The Evidence for Active Intervention in Weight Management: Perspectives for the Pharmacist
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Obesity: A Public Health Epidemic
Obesity has been described as a public health epidemic due to its increasing prevalence over the past several decades: since 1980, the prevalence of obesity has more than doubled worldwide, and in 2014, the number of obese adults was estimated at 600 million, or 13% of the adult population worldwide.1-3 In the United States alone, the occurrence of obesity is more than 2 times higher compared with the worldwide rate. Data from the 2011 to 2012 National Health and Nutrition Examination Survey (NHANES) indicate that approximately one-third (34.9%) of US adults are obese.4
As the prevalence of obesity has grown, so, too, have the medical impacts and economic costs of obesity-related comorbidities. These comorbidities include sleep apnea and cardiovascular risk factors or conditions, such as type 2 diabetes, dyslipidemia, hypertension, stroke, and coronary heart disease.5 Based on NHANES data from 1999 to 2010, approximately 19% of individuals who are obese have diabetes, 36% have hypertension, and 50% have dyslipidemia.6 The resulting economic burden on the US health care system is staggering: in 2010, an estimated 27.5% of total health care spending was on obesity-related illness, with the annual total estimated to be $315.8 billion.7
Recognition of Obesity as a Disease
In 2012, given the burden of obesity, the American Medical Association classified it as a disease, in agreement with other prominent medical bodies, such as the Obesity Society, the American Academy of Clinical Endocrinologists, and the Endocrine Society.8-11 By classifying obesity as a disease state and in recognition of the critical status of the obesity epidemic, the medical community hopes to promote greater awareness of the medical impact of obesity, including the increased cardiovascular risk, and to foster cooperation among stakeholders in the health care system to improve patient care and health outcomes for those with obesity.5,8
Clinical Benefits of Weight Loss
Weight loss can help reduce the burden associated with obesity and its many related comorbidities, which include type 2 diabetes, dyslipidemia, and sleep apnea. Relatively modest losses of 3% to 5% of initial body weight can have clinically meaningful effects on metabolic parameters, such as blood lipid levels and glycated hemoglobin.5 Sustained weight loss can also delay or prevent the onset of type 2 diabetes. A weight reduction of 6 lb to 12 lb (2.5 to 5.5 kg) maintained over 2 years has been estimated to reduce the risk of developing type 2 diabetes by 30% to 60%.5,12
Symptoms of obstructive sleep apnea also improve with a reduction in weight. In a study of adults who were overweight or obese and had obstructive sleep apnea, after 5 years of follow up, patients who successfully lost 5% or more of their initial body weight experienced 6.3 apnea events per hour compared with 14.6 apnea events per hour among patients who did not lose weight.13
Weight loss also decreases mortality. In observational studies, overweight and obese adults with type 2 diabetes who lost an average of 20 lb to 29 lb (9 to 13 kg) experienced a 25% reduction in mortality compared with a comparable group of patients whose weight was stable and who were not trying to lose weight.5,12,14
Guidelines for the Management of Overweight and Obesity
Evidence-based guidelines issued jointly by the American Heart Association, the American College of Cardiology, and The Obesity Society recommend lifestyle intervention and treatment based on body mass index (BMI) and the presence of weight-related comorbidities. According to these guidelines, interventions for weight reduction include lifestyle changes (eg, caloric restriction and physical activity), pharmacologic therapies, and bariatric surgery. The selection of a treatment plan is guided by BMI and comorbidities (Table).5
Caloric restriction and physical activity make up the foundation of treatment and should be considered in patients with a BMI of 30 kg/m2 or greater or 25 kg/m2 or greater with at least 1 obesity-associated comorbidity. Pharmacologic intervention may be considered as an adjunct to diet and exercise in patients who have not had sufficient success with lifestyle changes alone and have a BMI of 30 kg/m2 or greater or a BMI of 27 kg/m2 or greater with at least 1 obesity-associated comorbidity. Bariatric surgery is an option in patients who have not achieved success with lifestyle change (with or without pharmacologic therapy) and have a BMI of 40 kg/m2 or greater or 35 kg/m2 or greater with obesity-related comorbidities.5
Role of the Pharmacist
Health care professionals (HCPs), including pharmacists, can have a positive effect on patient health by educating patients about the benefits of even modest weight reduction. In 1 study, patients who were told they were overweight by an HCP were 88% more likely to lose 5% of their initial weight than patients who were not alerted to the weight problem.15
It is important for pharmacists to educate patients that obesity is a disease state and that it is associated with several comorbidities and an increased risk of cardiovascular events.5,8-11 Patients should be aware that a modest reduction in weight (3% to 5% of initial body weight) may have a clinically meaningful effect on cardiovascular risk factors, as previously mentioned.5
Pharmacists interact with patients with obesity-related comorbidities (eg, hypertension, type 2 diabetes, dyslipidemia) on a daily basis and can help identify those who would potentially benefit from more intensive weight-loss interventions. Based on guidelines for the management of overweight and obesity, pharmacists can direct patients to seek medical care when appropriate and provide counseling on options for weight reduction, including lifestyle modification and pharmacotherapy.
