. These represent the greatest numbers ever recorded in US history.3 With the increase in obesity we saw a concurrent growth in obesityrelated diseases such as diabetes, and this growth has resulted in improved awareness among providers. A big win for those seeking better treatment of obesity was in 2013 when the American Medical Association chose to recognize obesity as a complex chronic disease, stating that it requires medical attention just the same as any other chronic disease.3 The Centers for Disease Control and Prevention broadly defines a chronic disease as any condition that lasts 1 year or longer, requires ongoing medical attention, or limits activities of daily living, or both. If we look at it in this broad of a context, then obviously, obesity and its negative effects on the body would meet criteria. Still, others would argue that obesity is but an unfavorable health outcome that is the result of poor lifestyle choices, with no specific symptoms. A risk factor for disease but not a disease itself. This is largely perpetuated by traditional attitudes about obesity stemming from a narrow reference point that presumes that human behavior (ie, eating and lack of physical activity) alone causes
2
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Table 1 Classes of Obesitya Obesity Classification
BMI, kg/m2
Treatment Recommendations
Class 1 Class 2
30 to < 35 35 to < 40
Class 3
40
ILSM, meal replacements, or VLCD. Consider weight loss medications. ILSM, meal replacements, or VLCD. Consider weight loss medications and bariatric surgery if comorbidities. ILSM, meal replacements, or VLCD. Consider weight loss medication and bariatric surgery.
BMI ¼ body mass index; ILSM ¼ intensive lifestyle modification; VLCD ¼ very low-calorie diet. a Table adapted from United States Preventive Services Task Force recommendations for treatment based on BMI and comorbidities and Centers for Disease Control and Prevention classifications of obesity.3,4
obesity. The belief is that poor lifestyle behaviors alone give way to an altered physiology within the body, thus leading to disease. Lee Kaplan recently spoke at a conference through Harvard University’s Institute of Lifestyle Medicine and explained that this is likely an inadequate view of the physiology associated with obesity. He suggests that physiology drives such behaviors, which subsequently lead to defects in metabolism and the body’s regulatory function, thus interfering with health.5 Behavior modification may lead to modest changes, but this does not change the underlying defects in physiology.5 Even the most obesity-savvy health care providers would agree that poor lifestyle behaviors lead to obesity. The purpose of this report is not to argue that obesity is or is not a lifestyle disease but a challenge to look beyond lifestyle in the treatment of obesity. Lifestyle behaviors, such as diet, exercise, treatment of mood issues, stress, and sleep management, are all widely discussed in the treatment of obesity.
Barriers to Treatment One of the greatest challenges that the primary care provider must face in the treatment of obesity is to act as a dietitian, personal trainer, behavioral health specialist, and health coach, all in one. Effective treatment requires continuous attention and reinforcement by the health care provider, and this is simply not feasible in most current working environments. Yet, health care cost reduction goals place more responsibility on the shoulders of the primary care provider in the treatment of such diseases. Of course, a comprehensive multidisciplinary approach would certainly be more effective; however, in many cases, it is not an option. One barrier to treatment is that many providers feel that discussing weight with patients may cause them unnecessary embarrassment. Therefore, many providers are hesitant to initiate this conversation. The Awareness, Care, and Treatment In Obesity MaNagement (ACTION) survey reported that 65% of providers did not address weight with patients due to this fear. However, only approximately 15% of patients reported that they were embarrassed to discuss weight with their providers.6 Some providers feel that this topic is too difficult to address given the time constraints of a traditional office visit. Whereas in truth, a simple 3-minute lifestyle assessment may be enough to determine whether a patient’s nutritional patterns are reasonable, whether the patient is interested in losing weight, and what their emotional and physical obstacles might be. Another provider barrier to success in this area is often bias caused by low patient adherence to treatment plans.6 This often leads to providers feeling as though obesity treatment is a “lost cause” and not worth the effort needed to treat effectively. One factor affecting patient compliance is that there seems to be a “quick fix” mentality among patients. With the inclusion of fad diets that promise big results in short periods of time, it is harder to ensure long-term adherence to dietary changes. Of course, there
are other patient-related barriers as well. One may be a patient’s reluctance to seek assistance in weight management. Many patients may believe their weight is solely their responsibility, and this may prevent them from seeking help.6 Another issue may be that patients do not understand the effect their weight will have on their future health, and therefore do not feel a sense of urgency to approach this topic with their providers. In the ACTION survey, only approximately 54% of patients reported concern with how their future health would be affected by their current weight, whereas 93% of providers reported concerns.6
Diet and Exercise Diet is an area of debate in the treatment of obesity because the list of possible diets to follow is exhausting: keto, Atkins, Ornish, Mediterranean, and vegan, among many others. Yet while all these diets come with their own sets of risks and benefits, the truth remains: there simply is no one diet to rule them all. The goal of dietary counseling in the primary care setting should be focused more on mindfulness of eating. Tools such as calorie counting and journaling are still highly effective tools that often make a difference in the longterm success of dietary modifications.6 Dietary planning should be as individualized as any other treatment and should be focused on the patient needs and disease processes. Use of Medical Nutrition Therapy can be a referral source for the primary care provider, but until that can be arranged, patients should be instructed at the very least on what they should limit or avoid in their diet. Exercise continues to be a mainstay of obesity management; furthermore, inclusion of aerobic and resistance training has been found to have just as significant of an outcome as pharmacologic management in treatment of many disease processes.7 However, physical activity may not lead to better weight loss outcomes initially. In 2012, the National Cancer Institute funded a 12-month study that looked at the effectiveness of lifestyle interventions in obesity management. Study participants were broken into 3 groups: diet alone, exercise alone, and diet and exercise, and participants in these groups lost a mean 7.2 kg, 2.0 kg, and 8.9 kg, respectively.8 That combination diet and exercise is more successful than either diet or exercise alone was not surprising; however, it was somewhat surprising that this was not found superior to diet alone. The researchers felt that this was likely the result of many changes that occur in the body with exercise, including body composition changes. However, many participants also believed in obtaining a reward for certain goal achievements that may have thwarted their weight loss success. For instance, a beginner in a dietary plan may feel that calories burned through exercise could be “free calories” that may be cashed in for a reward, often in the form of a cheat meal.8 This suggests that at least initially, the focus of management should be primarily on diet, although exercise will always remain an important factor in the treatment of obesity and should be instituted once dietary modifications have been well established.
