by Staff Writer, MedPage Today August 18, 2015
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U.S. consumers now have a veritable fast-food menu of options when it comes to treatments for obesity: bypass surgeries, gastric sleeves, and lap bands; vagal nerve stimulators and balloons; and, of course, a growing list of weight loss drugs.
Yet this full plate of available therapies doesn’t seem to have had a major impact on the obesity epidemic — nearly 35% of Americans are obese, according to current figures on the CDC website, and the estimated annual medical cost of obesity in the U.S. was $147 billion in 2008.
In addition, according to a 2014 paper in the Journal of the American Medical Association, “overall, there have been no significant changes in obesity prevalence in youth or adults between 2003-2004 and 2011-2012.”
MedPage Today checked in with obesity and weight loss specialists for their take on the current treatment landscape. While they do use pharmacotherapy with their patients, and have referred patients for surgical interventions, they also expressed concerns that all the new treatment options are obscuring what should be the foundation of any treatment for weight management: lifestyle changes.
The Pharma Buffet
The area of obesity treatment that has expanded the most over the last few years is pharmaceuticals. After heavy lobbying from the industry, five drugs have been approved for treating obesity since 2010: liraglutide (Saxenda), orlistat (Xenical), lorcaserin (Belviq), phentermine and topiramate (Qsymia), and naltrexone (Contrave).
Craig Primack, MD, a medical weight loss specialist at the Scottsdale Weight Loss Center in Arizona, said that he does prescribe these drugs, but he also advocates for dietary changes and exercise. He said that the drugs “definitely have a place when understanding the problem is not in will power, but in the hypothalamus and the hormones that control appetite and fullness.”
He also stressed that the drugs are not a cure for excess weight.
“Obesity is at this point only treatable and not curable,” he wrote in an email to MedPage Today. “If someone stops what they were doing that was working [for weight loss], they will regain.”
Indeed, the long-term benefits to weight loss of the drugs are unclear, in part because of their novelty. There’s also some evidence that the drugs can pose serious cardiovascular health risks.
On the Surgical Table
Data indicates that patients can attain significant weight loss with surgical approaches, such as roux-en-y gastric bypass surgery, laparoscopic adjustable gastric banding, biliopancreatic diversion with duodenal switch, and gastric sleeve surgery.
But these approaches are far from perfect. A recent 5-year follow-up of patients who underwent laparoscopic sleeve gastrectomy found that only 20% of them maintained complete remission of type 2 diabetes, and the percentage of excess weight loss declined from 77% to 56%.
In addition, there are 10,000 people in the U.S. who qualify for bariatric surgery for every one surgeon qualified to do it, according to Tom Rifai, MD, a weight loss specialist at St. Joseph Mercy Hospital in Michigan. Surgery is also often very expensive, and the insurance industry has been slow in catching up with the obesity treatments.
“Bariatric surgery can’t be the only answer,” Rifai said.
There are other options. Last month the FDA approved gastric dual-balloons that are inserted into the stomach and meant to trigger feelings of fullness, thus limiting overeating. The balloon appeared to help patients lose more weight than exercise and diet alone did, but there are still relatively few data. Earlier this month, another balloon was approved.
There are also vagal nerve simulators, which have performed well against sham in early trials. But here, too, the data are limited, and many experts question the effectiveness of the device in the real world.
A Lifestyle of Healthy Weight
It’s possible that the options for treating obesity just aren’t advanced enough yet — there are not enough skilled surgeons, not enough reliable drugs, and not enough devices. But experts told MedPage Today that unless there are significant changes to the environmental factors in modern society that make it easy to sit all day and to overeat, there’s little hope of beating the obesity epidemic.
There are no legal repercussions for overeating. “It’s not like alcohol, where if you drink and drive you’ll go to jail — nobody gets punished for eating too much,” Rifai pointed out.
He added that medical management of weight loss and lifestyle changes need to go hand-in-hand.
“The problem is changing our environment and culture so healthy choices are the default,” Rifai added.
“The importance of a healthy lifestyle cannot be forgotten regardless of potential breakthrough treatments,” commented Skylar Griggs, MS, RD, a dietitian at Boston Children’s Hospital. “Positive lifestyle changes that are measurable over time, and more importantly, do-able in day-to-day life are often the ones that stick.”
David Katz, MD,MPH, of Yale University School of Medicine in New Haven, Conn., wrote that the temptation to turn to medical solutions and technologies is fueled in part by the failure of clinical counseling. “One of the reasons counseling is so often ineffective is that we send patients right back out into an environment that actively conspires against weight control,” he wrote in an email to MedPage Today.
He added that he still considers counseling to be the first line of defense and that all clinicians should engage in it. “But we need cultural supports. We need prevailing opportunities for our patients to find and choose wholesome food, and fit activity into every day. Those opportunities need to be incorporated as a matter of routine into work places and schools, restaurants and cafeterias and supermarkets,” he wrote.
“Until these things happen, we are whistling our counsel into a deafening wind,” he added.
Primack wrote that there are some significant changes that have already happened, and that “our society has to begin to understand that weight is a medical disease.”
But the cultural conditions that require millions of Americans to sit at their desks all day, and the availability of cheap, calorie-loaded unhealthy food, may be difficult to change. It will likely require new policies and the cooperation of government and scientists — and there will have to be a fundamental change in food consumption habits.
Katz wrote that there’s a real risk of losing sight of the importance of lifestyle changes to losing weight. “In general, we are quite prone to overmedicalizing,” he wrote. Drugs and surgeries may be sending the message that we should look past the problem — that Americans consume too many calories — and focus on its outcome.
He added that there is a legitimate role for surgery, pharmacotherapy, and devices, “but from the perspective of a public health mired in epidemic obesity, it is a very, very small place,” he wrote. “The fundamental problem is social, environmental, and cultural — and the most important, cost-effective, generalizable solutions must be directed here.”
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The Weight Loss Menu: Surgery with a Side of Meds? – MedPage Today
by Staff Writer, MedPage Today August 18, 2015