- Bray GA, Bellanger T. Epidemiology, trends, and morbidities of obesity and the metabolic syndrome. Endocrine. 2006;29(1):109-117.
- Jensen MD, Ryan DH, Apovian CM, et al. 2013 Report on the Management of Overweight and Obesity in Adults: Full Panel Report Supplement. Washington, DC: American College of Cardiology; 2013. http://jaccjacc.cardiosource.com/acc_documents/2013_FPR_S5_Obesity.pdf. Accessed April 20, 2015.
- Obesity and overweight fact sheet. World Health Organization website. www.who.int/mediacentre/factsheets/fs311/en/#. Updated January 2015. Accessed April 20, 2015.
- Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA. 2014;311(8):806-814. doi: 10.1001/jama.2014.732.
- Jensen MD, Ryan DH, Apovian CM, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines; Obesity Society. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. J Am Coll Cardiol. 2014;63(25 Pt B):2985-3023. doi: 10.1016/j.jacc.2013.11.004.
- Saydah S, Bullard KM, Cheng Y, et al. Trends in cardiovascular disease risk factors by obesity level in adults in the United States, NHANES 1999-2010. Obesity (Silver Spring). 2014;22(8):1888-1895. doi: 10.1002/oby.20761.
- Cawley J, Meyerhoefer C, Biener A, Hammer M, Wintfeld N. Savings in medical expenditures associated with reductions in body mass index among US adults with obesity, by diabetes status. Pharmacoeconomics. Published online: November 9, 2014. doi: 10.1007/s40273-014-0230-2.
- Fryhofer SA. Is obesity a disease? In: Report of the Council on Science and Public Health. Paper presented at: 2012 Annual Meeting of the American Medical Association. CSAPH Report 3-A-13. www.ama-assn.org/assets/meeting/2013a/a13-addendum-refcomm-d.pdf. Accessed April 20, 2015.
- Mechanick JI, Garber AJ, Handelsman Y, Garvey WT. American Association of Clinical Endocrinologists’ position statement on obesity and obesity medicine. Endocr Pract. 2012;18(5):642-648. doi: 10.4158/EP12160.PS.
- 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. doi: 10.1210/jc.2014-3415.
- Council of the Obesity Society. Obesity as a disease: the Obesity Society Council resolution. Obesity (Silver Spring). 2008;16(6):1151. doi: 10.1038/oby.2008.246.
- Aucott L, Poobalan A, Smith WC, et al. Weight loss in obese diabetic and non-diabetic individuals and long-term diabetes outcomes--a systematic review. Diabetes Obes Metab. 2004;6(2):85-94.
- Tuomilehto H, Seppä J, Uusitupa M, et al; Kuopio Sleep Apnea Group. The impact of weight reduction in the prevention of the progression of obstructive sleep apnea: an explanatory analysis of a 5-year observational follow-up trial. Sleep Med. 2014;15(3):329-335. doi: 10.1016/j.sleep.2013.11.786.
- Poobalan AS, Aucott LS, Smith WC, Avenell A, Jung R, Broom J. Long-term weight loss effects on all cause mortality in overweight/obese populations. Obes Rev. 2007;8(6):503-513.
- Pool AC, Kraschnewski JL, Cover LA, et al. The impact of physician weight discussion on weight loss in US adults. Obes Res Clin Pract. 2014;8(2):e131-e139. doi: 10.1016/j.orcp.2013.03.003.
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