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Stress Management Stress is felt to be a factor in the development of obesity because it often leads to food cravings, overeating, and fat accrual. Although the acute stress response is generally considered an energetically costly activity that serves to mobilize energy stores for immediate use, chronic stress promotes acquisition or redistribution of energy stores, or both, which could result in obesity. The exact mechanism is not clearly understood but is felt to be at least partially related to hormone dysregulation.9 Many hormones play a role in weight management, including glucagon, leptin, ghrelin, and cortisol; however, cortisol is generally considered the primary hormone in the biologic stress response. Increased long-term cortisol levels have been found to contribute to obesity, although not all of these patients will have increased cortisol levels.10 Nonetheless, obesity is also often associated with factors (other than stress itself) that increase cortisol production such as consumption of foods with a high glycemic index and lack of sleep. This suggests a vicious cycle in which glucocorticoid action, obesity, and stress interact and amplify each other, making this one of the most difficult factors to modify in the treatment of obesity.8 Use of behavioral health professionals could help in treatment of patients with underlying mood disorders; however, this can represent an access issue for many areas. Therefore, an easy way to assess for these in the primary care setting is to use tools such as the Patient Health Questionnaire-9 (PHQ 9) and Generalized Anxiety Disorder 7-item (GAD 7) scale. Treatment of mood disorders can lead to better behavior modification and stress reduction.10 Pharmacologic treatment can be difficult because there seems to be an obesogenic quality to many of these medications. Medications like paroxetine hydrochloride and venlafaxine tend to result in a significant weight gain and should be avoided in the high-risk patient, whereas other medications, including bupropion, can aid in weight loss and may be used to treat both mood disorders and maladaptive food behaviors. Nonpharmacologic interventions should be focused on relaxation techniques including meditation, yoga and improved quality of sleep.11 Sleep The recommended duration of sleep for an adult is between 7 and 8 hours per night. However, a recent poll by the National Sleep Foundation showed that only approximately 10% of Americans prioritized sleep over other aspects of their life.12 The average American gets about 6 hours of sleep each night, and many others reported much less than that. Numerous studies have found a significant association between short sleep and obesity risk. This is important because sleep is a modulator of neuroendocrine function and glucose metabolism.9 Lack of sleep can lead to a decrease in glucose tolerance, insulin sensitivity, and leptin levels, with increases seen in cortisol, ghrelin, appetite, and hunger. Leptin and ghrelin are 2 of the most discussed hormones in weight management. Leptin is a hormone that is related to the perception of satiety, whereas ghrelin is known as the “hunger hormone,” both of which are greatly regulated by sleep. Spiegel et al9 analyzed the 24-hour ghrelin profile in sleep and found that sleep resulted in an inhibitory effect on secretion of ghrelin. Sleep has also been felt to affect energy balance, because leptin by itself increases energy expenditure. Therefore, changes in leptin after sleep deprivation can affect both this and caloric intake. When treating obesity in the primary care setting, assessment of sleep duration and quality should be performed at each visit. Reinforcement should be provided for maintenance of good sleep
3
hygiene behaviors with encouragement toward adequate sleep duration. Screening for obstructive sleep apnea (OSA) should be performed initially, which can be quickly done with the Epworth Sleepiness Scale or STOP-BANG (snoring, tired, observed, pressureeBMI > 35 kg/m2, age > 50 years; neck size large; gender) questionnaire. OSA is considered both a consequence of as well as a contributor to obesity. Contributing Diseases and Medications The causative factors of obesity are hard to define because the mechanism by which some diseases could contribute to obesity are often not well defined. This often raises the question, does the disease process cause the obesity or does the obesity create the disease process? Regardless of cause or effect, there does seem to be a strong correlation of increased risk of obesity in patients with polycystic ovary syndrome (PCOS), hypothyroidism, Cushing syndrome, depression, OSA, increased age in both sexes, and arthritic diseases that lead to inactivity.13 Knowing factors that can increase risk should lead to better assessment and management of diseases that may result in or worsen obesity. In such cases, weight loss modalities should be targeted at the mechanism of dysfunction specific to the disease and not necessarily at the weight itself. An example of this would be PCOS, because there are multiple hormonal factors that affect weight regulation in these patients. PCOS contributes to multiple hormonal changes that can affect weight regulation, including insulin resistance, excess androgen production, and increased ghrelin production. Insulin resistance and increased insulin production occur independently of obesity but are also substantially worsened by it. It is important to note when treating obesity in those with PCOS that a normal fasting glucose does not exclude glucose intolerance and should always be a focus area for treatment.14 In the treatment of PCOS adding adjunctive pharmacologic management with medications such as spironolactone and metformin can significantly increase weight loss success. Additionally, studies show that the addition of metformin can often lead to a decreased risk of development of type 2 diabetes in the future. Hyperandrogenemia has been shown to lead to greater adiposity and even compound the already existing insulin resistance. Women with PCOS tend to have higher levels of the hormone ghrelin, leading to increased appetite and intake. Finally, there is also a correlation between PCOS and OSA, again independent of obesity.15 If OSA is present, it contributes to further hormonal dysregulation with resultant weight gain. In summary, weight management in this population needs to be multifaceted with evaluation and treatment of sleep issues, including possible OSA, improvement in insulin sensitivity, reversal of hyperandrogenemia, implementation of a low glycemic index diet, and assistance with appetite control. Therefore, instructing the patient with PCOS to simply increase physical activity and modify diet would be a grossly inadequate treatment plan. These patients often need medication management along with behavior modification to meet weight loss goals. All primary care providers treat patients with obesity, even if they are not actually treating the obesity itself. It is thus important to be aware of medication adjustments that can facilitate weight loss or to avoid certain medications that increase risk. Medications that do cause weight gain include antihistamines, b-blockers, some antidepressants (specifically venlafaxine and paroxetine), antipsychotics, medications prescribed for epilepsy, and insulin. In some instances, modifications to medication plans can facilitate weight loss or prevent further weight gain. Simple examples of some of these changes might include changing venlafaxine to bupropion to treat depression or modifying diabetic medications to include a
4
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Table 2 Medications Available to Treat Obesitya Drugb
Mechanism of Action
Precise MOA unknown, combination sympathomimetic amine anorectic with increase GABA activity Contrave (Wellbutrin DNRI with opioid antagonist and naltrexone)
Qsymia (phentermine and topiramate)
Lorcaserin
Selective serotonergic 5-HT2C receptor agonist.
Liraglutide
GLP-1 agonist
Orlistat
Causes excretion of approximately 25%-30% of ingested fat in stool
Precautions
Drug Interactions
Weight Loss at 1 Year
Increased heart rate, suicidal behavior Oral contraception, CNS depressants, and ideation, mood and sleep disorders, potassium wasting diuretics. metabolic acidosis, elevated creatinine
6.7 kg with 7.5/46 mg; 8.9 kg with 15/92 mg
Suicidal behavior or ideation, seizure risk, increase in blood pressure and heart rate, hepatotoxicity, angle-closure glaucoma
6.2 kg
MAOI, CYP2D6 substrates, CYP2B6 inhibitors and inducers, drugs that lower seizure threshold. Naltrexone can increase opioid levels and should be avoided in chronic pain patients. Serotonergic drugs
3.2 kg Serotonin syndrome, neuroleptic syndrome, valvular heart disease, cognitive impairment, psychiatric disorders, priapism Thyroid cancer, pancreatitis, Drug impacted by delayed gastric emptying 6.2 kg gallbladder disease, hypoglycemia, increase in heart rate, renal impairment, hypersensitivity, suicidal 2.5kg with 60 mg; Pain in stomach, pale stools, dark urine, Decreases fat soluble agent absorption 3.4 kg with 120 mg loss of appetite, weakness, jaundice, hypersensitivity, fecal incontinence
5-HT2C ¼ 5-hydroxytryptamine 2C; CNS ¼ central nervous system; CYP2B6 ¼ cytochrome P450 2B6; CYP2D6 ¼ cytochrome P450 2D6; DNRI, dopamineenorepinephrine uptake inhibitor; GABA ¼ gamma-aminobutyric acid; GLP-1 ¼ glucagon-like peptide-1; MAOI ¼ monoamine oxidase inhibitor; MOA ¼ method of action. a Table created using information from Apovian et al.16 b Qsymia (VIVUS, Campbell, CA); Contrave (Nalpropion Pharmaceuticals, San Diego, CA).
sodiumeglucose cotransporter-2 inhibitor or glucagon-like peptide-1 to assist with weight loss.
Medical Management of Obesity Obviously, medications cannot take the place of diet, exercise, and other lifestyle modifications. However, in terms of pharmacologic management, now is one of the best times to treat obesity because there are numerous US Food and Drug Administrationapproved medications currently available (Table 2).16 The Endocrine Society recommends using diet, exercise, and behavior modification for weight management along with medications to reduce food intake and increase physical activity. If a patient responds well by losing at least 5% of their body weight in 3 months on an obesity medication, the medication should be continued.15 As with any intervention for treating obesity, the choice of medication should be individualized to the needs of the patient. Orlistat is the first-line recommendation for weight management. It is also the only FDA-approved medication available over the counter, marketed as Alli (GSK Consumer Healthcare, Warren, NJ). Orlistat is a gastric and pancreatic lipase inhibitor that reduces dietary fat absorption. This class of medication can be particularly helpful in patients with lower BMI (ie, > 27 kg/m2) with comorbid issues such as diabetes and hyperlipidemia. It has been effective for small but clinically significant weight loss compared with diet alone. Orlistat is the only weight loss medication currently indicated for treatment of childhood obesity and has been safely studied in children older than 12 years.17 Liraglutide is an injectable glucagon-like peptide-1 medication used for treatment of obesity. This class is most often used in the treatment of diabetes. Therefore, its use may be beneficial in patients with comorbid glucose intolerance because it decreases insulin resistance. It also regulates leptin and ghrelin, suppresses appetite, and slows food transit through the gut, leading to early and prolonged satiety.18 Qsymia (VIVUS, Campbell, CA) is a combination of phentermine and topiramate. Phentermine is a widely used appetite suppressant but in monotherapy may lose efficacy in few weeks. Topiramate is a medication commonly used for migraine headaches that has the
side effect of weight loss, particularly at high doses. The benefit of this medication is that it not only leads to less food cravings but can also increase food aversion to carbohydrates. Compared with other drugs, this combination was associated with the highest odds of losing at least 5% of body weight. Research suggests that this combination is the most effective weight loss medication to date, with people achieving on average 21.6 pounds lost after being on the maximum dose for 1 year.16 Lorcaserin is like a selective serotonin reuptake inhibitor in its formulation and is used to suppress appetite without the cardiovascular side effects of stimulant medications. The efficacy of lorcaserin was evaluated in 2 separate studies, and at the end of year 1 in both studies, 47.5% of patients on lorcaserin lost 5% or more of their body weight compared with 20% in the placebo group, and 22% of participants lost more than 10%.19 Contrave (Nalpropion Pharmaceuticals, San Diego, CA) is the combination of naltrexone and bupropion. This is indicated in the long-term management of obesity. The mechanism by which this combination assists with weight loss is not entirely understood, although it is felt that its action on the central nervous system regulates the reward pathways leading to weight reduction by modulating reward values and goal-directed behaviors.10 Not traditionally a weight loss medication but worthy of mention in this section would be the drug lisdexamfetamine. Although lisdexamfetamine is used in the treatment of attention deficit hyperactivity disorder, it is also FDA approved for binge eating disorder at doses greater than 50 mg.20
Bariatric Referral Bariatric surgery is a valuable tool in the treatment of morbid obesity, indicated for patients with BMIs > 40 kg/m2 or > 35 kg/m2 with comorbidities. Overall, bariatric surgery is the most costeffective treatment for severe obesity, yet less than 1% of patients with severe obesity undergo it.21 Some of this is the result of a perceived cost barrier, although the operation is better covered now than in years past. Also, clinicians continue to recommend it to their patients less frequently than they should. Although studies show that the general attitude is a favorable one,
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the hesitation seems to be the result of a lack of comfort with treating the bariatric patient postoperatively. Regardless of hesitation, it was noted that patients were significantly more likely to pursue bariatric procedures when recommended by their primary care provider. Conclusion Obesity is a complex, chronic disease that requires a multifactorial approach to assessment and treatment. However, the increasing prevalence of obesity and negative health outcomes necessitates a paradigm change regarding obesity treatment. Owing to increasing demands on primary care providers with less time to spend with each patient, the management of obesity can seem daunting. However, it is important to remember that obesity can and should be treated and that patients can be successful in their weight loss goals with assistance from their medical provider. Obesity treatment extends far beyond basic instructions to “eat less and exercise more.” Assessment of food and activity behaviors is still important in the treatment of obesity. However, to treat obesity more comprehensively and effectively, the clinician needs to look beyond lifestyle and assess the patient’s risks for obesity and obesity-related diseases, identify and treat contributing factors and diseases that are potentially modifiable with regard to obesity, and increase knowledge of both pharmacologic and nonpharmacologic treatments for obesity. Helpful Links Lifestyle assessment FANTASTIC Lifestyle Assessment Tool
Sleep
STOP-BANG Epworth Sleepiness Scale Sleep Hygiene
Behavioral assessment tools
PHQ 9
GAD
Stress Diet
Exercise
Stress management tools Recommended daily intake American Heart Association exercise recommendations
https://cpb-ca-c1.wpmucdn. com/myriverside.sd43.bc.ca/dist/ 6/45/files/2014/01/FantasticLifestyle-Checklist-Fillable1smptgc.pdf http://stopbang.ca/osa/ screening.php https://www.sleepapnea.org/ assets/files/pdf/ESS%20PDF% 201990-97.pdf https://www.sleepfoundation. org/articles/sleep-hygiene http://www.phqscreeners.com/ sites/g/files/g10016261/f/ 201412/PHQ-9_English.pdf https://www.integration. samhsa.gov/clinical-practice/ GAD708.19.08Cartwright.pdf https://nccih.nih.gov/health/ stress/relaxation.htm https://ods.od.nih.gov/Health_ Information/Dietary_Reference_ Intakes.aspx https://www.heart.org/en/ healthy-living/fitness/fitnessbasics/aha-recs-for-physicalactivity-in-adults
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References 1. Gonzalez-Campoy JM. Obesity in America: A Growing Concern; EndocrineWeb, https://www.endocrineweb.com/conditions/obesity/obesityamerica-growing-concern. February 2019. Accessed June 28, 2019. 2. Centers for Disease Control and Prevention. Overweight & Obesity. Adult Obesity Facts. https://www.cdc.gov/obesity/data/adult.html. August 13, 2018. Accessed June 28, 2019. 3. Devitt M. New Report Shows U.S. Obesity Epidemic Continues to Worsen. American Academy of Family Physicians. https://www.aafp.org/news/health-of-thepublic/20181015obesityrpt.html. October 15. 2018, Accessed June 28, 2019. 4. Yao AC. Screening for and management of obesity in adults: U.S. Preventive Services Task Force recommendation statement: a policy review. Ann Med Surg (Lond). 2012;2(1):18-21. https://doi.org/10.1016/S2049-0801(13)70022-0. 5. Kaplan L. Obesity and Metabolic Risk. Different Disorders, Different Treatments. Boston, MA: Harvard Institute of Lifestyle Medicine Lecture; 2017. 6. Kaplan LM, Golden A, Jinnett K, et al. Perceptions of barriers to effective obesity care: results from the national ACTION Study. Obesity (Silver Spring). 2018;26(1):61-69. https://doi.org/10.1002/oby.22054. 7. Russell E. Exercise is medicine. CMAJ. 2013;185(11):E526. https://doi.org/ 10.1503/cmaj.109-4501. 8. Foster-Schubert KE, Alfano CM, Duggan CR, et al. Effect of diet and exercise alone or combined on weight and body composition in overweight-to-obese postmenopausal women. Obesity (Silver Spring). 2012;20:1628-1638. https:// doi.org/10.1038/oby.2011.76. 9. Spiegel K, Tasali E, Leproult R, Cauter EV. Effects of poor and short sleep on glucose metabolism and obesity risk. Nat Rev Endocrinol. 2009;5(5):253-261. https://doi.org/10.1038/nrendo.2009.23. 10. Wang G-J, Furey M. Study of the effect of naltrexone SR and bupropion SR combination therapy (CONTRAVE TM) in functional magnetic resonance imaging (fMRI) changes in subjects with uncomplicated overweight or obesity. Office of Scientific and Technical Information. US Department of Energy. https://osti.gov/scitech/servlets/purl/1079411. October 31, 2011. Accessed June 28, 2019. 11. Skolnik NS, Horn DB. Answers to clinical questions in the primary care management of people with obesity: lifestyle management. J Fam Pract. 2016;65(7 Suppl):S13-S16. 12. National Sleep Foundation. Sleep.org. https://sleep.org/. 2019. Accessed June 28, 2019. 13. Mayo Clinic. Obesity. Diagnosis and Treatment. http://www.mayoclinic.org/ diseases-conditions/obesity/basics/treatment/con-20014834. Accessed June 28, 2019. 14. Sam S. Obesity and polycystic ovary syndrome. Obes Manag. 2007;3(2):69-73. https://doi.org/10.1089/obe.2007.0019. 15. Vgontzas AN, Legro RS, Bixler EO, Grayev A, Kales A, Chrousos GP. Polycystic ovary syndrome is associated with obstructive sleep apnea and daytime sleepiness. J Clin Endocrinol Metab. 2001;86(2):517-520. https://doi.org/ 10.1210/jcem.86.2.7185. 16. Apovian CM, Aronne LJ, Bessesen DH, et al. Endocrine Society. Pharmacological management of obesity: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2015;100(2):342-362. https://doi.org/10.1210/jc.2014-3415. 17. Foxcroft DR. Orlistat for the treatment of obesity: cost utility model. Obes Rev. 2005;6(4):323-328. https://doi.org/10.1111/j.1467-789X.2005.00211.x. 18. Plourde G. Saxenda in the management of obesity in a type 2 diabetes mellitus patient: a case report. Clin Res Diab Endocrinol. 2018;1(1):1-7. 19. Gustafson A, King C, Rey JA. Lorcaserin (Belviq): a selective serotonin 5-HT2C agonist in the treatment of obesity. P T. 2013;l38(9):525-534. 20. Guerdjikova AI, Mori N, Casuto LS, McElroy SL. Novel pharmacologic treatment in acute binge eating disorder - role of lisdexamfetamine. Neuropsychiatr Dis Treat. 2016;12:833-841. https://doi.org/10.2147/NDT.S80881. 21. Funk LM, Jolles S, Greenberg CC, Voils CI. Primary care physician approaches to severe obesity treatment and bariatric surgery: a qualitative study. Surg Obes Relat Dis. 2015;11(6 Suppl):S1. https://doi.org/10.1016/j.soard.2015.10.002.
Jayme Taylor, MSN, FNP-BC, CSOWM, is a nurse practitioner with St. John Clinic, Bartlesville, OK, as well as owner and nurse practitioner at Rx Health & Wellness, Owasso, OK. She can be contacted at [email protected]. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest.
Contents lists available at ScienceDirect
The Journal for Nurse Practitioners journal homepage: www.npjournal.org
Looking Beyond Lifestyle: A Comprehensive Approach to the Treatment of Obesity in the Primary Care Setting Jayme Taylor, MSN, FNP-BC a b s t r a c t Keywords: lifestyle behaviors obesity obesity as a chronic disease obesogenic diseases obesogenic medications pharmacologic treatment of obesity primary care
Obesity is a growing public health concern due to its increased health risks and comorbidities. Currently, the number of those affected is the highest ever seen in United States history. Obesity treatment in the primary care setting is generally focused on the very basic lifestyle modifications of diet and exercise; however, obesity is a complex chronic disease that is often multifactorial and requires modification to areas other than lifestyle behaviors alone. Primary care clinicians often see obesity as too difficult or time consuming to treat in the primary care setting, and due to factors including lack of comfort or familiarity in treatment, low patient adherence, and time constraints, providers often choose to avoid treatment altogether. This report challenges providers to look beyond lifestyle in the assessment and treatment of obesity, and recommendations are given for comprehensive management of obesity in the primary care setting. © 2019 Elsevier Inc. All rights reserved.
Introduction Health care reform is tasking providers to increase focus on the wellness of populations through health maintenance and disease prevention. As a result, issues such as obesity, behavioral health, and substance abuse have become major public health concerns. With the current mode of health care delivery, focusing on these issues can be a somewhat difficult and time-consuming process. This is especially true of obesity itself because this is often an integration of all these public health concerns into a single disease process. Many would argue that obesity is one of the greatest health care concerns affecting Americans today. Therefore, obesity needs to be viewed as a treatable chronic disease process, and there needs to be a greater focus on treatment in the primary care setting. This report aims to provide practical recommendations regarding assessment and treatment of obesity, including lifestyle modifications, treatment beyond lifestyle modifications, and an exploration of common barriers to treatment. Obesity as a Disease Current data indicate that the combined prevalence of overweight and obesity in the United States is 69.2%.1 Many obesity recommendations also apply to those who are classified as overweight; however, for the purpose of this report, I will focus on obesity alone. Obesity is defined by Centers for Disease Control and Prevention as a weight that is higher than what is considered a healthy weight given height. A healthy weight is determined by https://doi.org/10.1016/j.nurpra.2019.09.021 1555-4155/© 2019 Elsevier Inc. All rights reserved.
calculating the body mass index (BMI) as kg/m2. Obesity is defined as a BMI measurement greater than 30 kg/m2. However, this is often broken down further into classes 1 to 3 (Table 1).2e4 These categories are important when discussing treatment, because as with any disease process, the aggressiveness in which to treat obesity should be directed by the severity of the disease. National Health and Nutrition Examination Survey data for 2015 to 2016 reported that nationally, 39.6% of adults and 18.5% of children had a BMI that met criteria for diagnosis of obesity. These represent the greatest numbers ever recorded in US history.3 With the increase in obesity we saw a concurrent growth in obesityrelated diseases such as diabetes, and this growth has resulted in improved awareness among providers. A big win for those seeking better treatment of obesity was in 2013 when the American Medical Association chose to recognize obesity as a complex chronic disease, stating that it requires medical attention just the same as any other chronic disease.3 The Centers for Disease Control and Prevention broadly defines a chronic disease as any condition that lasts 1 year or longer, requires ongoing medical attention, or limits activities of daily living, or both. If we look at it in this broad of a context, then obviously, obesity and its negative effects on the body would meet criteria. Still, others would argue that obesity is but an unfavorable health outcome that is the result of poor lifestyle choices, with no specific symptoms. A risk factor for disease but not a disease itself. This is largely perpetuated by traditional attitudes about obesity stemming from a narrow reference point that presumes that human behavior (ie, eating and lack of physical activity) alone causes
2
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Table 1 Classes of Obesitya Obesity Classification
BMI, kg/m2
Treatment Recommendations
Class 1 Class 2
30 to < 35 35 to < 40
Class 3
40
ILSM, meal replacements, or VLCD. Consider weight loss medications. ILSM, meal replacements, or VLCD. Consider weight loss medications and bariatric surgery if comorbidities. ILSM, meal replacements, or VLCD. Consider weight loss medication and bariatric surgery.
BMI ¼ body mass index; ILSM ¼ intensive lifestyle modification; VLCD ¼ very low-calorie diet. a Table adapted from United States Preventive Services Task Force recommendations for treatment based on BMI and comorbidities and Centers for Disease Control and Prevention classifications of obesity.3,4
obesity. The belief is that poor lifestyle behaviors alone give way to an altered physiology within the body, thus leading to disease. Lee Kaplan recently spoke at a conference through Harvard University’s Institute of Lifestyle Medicine and explained that this is likely an inadequate view of the physiology associated with obesity. He suggests that physiology drives such behaviors, which subsequently lead to defects in metabolism and the body’s regulatory function, thus interfering with health.5 Behavior modification may lead to modest changes, but this does not change the underlying defects in physiology.5 Even the most obesity-savvy health care providers would agree that poor lifestyle behaviors lead to obesity. The purpose of this report is not to argue that obesity is or is not a lifestyle disease but a challenge to look beyond lifestyle in the treatment of obesity. Lifestyle behaviors, such as diet, exercise, treatment of mood issues, stress, and sleep management, are all widely discussed in the treatment of obesity.
Barriers to Treatment One of the greatest challenges that the primary care provider must face in the treatment of obesity is to act as a dietitian, personal trainer, behavioral health specialist, and health coach, all in one. Effective treatment requires continuous attention and reinforcement by the health care provider, and this is simply not feasible in most current working environments. Yet, health care cost reduction goals place more responsibility on the shoulders of the primary care provider in the treatment of such diseases. Of course, a comprehensive multidisciplinary approach would certainly be more effective; however, in many cases, it is not an option. One barrier to treatment is that many providers feel that discussing weight with patients may cause them unnecessary embarrassment. Therefore, many providers are hesitant to initiate this conversation. The Awareness, Care, and Treatment In Obesity MaNagement (ACTION) survey reported that 65% of providers did not address weight with patients due to this fear. However, only approximately 15% of patients reported that they were embarrassed to discuss weight with their providers.6 Some providers feel that this topic is too difficult to address given the time constraints of a traditional office visit. Whereas in truth, a simple 3-minute lifestyle assessment may be enough to determine whether a patient’s nutritional patterns are reasonable, whether the patient is interested in losing weight, and what their emotional and physical obstacles might be. Another provider barrier to success in this area is often bias caused by low patient adherence to treatment plans.6 This often leads to providers feeling as though obesity treatment is a “lost cause” and not worth the effort needed to treat effectively. One factor affecting patient compliance is that there seems to be a “quick fix” mentality among patients. With the inclusion of fad diets that promise big results in short periods of time, it is harder to ensure long-term adherence to dietary changes. Of course, there
are other patient-related barriers as well. One may be a patient’s reluctance to seek assistance in weight management. Many patients may believe their weight is solely their responsibility, and this may prevent them from seeking help.6 Another issue may be that patients do not understand the effect their weight will have on their future health, and therefore do not feel a sense of urgency to approach this topic with their providers. In the ACTION survey, only approximately 54% of patients reported concern with how their future health would be affected by their current weight, whereas 93% of providers reported concerns.6
Diet and Exercise Diet is an area of debate in the treatment of obesity because the list of possible diets to follow is exhausting: keto, Atkins, Ornish, Mediterranean, and vegan, among many others. Yet while all these diets come with their own sets of risks and benefits, the truth remains: there simply is no one diet to rule them all. The goal of dietary counseling in the primary care setting should be focused more on mindfulness of eating. Tools such as calorie counting and journaling are still highly effective tools that often make a difference in the longterm success of dietary modifications.6 Dietary planning should be as individualized as any other treatment and should be focused on the patient needs and disease processes. Use of Medical Nutrition Therapy can be a referral source for the primary care provider, but until that can be arranged, patients should be instructed at the very least on what they should limit or avoid in their diet. Exercise continues to be a mainstay of obesity management; furthermore, inclusion of aerobic and resistance training has been found to have just as significant of an outcome as pharmacologic management in treatment of many disease processes.7 However, physical activity may not lead to better weight loss outcomes initially. In 2012, the National Cancer Institute funded a 12-month study that looked at the effectiveness of lifestyle interventions in obesity management. Study participants were broken into 3 groups: diet alone, exercise alone, and diet and exercise, and participants in these groups lost a mean 7.2 kg, 2.0 kg, and 8.9 kg, respectively.8 That combination diet and exercise is more successful than either diet or exercise alone was not surprising; however, it was somewhat surprising that this was not found superior to diet alone. The researchers felt that this was likely the result of many changes that occur in the body with exercise, including body composition changes. However, many participants also believed in obtaining a reward for certain goal achievements that may have thwarted their weight loss success. For instance, a beginner in a dietary plan may feel that calories burned through exercise could be “free calories” that may be cashed in for a reward, often in the form of a cheat meal.8 This suggests that at least initially, the focus of management should be primarily on diet, although exercise will always remain an important factor in the treatment of obesity and should be instituted once dietary modifications have been well established.
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Stress Management Stress is felt to be a factor in the development of obesity because it often leads to food cravings, overeating, and fat accrual. Although the acute stress response is generally considered an energetically costly activity that serves to mobilize energy stores for immediate use, chronic stress promotes acquisition or redistribution of energy stores, or both, which could result in obesity. The exact mechanism is not clearly understood but is felt to be at least partially related to hormone dysregulation.9 Many hormones play a role in weight management, including glucagon, leptin, ghrelin, and cortisol; however, cortisol is generally considered the primary hormone in the biologic stress response. Increased long-term cortisol levels have been found to contribute to obesity, although not all of these patients will have increased cortisol levels.10 Nonetheless, obesity is also often associated with factors (other than stress itself) that increase cortisol production such as consumption of foods with a high glycemic index and lack of sleep. This suggests a vicious cycle in which glucocorticoid action, obesity, and stress interact and amplify each other, making this one of the most difficult factors to modify in the treatment of obesity.8 Use of behavioral health professionals could help in treatment of patients with underlying mood disorders; however, this can represent an access issue for many areas. Therefore, an easy way to assess for these in the primary care setting is to use tools such as the Patient Health Questionnaire-9 (PHQ 9) and Generalized Anxiety Disorder 7-item (GAD 7) scale. Treatment of mood disorders can lead to better behavior modification and stress reduction.10 Pharmacologic treatment can be difficult because there seems to be an obesogenic quality to many of these medications. Medications like paroxetine hydrochloride and venlafaxine tend to result in a significant weight gain and should be avoided in the high-risk patient, whereas other medications, including bupropion, can aid in weight loss and may be used to treat both mood disorders and maladaptive food behaviors. Nonpharmacologic interventions should be focused on relaxation techniques including meditation, yoga and improved quality of sleep.11 Sleep The recommended duration of sleep for an adult is between 7 and 8 hours per night. However, a recent poll by the National Sleep Foundation showed that only approximately 10% of Americans prioritized sleep over other aspects of their life.12 The average American gets about 6 hours of sleep each night, and many others reported much less than that. Numerous studies have found a significant association between short sleep and obesity risk. This is important because sleep is a modulator of neuroendocrine function and glucose metabolism.9 Lack of sleep can lead to a decrease in glucose tolerance, insulin sensitivity, and leptin levels, with increases seen in cortisol, ghrelin, appetite, and hunger. Leptin and ghrelin are 2 of the most discussed hormones in weight management. Leptin is a hormone that is related to the perception of satiety, whereas ghrelin is known as the “hunger hormone,” both of which are greatly regulated by sleep. Spiegel et al9 analyzed the 24-hour ghrelin profile in sleep and found that sleep resulted in an inhibitory effect on secretion of ghrelin. Sleep has also been felt to affect energy balance, because leptin by itself increases energy expenditure. Therefore, changes in leptin after sleep deprivation can affect both this and caloric intake. When treating obesity in the primary care setting, assessment of sleep duration and quality should be performed at each visit. Reinforcement should be provided for maintenance of good sleep
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hygiene behaviors with encouragement toward adequate sleep duration. Screening for obstructive sleep apnea (OSA) should be performed initially, which can be quickly done with the Epworth Sleepiness Scale or STOP-BANG (snoring, tired, observed, pressureeBMI > 35 kg/m2, age > 50 years; neck size large; gender) questionnaire. OSA is considered both a consequence of as well as a contributor to obesity. Contributing Diseases and Medications The causative factors of obesity are hard to define because the mechanism by which some diseases could contribute to obesity are often not well defined. This often raises the question, does the disease process cause the obesity or does the obesity create the disease process? Regardless of cause or effect, there does seem to be a strong correlation of increased risk of obesity in patients with polycystic ovary syndrome (PCOS), hypothyroidism, Cushing syndrome, depression, OSA, increased age in both sexes, and arthritic diseases that lead to inactivity.13 Knowing factors that can increase risk should lead to better assessment and management of diseases that may result in or worsen obesity. In such cases, weight loss modalities should be targeted at the mechanism of dysfunction specific to the disease and not necessarily at the weight itself. An example of this would be PCOS, because there are multiple hormonal factors that affect weight regulation in these patients. PCOS contributes to multiple hormonal changes that can affect weight regulation, including insulin resistance, excess androgen production, and increased ghrelin production. Insulin resistance and increased insulin production occur independently of obesity but are also substantially worsened by it. It is important to note when treating obesity in those with PCOS that a normal fasting glucose does not exclude glucose intolerance and should always be a focus area for treatment.14 In the treatment of PCOS adding adjunctive pharmacologic management with medications such as spironolactone and metformin can significantly increase weight loss success. Additionally, studies show that the addition of metformin can often lead to a decreased risk of development of type 2 diabetes in the future. Hyperandrogenemia has been shown to lead to greater adiposity and even compound the already existing insulin resistance. Women with PCOS tend to have higher levels of the hormone ghrelin, leading to increased appetite and intake. Finally, there is also a correlation between PCOS and OSA, again independent of obesity.15 If OSA is present, it contributes to further hormonal dysregulation with resultant weight gain. In summary, weight management in this population needs to be multifaceted with evaluation and treatment of sleep issues, including possible OSA, improvement in insulin sensitivity, reversal of hyperandrogenemia, implementation of a low glycemic index diet, and assistance with appetite control. Therefore, instructing the patient with PCOS to simply increase physical activity and modify diet would be a grossly inadequate treatment plan. These patients often need medication management along with behavior modification to meet weight loss goals. All primary care providers treat patients with obesity, even if they are not actually treating the obesity itself. It is thus important to be aware of medication adjustments that can facilitate weight loss or to avoid certain medications that increase risk. Medications that do cause weight gain include antihistamines, b-blockers, some antidepressants (specifically venlafaxine and paroxetine), antipsychotics, medications prescribed for epilepsy, and insulin. In some instances, modifications to medication plans can facilitate weight loss or prevent further weight gain. Simple examples of some of these changes might include changing venlafaxine to bupropion to treat depression or modifying diabetic medications to include a
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Table 2 Medications Available to Treat Obesitya Drugb
Mechanism of Action
Precise MOA unknown, combination sympathomimetic amine anorectic with increase GABA activity Contrave (Wellbutrin DNRI with opioid antagonist and naltrexone)
Qsymia (phentermine and topiramate)
Lorcaserin
Selective serotonergic 5-HT2C receptor agonist.
Liraglutide
GLP-1 agonist
Orlistat
Causes excretion of approximately 25%-30% of ingested fat in stool
Precautions
Drug Interactions
Weight Loss at 1 Year
Increased heart rate, suicidal behavior Oral contraception, CNS depressants, and ideation, mood and sleep disorders, potassium wasting diuretics. metabolic acidosis, elevated creatinine
6.7 kg with 7.5/46 mg; 8.9 kg with 15/92 mg
Suicidal behavior or ideation, seizure risk, increase in blood pressure and heart rate, hepatotoxicity, angle-closure glaucoma
6.2 kg
MAOI, CYP2D6 substrates, CYP2B6 inhibitors and inducers, drugs that lower seizure threshold. Naltrexone can increase opioid levels and should be avoided in chronic pain patients. Serotonergic drugs
3.2 kg Serotonin syndrome, neuroleptic syndrome, valvular heart disease, cognitive impairment, psychiatric disorders, priapism Thyroid cancer, pancreatitis, Drug impacted by delayed gastric emptying 6.2 kg gallbladder disease, hypoglycemia, increase in heart rate, renal impairment, hypersensitivity, suicidal 2.5kg with 60 mg; Pain in stomach, pale stools, dark urine, Decreases fat soluble agent absorption 3.4 kg with 120 mg loss of appetite, weakness, jaundice, hypersensitivity, fecal incontinence
5-HT2C ¼ 5-hydroxytryptamine 2C; CNS ¼ central nervous system; CYP2B6 ¼ cytochrome P450 2B6; CYP2D6 ¼ cytochrome P450 2D6; DNRI, dopamineenorepinephrine uptake inhibitor; GABA ¼ gamma-aminobutyric acid; GLP-1 ¼ glucagon-like peptide-1; MAOI ¼ monoamine oxidase inhibitor; MOA ¼ method of action. a Table created using information from Apovian et al.16 b Qsymia (VIVUS, Campbell, CA); Contrave (Nalpropion Pharmaceuticals, San Diego, CA).
sodiumeglucose cotransporter-2 inhibitor or glucagon-like peptide-1 to assist with weight loss.
Medical Management of Obesity Obviously, medications cannot take the place of diet, exercise, and other lifestyle modifications. However, in terms of pharmacologic management, now is one of the best times to treat obesity because there are numerous US Food and Drug Administrationapproved medications currently available (Table 2).16 The Endocrine Society recommends using diet, exercise, and behavior modification for weight management along with medications to reduce food intake and increase physical activity. If a patient responds well by losing at least 5% of their body weight in 3 months on an obesity medication, the medication should be continued.15 As with any intervention for treating obesity, the choice of medication should be individualized to the needs of the patient. Orlistat is the first-line recommendation for weight management. It is also the only FDA-approved medication available over the counter, marketed as Alli (GSK Consumer Healthcare, Warren, NJ). Orlistat is a gastric and pancreatic lipase inhibitor that reduces dietary fat absorption. This class of medication can be particularly helpful in patients with lower BMI (ie, > 27 kg/m2) with comorbid issues such as diabetes and hyperlipidemia. It has been effective for small but clinically significant weight loss compared with diet alone. Orlistat is the only weight loss medication currently indicated for treatment of childhood obesity and has been safely studied in children older than 12 years.17 Liraglutide is an injectable glucagon-like peptide-1 medication used for treatment of obesity. This class is most often used in the treatment of diabetes. Therefore, its use may be beneficial in patients with comorbid glucose intolerance because it decreases insulin resistance. It also regulates leptin and ghrelin, suppresses appetite, and slows food transit through the gut, leading to early and prolonged satiety.18 Qsymia (VIVUS, Campbell, CA) is a combination of phentermine and topiramate. Phentermine is a widely used appetite suppressant but in monotherapy may lose efficacy in few weeks. Topiramate is a medication commonly used for migraine headaches that has the
side effect of weight loss, particularly at high doses. The benefit of this medication is that it not only leads to less food cravings but can also increase food aversion to carbohydrates. Compared with other drugs, this combination was associated with the highest odds of losing at least 5% of body weight. Research suggests that this combination is the most effective weight loss medication to date, with people achieving on average 21.6 pounds lost after being on the maximum dose for 1 year.16 Lorcaserin is like a selective serotonin reuptake inhibitor in its formulation and is used to suppress appetite without the cardiovascular side effects of stimulant medications. The efficacy of lorcaserin was evaluated in 2 separate studies, and at the end of year 1 in both studies, 47.5% of patients on lorcaserin lost 5% or more of their body weight compared with 20% in the placebo group, and 22% of participants lost more than 10%.19 Contrave (Nalpropion Pharmaceuticals, San Diego, CA) is the combination of naltrexone and bupropion. This is indicated in the long-term management of obesity. The mechanism by which this combination assists with weight loss is not entirely understood, although it is felt that its action on the central nervous system regulates the reward pathways leading to weight reduction by modulating reward values and goal-directed behaviors.10 Not traditionally a weight loss medication but worthy of mention in this section would be the drug lisdexamfetamine. Although lisdexamfetamine is used in the treatment of attention deficit hyperactivity disorder, it is also FDA approved for binge eating disorder at doses greater than 50 mg.20
Bariatric Referral Bariatric surgery is a valuable tool in the treatment of morbid obesity, indicated for patients with BMIs > 40 kg/m2 or > 35 kg/m2 with comorbidities. Overall, bariatric surgery is the most costeffective treatment for severe obesity, yet less than 1% of patients with severe obesity undergo it.21 Some of this is the result of a perceived cost barrier, although the operation is better covered now than in years past. Also, clinicians continue to recommend it to their patients less frequently than they should. Although studies show that the general attitude is a favorable one,
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the hesitation seems to be the result of a lack of comfort with treating the bariatric patient postoperatively. Regardless of hesitation, it was noted that patients were significantly more likely to pursue bariatric procedures when recommended by their primary care provider. Conclusion Obesity is a complex, chronic disease that requires a multifactorial approach to assessment and treatment. However, the increasing prevalence of obesity and negative health outcomes necessitates a paradigm change regarding obesity treatment. Owing to increasing demands on primary care providers with less time to spend with each patient, the management of obesity can seem daunting. However, it is important to remember that obesity can and should be treated and that patients can be successful in their weight loss goals with assistance from their medical provider. Obesity treatment extends far beyond basic instructions to “eat less and exercise more.” Assessment of food and activity behaviors is still important in the treatment of obesity. However, to treat obesity more comprehensively and effectively, the clinician needs to look beyond lifestyle and assess the patient’s risks for obesity and obesity-related diseases, identify and treat contributing factors and diseases that are potentially modifiable with regard to obesity, and increase knowledge of both pharmacologic and nonpharmacologic treatments for obesity. Helpful Links Lifestyle assessment FANTASTIC Lifestyle Assessment Tool
Sleep
STOP-BANG Epworth Sleepiness Scale Sleep Hygiene
Behavioral assessment tools
PHQ 9
GAD
Stress Diet
Exercise
Stress management tools Recommended daily intake American Heart Association exercise recommendations
https://cpb-ca-c1.wpmucdn. com/myriverside.sd43.bc.ca/dist/ 6/45/files/2014/01/FantasticLifestyle-Checklist-Fillable1smptgc.pdf http://stopbang.ca/osa/ screening.php https://www.sleepapnea.org/ assets/files/pdf/ESS%20PDF% 201990-97.pdf https://www.sleepfoundation. org/articles/sleep-hygiene http://www.phqscreeners.com/ sites/g/files/g10016261/f/ 201412/PHQ-9_English.pdf https://www.integration. samhsa.gov/clinical-practice/ GAD708.19.08Cartwright.pdf https://nccih.nih.gov/health/ stress/relaxation.htm https://ods.od.nih.gov/Health_ Information/Dietary_Reference_ Intakes.aspx https://www.heart.org/en/ healthy-living/fitness/fitnessbasics/aha-recs-for-physicalactivity-in-adults
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References 1. Gonzalez-Campoy JM. Obesity in America: A Growing Concern; EndocrineWeb, https://www.endocrineweb.com/conditions/obesity/obesityamerica-growing-concern. February 2019. Accessed June 28, 2019. 2. Centers for Disease Control and Prevention. Overweight & Obesity. Adult Obesity Facts. https://www.cdc.gov/obesity/data/adult.html. August 13, 2018. Accessed June 28, 2019. 3. Devitt M. New Report Shows U.S. Obesity Epidemic Continues to Worsen. American Academy of Family Physicians. https://www.aafp.org/news/health-of-thepublic/20181015obesityrpt.html. October 15. 2018, Accessed June 28, 2019. 4. Yao AC. Screening for and management of obesity in adults: U.S. Preventive Services Task Force recommendation statement: a policy review. Ann Med Surg (Lond). 2012;2(1):18-21. https://doi.org/10.1016/S2049-0801(13)70022-0. 5. Kaplan L. Obesity and Metabolic Risk. Different Disorders, Different Treatments. Boston, MA: Harvard Institute of Lifestyle Medicine Lecture; 2017. 6. Kaplan LM, Golden A, Jinnett K, et al. Perceptions of barriers to effective obesity care: results from the national ACTION Study. Obesity (Silver Spring). 2018;26(1):61-69. https://doi.org/10.1002/oby.22054. 7. Russell E. Exercise is medicine. CMAJ. 2013;185(11):E526. https://doi.org/ 10.1503/cmaj.109-4501. 8. Foster-Schubert KE, Alfano CM, Duggan CR, et al. Effect of diet and exercise alone or combined on weight and body composition in overweight-to-obese postmenopausal women. Obesity (Silver Spring). 2012;20:1628-1638. https:// doi.org/10.1038/oby.2011.76. 9. Spiegel K, Tasali E, Leproult R, Cauter EV. Effects of poor and short sleep on glucose metabolism and obesity risk. Nat Rev Endocrinol. 2009;5(5):253-261. https://doi.org/10.1038/nrendo.2009.23. 10. Wang G-J, Furey M. Study of the effect of naltrexone SR and bupropion SR combination therapy (CONTRAVE TM) in functional magnetic resonance imaging (fMRI) changes in subjects with uncomplicated overweight or obesity. Office of Scientific and Technical Information. US Department of Energy. https://osti.gov/scitech/servlets/purl/1079411. October 31, 2011. Accessed June 28, 2019. 11. Skolnik NS, Horn DB. Answers to clinical questions in the primary care management of people with obesity: lifestyle management. J Fam Pract. 2016;65(7 Suppl):S13-S16. 12. National Sleep Foundation. Sleep.org. https://sleep.org/. 2019. Accessed June 28, 2019. 13. Mayo Clinic. Obesity. Diagnosis and Treatment. http://www.mayoclinic.org/ diseases-conditions/obesity/basics/treatment/con-20014834. Accessed June 28, 2019. 14. Sam S. Obesity and polycystic ovary syndrome. Obes Manag. 2007;3(2):69-73. https://doi.org/10.1089/obe.2007.0019. 15. Vgontzas AN, Legro RS, Bixler EO, Grayev A, Kales A, Chrousos GP. Polycystic ovary syndrome is associated with obstructive sleep apnea and daytime sleepiness. J Clin Endocrinol Metab. 2001;86(2):517-520. https://doi.org/ 10.1210/jcem.86.2.7185. 16. Apovian CM, Aronne LJ, Bessesen DH, et al. Endocrine Society. Pharmacological management of obesity: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2015;100(2):342-362. https://doi.org/10.1210/jc.2014-3415. 17. Foxcroft DR. Orlistat for the treatment of obesity: cost utility model. Obes Rev. 2005;6(4):323-328. https://doi.org/10.1111/j.1467-789X.2005.00211.x. 18. Plourde G. Saxenda in the management of obesity in a type 2 diabetes mellitus patient: a case report. Clin Res Diab Endocrinol. 2018;1(1):1-7. 19. Gustafson A, King C, Rey JA. Lorcaserin (Belviq): a selective serotonin 5-HT2C agonist in the treatment of obesity. P T. 2013;l38(9):525-534. 20. Guerdjikova AI, Mori N, Casuto LS, McElroy SL. Novel pharmacologic treatment in acute binge eating disorder - role of lisdexamfetamine. Neuropsychiatr Dis Treat. 2016;12:833-841. https://doi.org/10.2147/NDT.S80881. 21. Funk LM, Jolles S, Greenberg CC, Voils CI. Primary care physician approaches to severe obesity treatment and bariatric surgery: a qualitative study. Surg Obes Relat Dis. 2015;11(6 Suppl):S1. https://doi.org/10.1016/j.soard.2015.10.002.
Jayme Taylor, MSN, FNP-BC, CSOWM, is a nurse practitioner with St. John Clinic, Bartlesville, OK, as well as owner and nurse practitioner at Rx Health & Wellness, Owasso, OK. She can be contacted at [email protected]. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest.